,,notes ,,on ,,nursing3 ,,what ,,it ,,is1 ,,and ,,what ,,it ,,is ,,not4 ,,by ,,florence ,,nightingale4 ,,new ,,york3 ,d4 ,,appleton ,,and ,,company #gb ,,fifth ,,avenue #ahih4 ,,preface4 ,the following notes are by no means intended as a rule of thought by which nurses can teach themselves to nurse1 still less as a manual to teach nurses to nurse4 ,they are meant simply to give hints for thought to women who have personal charge of the health of others4 ,every woman1 or at least almost every woman1 in ,england has1 at one time or another of her life1 charge of the personal health of somebody1 whether child or invalid1--in other words1 every woman is a nurse4 ,every day sanitary knowledge1 or the knowledge of nursing1 or in other words1 of how to put the constitution in such a state as that it will have no disease1 or that it can recover from disease1 takes a higher place4 ,it is recognized as the knowledge which every one ought to have--distinct from medical knowledge1 which only a profession can have4 ,if1 then1 every woman must at some time or other of her life1 become a nurse1 i4e41 have charge of somebody's health1 how immense and how valuable would be the produce of her united experience if every woman would think how to nurse4 ,i do not pretend to teach her how1 ,i ask her to teach herself1 and for this purpose ,i venture to give her some hints4 ,,table ,,of ,,contents4 ,,ventilation ,,and ,,warming ,,health ,,of ,,houses ,,petty ,,management ,,noise ,,variety ,,taking ,,food ,,what ,,food8 ,,bed ,,and ,,bedding ,,light ,,cleanliness ,,of ,,rooms ,,and ,,walls ,,personal ,,cleanliness ,,chattering ,,hopes ,,and ,,advices ,,observation ,,of ,,the ,,sick ,,conclusion ,,appendix ,,notes ,,on ,,nursing3 ,,what ,,it ,,is1 ,,and ,,what ,,it ,,is ,,not4 99 99 99 99 99 ,sidenote3 ,disease a reparative process4 ,shall we begin by taking it as a general principle--that all disease1 at some period or other of its course1 is more or less a reparative process1 not necessarily accompanied with suffering3 an effort of nature to remedy a process of poisoning or of decay1 which has taken place weeks1 months1 sometimes years beforehand1 unnoticed1 the termination of the disease being then1 while the antecedent process was going on1 determined8 ,if we accept this as a general principle1 we shall be immediately met with anecdotes and instances to prove the contrary4 ,just so if we were to take1 as a principle--all the climates of the earth are meant to be made habitable for man1 by the efforts of man--the objection would be immediately raised1--,will the top of ,mount ,blanc ever be made habitable8 ,our answer would be1 it will be many thousands of years before we have reached the bottom of ,mount ,blanc in making the earth healthy4 ,wait till we have reached the bottom before we discuss the top4 ,sidenote3 ,of the sufferings of disease1 disease not always the cause4 ,in watching diseases1 both in private houses and in public hospitals1 the thing which strikes the experienced observer most forcibly is this1 that the symptoms or the sufferings generally considered to be inevitable and incident to the disease are very often not symptoms of the disease at all1 but of something quite different--of the want of fresh air1 or of light1 or of warmth1 or of quiet1 or of cleanliness1 or of punctuality and care in the administration of diet1 of each or of all of these4 ,and this quite as much in private as in hospital nursing4 ,the reparative process which ,nature has instituted and which we call disease1 has been hindered by some want of knowledge or attention1 in one or in all of these things1 and pain1 suffering1 or interruption of the whole process sets in4 ,if a patient is cold1 if a patient is feverish1 if a patient is faint1 if he is sick after taking food1 if he has a bed-sore1 it is generally the fault not of the disease1 but of the nursing4 ,sidenote3 ,what nursing ought to do4 ,i use the word nursing for want of a better4 ,it has been limited to signify little more than the administration of medicines and the application of poultices4 ,it ought to signify the proper use of fresh air1 light1 warmth1 cleanliness1 quiet1 and the proper selection and administration of diet--all at the least expense of vital power to the patient4 ,sidenote3 ,nursing the sick little understood4 ,it has been said and written scores of times1 that every woman makes a good nurse4 ,i believe1 on the contrary1 that the very elements of nursing are all but unknown4 ,by this ,i do not mean that the nurse is always to blame4 ,bad sanitary1 bad architectural1 and bad administrative arrangements often make it impossible to nurse4 ,but the art of nursing ought to include such arrangements as alone make what ,i understand by nursing1 possible4 ,the art of nursing1 as now practised1 seems to be expressly constituted to unmake what ,god had made disease to be1 viz41 a reparative process4 ,sidenote3 ,nursing ought to assist the reparative process4 ,to recur to the first objection4 ,if we are asked1 ,is such or such a disease a reparative process8 ,can such an illness be unaccompanied with suffering8 ,will any care prevent such a patient from suffering this or that8--,i humbly say1 ,i do not know4 ,but when you have done away with all that pain and suffering1 which in patients are the symptoms not of their disease1 but of the absence of one or all of the above-mentioned essentials to the success of ,nature's reparative processes1 we shall then know what are the symptoms of and the sufferings inseparable from the disease4 ,another and the commonest exclamation which will be instantly made is-- ,would you do nothing1 then1 in cholera1 fever1 c48--so deep-rooted and universal is the conviction that to give medicine is to be doing something1 or rather everything2 to give air1 warmth1 cleanliness1 c41 is to do nothing4 ,the reply is1 that in these and many other similar diseases the exact value of particular remedies and modes of treatment is by no means ascertained1 while there is universal experience as to the extreme importance of careful nursing in determining the issue of the disease4 ,sidenote3 ,nursing the well4 ,,ii4 ,the very elements of what constitutes good nursing are as little understood for the well as for the sick4 ,the same laws of health or of nursing1 for they are in reality the same1 obtain among the well as among the sick4 ,the breaking of them produces only a less violent consequence among the former than among the latter1--and this sometimes1 not always4 ,it is constantly objected1--,but how can ,i obtain this medical knowledge8 ,i am not a doctor4 ,i must leave this to doctors4 ,sidenote3 ,little understood4 ,oh1 mothers of families6 ,you who say this1 do you know that one in every seven infants in this civilized land of ,england perishes before it is one year old8 ,that1 in ,london1 two in every five die before they are five years old8 ,and1 in the other great cities of ,england1 nearly one out of two8#a ,the life duration of tender babies 7as some ,saturn1 turned analytical chemist1 says7 is the most delicate test of sanitary conditions4 ,is all this premature suffering and death necessary8 ,or did ,nature intend mothers to be always accompanied by doctors8 ,or is it better to learn the piano-forte than to learn the laws which subserve the preservation of offspring8 ,macaulay somewhere says1 that it is extraordinary that1 whereas the laws of the motions of the heavenly bodies1 far removed as they are from us1 are perfectly well understood1 the laws of the human mind1 which are under our observation all day and every day1 are no better understood than they were two thousand years ago4 ,but how much more extraordinary is it that1 whereas what we might call the coxcombries of education--e4g41 the elements of astronomy--are now taught to every school-girl1 neither mothers of families of any class1 nor school-mistresses of any class1 nor nurses of children1 nor nurses of hospitals1 are taught anything about those laws which ,god has assigned to the relations of our bodies with the world in which ,he has put them4 ,in other words1 the laws which make these bodies1 into which ,he has put our minds1 healthy or unhealthy organs of those minds1 are all but unlearnt4 ,not but that these laws--the laws of life--are in a certain