 I will mention one or two of the most common errors among women in charge of sick, respecting sick diet. One is the belief that beef tea is the most nutritive of all articles. Now, just try and boil down a pound of beef into beef tea, evaporate your beef tea, and see what is left of your beef. You will find that there is barely a teaspoonful of solid nourishment to half a pint of water in beef tea, nevertheless there is a certain reparative quality in it. We do not know what, as there is in tea, but it may be safely given in almost any inflammatory disease, and is as little to be depended upon with the healthy or convalescent where much nourishment is required. Again, it is an ever-ready saw that an egg is equivalent to a pound of meat, whereas it is not so at all. Also, it is seldom noticed with how many patients, particularly of nervous or bilious temperament, eggs disagree. All puddings made with eggs are distasteful to them in consequence. An egg whipped up with wine is often the only form in which they can take this kind of nourishment. Again, if the patient has attained to eating meat, it is supposed that to give him meat is the only thing needful for his recovery, whereas scorbutic saws have been actually known to appear among sick persons living in the midst of plenty in England, which could be traced to no other sauce than this, that is, that the nurse, depending on meat alone, had allowed the patient to be without vegetables for a considerable time, these latter being so badly cooked that he always left them untouched. Arrowroot is another grand dependence of the nurse. As a vehicle for wine, and as a restorative quickly prepared, it is all very well, but it is nothing but starch and water. Flour is both more nutritive and less liable to ferment, and is preferable wherever it can be used. Again, milk and the preparations from milk are most important article of food for the sick. Butter is the lightest kind of animal fat, and though it wants the sugar and some of the other elements which there are in milk, yet it is most valuable both in itself and in enabling the patient to eat more bread. Flour, oats, groats, barley, and their kind are, as we have already said, preferable in all their preparations to all the preparations of arrowroot, sago, tapioca, and their kind. Cream, in many long chronic diseases, is quite irreplaceable by any other article whatever. It seems to act in the same manner as beef tea, and to most it is much easier of digestion than milk. In fact it seldom disagrees. Cheese is not usually digestible by the sick, but it is pure nourishment for repairing waste, and I have seen sick, and not a few either, whose craving for cheese showed how much it was needed by them. But if fresh milk is so valuable a food for the sick, the least change or sourness in it makes it, of all articles perhaps, the most injurious. Diarrhea is a common result of fresh milk allowed to become a tall sour. The nurse, therefore, ought to exercise her utmost care in this. In large institutions for the sick, even the poorest, the utmost care is exercised. When a milk ice is used for this express purpose every summer, while a private patient perhaps, never tastes a drop of milk that is not sour, all through the hot weather, so little does the private nurse understand the necessity of such care. Yet, if you consider that the only drop of real nourishment in your patient's tea is the drop of milk, and how much almost all English patients depend upon their tea, you will see the great importance of not depriving your patient of this drop of milk. Buttermilk, a totally different thing, is often very useful, especially in fevers. In laying down rules of diet, by the amounts of solid nutriment in different kinds of food, it is constantly lost sight of what the patient requires to repair his waste, what he can take and what he cannot. You cannot diet a patient from a book. You cannot make up the human body as you would make up a prescription. So many parts carboniferous, so many parts nitrogenous, will constitute a perfect diet for the patient. The nurse's observation here will materially assist the doctor. The patient's fancies will materially assist the nurse. For instance, sugar is one of the most nutritive of all articles, being pure carbon, and is particularly recommended in some books. But the vast majority of all patients in England, young and old, male and female, rich and poor, hospital and private, dislike sweet things. And while I have never known a person take to sweets while he was ill, who disliked them when he was well, I have known many fond of them when in health, who in sickness would leave off anything sweet, even to sugar in tea. Sweet puddings, sweet drinks are their aversion. The furred tongue almost always likes what is sharp or pungent. All butic patients are an exception, they often crave for sweetmeats and jams. Jelly is another article of diet in great favour with nurses and friends of the sick. Even if it could be eaten solid, it would not nourish, but it is simply the height of folly to take an eighth of an ounce of gelatin, and make it into a certain bulk by dissolving it in water, and then to give it to the sick, as if the mere bulk represented nourishment. It is now known that jelly does not nourish, that it has a tendency to produce diarrhea, and to trust to it to repair the waste of a diseased constitution is simply to starve the sick under the guise of feeding them. If a hundred spoonfuls of jelly were given in the course of the day, you would have given one spoonful of gelatin, which spoonful has no nutritive power whatever. And nevertheless, gelatin contains a large quantity of nitrogen, which is one of the most powerful elements in nutrition. On the other hand, beef tea may be chosen as an illustration of great nutrient power in sickness, coexisting with a very small amount of solid nitrogenous matter. Dr. Christensen says that everyone will be struck with the readiness with which certain classes of patients will often take diluted meat juice, or beef tea repeatedly, when they refuse all other kinds of food. This is particularly remarkable in cases of gastric fever in which, he says, little or nothing else besides beef tea or diluted meat juice has been taken for weeks or even months, and yet a pint of beef tea contains scarcely a quarter of an ounce of anything but water. The result is so striking that he asks what is its mode of action. Not simply nutrient. A quarter ounce of the most nutritive material cannot nearly replace the daily wear and tear of the tissues in any circumstances. Possibly, he says, it belongs to a new denomination of remedies. It has been observed that a small quantity of beef tea added to other articles of nutrition augments their power out of all proportion to the additional amount of solid matter. The reason why jelly should be innutricious and beef tea nutritious to the sick is a secret yet undiscovered, but it clearly shows that careful observation of the sick is the only clue to the best dietary. Chemistry has yet afforded little insight into the dieting of the sick. All that chemistry can tell us is the amount of carboniferous or nitrogenous elements discoverable in different dietic articles. Nature's given us lists of dietic substances arranged in the order of their richness in one or other of these principles, but that is all. In the great majority of cases the stomach of the patient is guided by other principles of selection than merely the amount of carbon or nitrogen in the diet. No doubt, in this as in other things nature has very definite rules for her guidance, but these rules can only be ascertained by the most careful observation at the bedside. She there teaches us that living chemistry, the chemistry of reparation, is something different from the chemistry of the laboratory. Organic chemistry is useful, as all knowledge is, when we come face to face with nature, but it by no means follows that we should learn in the laboratory any one of the reparative processes going on in disease. Again, the nutritive power of milk and of the preparations from milk is very much undervalued. There is nearly as much nourishment in half a pint of milk as there is in quarter a pound of meat. But this is not the whole question or nearly the whole. The main question is what the patient's stomach can assimilate or derive nourishment from, and of this the patient's stomach is the sole judge. Chemistry cannot tell us this. The patient's stomach must be its own chemist. The diet which will keep the healthy man healthy will kill the sick one. The same beef, which is the most nutritive of all meat and which nourishes the healthy man, is the least nourishing of all food to the sick man, whose half-dead stomach can assimilate no part of it, that is, make no food out of it. On a diet of beef tea, healthy men, on the other hand, speedily lose their strength. I have known patients live for many months without touching bread because they could not eat baker's bread. These were mostly country patients, but not all. Homemade bread or brown bread is a most important article of diet for many patients. The use of Asperians may be entirely superseded by it. Oatcake is another. To watch for the opinions, then, which the patient's stomach gives, rather than to read analyses of foods, is the business of all those who have to settle what the patient is to eat, perhaps the most important thing to be provided for him after the air he is to breathe. Now, the medical man who sees the patient only once a day, or even only once or twice a week, cannot possibly tell this without the assistance of the patient himself, or of those who are in constant observation on the patient. The utmost the medical man can tell is whether the patient is weaker or stronger at this visit than he was at the last visit. I should therefore say that incomparably the most important office of the nurse, after she has taken care of the patient's air, is to take care to observe the effect of his food and to report it to the medical attendant. It is quite incalculable the good that would certainly come from such sound and close observation in this almost neglected branch of nursing, or the help it would give to the medical man. A great deal too much against tea is said by wise people, and a great deal too much of tea is given to the sick by foolish people. When you see the natural and almost universal craving in English sick for their tea, you cannot but feel that nature knows what she is about. But a little tea or coffee restores them quite as much as a great deal, and a great deal of tea and especially of coffee impairs the little power of digestion they have. Yet a nurse, because she sees how one or two cups of tea or coffee restores her patient, thinks that three or four cups will do twice as much. It is however certain that there is nothing yet discovered which is a substitute to the English patient for his cup of tea. He can take it when he can take nothing else, and he often can't take anything else if he has it not. I should be very glad if any of the abusers of tea would point out what to give to an English patient after a sleepless night instead of tea. If you give it at five or six o'clock in the morning, he may even sometimes fall asleep after it and get perhaps his only two or three hours sleep during the twenty-four. At the same time you should never give tea or coffee to the sick as a rule after five o'clock in the afternoon. Sleeplessness in the early night is from excitement generally and is increased by tea or coffee. Sleeplessness which continues to the early morning is from exhaustion often and is relieved by tea. The only English patients I have ever known refuse tea have been typhus cases, and the first sign of their getting better was their craving again for tea. In general the dry and dirty tongue always prefers tea to coffee and will quite decline milk and less with tea. Coffee is a better restorative than tea, but a greater impera of the digestion. Let the patient's taste decide. You will say