measure understood1 but not even mothers think it worth their while to study them--to study how to give their children healthy existences4 ,they call it medical or physiological knowledge1 fit only for doctors4 ,another objection4 ,we are constantly told1--,but the circumstances which govern our children's healths are beyond our control4 ,what can we do with winds8 ,there is the east wind4 ,most people can tell before they get up in the morning whether the wind is in the east4 ,to this one can answer with more certainty than to the former objections4 ,who is it who knows when the wind is in the east8 ,not the ,highland drover1 certainly1 exposed to the east wind1 but the young lady who is worn out with the want of exposure to fresh air1 to sunlight1 c4 ,put the latter under as good sanitary circumstances as the former1 and she too will not know when the wind is in the east4 ,,footnotes3 #a ,sidenote3 ,curious deductions from an excessive death rate4 ,upon this fact the most wonderful deductions have been strung4 ,for a long time an announcement something like the following has been going the round of the papers3--,more than #be1jjj children die every year in ,london under #aj years of age2 therefore we want a ,children's ,hospital4 ,this spring there was a prospectus issued1 and divers other means taken to this effect3--,there is a great want of sanitary knowledge in women2 therefore we want a ,women's ,hospital4 ,now1 both the above facts are too sadly true4 ,but what is the deduction8 ,the causes of the enormous child mortality are perfectly well known2 they are chiefly want of cleanliness1 want of ventilation1 want of whitewashing2 in one word1 defective household hygiene4 ,the remedies are just as well known2 and among them is certainly not the establishment of a ,child's ,hospital4 ,this may be a want2 just as there may be a want of hospital room for adults4 ,but the ,registrar-,general would certainly never think of giving us as a cause for the high rate of child mortality in 7say7 ,liverpool that there was not sufficient hospital room for children2 nor would he urge upon us1 as a remedy1 to found an hospital for them4 ,again1 women1 and the best women1 are wofully deficient in sanitary knowledge2 although it is to women that we must look1 first and last1 for its application1 as far as household hygiene is concerned4 ,but who would ever think of citing the institution of a ,women's ,hospital as the way to cure this want8 ,we have it1 indeed1 upon very high authority that there is some fear lest hospitals1 as they have been hitherto1 may not have generally increased1 rather than diminished1 the rate of mortality--especially of child mortality4 ,i4 ,,ventilation ,,and ,,warming4 ,sidenote3 ,first rule of nursing1 to keep the air within as pure as the air without4 ,the very first canon of nursing1 the first and the last thing upon which a nurse's attention must be fixed1 the first essential to a patient1 without which all the rest you can do for him is as nothing1 with which ,i had almost said you may leave all the rest alone1 is this3 ,,to ,,keep ,,the ,,air ,,he ,,breathes ,,as ,,pure ,,as ,,the ,,external ,,air1 ,,without ,,chilling ,,him4 ,yet what is so little attended1 to8 ,even where it is thought of at all1 the most extraordinary misconceptions reign about it4 ,even in admitting air into the patient's room or ward1 few people ever think1 where that air comes from4 ,it may come from a corridor into which other wards are ventilated1 from a hall1 always unaired1 always full of the fumes of gas1 dinner1 of various kinds of mustiness2 from an underground kitchen1 sink1 washhouse1 water-closet1 or even1 as ,i myself have had sorrowful experience1 from open sewers loaded with filth2 and with this the patient's room or ward is aired1 as it is called--poisoned1 it should rather be said4 ,always1 air from the air without1 and that1 too1 through those windows1 through which the air comes freshest4 ,from a closed court1 especially if the wind do not blow that way1 air may come as stagnant as any from a hall or corridor4 ,again1 a thing ,i have often seen both in private houses and institutions4 ,a room remains uninhabited2 the fireplace is carefully fastened up with a board2 the windows are never opened2 probably the shutters are kept always shut2 perhaps some kind of stores are kept in the room2 no breath of fresh air can by possibility enter into that room1 nor any ray of sun4 ,the air is as stagnant1 musty1 and corrupt as it can by possibility be made4 ,it is quite ripe to breed small-pox1 scarlet-fever1 diphtheria1 or anything else you please4#a ,yet the nursery1 ward1 or sick room adjoining will positively be aired 787 by having the door opened into that room4 ,or children will be put into that room1 without previous preparation1 to sleep4 ,a short time ago a man walked into a back-kitchen in ,queen square1 and cut the throat of a poor consumptive creature1 sitting by the fire4 ,the murderer did not deny the act1 but simply said1 ,it's all right4 ,of course he was mad4 ,but in our case1 the extraordinary thing is that the victim says1 ,it's all right1 and that we are not mad4 ,yet1 although we nose the murderers1 in the musty unaired unsunned room1 the scarlet fever which is behind the door1 or the fever and hospital gangrene which are stalking among the crowded beds of a hospital ward1 we say1 ,it's all right4 ,sidenote3 ,without chill4 ,with a proper supply of windows1 and a proper supply of fuel in open fire places1 fresh air is comparatively easy to secure when your patient or patients are in bed4 ,never be afraid of open windows then4 ,people don't catch cold in bed4 ,this is a popular fallacy4 ,with proper bed-clothes and hot bottles1 if necessary1 you can always keep a patient warm in bed1 and well ventilate him at the same time4 ,but a careless nurse1 be her rank and education what it may1 will stop up every cranny and keep a hot-house heat when her patient is in bed1-- and1 if he is able to get up1 leave him comparatively unprotected4 ,the time when people take cold 7and there are many ways of taking cold1 besides a cold in the nose17 is when they first get up after the two-fold exhaustion of dressing and of having had the skin relaxed by many hours1 perhaps days1 in bed1 and thereby rendered more incapable of re-action4 ,then the same temperature which refreshes the patient in bed may destroy the patient just risen4 ,and common sense will point out1 that1 while purity of air is essential1 a temperature must be secured which shall not chill the patient4 ,otherwise the best that can be expected will be a feverish re-action4 ,to have the air within as pure as the air without1 it is not necessary1 as often appears to be thought1 to make it as cold4 ,in the afternoon again1 without care1 the patient whose vital powers have then risen often finds the room as close and oppressive as he found it cold in the morning4 ,yet the nurse will be terrified1 if a window is opened4#b ,sidenote3 ,open windows4 ,i know an intelligent humane house surgeon who makes a practice of keeping the ward windows open4 ,the physicians and surgeons invariably close them while going their rounds2 and the house surgeon very properly as invariably opens them whenever the doctors have turned their backs4 ,in a little book on nursing1 published a short time ago1 we are told1 that1 with proper care it is very seldom that the windows cannot be opened for a few minutes twice in the day to admit fresh air from without4 ,i should think not2 nor twice in the hour either4 ,it only shows how little the subject has been considered4 ,sidenote3 ,what kind of warmth desirable4 ,of all methods of keeping patients warm the very worst certainly is to depend for heat on the breath and bodies of the sick4 ,i have known a medical officer keep his ward windows hermetically closed4 ,thus exposing the sick to all the dangers of an infected atmosphere1 because he was afraid that1 by admitting fresh air1 the temperature of the ward would be too much lowered4 ,this is a destructive fallacy4 ,to attempt to keep a ward warm at the expense of making the sick repeatedly breathe their own hot1 humid1 putrescing atmosphere is a certain way to delay recovery or to destroy life4 ,sidenote3 ,bedrooms almost universally foul4 ,do you ever go into the bed-rooms of any persons of any class1 whether they contain one1 two1 or twenty people1 whether they hold sick or well1 at night1 or before the windows are opened in the morning1 and ever find the air anything but unwholesomely close and foul8 ,and why should it be so8 ,and of how much importance it is that it should not be so8 ,during sleep1 the human body1 even when in health1 is far more injured by the influence of foul air than when awake4 ,why can't you keep the air all night1 then1 as pure as the air without in the rooms you sleep in8 ,but for this1 you must have sufficient outlet for the impure air you make yourselves to go out2 sufficient inlet for the pure air from without to come in4 ,you must have open chimneys1 open windows1 or ventilators2 no close curtains round your beds2 no shutters or curtains to your windows1 none of the contrivances by which you undermine your own health or destroy the chances of recovery of your sick4#c ,sidenote3 ,when warmth must be most carefully looked to4 ,a careful nurse will keep a constant watch over her sick1 especially weak1 protracted1 and collapsed cases1 to guard against the effects of the loss of vital heat by the patient himself4 ,in certain diseased states much less heat is produced than in health2 and there is a constant tendency to the decline and ultimate extinction of the vital powers by the call made upon them to sustain the heat of the body4 ,cases where this occurs should be watched with the greatest care from hour to hour1 ,i had almost said from minute to minute4 ,the feet and legs should be examined by the hand from time to time1 and whenever a tendency to chilling is discovered1 hot bottles1 hot bricks1 or warm flannels1 with some warm drink1 should be made use of until the temperature is restored4 ,the fire should be1 if necessary1 replenished4 ,patients are frequently lost in the latter stages of disease from want of attention to such simple precautions4 ,the nurse may be trusting to the patient's diet1 or to his medicine1 or to the occasional dose of stimulant which she is directed to give him1 while the patient is all the while sinking from want of a little external warmth4 ,such cases happen at all times1 even during the height of summer4 ,this fatal chill is most apt to occur towards early morning at the period of the lowest temperature of the twenty-four hours1 and at the time when the effect of the preceding day's diets is exhausted4 ,generally speaking1 you may expect that weak patients will suffer cold much more in the morning than in the evening4 ,the vital powers are much lower4 ,if they are feverish at night1 with burning hands and feet1 they are almost sure to be chilly and shivering in the morning4 ,but nurses are very fond of heating the foot-warmer at night1 and of neglecting it in the morning1 when they are busy4 ,i should reverse the matter4 ,all these things require common sense and care4 ,yet perhaps in no one single thing is so little common sense shown1 in all ranks1 as in nursing4#d ,sidenote3 ,cold air not ventilation1 nor fresh air a method of chill4 ,the extraordinary confusion between cold and ventilation1 even in the minds of well educated people1 illustrates this4 ,to make a room cold is by no means necessarily to ventilate it4 ,nor is it at all necessary1 in order to ventilate a room1 to chill it4 ,yet1 if a nurse finds a room close1 she will let out the fire1 thereby making it closer1 or she will open the door into a cold room1 without a fire1 or an open window in it1 by way of improving the ventilation4 ,the safest atmosphere of all for a patient is a good fire and an open window1 excepting in extremes of temperature4 7,yet no nurse can ever be made to understand this47 ,to ventilate a small room without draughts of course requires more care than to ventilate a large one4 ,sidenote3 ,night air4 ,another extraordinary fallacy is the dread of night air4 ,what air can we breathe at night but night air8 ,the choice is between pure night air from without and foul night air from within4 ,most people prefer the latter4 ,an unaccountable choice4 ,what will they say if it is proved to be true that fully one-half of all the disease we suffer from is occasioned by people sleeping with their windows shut8 ,an open window most nights in the year can never hurt any one4 ,this is not to say that light is not necessary for recovery4 ,in great cities1 night air is often the best and purest air to be had in the twenty-four hours4 ,i could better understand in towns shutting the windows during the day than during the night1 for the sake of the sick4 ,the absence of smoke1 the quiet1 all tend to making night the best time for airing the patients4 ,one of our highest medical authorities on ,consumption and ,climate has told me that the air in ,london is never so good as after ten o'clock at night4 ,sidenote3 ,air from the outside4 ,open your windows1 shut your doors4 ,always air your room1 then1 from the outside air1 if possible4 ,windows are made to open2 doors are made to shut--a truth which seems extremely difficult of apprehension4 ,i have seen a careful nurse airing her patient's room through the door1 near to which were two gaslights1 7each of which consumes as much air as eleven men17 a kitchen1 a corridor1 the composition of the atmosphere in which consisted of gas1 paint1 foul air1 never changed1 full of effluvia1 including a current of sewer air from an ill-placed sink1 ascending in a continual stream by a well-staircase1 and discharging themselves constantly into the patient's room4 ,the window of the said room1 if opened1 was all that was desirable to air it4 ,every room must be aired from without--every passage from without4 ,but the fewer passages there are in a hospital the better4 ,sidenote3 ,smoke4 ,if we are to preserve the air within as pure as the air without1 it is needless to say that the chimney must not smoke4 ,almost all smoky chimneys can be cured--from the bottom1 not from the top4 ,often it is only necessary to have an inlet for air to supply the fire1 which is feeding itself1 for want of this1 from its own chimney4 ,on the other hand1 almost all chimneys can be made to smoke by a careless nurse1 who lets the fire get low and then overwhelms it with coal2 not1 as we verily believe1 in order to spare herself trouble1 7for very rare is unkindness to the sick71 but from not thinking what she is about4 ,sidenote3 ,airing damp things in a patient's room4 ,in laying down the principle that this first object of the nurse must be to keep the air breathed by her patient as pure as the air without1 it must not be forgotten that everything in the room which can give off effluvia1 besides the patient1 evaporates itself into his air4 ,and it follows that there ought to be nothing in the room1 excepting him1 which can give off effluvia or moisture4 ,out of all damp towels1 c41 which become dry in the room1 the damp1 of course1 goes into the patient's air4 ,yet this of course seems as little thought of1 as if it were an obsolete fiction4 ,how very seldom you see a nurse who acknowledges by her practice that nothing at all ought to be aired in the patient's room1 that nothing at all ought to be cooked at the patient's fire6 ,indeed the arrangements often make this rule impossible to observe4 ,if the nurse be a very careful one1 she will1 when the patient leaves his bed1 but not his room1 open the sheets wide1 and throw the bed-clothes back1 in order to air his bed4 ,and she will spread the wet towels or flannels carefully out upon a horse1 in order to dry them4 ,now either these bed-clothes and towels are not dried and aired1 or they dry and air themselves into the patient's air4 ,and whether the damp and effluvia do him most harm in his air or in his bed1 ,i leave to you to determine1 for ,i cannot4 ,sidenote3 ,effluvia from excreta4 ,even in health people cannot repeatedly breathe air in which they live with impunity1 on account of its becoming charged with unwholesome matter from the lungs and skin4 ,in disease where everything given off from the body is highly noxious and dangerous1 not only must there be plenty of ventilation to carry off the effluvia1 but everything which the patient passes must be instantly removed away1 as being more noxious than even the emanations from the sick4 ,of the