that in cases of great thirst the patient's craving decides that it will drink a great deal of tea and that you cannot help it. But in these cases be sure that the patient requires diluence for quite other purposes than quenching the thirst. He wants a great deal of some drink, not only of tea, and the doctor will order what he is to have, barley water or lemonade or soda water and milk as the case may be. Lemon, quoted by Dr. Christison, says that among the well and active the infusion of one ounce of roasted coffee daily will diminish the waste going on in the body by one-fourth. And Dr. Christison adds that tea has the same property. Now this is actual experiment. Lemon weighs the man and finds the fact from his weight it is not deduced from any analysis of food. All experience among the sick shows the same thing. Cocoa is often recommended to the sick in lieu of tea or coffee. But independently of the fact that English sick very generally dislike cocoa it has quite a different effect from tea or coffee. It is an oily, starchy nut having no restorative power at all but simply increasing fat. It is pure mockery of the sick therefore to call it a substitute for tea. For any renovating stimulus it has you might just as well offer them chestnuts instead of tea. An almost universal error among nurses is in the bulk of the food and especially the drinks they offer to their patients. Supposed the patient ordered four ounces of brandy during the day. How is he to take this if you make it into four pints with diluting it? The same with tea and beef tea, with arrowroot, milk, etc. You have not increased the nourishment. You have not increased the renovating power of these articles by increasing their bulk. You have very likely diminished both by giving the patient's digestion more to do. And most likely of all the patient will leave half of what he has been ordered to take because he cannot swallow the bulk with which you have been pleased to invest it. It requires very nice observation and care and meets with hardly any to determine what will not be too thick or strong for the patient to take while giving him no more than the bulk which he is able to swallow. 8. Bed and Bedding A few words upon bedsteads and bedding and principally as regards patients who are entirely or almost entirely confined to bed. Feverishness is generally supposed to be a symptom of fever. In nine cases out of ten it is a symptom of bedding. The patient has had reintroduced into the body the emanations from himself which day after day and week after week saturate his unaired bedding. How can it be otherwise? Look at the ordinary bed in which a patient lies. If I were looking out for an example in order to show what not to do, I should take the specimen of an ordinary bed in a private house, a wooden bedstead, two or even three mattresses piled up to above the height of a table, a valance attached to the frame, nothing but a miracle could ever thoroughly dry or air such a bed and bedding. The patient must inevitably alternate between cold damp after his bed is made and warm damp before, both saturated with organic matter, and this from the time the mattresses are put under him till the time they are picked to pieces, if this is ever done. If you consider that an adult in health exhales by the lungs and skin in the twenty-four hours, three pints at least of moisture, loaded with organic matter ready to enter putrefraction, that in sickness the quantity is often greatly increased, the quality is always more noxious, just ask yourself next, where does all this moisture go to? Chiefly into the bedding, because it cannot go anywhere else, and it stays there, because except perhaps a weekly change of sheets, scarcely any other airing is attempted. The nurse will be careful to fidgetiness about airing the clean sheets from clean damp, but airing the dirty sheets from noxious damp will never even occur to her. Besides this, the most dangerous effluvia we know of are from the excretia of the sick. These are placed, at least temporarily, where they must throw their effluvia into the underside of the bed, and the space under the bed is never aired, it cannot be with our arrangements. Just not such a bed be always saturated, and be always the means of reintroducing into the system of the unfortunate patient who lies in it that excrementitious matter to eliminate which from the body nature had expressly appointed the disease. My heart always sinks within me when I hear the good housewife of every class say, I assure you the bed has been well slept in, and I can only hope it is not true. Is the bed already saturated with somebody else's damp before my patient comes to exhale into it his own damp? Has it not had a single chance to be aired? No, not one. It has been slept in every night. The only way of really nursing a real patient is to have an iron bedstead with recline springs which are permeable by the air up to the very mattress, no valance, of course. The mattress to be a thin hair one, the bed to be not above three-and-a-half feet wide. If the patient be entirely confined to his bed, there should be two such bedsteads, each bed to be made with mattress sheets, blankets, etc., complete. The patient to pass twelve hours in each bed, on no account to carry his sheets with him. The whole of the bedding to be hung up to air for each intermediate twelve hours. Of course, there are many cases where this cannot be done at all. Many more where only an approach to it can be made. I am indicating the ideal of nursing and what I have actually had done, but about the kind of bedstead there can be no doubt whether there be one or two provided. There is a prejudice in favour of a wide bed. I believe it to be a prejudice. All the refreshment of moving a patient from one side to the other of his bed is far more effectually secured by putting him into a fresh bed, and a patient who is really very ill does not stray far in bed. But it is said there is no room to put down a tray on a narrow bed. No goodness will ever put a tray on a bed at all. If the patient can turn on his side he will eat more comfortably from a bedside table, and on no account whatever should a bed ever be higher than a sofa. Otherwise the patient feels himself out of humanity's reach. He can get at nothing for himself. He can move nothing for himself. If the patient cannot turn, a table over the bed is a better thing. I need hardly say that a patient's bed should never have its side against the wall. The nurse must be able to get easily to both sides of the bed and to reach easily every part of the patient without stretching—a thing impossible if the bed be either too wide or too high. When I see a patient in a room nine or ten feet high, upon a bed between four and five feet high, with his head, when he is sitting up in bed, actually within two or three feet of the ceiling, I ask myself, is this expressly planned to produce that peculiarly distressing feeling common to the sick, that is, as if the walls and ceiling were closing in upon them, and they becoming sandwiches between floor and ceiling, which imagination is not, indeed, here so far from the truth? If, over and above this, the window stops short of the ceiling, then the patient's head may literally be raised above the stratum of fresh air, even when the window is open. Can human perversity any farther go in unmaking the process of restoration which God has made? The fact is that the heads of sleepers or of sick should never be higher than the throat of the chimney, which ensures their being in the current of best air, and we will not suppose it possible that you have closed your chimney with a chimney-board. If a bed is higher than a sofa, the difference of the fatigue of getting in and out of bed will just make the difference, very often, to the patient, who can get in and out of bed at all, of being able to take a few minutes exercise, either in the open air or in another room. It is so very odd that people never think of this, or of how many more times a patient who is in bed for the twenty-four hours is obliged to get in and out of bed than they are, who only, it is to be hoped, get into bed once and out of bed once during the twenty-four hours. A patient's bed should always be in the lightest spot in the room, and he should be able to see out of window. I need scarcely say that the old four-posed bed with curtains is utterly inadmissible, whether for sick or well. Hospital bedsteads are, in many respects, very much less objectionable than private ones. There is reason to believe that not a few of the apparently unaccountable cases of scruffula among children proceed from the habit of sleeping with a head under the bedclothes, and so inhaling air already breathed, which is further contaminated by exhalations from the skin. Patients are sometimes given to a similar habit, and it often happens that the bedclothes are so disposed that the patient must necessarily breathe air more or less contaminated by exhalations from his skin. A good nurse will be careful to attend to this. It is an important part, so to speak, of ventilation. It may be worthwhile to remark that where there is any danger of bedsores, a blanket should never be placed under the patient. It retains stamp and acts like a paltice. Never use anything but light Whitney blankets as bed covering for the sick. The heavy cotton impervious counterpane is bad for the very reason that it keeps in the emanations from the sick person, while the blanket allows them to pass through. Weak patients are invariably distressed by a great weight of bedclothes, which often prevents their getting any sound sleep whatever. Note. One word about pillows. Every weak patient, be his illness what it may, suffers more or less from difficulty in breathing. To take the weight of the body off the poor chest, which is hardly up to its work as it is, ought therefore to be the object of the nurse in arranging his pillows. Now, what does she do and what are the consequences? She piles the pillows one atop the other, like a wall of bricks. The head is thrown upon the chest, and the shoulders are pushed forward, so as not to allow the lungs room to expand. The pillows, in fact, lean upon the patient, not the patient upon the pillows. It is impossible to give a rule for this, because it must vary with the figure of the patient. And tall patients suffer much more than short ones, because of the drag of the long limbs upon the waist. But the object is to support, with the pillows, the back below the breathing apparatus, to allow the shoulders room to fall back, and to support the head without throwing it forward. The suffering of dying patients is immensely increased by neglect of these points, and many an invalid, too weak to drag about his pillows himself, slips his book, or anything at hand, behind the lower part of his back to support it. End of Section 8. Section 9 of Notes on Nursing by Florence Nightingale. This LibriVox recording is in the public domain. Section 9. Light. It is the unqualified result of all my experience with the sick, that second only to their need of fresh air is their need of light. That, after a close room, what hurts the most is a dark room. And that it is not only light, but direct sunlight they want. I had rather have the power of carrying my patient about after the sun, according to the aspect of the rooms, if circumstances permit, than let him linger in a room when the sun is off. People think the effect is upon the spirits only. This is by no means the case. The sun is not only a painter, but a sculptor. You admit that he does the photograph. Without going into any scientific exposition, we must admit that light has quite as real and tangible effects upon the human body. But this is not all. Who has not observed the purifying effect of light, and especially of direct sunlight, upon the air of a room? Here is an observation within everybody's experience. Go into a room where the shutters are always shut. In a sick room or a bedroom there should never be shutters shut. And though