fatal effects of the effluvia from the excreta it would seem unnecessary to speak1 were they not so constantly neglected4 ,concealing the utensils behind the vallance to the bed seems all the precaution which is thought necessary for safety in private nursing4 ,did you but think for one moment of the atmosphere under that bed1 the saturation of the under side of the mattress with the warm evaporations1 you would be startled and frightened too6 ,sidenote3 ,chamber utensils without lids4 ,the use of any chamber utensil without a lid#e should be utterly abolished1 whether among sick or well4 ,you can easily convince yourself of the necessity of this absolute rule1 by taking one with a lid1 and examining the under side of that lid4 ,it will be found always covered1 whenever the utensil is not empty1 by condensed offensive moisture4 ,where does that go1 when there is no lid8 ,earthenware1 or if there is any wood1 highly polished and varnished wood1 are the only materials fit for patients' utensils4 ,the very lid of the old abominable close-stool is enough to breed a pestilence4 ,it becomes saturated with offensive matter1 which scouring is only wanted to bring out4 ,i prefer an earthenware lid as being always cleaner4 ,but there are various good new-fashioned arrangements4 ,sidenote3 ,abolish slop-pails4 ,a slop pail should never be brought into a sick room4 ,it should be a rule invariable1 rather more important in the private house than elsewhere1 that the utensil should be carried directly to the water-closet1 emptied there1 rinsed there1 and brought back4 ,there should always be water and a cock in every water-closet for rinsing4 ,but even if there is not1 you must carry water there to rinse with4 ,i have actually seen1 in the private sick room1 the utensils emptied into the foot-pan1 and put back unrinsed under the bed4 ,i can hardly say which is most abominable1 whether to do this or to rinse the utensil in the sick room4 ,in the best hospitals it is now a rule that no slop-pail shall ever be brought into the wards1 but that the utensils1 shall be carried direct to be emptied and rinsed at the proper place4 ,i would it were so in the private house4 ,sidenote3 ,fumigations4 ,let no one ever depend upon fumigations1 disinfectants1 and the like1 for purifying the air4 ,the offensive thing1 not its smell1 must be removed4 ,a celebrated medical lecturer began one day1 ,fumigations1 gentlemen1 are of essential importance4 ,they make such an abominable smell that they compel you to open the window4 ,i wish all the disinfecting fluids invented made such an abominable smell that they forced you to admit fresh air4 ,that would be a useful invention4 ,,footnotes3 #a ,sidenote3 ,why are uninhabited rooms shut up8 ,the common idea as to uninhabited rooms is1 that they may safely be left with doors1 windows1 shutters1 and chimney-board1 all closed-- hermetically sealed if possible--to keep out the dust1 it is said2 and that no harm will happen if the room is but opened a short hour before the inmates are put in4 ,i have often been asked the question for uninhabited rooms4--,but when ought the windows to be opened8 ,the answer is--,when ought they to be shut8 #b ,it is very desirable that the windows in a sick room should be such that the patient shall1 if he can move about1 be able to open and shut them easily himself4 ,in fact1 the sick room is very seldom kept aired if this is not the case--so very few people have any perception of what is a healthy atmosphere for the sick4 ,the sick man often says1 ,this room where ,i spend #bb hours out of the #bd1 is fresher than the other where ,i only spend #b4 ,because here ,i can manage the windows myself4 ,and it is true4 #c ,sidenote3 ,an air-test of essential consequence4 ,dr4 ,angus ,smith's air test1 if it could be made of simpler application1 would be invaluable to use in every sleeping and sick room4 ,just as without the use of a thermometer no nurse should ever put a patient into a bath1 so should no nurse1 or mother1 or superintendent1 be without the air test in any ward1 nursery1 or sleeping-room4 ,if the main function of a nurse is to maintain the air within the room as fresh as the air without1 without lowering the temperature1 then she should always be provided with a thermometer which indicates the temperature1 with an air test which indicates the organic matter of the air4 ,but to be used1 the latter must be made as simple a little instrument as the former1 and both should be self-registering4 ,the senses of nurses and mothers become so dulled to foul air1 that they are perfectly unconscious of what an atmosphere they have let their children1 patients1 or charges1 sleep in4 ,but if the tell-tale air test were to exhibit in the morning1 both to nurses and patients1 and to the superior officer going round1 what the atmosphere has been during the night1 ,i question if any greater security could be afforded against a recurrence of the misdemeanor4 ,and oh1 the crowded national school6 where so many children's epidemics have their origin1 what a tale its air-test would tell6 ,we should have parents saying1 and saying rightly1 ,i will not send my child to that school1 the air-test stands at ',horrid4' ,and the dormitories of our great boarding schools6 ,scarlet fever would be no more ascribed to contagion1 but to its right cause1 the air-test standing at ,foul4 ,we should hear no longer of ,mysterious ,dispensations1 and of ,plague and ,pestilence1 being in ,god's hands1 when1 so far as we know1 ,he has put them into our own4 ,the little air-test would both betray the cause of these mysterious pestilences1 and call upon us to remedy it4 #d ,with private sick1 ,i think1 but certainly with hospital sick1 the nurse should never be satisfied as to the freshness of their atmosphere1 unless she can feel the air gently moving over her face1 when still4 ,but it is often observed that the nurses who make the greatest outcry against open windows1 are those who take the least pains to prevent dangerous draughts4 ,the door of the patients' room or ward must sometimes stand open to allow of persons passing in and out1 or heavy things being carried in and out4 ,the careful nurse will keep the door shut while she shuts the windows1 and then1 and not before1 set the door open1 so that a patient may not be left sitting up in bed1 perhaps in a profuse perspiration1 directly in the draught between the open door and window4 ,neither1 of course1 should a patient1 while being washed1 or in any way exposed1 remain in the draught of an open window or door4 #e ,sidenote3 ,don't make your sick room into a sewer4 ,but never1 never should the possession of this indispensable lid confirm you in the abominable practice of letting the chamber utensil remain in a patient's room unemptied1 except once in the #bd hours1 i4e41 when the bed is made4 ,yes1 impossible as it may appear1 ,i have known the best and most attentive nurses guilty of this2 aye1 and have known1 too1 a patient afflicted with severe diarrhoea for ten days1 and the nurse 7a very good one7 not know of it1 because the chamber utensil 7one with a lid7 was emptied only once in #bd hours1 and that by the housemaid who came in and made the patient's bed every evening4 ,as well might you have a sewer under the room1 or think that in a water-closet the plug need be pulled up but once a day4 ,also take care that your lid1 as well as your utensil1 be always thoroughly rinsed4 ,if a nurse declines to do these kinds of things for her patient1 because it is not her business1 ,i should say that nursing was not her calling4 ,i have seen surgical sisters1 women whose hands were worth to them two or three guineas a-week1 down upon their knees scouring a room or hut1 because they thought it otherwise not fit for their patients to go into4 ,i am far from wishing nurses to scour4 ,it is a waste of power4 ,but ,i do say that these women had the true nurse-calling--the good of their sick first1 and second only the consideration what it was their place to do--and that women who wait for the housemaid to do this1 or for the charwoman to do that1 when their patients are suffering1 have not the making of a nurse in them4 ,,ii4 ,,health ,,of ,,houses4#a ,sidenote3 ,health of houses4 ,five points essential4 ,there are five essential points