the room be uninhabited, though the air has never been polluted by the breathing of human beings, you will observe a close, musty smell of corrupt air—of air, that is, unpurified by the effect of the sun's rays. The mustiness of dark rooms and corners indeed is proverbial. The cheerfulness of a room, the usefulness of light in treating disease, is all important. A very high authority in hospital construction has said that people do not enough consider the difference between wards and dormitories in planning their buildings. But I go farther and say that healthy people never remember the difference between bedrooms and sick rooms in making arrangements for the sick. To a sleeper in health it does not signify what the view is from his bed. He ought never to be in it, accepting when asleep and at night. Aspect does not very much signify either, provided the sun reach his bedroom at some time in every day to purify the air, because he ought never to be in his bedroom except during the hours when there is no sun. But the case is exactly reversed with the sick, even should they be as many hours out of their beds as you are in yours, which probably they are not. Therefore, that they should be able, without raising themselves or turning in bed, to see out of window from their beds, to see sky and sunlight at least, if you can show them nothing else, I assert to be, if not of the very first importance for recovery, at least something very near it. And you should therefore look to the position of the beds of your sick, one of the very first things. If they can see out of two windows instead of one, so much the better. Again, the morning sun and the midday sun, the hours when they are quite certain not to be up, are of more importance to them if a choice must be made than the afternoon sun. Perhaps you can take them out of bed in the afternoon and set them by the window where they can see the sun. But the best rule is, if possible, to give them direct sunlight from the moment he rises till the moment he sets. Another great difference between the bedroom and the sick room is that the sleeper has a very large balance of fresh air to begin with when he begins the night, if his room has been open all day as it ought to be. The sick man has not, because all day he has been breathing the air in the same room and dirtying it by the emanations from himself. Far more care is therefore necessary to keep up a constant change of air in the sick room. It is hardly necessary to add that there are acute cases, particularly a few ophthalmic cases and diseases where the eye is morbidly sensitive, where a subdued light is necessary. But a dark north room is inadmissible even for these. You can always moderate the light by blinds and curtains. Heavy, thick, dark window or bed curtains should, however, hardly ever be used for any kind of sick in this country. A light white curtain at the head of the bed is, in general, all that is necessary and a green blind to the window to be drawn down only when necessary. One of the greatest observers of human things, not physiological, says in another language, where there is sun there is thought. All physiology goes to confirm this. Where is the shady side of deep valleys there is christenism. Where are cellars and the unsung sides of narrow streets there is the degeneracy and weakliness of the human race, mind and body equally degenerating. Put the pale withering plant and human being into the sun and, if not too far gone, each will recover health and spirit. It is a curious thing to observe how almost all patients lie with their faces turned towards the light, exactly as plants always make their way towards the light. A patient will even complain that it gives him pain lying on that side. Then why do you lie on that side? He does not know, but we do. It is because it is the side towards the window. A fashionable physician has recently published in a government report that he always turns his patient's faces from the light. Yes, but nature is stronger than fashionable physicians, and depend upon it she turns the faces back and towards such light as she can get. Walk through the wards of a hospital. Remember the bed-sides of private patients you have seen, and count how many sick you ever saw lying with their faces towards the wall. End of Section Nine. Section Ten of Notes on Nursing by Florence Nightingale. This Libra Rocks recording is in the public domain. Section Ten. Cleanliness of Rooms and Walls. It cannot be necessary to tell a nurse that she should be clean, or that she should keep her patient clean, seeing that the greater part of nursing consists in preserving cleanliness. No ventilation can freshen a room or ward where the most scrupulous cleanliness is not observed. Unless the wind be blowing through the windows at the rate of twenty miles an hour, dusty carpets, dirty wainscots, musty curtains, and furniture will infallibly produce a close smell. I have lived in a large and expensively furnished London house where the only constant inmate in two very lofty rooms with opposite windows was myself, and yet, owing to the above mentioned dirty circumstances, no opening of windows could ever keep those rooms from closeness. But the carpets and curtains having been turned out of the rooms altogether, they became instantly as fresh as could be wished. It is pure nonsense to say that in London a room cannot be kept clean. Many of our hospitals show the exact reverse. But no particle of dust is ever or can ever be removed or really got rid of by the present system of dusting. Dusting in these days means nothing but flapping the dust from one part of a room onto another with doors and windows closed. What you do it for I cannot think. You had much better leave the dust alone if you were not going to take it away altogether. For, from the time a room begins to be a room, up to the time when it ceases to be one, no one atom of dust ever actually leaves its precincts. Tidying a room means nothing now but removing a thing from one place, which it has kept clean for itself, onto another and a dirtier one. Flapping by way of cleaning is only admissible in the case of pictures or anything made of paper. The only way I know to remove dust, the plague of all lovers of fresh air, is to wipe everything with a damp cloth. And all furniture ought to be so made as that it may be wiped with a damp cloth without injury to itself, and so polished as that it may be damped without injury to others. To dust, as it is now practised, truly means to distribute dust more equally over a room. As to floors, the only really clean floor I know is the Berlin Lackard floor, which is wet rubbed and dry rubbed every morning to remove the dust. The French parquet is always more or less dusty, although infinitely superior in point of cleanliness and healthiness to our absorbent floor. For a sick room, a carpet is perhaps the worst expedient which could by any possibility have been invented. If you must have a carpet, the only safety is to take it up two or three times a year instead of once. A dirty carpet literally infects the room. And if you consider the enormous quantity of organic matter from the feet of people coming in, which must saturate it, this is by no means surprising. As for walls, the worst is the papered wall. The next worst is plaster. But the plaster can be redeemed by frequent lime washing. The paper requires frequent renewing. A glazed paper gets rid of a good deal of the danger. But the ordinary bedroom paper is all that it ought not to be. The close connection between ventilation and cleanliness is shown in this. An ordinary light paper will last clean much longer if there is an Arnot's ventilator in the chimney than it otherwise would. The best wall now extant is oil paint. From this you can wash the animal exuviae. These are what make a room musty. The best wall for a sick room or ward that could be made is pure white, non-absorbent cement or glass or glazed tiles if they were made slightly enough. Air can be soiled just like water. If you blow into water you will soil it with the animal matter from your breath. So it is with air. Air is always soiled in a room where walls and carpets are saturated with animal exhalations. Want of cleanliness then, in rooms and wards, which you have to guard against, may arise in three ways. 1. Dirty air coming in from without, soiled by sewer emanations, the evaporation from dirty streets, smoke, bits of unburned fuel, bits of straw, bits of horse-dung. If people would but cover the outside walls of their houses with plain or encaustic tiles, what an incalculable improvement would there be in light, cleanliness, dryness, warmth, and consequently economy? The play of a fire engine would then effectually wash the outside of a house. This kind of walling would stand next to paving in improving the health of towns. 2. Dirty air coming from within, from dust, which you often displace but never remove, and this recalls what ought to be a sine qua non. Have as few ledges in your room or ward as possible, and under no pretense, 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 your furniture. And, if you never clean your furniture properly, how can your rooms or wards be anything but musty? Ventilate as you please, the rooms will never be sweet. Besides this, there is a constant degradation, as it is called, taking place from everything except polished or glazed articles. For example, in colouring certain green papers arsenic is used. Now, in the very dust even, which is lying about rooms hung with this kind of green paper, arsenic has been distinctly detected. You see your dust is anything but harmless, yet you will let such dust lie about your ledges for months, your rooms forever. Again the fire fills the room with cold dust. 3. Dirty air coming from the carpet. Above all, take care of the carpets that the animal dirt left there by the feet of visitors does not stay there. Floors, unless the grain is filled up and polished, are just as bad. The smell from the floor of a school room or ward, when any moisture brings out the organic matter by which it is saturated, might alone be enough to warn us of the mischief that is going on. The outer air, then, can only be kept clean by sanitary improvements and by consuming smoke. The expense in soap, which the single improvement would save, is quite incalculable. The inside air can only be kept clean by excessive care in the ways mentioned above, to rid the walls, carpets, furniture, ledges, etc., of the organic matter and dust. Dust consisting greatly of this organic matter, with which they become saturated and which is what really makes the room musty. Without cleanliness, you cannot have all the effect of ventilation. Without ventilation, you can have no thorough cleanliness. Very few people, be they of what class they may, have any idea of the exquisite cleanliness required in the sick room. For much of what I have said applies less to the hospital than to the private sick room. The smoky chimney, the dusty furniture, the utensils emptied but once a day, often keep the air of the sick constantly dirty in the best private houses. The well have a curious habit of forgetting that what is to them but a trifling inconvenience to be patiently put up with is to the sick a source of suffering, delaying recovery, if not actually hastening death. The well are scarcely ever more than eight hours at most in the same room. Some change they can always make if only for a few minutes. Even during the supposed eight hours they can change their posture or their position in the room. But the sick man, who never leaves his bed, who cannot change by any movement of his own, his air, or his light, or his warmth, who cannot obtain quiet or get out of the smoke, or the smell, or the dust, he is really poisoned or depressed by what is to you the merest trifle. What can't be cured must be endured is the very worst and most dangerous maxim for a nurse which ever was made. Patience and resignation in her are but other words for carelessness or indifference, contemptible if in regard to herself, culpable if in regard to her sick. All diseases, the function of the skin, is, more or less, disordered, and in many, most important diseases, nature relieves herself almost entirely by the skin. This is particularly the case with children. But the excretion which comes from the skin is left there, and less removed by washing or by the clothes. Every nurse should keep this fact constantly in mind, for, if she allow her sick to remain unwashed, or their clothing to remain on them after being saturated with perspiration or other excretion, she is interfering injuriously with the natural processes of health just as effectually as if she were to give the patient a dose of slow poison by the mouth. Poisoning by the skin is no less certain than poisoning by the mouth, only it is slower in its operation. The amount of relief and comfort experienced by sick, after the skin has been carefully washed and dried, is one of the commonest observations made at a sick bed. But it must not be forgotten that the comfort and relief so obtained are not all. They are, in fact, nothing more than a sign that the vital powers have been relieved by removing something that was oppressing them. The nurse, therefore, must never put off attending to the personal cleanliness of her patient under the plea that all that is to be gained is a little relief, which can be quite as well given later. In all well-regulated hospitals, this ought to be, and 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 maintaining free ventilation, so is it necessary to keep the pores of the skin free from all obstructing excretions. The object, both of ventilation and of skin cleanliness, is pretty much the same, to it removing noxious matter from the system as rapidly as possible. Care should be taken in all these operations of sponging, washing, and cleansing the skin, not to expose too great a surface at once, so as to check the perspiration, which would renew the evil in another form. The various ways of washing the sick need not here be specified, the less so as the doctors ought to say which is to be used. In several forms of diarrhea, dysentery, etc., where the skin is hard and harsh, the relief afforded by washing with a great deal of soft soap is incalculable. In other cases, sponging with tepid soap and water, then with tepid water, and drying with a hot towel will be ordered. Every nurse ought to be careful to wash her hands very frequently during the day, if her face too, so much the better. One word as to cleanliness, merely as cleanliness. Compare the dirtiness of the water in which you have washed, when it is cold without soap, cold with soap, hot with soap. You will find the first has hardly removed any dirt at all, the second a little more, the third a great deal more. But hold your hand over a cup of hot water for a minute or two, and then, by merely rubbing with the finger, you will bring off flakes of dirt or dirty skin. After a vapor bath, you may peel your whole self clean in this way. What I mean is, that by simply washing or sponging with water, you do not really clean your skin. Take a rough towel, dip one corner in very hot water. If a little spirit be added to it, it will be more effectual. And then rub as if you were rubbing the towel into your skin with your fingers. The black flakes which will come off, will convince you that you were not clean before, however much soap and water you have used. These flakes are what require removing. And you can really keep yourself cleaner with a tumbler of hot water and a rough towel and rubbing, than with a whole apparatus of bath and soap and sponge, without rubbing. It is quite nonsense to say that anybody need be dirty. Patients have been kept clean by these means on a long voyage, when a basin full of water could not be afforded, and when they could not be moved out of their births, as if all the appurtenances of home had been at hand. Washing, however, with a large quantity of water, has quite other effects than those of mere cleanliness. The skin absorbs the water, and becomes softer and more perspirable. To wash with soap and soft water is therefore desirable, from other points of view, than that of cleanliness. End of Section XI. Section XII of Notes on Nursing by Florence Nightingale. This Libra Rocks recording is in the public domain. Section XII. Chattering Hopes and Advices. The Sick Man to His Advisors. My Advisors, the name is Legion. Somehow or other it seems a provision of the universal destinies that every man, woman and child should consider him, her or its self, privileged especially to advise me. Why? That is precisely what I want to know. And this is what I have to say to them. I have been advised to go to every place extant in and out of England, to take every kind of exercise by every kind of cart, carriage, yes and even swing, and dumbbell in existence. To imbibe every different kind of stimulus that ever has been invented. And this, when those best fitted to know, that is, medical men, after long and close attendance, had declared any journey out of the question, had prohibited any kind of motion whatever, had closely laid down the diet and drink. What would my Advisors say were they the medical attendants, and I the patient left their advice and took the casual Advisors? But the singularity in Legion's mind is this. It never occurs to him that everybody else is doing the same thing, and that I the patient must, per force say, in sheer defence like Rosalind, I could not do with all. Chattering hopes may seem an odd heading. But I really believe there is scarcely a greater worry, which invalids have to endure than the incurable hopes of their friends. There is no one practice against which I can speak more strongly from actual personal experience, wide and long, of its effects during sickness, observed both upon others and upon myself. I would appeal most seriously to all friends, visitors, and attendants of the sick, to leave off this practice of attempting to cheer the sick by making light of their danger, and by exaggerating their probabilities of recovery. Far more now than formerly does the medical attendant tell the truth to the sick, who are really desirous to hear it about their own 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 cursory observation, will weigh with the patient against the opinion of the medical attendant, given perhaps after years of observation, after using every help to diagnosis afforded by the stethoscope, the examination of pulse, tongue, etc., and certainly after much more observation than the friend can possibly have had. Supposing the patient to be possessed of common sense, how can their favourable opinion, if it is to be called an opinion at all, of the casual visitor cheer him, when different from that of the experienced attendant? Unquestionably the latter may, and often does, turn out to be wrong, but which is most likely to be wrong. The fact is that the patient is not cheered at all by these well-meaning, most tiresome friends. On the contrary, he is depressed and wearied. If, on the one hand, he exerts himself to tell each successive member of this too-numerous conspiracy, whose name is Legion, why he does not think as they do, in what respect he is worse, what symptoms exist that they know nothing of, he is fatigued instead of cheered, and his attention is fixed upon himself. In general, patients who are really ill do not want to talk about themselves. Hypercondriacs do, but again I say we are not on the subject of hypercondriacs. If, on the other hand, and which is much more frequently the case, the patient says nothing, but the Shakespearean, oh, ah, go to, and in good soothe, in order to escape from the conversation about himself the sooner, he is depressed by want of sympathy. He feels isolated in the midst of friends. He feels what convenience it would be if there were any single person to whom he could speak simply and openly without pulling the string upon himself of this shower-bath of silly hopes and encouragements, to whom he could express his wishes and directions without that person persisting in saying, I hope that it will please God yet to give you twenty years, or you have a long life of activity before you. How often we see at the end of biographies, or of cases recorded in medical papers, after a long illness, A died rather suddenly, or unexpectedly both to himself and to others. Unexpectedly to others, perhaps, who did not see because they did not look, but by no means unexpectedly to himself, as I feel entitled to believe, both from the internal evidence in such stories and from watching similar cases. There was every reason to expect that A would die, and he knew it, but he found it useless to insist upon his own knowledge to his friends. In these remarks I am alluding neither to acute cases which terminate rapidly, nor to nervous cases. By the first much interest in their own danger is very rarely felt. In writings of fiction, whether novels or biographies, these deathbeds are generally depicted as almost seraphic in lucidity of intelligence. Sadly, large has been my experience in deathbeds, and I can only say that I have seldom or never seen such. Indifference, accepting with regard to bodily suffering, or to some duty the dying man desires to perform, is the far more usual state. The nervous case, on the other hand, delights in figuring to himself and others a fictitious danger. But the long, chronic case, who knows too well himself, and who has been told by his physician that he will never enter active life again, who feels that every month he has to give up something he could do the month before. Oh, spare such sufferers your chattering hopes. You do not know how you worry and worry them. Such real sufferers cannot bear to talk of themselves, still lest a hope for what they cannot at all expect. So also, as to all the advice showered so profusely upon such sick, to leave off some occupation, to try some other doctor, some other house, climate, pill, powder, or specific. I say nothing of the inconsistency, for these advisors are sure to be the same persons who exhorted the sick person not to believe his own doctor's prognostics, because doctors are always mistaken, but to believe some other doctor because this doctor is always right. Sure also are these advisors to be the persons to bring the sick man fresh occupation, while exhorting him to leave his own. Wonderful is the face with which friends, lay, and medical, will come in and worry the patient with recommendations to do something or other, having just as little knowledge as to its being feasible, or even safe for him, as if they were to recommend a man to take exercise, not knowing he had broken his leg. What would the friend say if he were the medical attendant, and if the patient, because some other friend had come in, because somebody, anybody, nobody, had recommended something, anything, nothing, would disregard his orders, and take that other body's recommendations? But people never think of this. A celebrated historical personage has related to the common places which, when on the eve of executing a remarkable resolution, were showered in nearly the same words by every one around successively for a period of six months. To these, the personage states that it was found least trouble always to reply the same thing, that is, that it could not be supposed that such a resolution had been taken without sufficient previous consideration, to patients enduring every day for years from every friend or acquaintance, either by letter or viva voce, some torment of this kind, I would suggest the same answer. It would indeed be spared if such friends and acquaintances would but consider for one moment that it is probable that the patient has heard such advice at least fifty times before, and that, had it been practicable, it would have been practised long ago. But of such consideration there appears to be no chance. Strange, though true, the people should be just the same in these things as they were a few hundred