in securing the health of houses3-- #a4 ,pure air4 #b4 ,pure water4 #c4 ,efficient drainage4 #d4 ,cleanliness4 #e4 ,light4 ,without these1 no house can be healthy4 ,and it will be unhealthy just in proportion as they are deficient4 ,sidenote3 ,pure air4 #a4 ,to have pure air1 your house be so constructed as that the outer atmosphere shall find its way with ease to every corner of it4 ,house architects hardly ever consider this4 ,the object in building a house is to obtain the largest interest for the money1 not to save doctors' bills to the tenants4 ,but1 if tenants should ever become so wise as to refuse to occupy unhealthy constructed houses1 and if ,insurance ,companies should ever come to understand their interest so thoroughly as to pay a ,sanitary ,surveyor to look after the houses where their clients live1 speculative architects would speedily be brought to their senses4 ,as it is1 they build what pays best4 ,and there are always people foolish enough to take the houses they build4 ,and if in the course of time the families die off1 as is so often the case1 nobody ever thinks of blaming any but ,providence#b for the result4 ,ill-informed medical men aid in sustaining the delusion1 by laying the blame on current contagions4 ,badly constructed houses do for the healthy what badly constructed hospitals do for the sick4 ,once insure that the air in a house is stagnant1 and sickness is certain to follow4 ,sidenote3 ,pure water4 #b4 ,pure water is more generally introduced into houses than it used to be1 thanks to the exertions of the sanitary reformers4 ,within the last few years1 a large part of ,london was in the daily habit of using water polluted by the drainage of its sewers and water closets4 ,this has happily been remedied4 ,but1 in many parts of the country1 well water of a very impure kind is used for domestic purposes4 ,and when epidemic disease shows itself1 persons using such water are almost sure to suffer4 ,sidenote3 ,drainage4 #c4 ,it would be curious to ascertain by inspection1 how many houses in ,london are really well drained4 ,many people would say1 surely all or most of them4 ,but many people have no idea in what good drainage consists4 ,they think that a sewer in the street1 and a pipe leading to it from the house is good drainage4 ,all the while the sewer may be nothing but a laboratory from which epidemic disease and ill health is being distilled into the house4 ,no house with any untrapped drain pipe communicating immediately with a sewer1 whether it be from water closet1 sink1 or gully-grate1 can ever be healthy4 ,an untrapped sink may at any time spread fever or pyaemia among the inmates of a palace4 ,sidenote3 ,sinks4 ,the ordinary oblong sink is an abomination4 ,that great surface of stone1 which is always left wet1 is always exhaling into the air4 ,i have known whole houses and hospitals smell of the sink4 ,i have met just as strong a stream of sewer air coming up the back staircase of a grand ,london house from the sink1 as ,i have ever met at ,scutari2 and ,i have seen the rooms in that house all ventilated by the open doors1 and the passages all unventilated by the closed windows1 in order that as much of the sewer air as possible might be conducted into and retained in the bed-rooms4 ,it is wonderful4 ,another great evil in house construction is carrying drains underneath the house4 ,such drains are never safe4 ,all house drains should begin and end outside the walls4 ,many people will readily admit1 as a theory1 the importance of these things4 ,but how few are there who can intelligently trace disease in their households to such causes6 ,is it not a fact1 that when scarlet fever1 measles1 or small-pox appear among the children1 the very first thought which occurs is1 where the children can have caught the disease8 ,and the parents immediately run over in their minds all the families with whom they may have been4 ,they never think of looking at home for the source of the mischief4 ,if a neighbour's child is seized with small-pox1 the first question which occurs is whether it had been vaccinated4 ,no one would undervalue vaccination2 but it becomes of doubtful benefit to society when it leads people to look abroad for the source of evils which exist at home4 ,sidenote3 ,cleanliness4 #d4 ,without cleanliness1 within and without your house1 ventilation is comparatively useless4 ,in certain foul districts of ,london1 poor people used to object to open their windows and doors because of the foul smells that came in4 ,rich people like to have their stables and dunghill near their houses4 ,but does it ever occur to them that with many arrangements of this kind it would be safer to keep the windows shut than open8 ,you cannot have the air of the house pure with dung-heaps under the windows4 ,these are common all over ,london4 ,and yet people are surprised that their children1 brought up in large well-aired nurseries and bed-rooms suffer from children's epidemics4 ,if they studied ,nature's laws in the matter of children's health1 they would not be so surprised4 ,there are other ways of having filth inside a house besides having dirt in heaps4 ,old papered walls of years' standing1 dirty carpets1 uncleansed furniture1 are just as ready sources of impurity to the air as if there were a dung-heap in the basement4 ,people are so unaccustomed from education and habits to consider how to make a home healthy1 that they either never think of it at all1 and take every disease as a matter of course1 to be resigned to when it comes as from the hand of ,providence2 or if they ever entertain the idea of preserving the health of their household as a duty1 they are very apt to commit all kinds of negligences and ignorances in performing it4 ,sidenote3 ,light4 #e4 ,a dark house is always an unhealthy house1 always an ill-aired house1 always a dirty house4 ,want of light stops growth1 and promotes scrofula1 rickets1 c41 among the children4 ,people lose their health in a dark house1 and if they get ill they cannot get well again in it4 ,more will be said about this farther on4 ,sidenote3 ,three common errors in managing the health of houses4 ,three out of many negligences1 and ignorances in managing the health of houses generally1 ,i will here mention as specimens--#a4 ,that the female head in charge of any building does not think it necessary to visit every hole and corner of it every day4 ,how can she expect those who are under her to be more careful to maintain her house in a healthy condition than she who is in charge of it8--#b4 ,that it is not considered essential to air1 to sun1 and to clean rooms while uninhabited2 which is simply ignoring the first elementary notion of sanitary things1 and laying the ground ready for all kinds of diseases4--#c4 ,that the window1 and one window1 is considered enough to air a room4 ,have you never observed that any room without a fire-place is always close8 ,and1 if you have a fire-place1 would you cram it up not only with a chimney-board1 but perhaps with a great wisp of brown paper1 in the throat of the chimney--to prevent the soot from coming down1 you say8 ,if your chimney is foul1 sweep it2 but don't expect that you can ever air a room with only one aperture2 don't suppose that to shut up a room is the way to keep it clean4 ,it is the best way to foul the room and all that is in it4 ,don't imagine that if you1 who are in charge1 don't look to all these things yourself1 those under you will be more careful than you are4 ,it appears as if the part of a mistress now is to complain of her servants1 and to accept their excuses--not to show them how there need be neither complaints made nor excuses4 ,sidenote3 ,head in charge must see to ,house ,hygiene1 not do it herself4 ,but again1 to look to all these things yourself does not mean to do them yourself4 ,i always open the windows1 the head in charge often says4 ,if you do it1 it is by so much the better1 certainly1 than if it were not done at all4 ,but can you not insure that it is done when not done by yourself8 ,can you insure that it is not undone when your back is turned8 ,this is what being in charge means4 ,and a very important meaning it is1 too4 ,the former only implies that just what you can do with your own hands is done4 ,the latter that what ought to be done is always done4 ,sidenote3 ,does ,god think of these things so seriously8 ,and now1 you think these things trifles1 or at least exaggerated4 ,but what you think or what ,i think matters little4 ,let us see what ,god thinks of them4 ,god always justifies ,his ways4 ,while we are thinking1 ,he has been teaching4 ,i have known cases of hospital pyaemia quite as severe in handsome private houses as in any of the worst hospitals1 and from the same cause1 viz41 foul air4 ,yet nobody learnt the lesson4 ,nobody learnt anything at all from it4 ,they went on thinking-- thinking that the sufferer had scratched his thumb1 or that it was singular that all the servants had whitlows1 or that something was much about this year2 there is always sickness in our house4 ,this is a favourite mode of thought--leading not to inquire what is the uniform cause of these general whitlows1 but to stifle all inquiry4 ,in what sense is sickness being always there1 a justification of its being there at all8 ,sidenote3 ,how does ,he carry out ,his laws8 ,sidenote3 ,how does ,he teach ,his laws8 ,i will tell you what was the cause of this hospital pyaemia being in that large private house4 ,it was that the sewer air from an ill-placed sink was carefully conducted into all the rooms by sedulously opening all the doors1 and closing all the passage windows4 ,it was that the slops were emptied into the foot pans6--it was that the utensils were never properly rinsed2--it was that the chamber crockery was rinsed with dirty water2--it was that the beds were never properly shaken1 aired1 picked to pieces1 or changed4 ,it was that the carpets and curtains were always musty2--it was that the furniture was always dusty2--it was that the papered walls were saturated with dirt2--it was that the floors were never cleaned2--it was that the uninhabited rooms were never sunned1 or cleaned1 or aired2--it was that the cupboards were always reservoirs of foul air2--it was that the windows were always tight shut up at night2-- it was that no window was ever systematically opened even in the day1 or that the right window was not opened4 ,a person gasping for air might open a window for himself4 ,but the servants were not taught to open the windows1 to shut the doors2 or they opened the windows upon a dank well between high walls1 not upon the airier court2 or they opened the room doors into the unaired halls and passages1 by way of airing the rooms4 ,now all this is not fancy1 but fact4 ,in that handsome house ,i have known in one summer three cases of hospital pyaemia1 one of phlebitis1 two of consumptive cough2 all the immediate products of foul air4 ,when1 in temperate climates1 a house is more unhealthy in summer than in winter1 it is a certain sign of something wrong4 ,yet nobody learns the lesson4 ,yes1 ,god always justifies ,his ways4 ,he is teaching while you are not learning4 ,this poor body loses his finger1 that one loses his life4 ,and all from the most easily preventible causes4#c ,sidenote3 ,physical degeneration in families4 ,its causes4 ,the houses of the grandmothers and great grandmothers of this generation1 at least the country houses1 with front door and back door always standing open1 winter and summer1 and a thorough draught always blowing through--with all the scrubbing1 and cleaning1 and polishing1 and scouring which used to go on1 the grandmothers1 and still more the great grandmothers1 always out of doors and never with a bonnet on except to go to church1 these things entirely account for the fact so often seen of a great grandmother1 who was a tower of physical vigour descending into a grandmother perhaps a little less vigorous but still sound as a bell and healthy to the core1 into a mother languid and confined to her carriage and house1 and lastly into a daughter sickly and confined to her bed4 ,for1 remember1 even with a general decrease of mortality you may often find a race thus degenerating and still oftener a family4 ,you may see poor little feeble washed-out rags1 children of a noble stock1 suffering morally and physically1 throughout their useless1 degenerate lives1 and yet people who are going to marry and to bring more such into the world1 will consult nothing but their own convenience as to where they are to live1 or how they are to live4 ,sidenote3 ,don't make your sickroom into a ventilating shaft for the whole house4 ,with regard to the health of houses where there is a sick person1 it often happens that the sick room is made a ventilating shaft for the rest of the house4 ,for while the house is kept as close1 unaired1 and dirty as usual1 the window of the sick room is kept a little open always1 and the door occasionally4 ,now1 there are certain sacrifices which a house with one sick person in it does make to that sick person3 it ties up its knocker2 it lays straw before it in the street4 ,why can't it keep itself thoroughly clean and unusually well aired1 in deference to the sick person8 ,sidenote3 ,infection4 ,we must not forget what1 in ordinary language1 is called ,infection2#d--;a thing of which people are generally so afraid that they frequently follow the very practice in regard to it which they ought to avoid4 ,nothing used to be considered so infectious or contagious as small-pox2 and people not very long ago used to cover up patients with heavy bed clothes1 while they kept up large fires and shut the windows4 ,small-pox1 of course1 under this regime1 is very infectious4 ,people are somewhat wiser now in their management of this disease4 ,they have ventured to cover the patients lightly and to keep the windows open2 and we hear much less of the infection of small-pox than we used to do4 ,but do people in our days act with more wisdom on the subject of infection in fevers--scarlet fever1 measles1 c4--than their forefathers did with small-pox8 ,does not the popular idea of infection involve that people should take greater care of themselves than of the patient8 that1 for instance1 it is safer not to be too much with the patient1 not to attend too much to his wants8 ,perhaps the best illustration of the utter absurdity of this view of duty in attending on infectious diseases is afforded by what was very recently the practice1 if it is not so even now1 in some of the ,european lazarets--in which the plague-patient used to be condemned to the horrors of filth1 overcrowding1 and want of ventilation1 while the medical attendant was ordered to examine the patient's tongue through an opera-glass and to toss him a lancet to open his abscesses with8 ,true nursing ignores infection1 except to prevent it4 ,cleanliness and fresh air from open windows1 with unremitting attention to the patient1 are the only defence a true nurse either asks or needs4 ,wise and humane management of the patient is the best safeguard against infection4 ,sidenote3 ,why must children have measles1 c41 ,there are not a few popular opinions1 in regard to which it is useful at times to ask a question or two4 ,for example1 it is commonly thought that children must have what are commonly called children's epidemics1 current contagions1 c41 in other words1 that they are born to have measles1 hooping-cough1 perhaps even scarlet fever1 just as they are born to cut their teeth1 if they live4 ,now1 do tell us1 why must a child have measles8 ,oh because1 you say1 we cannot keep it from infection--other children have measles--and it must take them--and it is safer that it should4 ,but why must other children have measles8 ,and if they have1 why must yours have them too8 ,if you believed in and observed the laws for preserving the health of houses which inculcate cleanliness1 ventilation1 white-washing1 and other means1 and which1 by the way1 are laws1 as implicitly as you believe in the popular opinion1 for it is nothing more than an opinion1 that your child must have children's epidemics1 don't you think that upon the whole your child would be more likely to escape altogether8 ,,footnotes3 #a ,sidenote3 ,health of carriages4 ,the health of carriages1 especially close carriages1 is not of sufficient universal importance to mention here1 otherwise than cursorily4 ,children1 who are always the most delicate test of sanitary conditions1 generally cannot enter a close carriage without being sick-- and very lucky for them that it is so4 ,a close carriage1 with