years ago. To me, these common places, leaving their smear upon the cheerful, single-hearted, constant devotion to duty, which is so often seen in a decline of such sufferers, recall the slimy trail left by the snail, on the sunny southern garden wall, loaded with fruit. No mockery in the world is so hollow as the advice showered upon the sick. It is of no use for the sick to say anything, for what the advisor wants is not to know the truth about the state of the patient, but to turn whatever the sick may say to the support of his own argument. Set forth it must be repeated without any inquiry whatever into the patient's real condition. But it would be impertinent or indecent in me to make such an inquiry, says the advisor. True. And how much more impertinent is it to give your advice when you can know nothing about the truth and admit you could not inquire into it? To nurses, I say, these are the visitors who do your patient harm. When you hear him told, one, that he has nothing the matter with him and that he wants cheering, two, that he is committing suicide and that he wants preventing, three, that he is the tool of somebody who makes use of him for a purpose, four, that he will listen to nobody but is obstinately bent upon his own way, and five, that he ought to be called to the sense of duty and is flying in the face of providence, then know that your patient is receiving all the injury that he can receive from a visitor. How little the real sufferings of illness are known or understood. How little does anyone in good health fancy him or even herself into the life of a sick person. Do you who are about the sick or who visit the sick try and give them some pleasure. Remember to tell them what will do so. How often in such visits the sick person has to do the whole conversation, exerting his own imagination and memory, while you would take the visitor absorbed in his own anxieties, making no effort of memory or imagination for the sick person. Oh, my dear, I have so much to think of, I really quite forgot to tell him that. Besides, I thought he would know it, says the visitor to another friend. How could he know it? Depend upon it, the people who say this are really those who have little to think of. There are many burdened with business who always manage to keep a pigeon-hole in their minds, full of things to tell the invalid. I do not say, don't tell him your anxieties. I believe it is good for him and good for you, too. But if you tell him what is anxious, surely you can remember to tell him what is pleasant, too. A sick person does so enjoy hearing good news, for instance, of a love and courtship, while in progress to a good ending. If you tell him only when the marriage takes place, he loses half the pleasure, which God knows he has little enough of, and tend to one, but you have told him of some love-making with a bad ending. A sick person also intensely enjoys hearing of any material good, any positive or practical success of the right. He has so much of books and fiction, of principles and precepts and theories. Do, instead of advising him with advice he has heard at least fifty times before, tell him of one benevolent act which has really succeeded practically. It is like a day's health to him. You have no idea what the craving of sick with undiminished power of thinking, but little power of doing, is to hear of good practical action when they can no longer partake in it. Do observe these things with a sick. Do remember how their life is to them disappointed and incomplete. You can see them lying there with miserable disappointments, from which they can have no escape but death, and you can't remember to tell them of what would give them so much pleasure, or at least an hour's variety. They don't want you to be lacrimose and whining with them. They like you to be fresh and active and interested, but they cannot bear absence of mind, and they are so tired of the advice and preaching they receive from everybody, no matter who 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 bad for the baby, why it is bad for the invalid too, and therefore of course you will correct it for both. It freshens up a sick person's whole mental atmosphere to see the baby, and for a young child, if unspoiled, will generally adapt itself wonderfully to the ways of a sick person, if the time they spend together is not too long. If you knew how unreasonably sick people suffer from reasonable causes of distress, you would take more pains about all these things. An infant laid upon the sick bed will do the sick person, thus suffering, more good than all your logic. A piece of good news will do the same. Perhaps you are afraid of disturbing him. You say there is no comfort for his present cause of affliction. It is perfectly reasonable. The distinction is this. If he is obliged to act, do not disturb him with another subject of thought just yet. Help him to do what he wants to do. But, if he has done this, or nothing can be done, then disturb him by all means. You will relieve, more effectively, unreasonable suffering from reasonable causes, by telling him the news, showing him the baby, or giving him something new to think of, or to look at, than by all the logic in the world. It has been very justly said that the sick are like children in this, that there is no proportion in events to them. Now it is your business as their visitor to restore this right proportion for them, to show them what the rest of the world is doing. How can they find it out otherwise? You will find them far more open to conviction than children in this. And you will find that their unreasonable intensity of suffering from unkindness, from want of sympathy, etc., will disappear with their freshened interest in the big world's events. But then you must be able to give them real interests, not gossip. Note. There are two classes of patients which are unfortunately becoming more common every day, especially among women of the richer orders, to whom all these remarks are preeminently inapplicable. One, those who make health an excuse for doing nothing, and, at the same time, allege that the being able to do nothing is their only grief. Two, those who have bought upon themselves ill health by over pursuit of amusement, which they and their friends have most unhappily called intellectual activity. I scarcely know a greater injury that can be inflicted than the advice too often given to the first class to vegetate, or the admiration too often bestowed on the latter class for pluck. End of Section 12. Section 13 of Notes on Nursing by Florence Nightingale. This Libra Rock's recording is in the public domain. Section 13. Observation of the Sick. There is no more silly or universal question scarcely asked than this. Is he better? Ask it of the medical attendant, if you please. But of whom else, if you wish for a real answer to your question, would you ask it? Certainly not of the casual visitor, certainly not of the nurse, while the nurse's observation is so little exercised as it is now. What you want are facts, not opinions, for who can have any opinion of any value as to whether the patient is better or worse, accepting the constant medical attendant, or the really observing nurse. The most important practical lesson that can be given to nurses is to teach them what to observe, how to observe, what symptoms indicate improvement, what the reverse, which are of importance, which are of none, which are the evidence of neglect, and of what kind of neglect. All this is what ought to make part, and an essential part, of the training of every nurse. At present how few there are, either professional or unprofessional, who really know at all whether any sick person they may be with is better or worse. The vagueness and looseness of the information one receives in answer to that much abused question, is he better? Would be ludicrous if it were not painful. The only sensible answer, in the present state of knowledge about sickness, would be, how can I know? I cannot tell how he was when I was not with him. I can record but a very few specimens of the answers which I have heard made by friends and nurses, and accepted by physicians and surgeons at the very bedside of the patient, who could have contradicted every word, but did not, sometimes from amiability, often from shyness, oftenest from langer. How often have the bowels acted, nurse? Once, sir. This generally means that the utensil has been emptied once, it having been used perhaps seven or eight times. Do you think the patient is much weaker than he was six weeks ago? Oh, no, sir, you know it is very long since he has been up and dressed, and he can get across the room now. This means that the nurse has not observed that whereas six weeks ago he sat up and occupied himself in bed, he now lies still doing nothing, that although he can get across the room, he cannot stand for five seconds. Another patient, who is eating well, recovering steadily, although slowly from fever, but cannot walk or stand, is represented to the doctor as making no progress at all. Questions too, as asked now, but too generally, of or about patients, would obtain no information at all about them, even if the person asked of had every information to give. The question is generally a leading question, and it is singular that people never think what must be the answer to this question before they ask it. For instance, has he had a good night? Now, one patient will think he has a bad night if he has not slept ten hours without waking. Another does not think he has a bad night if he has had intervals of dosing regularly. The same answer has actually been given as regarded to patients, one who had been entirely sleepless for five times twenty-four hours and died of it, and another who had not slept the sleep of a regular night without waking. Why cannot the question be asked, how many hours sleep has had, and at what hours of the night? I have never closed my eyes all night, an answer as frequently made when the speaker has had several hours sleep as when he has had none would then be less often said. Lies, intentional and unintentional, a much seldomer told in answer to precise than leading questions. Another frequent error is to inquire whether one cause remains, and not whether the effect which may be produced by a great many different causes not inquired after remains, as when it is asked whether there was noise in the street last night, and if there were not the patient is reported, without more ado, to have had a good night. Patients are completely taken aback by these kinds of leading questions, and give only the exact amount of information asked for even when they know it to be completely misleading. The shyness of patients is seldom allowed for. How few there are, who by five or six pointed questions can elicit the whole case, and get accurately to know and to be able to report where the patient is. I knew a very clever physician of large dispensary and hospital practice, who invariably began his examination of each patient with, put your finger where you be bad. That man would never waste his time with collecting inaccurate information from nurse or patient. Leading questions always collect inaccurate information. At a recent celebrated trial, the following leading question was put successively to nine distinguished medical men. Can you attribute these symptoms to anything else but poison? And out of the nine, eight answered, No, without any qualification whatever. It appeared upon cross-examination, one, that none of them had ever seen a case of the kind of poisoning supposed, two, that none of them had ever seen a case of the kind of disease to which the death, if not to poison, was attributable, three, that none of them were even aware of the main fact of the disease and condition to which the death was attributable. Surely nothing stronger can be adduced to prove what use leading questions are of and what they lead to. I had rather not say how many instances I have known where, owing to the system of leading questions, the patient has died, and the attendants have been actually unaware of the principal feature of the case. It is useless to go through all the particulars, besides sleep, in which people have a peculiar talent for gleaning inaccurate information. As to food, for instance, I often think that most common question, how is your appetite, can only be put because the questioner believes the question really has nothing to matter with him, which is very often the case. But when there is, the remark holds good which has been made about sleep. The same answer will often be made as regards a patient who cannot take two ounces of solid food per diem, and a patient who does not enjoy five meals a day as much as usual. Again, the question, how is your appetite, is often put when how is your digestion, is the question meant. No doubt the two things depend on one another, but they are quite different. Many a patient can eat if you can only tempt his appetite. The fault lies in your not having got him the thing that he fancies. But many another patient does not care between grapes and turnips. Everything is equally distasteful to him. He would try to eat anything which would do him good, but everything makes him worse. The fault here generally lies in the cooking. It is not his appetite which requires tempting. It is his digestion which requires sparing. Good sick cookery will save the digestion half its work. There may be four different causes, any one of which will produce the same result, that is, the patient slowly starving to death from want of nutrition. One, defect in cooking. Two, defect in choice of diet. Three, defect in choice of hours for taking diet. Four, defect of appetite in patient. Yet all these are generally comprehended in the one sweeping assertion that the patient has no appetite. Surely many lives might be saved by drawing a closer distinction, for the remedies are as diverse as the causes. The remedy for the first is to cook better, for the second to choose other articles of diet, for the third to watch for the hours when the patient is in want of food, for the fourth to show him what he likes and sometimes unexpectedly. But no one of these remedies will do for any of the other defects not corresponding with it. I cannot too often repeat that patients are generally either too languid to observe these things or too shy to speak about them, nor is it well that they should be made to observe them it fixes their attention upon themselves. Again I say what is the nurse or friend therefore except to take notice of these things instead of the patient doing so. Again the question is sometimes put, is there diarrhea? And the answer will be the same whether it is just merging into cholera, whether it is a trifling degree brought on by some trifling indiscretion which will cease the moment the cause is removed, or whether there is no diarrhea at all but simply relaxed bowels. It is useless to multiply instances of this kind. As long as observation is so little cultivated as it is now, I do believe that it is better for the physician not to see the friends of the patient at all, they will often mislead him than not and as often by making the patient out worse as better than he really is. In the case of infants everything must depend on the accurate observation of the nurse or mother who has to report, and how seldom is this condition of accuracy fulfilled. A celebrated man, though celebrated only for foolish things, has told us that one of his main objects in the education of his son was to give him a ready habit of accurate observation, a certainty of perception, and that for this purpose one of his means was a month's course as follows. He took the boy rapidly past a toy-shop. The father and son then described to each other as many of the objects as they could which they had seen in passing the windows, noting them down with pencil and paper, and returning afterwards to verify their own accuracy. The boy always succeeded best, e.g. if the father described thirty objects, the boy did forty, and scarcely ever made a mistake. I have often thought how wise a piece of education this would be for much higher objects, and in our calling of nurses the thing itself is essential, for it may safely be said not that the habit of ready and correct observation will by itself make us useful nurses, but that without it we shall be useless with all our devotion. I have known a nurse in charge of a set of wards who not only carried in her head all the little varieties in the diets which each patient was allowed to fix for himself, but also exactly what each patient had taken during each day. I have known another nurse in charge of one single patient who took away his meals day after day or but untouched, and never knew it. If you find it helps you to note down such things on a piece of paper in pencil, by all means do so. I think it more often lames than strengthens the memory and observation, but if you cannot get the habit of observation one way or another, 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 ounce of solid food is, how much an ounce of liquid. You will find this helps your observation and memory very much, you will then say to yourself, A took about an ounce of his meat to-day, B took three times in twenty-four hours about a quarter of a pint of beef tea, instead of saying, B has taken nothing all day, or I gave A his dinner as usual. I have known several of our real old-fashioned hospital sisters, who could, as accurately as a measuring-glass, measure out all their patient's wine and medicine by the eye, and never be wrong. I do not recommend this, one must be very sure of oneself to do it. I only mention it because if a nurse can by practice measure medicine by the eye, surely she is no nurse who cannot measure by the eye about how much food in ounces her patient has taken. In hospitals, those who cut up the diets give with quite sufficient accuracy to each patient his twelve ounces or his six ounces of meat without weighing. Yet a nurse will often have patients loathing all food and incapable of any will to get well, who just tumble over the contents of the plate or dip the spoon in the cup to deceive the nurse, and she will take it away without ever seeing that there is just the same quantity of food as when she brought it, and she will tell the doctor, too, that the patient has eaten all his diets as usual, when all she ought to have meant is that she has taken away his diets as usual. Now what kind of nurse is this? I would call attention to something else in which nurses frequently fail in observation. There is a well-marked distinction between the excitable and what I will call the accumulative temperament in patients. One will blaze up at once under any shock or anxiety and sleep very comfortably after it. Another will seem quite calm and even torpid under the same shock, and people say he hardly felt it at all, yet you will find him some time after slowly sinking. The same remark applies to the action of narcotics, of aperions, which in the one take effect directly, in the other not perhaps for twenty-four hours. A journey, a visit, an unwanted exertion, will effect the one immediately, but he recovers after it. The other bears it very well at the time, apparently, and dies or is prostrated for life by it. People often say how difficult the excitable temperament is to manage. I say, how difficult is the accumulative temperament? With the first you have an outbreak which you could anticipate, and it is all over. With the second you never know where you are, you never know when the consequences are over, and it requires your closest observation to know what are the consequences of what, for the consequent by no means follows immediately upon the antecedent, and course observation is utterly at fault. Almost all superstitions are owing to bad observation, to the post-hoc ergo-proptahoc, and bad observers are almost all superstitious. Farmers used to attribute disease among cattle to witchcraft. Weddings have been attributed to seeing one magpie, deaths to seeing three, and I have heard the most highly educated nowadays draw consequences for the sick, closely resembling these. Another remark. Although there is unquestionably a physiognomy of disease, as well as of health, of all parts of the body, the face is perhaps the one which tells the least to the common observer or the casual visitor. Because, of all parts of the body, it is the one most exposed to other influences besides health. And people never, or scarcely ever, observe enough to know how to distinguish between the effect of exposure, of robust health, of a tender skin, of a tendency to congestion, of suffusion, flushing, or many other things. Again, the face is often the last to show emaciation. I should say that the hand was a much sureer test than the face, both as to flesh, colour, circulation, etc., etc. It is true that there are some diseases which are only betrayed at all by something in the face, for example, the eye or the tongue, as great irritability of brain by the appearance of the pupil of the eye. But we are talking of casual, not minute observation, and few minute observers will hesitate to say that far more untruth than truth is conveyed by the oft-repeated words, he looks well, or ill, or better, or worse. Wonderful is the way in which people will go upon the slightest observation, or often upon no observation at all, or upon some sore which the world's experience, if it had any, would have pronounced utterly false long ago. I have known patients dying of sheer pain, exhaustion, and want of sleep, for one of the most lingering and painful diseases known, preserve till within a few days of death, not only the healthy colour of the cheek, but the muddled appearance of a robust child. And scores of times have I heard these unfortunate creatures assailed with, I am glad to see you looking so well. I see no reason why you should not live till ninety years of age. Why don't you take a little more exercise and amusement? With all the other common places with which we are so familiar. There is, unquestionably, a physiognomy of disease. Let the nurse learn it. The experienced nurse can always tell that a person has taken a narcotic the night before by the patchiness of the colour about the face, when the reaction of depression has set in, that very colour which the inexperienced will point to as a proof of health. There is again a faintness which does not betray itself by the colour at all, or in which the patient becomes brown instead of white. There is a faintness of another kind which it is true can always be seen by the paleness. But the nurse seldom distinguishes. She will talk to the patient who is too faint to move without the least scruple, unless he is pale, and unless, luckily for him, the muscles of the throat are affected and he loses his voice. Yet these two faintnesses are perfectly distinguishable by the mere countenance of the patient. Again the nurse must distinguish between the idiosyncrasies of patients. One likes to suffer out all his suffering alone, to be as little looked after as possible. Another likes to be perpetually made much of and pitied and to have someone always by him. Both these peculiarities might be observed and indulged much more than they are. For quite as often does it happen that a busy attendance is forced upon the first patient, who wishes for nothing but to be let alone, as that the second is left to think himself neglected. Again I think that few things press so heavily on one's suffering from long and incurable illness, as the necessity of recording in words, from time to time, for the information of the nurse, who will not otherwise see, that he cannot do this or that, which he could do a month or a year ago. What is a nurse there for if she cannot observe these things for herself? Yet I have known, and known to among those, and chiefly among those, who money and position put in possession of everything which money and position could give. I have known, I say, more accidents, fatal, slowly, or