the horse-hair cushions and linings always saturated with organic matter1 if to this be added the windows up1 is one of the most unhealthy of human receptacles4 ,the idea of taking an airing in it is something preposterous4 ,dr4 ,angus ,smith has shown that a crowded railway carriage1 which goes at the rate of #cj miles an hour1 is as unwholesome as the strong smell of a sewer1 or as a back yard in one of the most unhealthy courts off one of the most unhealthy streets in ,manchester4 #b ,god lays down certain physical laws4 ,upon ,his carrying out such laws depends our responsibility 7that much abused word71 for how could we have any responsibility for actions1 the results of which we could not foresee--which would be the case if the carrying out of ,his laws were not certain4 ,yet we seem to be continually expecting that ,he will work a miracle--i4e41 break ,his own laws expressly to relieve us of responsibility4 #c ,sidenote3 ,servants rooms4 ,i must say a word about servants' bed-rooms4 ,from the way they are built1 but oftener from the way they are kept1 and from no intelligent inspection whatever being exercised over them1 they are almost invariably dens of foul air1 and the servants' health suffers in an unaccountable 787 way1 even in the country4 ,for ,i am by no means speaking only of ,london houses1 where too often servants are put to live under the ground and over the roof4 ,but in a country mansion1 which was really a mansion1 7not after the fashion of advertisements17 ,i have known three maids who slept in the same room ill of scarlet fever4 ,how catching it is1 was of course the remark4 ,one look at the room1 one smell of the room1 was quite enough4 ,it was no longer unaccountable4 ,the room was not a small one2 it was up stairs1 and it had two large windows--but nearly every one of the neglects enumerated above was there4 #d ,sidenote3 ,diseases are not individuals arranged in classes1 like cats and dogs1 but conditions growing out of one another4 ,is it not living in a continual mistake to look upon diseases1 as we do now1 as separate entities1 which must exist1 like cats and dogs8 instead of looking upon them as conditions1 like a dirty and a clean condition1 and just as much under our own control2 or rather as the reactions of kindly nature1 against the conditions in which we have placed ourselves4 ,i was brought up1 both by scientific men and ignorant women1 distinctly to believe that small-pox1 for instance1 was a thing of which there was once a first specimen in the world1 which went on propagating itself1 in a perpetual chain of descent1 just as much as that there was a first dog1 7or a first pair of dogs17 and that small-pox would not begin itself any more than a new dog would begin without there having been a parent dog4 ,since then ,i have seen with my eyes and smelt with my nose small-pox growing up in first specimens1 either in close rooms1 or in overcrowded wards1 where it could not by any possibility have been caught1 but must have begun4 ,nay1 more1 ,i have seen diseases begin1 grow up1 and pass into one another4 ,now1 dogs do not pass into cats4 ,i have seen1 for instance1 with a little overcrowding1 continued fever grow up2 and with a little more1 typhoid fever2 and with a little more1 typhus1 and all in the same ward or hut4 ,would it not be far better1 truer1 and more practical1 if we looked upon disease in this light8 ,for diseases1 as all experiences hows1,transcriber's note3 ,possibly typo for show are adjectives1 not noun substantives4 ,,iii4 ,,petty ,,management4 ,sidenote3 ,petty management4 ,all the results of good nursing1 as detailed in these notes1 may be spoiled or utterly negatived by one defect1 viz43 in petty management1 or in other words1 by not knowing how to manage that what you do when you are there1 shall be done when you are not there4 ,the most devoted friend or nurse cannot be always there4 ,nor is it desirable that she should4 ,and she may give up her health1 all her other duties1 and yet1 for want of a little management1 be not one-half so efficient as another who is not one-half so devoted1 but who has this art of multiplying herself--that is to say1 the patient of the first will not really be so well cared for1 as the patient of the second4 ,it is as impossible in a book to teach a person in charge of sick how to manage1 as it is to teach her how to nurse4 ,circumstances must vary with each different case4 ,but it is possible to press upon her to think for herself3 ,now what does happen during my absence8 ,i am obliged to be away on ,tuesday4 ,but fresh air1 or punctuality is not less important to my patient on ,tuesday than it was on ,monday4 ,or3 ,at #aj ,p4,m4 ,i am never with my patient2 but quiet is of no less consequence to him at #aj than it was at #e minutes to #aj4 ,curious as it may seem1 this very obvious consideration occurs comparatively to few1 or1 if it does occur1 it is only to cause the devoted friend or nurse to be absent fewer hours or fewer minutes from her patient--not to arrange so as that no minute and no hour shall be for her patient without the essentials of her nursing4 ,sidenote3 ,illustrations of the want of it4 ,a very few instances will be sufficient1 not as precepts1 but as illustrations4 ,sidenote3 ,strangers coming into the sick room4 ,a strange washerwoman1 coming late at night for the things1 will burst in by mistake to the patient's sickroom1 after he has fallen into his first doze1 giving him a shock1 the effects of which are irremediable1 though he himself laughs at the cause1 and probably never even mentions it4 ,the nurse who is1 and is quite right to be1 at her supper1 has not provided that the washerwoman shall not lose her way and go into the wrong room4 ,sidenote3 ,sick room airing the whole house4 ,the patient's room may always have the window open4 ,but the passage outside the patient's room1 though provided with several large windows1 may never have one open4 ,because it is not understood that the charge of the sick-room extends to the charge of the passage4 ,and thus1 as often happens1 the nurse makes it her business to turn the patient's room into a ventilating shaft for the foul air of the whole house4 ,sidenote3 ,uninhabited room fouling the whole house4 ,an uninhabited room1 a newly-painted room1#a an uncleaned closet or cupboard1 may often become the reservoir of foul air for the whole house1 because the person in charge never thinks of arranging that these places shall be always aired1 always cleaned2 she merely opens the window herself when she goes in4 ,sidenote3 ,delivery and non-delivery of letters and messages4 ,an agitating letter or message may be delivered1 or an important letter or message not delivered2 a visitor whom it was of consequence to see1 may be refused1 or whom it was of still more consequence to not see may be admitted--because the person in charge has never asked herself this question1 ,what is done when ,i am not there8#b ,at all events1 one may safely say1 a nurse cannot be with the patient1 open the door1 eat her meals1 take a message1 all at one and the same time4 ,nevertheless the person in charge never seems to look the impossibility in the face4 ,add to this that the attempting this impossibility does more to increase the poor patient's hurry and nervousness than anything else4 ,sidenote3 ,partial measures such as being always in the way yourself1 increase instead of saving the patient's anxiety4 ,because they must be only partial4 ,it is never thought that the patient remembers these things if you do not4 ,he has not only to think whether the visit or letter may arrive1 but whether you will be in the way at the particular day and hour when it may arrive4 ,so that your partial measures for being in the way yourself1 only increase the necessity for his thought4 ,whereas1 if you could but arrange that the thing should always be done whether you are there or not1 he need never think at all about it4 ,for the above reasons1 whatever a patient can do for himself1 it is better1 i4e4 less anxiety1 for him to do for himself1 unless the person in charge has the spirit of management4 ,it is evidently much less exertion for a patient to answer a letter for himself by return of post1 than to have four conversations1 wait five days1 have six anxieties before it