rapidly, arising from this want of observation among nurses than from almost anything else. Because a patient could get out of a warm bath alone a month ago, because a patient could walk as far as his bell a week ago, the nurse concludes that he can do so now. She has never observed the change, and the patient is lost from being left in a helpless state of exhaustion, till someone accidentally comes in. And this not from any unexpected apoplectic, paralytic, or fainting fit, though even these could be expected far more, at least than they are now, if we did but observe. No, from the expected, or to be expected, inevitable, visible, calculable, uninterrupted increase of weakness, which none need fail to observe. Again, a patient not usually confined to bed is compelled by an attack of diarrhea, vomiting, or other accident, to keep his bed for a few days. He gets up for the first time, and the nurse lets him go into another room, without coming in a few minutes afterwards, to look after him. It never occurs to her that he is quite certain to be faint, or cold, or to want something. She says, as her excuse, oh, he does not like to be fidgeted after. Yes, he said so some weeks ago, but he never said he did not like to be fidgeted after, when he is in the state he is in now, and if he did, you ought to make some excuse to go into him. More patients have been lost in this way than is at all generally known. That is, from relapses brought on by being left for an hour or two, faint, or cold, or hungry, after getting up for the first time. Yet it appears that scarcely any improvement in the faculty of observing is being made. Vast has been the increase of knowledge in pathology, that science which teaches us the final change produced by disease on the human frame, scarce any in the art of observing the science of the change while in progress. Or rather, is it not to be feared that observation as an essential part of medicine has been declining? Which of us has not heard fifty times, from one or another, a nurse, or a friend of the sick, I and a medical friend, too, the following remark? So A is worse, or B is dead, I saw him the day before, I thought him so much better, there certainly was no change from which one could have expected so sudden a change. I have never heard any one say, though one would think it the more natural thing. There must have been some appearance which I should have seen if I had but looked. Let me try and remember what there was, that I may observe another time. No, this is not what people say. They boldly assert that there was nothing to observe, not that their observation was at fault. Let people who have to observe sickness and death look back and try to register in their observation the appearances which have preceded relapse, attack, or death, and not assert that there were none, or that there were not the right ones. A want of the habit of observing conditions, and an inveterate habit of taking averages, are each of them often equally misleading. Men whose profession, like that of medical men, leads them to observe only, or chiefly, palpable, and permanent organic changes, are just as often wrong in their opinion of the result as those who do not observe at all. For instance, there is a broken leg. The surgeon has only to look at it once to know. It will not be different if he sees it in the morning to what it would have been had he seen it in the evening. And in whatever conditions the patient is, or is likely to be, there will still be the broken leg until it is set. The same with many organic diseases. An experienced physician has but to feel the pulse once, and he knows that there is aneurysm which will kill some time or other. But with the great majority of cases there is nothing of the kind, and the power of forming any correct opinion as to the result must entirely depend upon an inquiry into all the conditions in which the patient lives. In a complicated state of society in large towns, death, as every one of great experience knows, is far less often produced by any one organic disease than by some illness, after many other diseases, producing just the sum of exhaustion necessary for death. There is nothing so absurd, nothing so misleading, as the verdict one so often hears. So and so has no organic disease. There is no reason why he should not live to extreme old age. Sometimes the clause is added, sometimes not. Provided he has quiet, good food, good air, etc, etc, etc. The verdict is repeated by ignorant people without the latter clause, or there is no possibility of the conditions of the latter clause being obtained, and this, the only essential part of the whole, is made of no effect. I have heard a physician, deservedly eminent, assure the friends of a patient of his recovery. Why? Because he had now prescribed a course every detail of which the patient had followed for years, and because he had forbidden a course which the patient could not by any possibility alter. Undoubtedly a person of no scientific knowledge whatever, but of observation and experience in these kinds of conditions, will be able to arrive at a much truer guess as to the probable duration of life of members of a family or inmates of a house, than the most scientific physician to whom the same persons are brought to have their pulse felt, no inquiry being made into their conditions. In life insurance, and such like societies, why they instead of having the persons examined by a medical man, to have the houses, conditions, ways of life of these persons examined, at how much truer results would they arrive? W. Smith appears a fine hail-man, but it might be known that the next cholera epidemic he runs a bad chance. Mr. and Mrs. J. are a strong healthy couple, but it might be known that they live in such a house, in such a part of London, so near the river, that they will kill four fifths of their children. Which of the children will be the ones to survive might also be known? Averages again seduce us away from minute observation. Average mortalities merely tell that so many percent die in this town, and so many in that, per annum. But whether A or B will be among these, the average rate, of course, does not tell. We know, say, that from twenty-two to twenty-four per thousand will die in London next year. But minute inquiries into conditions enable us to know that in such a district, may in such a street, or even on one side of that street, in such a particular house, or even on one floor of that particular house, will be the excess of mortality, that is, the person will die who ought not to have died before old age. Now, would it not very materially alter the opinion of whoever was endeavouring to form one, if he knew that from that floor, of that house, of that street, the man came? Much more precise might be our observations even than this, and much more correct our conclusions. It is well known that the same names may be seen constantly recurring on work-house books for generations—that is, the persons were born and brought up, and will be born and brought up, generation after generation, in the conditions which make paupers. Death and disease are like the work-house, they take from the same family the same house, or in other words the same conditions. Why will we not observe what they are? The close observer may safely predict that such a family, whether its members marry or not, will become extinct, that such another will degenerate morally and physically. But who learns the lesson? On the contrary, it may be well known that the children die in such a house at the rate of eight out of ten. One would think that nothing more need be said, for how could Providence speak more distinctly? Yet nobody listens. The family goes on living there till it dies out, and then some other family takes it. Neither would they listen if one rose from the dead. In dwelling upon the vital importance of sound observation, it must never be lost sight of what observation is for. It is not for the sake of piling up miscellaneous information or curious facts, but for the sake of saving life and increasing health and comfort. The caution may seem useless, but it is quite surprising how many men—some women do it too—practically behave as if the scientific end were the only one in view, or as if the sick body were but a reservoir for stowing medicines into, and the surgical disease, only a curious case the sufferer has made for the attendant's special information. This is really no exaggeration. You think, if you suspected your patient was being poisoned, say by a copper kettle, you would instantly, as you ought, cut off all possible connection between him and the suspected source of the injury, without regard to the fact that a curious mind of observation is therefore lost. But it is not everybody who does so, and it has actually been made a question of medical ethics. What should the medical man do if he suspected poisoning? The answer seems a very simple one—insist upon a confidential nurse being placed with a patient, or give up the case. And remember, every nurse should be one who is to be depended upon, in other words, capable of being a confidential nurse. She does not know how soon she may find herself placed in such a situation. She must be no gossip, no vain talker. She should never answer questions about her sick, except those who have a right to ask them. She must, I need not say, be strictly sober and honest. But more than this, she must be a religious and devoted woman. She must have a respect for her own calling, because God's precious gift of life is often literally placed in her hands. She must be a sound and close and quick observer, and she must be a woman of delicate and decent feeling. To return to the question of what observation is for, it would really seem as if some had considered it as its own end, as if detection, not cure, was their business. No more, in a recent celebrated trial, three medical men, according to their own account, suspected poison, prescribed for dysentery, and left the patient to the poisoner. This is an extreme case. But, in a small way, the same manner of acting falls under the cognizance of us all. How often the attendants of a case have stated that they knew perfectly well that the patient could not get well in such an air, in such a room, or under such circumstances, yet have gone on dosing him with medicine, and making no effort to remove the poison from him, or him from the poison which they knew was killing him. Nay, more, have sometimes not so much as mentioned their conviction in the right quarter, that is, to the only person who could act in the matter. End of Section 13. The whole of the preceding remarks apply even more to children and to puerperal women than to patients in general. They also apply to the nursing of surgical, quite as much as to that of medical cases. Indeed, if it be possible, cases of external injury require such care even more than sick. In surgical wards, one duty of every nurse certainly is prevention. Fever, or hospital gangrene, or paemia, or purulent discharge of some kind, supervene. Has she a case of compound fracture, of amputation, or of chrysepolis? It may depend very much on how she looks upon the things enumerated in these notes, whether one or other of these hospital diseases attacks her patient or not. If she allows her ward to become filled with a peculiar close-fetted smell so apt to be produced among surgical cases, especially where there is great supuration and discharge, she may see a vigorous patient in the prime of life gradually sink and die, where, according to all human probability, he ought to have recovered. The surgical nurse must ever be on the watch, ever on her guard, against want of cleanliness, foul air, want of light, and of warmth. Nevertheless, let no one think that because sanitary nursing is the subject of these notes, therefore what may be called the handicraft of nursing is to be undervalued. A patient may be left to bleed to death in a sanitary palace. Another who cannot move himself may die of bed-sores, because the nurse does not know how to change and clean him, while he has every requisite of air, light, and quiet. But nursing, as a handicraft, has not been treated of here for three reasons. One, that these notes do not pretend to be a manual for nursing any more than for cooking for the sick. Two, that the writer, who has herself seen more of what may be called surgical nursing, that is, practical manual nursing, than perhaps any one in Europe, honestly believes that it is impossible to learn it from any book, and that it can only be thoroughly learnt in the wards of a hospital, and she also honestly believes that the perfection of surgical nursing may be seen practised by the old-fashioned sister of a London hospital, as it can be seen nowhere else in Europe. Three, while thousands die of foul air, etc., who have this surgical nursing to perfection, the converse is comparatively rare. To revert to children, they are much more susceptible than grown people to all noxious influences. They are affected by the same things, but much more quickly and seriously, that is, by want of fresh air, of proper warmth, want of cleanliness in house, clothes, bedding, or body, by startling noises, improper food, or want of punctuality, by dullness, and by want of light, by too much or too little covering in bed, or when up, by want of the spirit of management generally in those in charge of them. One can therefore only press the importance, as being yet greater in the case of children, greatest in the case of sick children, of attending to these things. That which, however, above all is known to injure children seriously, is foul air, and most seriously at night. Keeping the rooms where they sleep tight shut up is destruction to them. And, if the child's breathing be disordered by disease, a few hours only of such foul air may endanger its life, even when no inconvenience is felt by grown-up persons in the same room. The following passages, taken out of an excellent lecture on sudden death in infancy and childhood, just published, show the vital importance of careful nursing of children. In the great majority of instances, when death suddenly befalls the infant or young child, it is an accident. It is not a necessary, inevitable result of any disease from which it is suffering. It may be here added that it would be very desirable to know how often death is, with adults, not a necessary inevitable result of any disease. Amidst the word sudden, for sudden death is comparatively rare in middle age, and the sentence is almost equally true for all ages. The following causes of accidental death in sick children are enumerated. Sudden noises which startle, a rapid change of temperature which chills the surface, though only for a moment, a rude awakening from sleep, or even an over-hasty or an over-full meal, any sudden impression on the nervous system, any hasty alteration of posture, in short, any cause whatever by which the respiratory process may be disturbed. It may again be added that with very weak adult patients these causes are also—not often suddenly fatal, it is true—but very much oftener than is at all generally known, irreparable in their consequences, both for children and for adults, both for sick and for well, although more certainly in the case of sick children than in any others. I would here again repeat the most frequent and most fatal cause of all is sleeping even for a few hours, much more for weeks and months, in foul air—a condition which, more than any other condition, disturbs the respiratory process and tends to produce accidental death in disease. I need hardly here repeat the warning against any confusion of ideas between cold and fresh air. You may chill a patient fatally without giving him fresh air at all, and you can quite well, and a much better, give him fresh air without chilling him. This is the test of a good nurse. In cases of long recurring faintnesses from disease, for instance, especially disease which affects the organs of breathing, fresh air to the lungs, warmth to the surface, and often, as soon as the patient can swallow, hot drink—these are the right remedies, and the only 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 leaving the body cold, or perhaps throwing a greater weight of clothes upon it, when already it is generating too little heat. Breathing carefully, anxiously, as though respiration was a function which required all the attention for its performance, is cited as a not unusual state in children, and as one calling for care in all the things enumerated above. That breathing becomes an almost voluntary act, even in grown-up patients who are very weak, must often have been remarked. Disease having interfered with the perfect accomplishment of the respiratory function, some sudden demand for its complete exercise, issues in the sudden standstill of the whole machinery, is given as one process. Life goes out, for want of nervous power to keep the vital functions in activity, is given as another, by which accidental death is most often brought to pass in infancy. Also in middle age, both these processes may be seen ending in death, although generally not suddenly. And I have seen, even in middle age, the sudden standstill here mentioned, and from the same causes, to sum up. The answer to two of the commonest objections urged, one by women themselves, the other by men, against the desirableness of sanitary knowledge for women, plus a caution, comprises the whole argument for the art of nursing. One. It is often said by men that it is unwise to teach women anything about these laws of health, because they will take to Physicking, that there is a great deal too much of amateur Physicking as it is, which is indeed true. One eminent physician told me that he had known more Calomel given, both at a pinch and for a continuance, by mothers, governesses and nurses, to children, than he had ever heard of a physician prescribing in all his experience. Another says that women's only idea in medicine is Calomel and Appareance. This is undeniably too often the case. There is nothing ever seen in any professional practice, like the reckless Physicking by amateur females. But this is just what the really experienced and observing nurse does not do. She neither physics herself nor others. And to cultivate in things pertaining to health observation and experience in women who are mothers, governesses or nurses, is just the way to do away with amateur Physicking. And if the doctors did but know it, to make the nurses obedient to them helps to them instead of hindrances. Such education in women would indeed diminish the doctor's work. But no one really believes that doctors wish that there should be more illnesses in order to have more work. Two. It is often said by women that they cannot know anything of the laws of health or what to do to preserve their children's health, because they can know nothing of pathology or cannot dissect. A confusion of ideas which it is hard to attempt to disentangle. Pathology teaches the harm that disease has done, but it teaches nothing more. We know nothing of the principle of health, the positive of which pathology is the negative, except from observation and experience. And nothing but observation and experience will teach us the ways to maintain or to bring back the state of health. It is often thought that medicine is the curative process. It is no such thing. Medicine is the surgery 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 is an obstruction to cure, but nature heals the wound. So it is with medicine. The function of an organ becomes obstructed. Medicine, so far as we know, assists nature to remove the obstruction, but does nothing more. And what nursing has to do in either case is to put the patient in the best condition for nature to act upon him. Generally, just the contrary is done. You think fresh air and quiet and cleanliness extravagant, perhaps dangerous luxuries, which should be given to the patient only when quite convenient, and medicine, the sine qua no, the panacea. If I have succeeded in any measure in dispelling this illusion, and in showing what true nursing is and what it is not, my object will have been answered. Now for the caution. Three. It seems a commonly received idea among men and even among women themselves, that it requires nothing but a disappointment in love, the want of an object, a general disgust or incapacity for other things, to turn a woman into a good nurse. This reminds one of the parish where a stupid old man was set to be schoolmaster because he was past keeping the pigs. Apply the above receipt for making a good nurse to making a good servant, and the receipt will be found to fail. Yet popular novelists of recent days have invented ladies disappointed in love or fresh out of the drawing-room, turning into the war hospitals to find their wounded lovers, and when found, forthwith abandoning their sick ward for their lover, as might be expected. Yet in the estimation of the authors, these ladies were none the worse for that, but on the contrary were heroines of nursing. What cruel mistakes are sometimes made by benevolent men and women in matters of business about which they can know nothing and think they know a great deal. The everyday management of a large ward, let alone of a hospital, the knowing what are the laws of life and death for men, and what the laws of health for wards, and wards are healthy or unhealthy, mainly according to the knowledge or ignorance of the nurse, are not these matters of sufficient importance and difficulty to require learning by experience and careful inquiry, just as much as any other art? They do not come by inspiration to the lady disappointed in love, nor to the poor work-house drudge hard up for a livelihood. And terrible is the injury which has followed to the sick from such wild notions. In this respect, and why is it so? In Roman Catholic countries, both writers and workers are, in theory at least, far before ours. They would never think of such a beginning for a good working superior or sister of charity, and many a superior has refused to admit a postulant who appeared to have no better vocation or reasons for offering herself than these. It is true we make no vows. But is a vow necessary to convince us that the true spirit for learning any art, most especially an art of charity, a right, is not a disgust to everything or something else? Do we really place the love of our kind, and of nursing as one branch of it, so low as this? What would the Mayor Angelique of Port Royal, what would our own Mrs. Fry have said to this? Note. I would earnestly ask my sisters to keep clear of both the jargons now current everywhere, for they are equally jargons, of the jargon namely about the rights of women, which urges women to do all that men do, including the medical and other professions, merely because men do it, and 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 of their duty as women, and because this is women's work and that is men's, and these are things which women should not do, which is all assertion and nothing more. Surely women should bring the best she has, whatever that is, to the work of God's world, without attending to either of these cries. For what are they, both of them, the one that just as much as the other, but listening to the, what will people say, to opinion, to the voices from without? And as a wise man has said, no one has ever done anything great or useful by listening to the voices from without. You do not want the effect of your good things to be how wonderful for a woman, nor would you be deterred from good things by hearing it said, yes, but she ought not to have done this because it is not suitable for a woman. But you want to do the thing that is good, whether it is suitable for a woman or not. It does not make a thing good that it is remarkable that a woman should have been able to do it. Neither does it make a thing bad which would have been good had a man done it, that it has been done by a woman. Oh, leave these jargons and go your way straight