is off his mind1 before the person who has to answer it has done so4 ,apprehension1 uncertainty1 waiting1 expectation1 fear of surprise1 do a patient more harm than any exertion4 ,remember1 he is face to face with his enemy all the time1 internally wrestling with him1 having long imaginary conversations with him4 ,you are thinking of something else4 ,rid him of his adversary quickly1 is a first rule with the sick4#c ,for the same reasons1 always tell a patient and tell him beforehand when you are going out and when you will be back1 whether it is for a day1 an hour1 or ten minutes4 ,you fancy perhaps that it is better for him if he does not find out your going at all1 better for him if you do not make yourself of too much importance to him2 or else you cannot bear to give him the pain or the anxiety of the temporary separation4 ,no such thing4 ,you ought to go1 we will suppose4 ,health or duty requires it4 ,then say so to the patient openly4 ,if you go without his knowing it1 and he finds it out1 he never will feel secure again that the things which depend upon you will be done when you are away1 and in nine cases out of ten he will be right4 ,if you go out without telling him when you will be back1 he can take no measures nor precautions as to the things which concern you both1 or which you do for him4 ,sidenote3 ,what is the cause of half the accidents which happen8 ,if you look into the reports of trials or accidents1 and especially of suicides1 or into the medical history of fatal cases1 it is almost incredible how often the whole thing turns upon something which has happened because he1 or still oftener she1 was not there4 ,but it is still more incredible how often1 how almost always this is accepted as a sufficient reason1 a justification2 why1 the very fact of the thing having happened is the proof of its not being a justification4 ,the person in charge was quite right not to be there1 he was called away for quite sufficient reason1 or he was away for a daily recurring and unavoidable cause2 yet no provision was made to supply his absence4 ,the fault was not in his being away1 but in there being no management to supplement his being away4 ,when the sun is under a total eclipse or during his nightly absence1 we light candles4 ,but it would seem as if it did not occur to us that we must also supplement the person in charge of sick or of children1 whether under an occasional eclipse or during a regular absence4 ,in institutions where many lives would be lost and the effect of such want of management would be terrible and patent1 there is less of it than in the private house4#d ,but in both1 let whoever is in charge keep this simple question in her head 7not1 how can ,i always do this right thing myself1 but7 how can ,i provide for this right thing to be always done8 ,then1 when anything wrong has actually happened in consequence of her absence1 which absence we will suppose to have been quite right1 let her question still be 7not1 how can ,i provide against any more of such absences8 which is neither possible nor desirable1 but7 how can ,i provide against anything wrong arising out of my absence8 ,sidenote3 ,what it is to be in charge4 ,how few men1 or even women1 understand1 either in great or in little things1 what it is the being in charge--,i mean1 know how to carry out a charge4 ,from the most colossal calamities1 down to the most trifling accidents1 results are often traced 7or rather not traced7 to such want of some one in charge or of his knowing how to be in charge4 ,a short time ago the bursting of a funnel-casing on board the finest and strongest ship that ever was built1 on her trial trip1 destroyed several lives and put several hundreds in jeopardy--not from any undetected flaw in her new and untried works--but from a tap being closed which ought not to have been closed--from what every child knows would make its mother's tea-kettle burst4 ,and this simply because no one seemed to know what it is to be in charge1 or who was in charge4 ,nay more1 the jury at the inquest actually altogether ignored the same1 and apparently considered the tap in charge1 for they gave as a verdict accidental death4 ,this is the meaning of the word1 on a large scale4 ,on a much smaller scale1 it happened1 a short time ago1 that an insane person burned herself slowly and intentionally to death1 while in her doctor's charge and almost in her nurse's presence4 ,yet neither was considered at all to blame4 ,the very fact of the accident happening proves its own case4 ,there is nothing more to be said4 ,either they did not know their business or they did not know how to perform it4 ,to be in charge is certainly not only to carry out the proper measures yourself but to see that every one else does so too2 to see that no one either wilfully or ignorantly thwarts or prevents such measures4 ,it is neither to do everything yourself nor to appoint a number of people to each duty1 but to ensure that each does that duty to which he is appointed4 ,this is the meaning which must be attached to the word by 7above all7 those in charge of sick1 whether of numbers or of individuals1 7and indeed ,i think it is with individual sick that it is least understood4 ,one sick person is often waited on by four with less precision1 and is really less cared for than ten who are waited on by one2 or at least than #dj who are waited on by #d2 and all for want of this one person in charge47 ,it is often said that there are few good servants now2 ,i say there are few good mistresses now4 ,as the jury seems to have thought the tap was in charge of the ship's safety1 so mistresses now seem to think the house is in charge of itself4 ,they neither know how to give orders1 nor how to teach their servants to obey orders--i4e41 to obey intelligently1 which is the real meaning of all discipline4 ,again1 people who are in charge often seem to have a pride in feeling that they will be missed1 that no one can understand or carry on their arrangements1 their system1 books1 accounts1 c41 but themselves4 ,it seems to me that the pride is rather in carrying on a system1 in keeping stores1 closets1 books1 accounts1 c41 so that any body can understand and carry them on--so that1 in case of absence or illness1 one can deliver every thing up to others and know that all will go on as usual1 and that one shall never be missed4 ,sidenote3 ,why hired nurses give so much trouble4 ,,note4--,it is often complained1 that professional nurses1 brought into private families1 in case of sickness1 make themselves intolerable by ordering about the other servants1 under plea of not neglecting the patient4 ,both things are true2 the patient is often neglected1 and the servants are often unfairly put upon4 ,but the fault is generally in the want of management of the head in charge4 ,it is surely for her to arrange both that the nurse's place is1 when necessary1 supplemented1 and that the patient is never neglected--things with a little management quite compatible1 and indeed only attainable together4 ,it is certainly not for the nurse to order about the servants4 ,,footnotes3 #a ,sidenote3 ,lingering smell of paint a want of care4 ,that excellent paper1 the ,builder1 mentions the lingering of the smell of paint for a month about a house as a proof of want of ventilation4 ,certainly--and1 where there are ample windows to open1 and these are never opened to get rid of the smell of paint1 it is a proof of want of management in using the means of ventilation4 ,of course the smell will then remain for months4 ,why should it go8 #b ,sidenote3 ,why let your patient ever be surprised8 ,why should you let your patient ever be surprised1 except by thieves8 ,i do not know4 ,in ,england1 people do not come down the chimney1 or through the window1 unless they are thieves4 ,they come in by the door1 and somebody must open the door to them4 ,the somebody charged with opening the door is one of two1 three1 or at most four persons4 ,why cannot these1 at most1 four persons be put in charge as to what is to be done when there is a ring at the door-bell8 ,the sentry at a post is changed much oftener than any servant at a private house or institution can possibly be4 ,but what should we think of such an excuse as this3 that the enemy had entered such a post because ,a and not ,b had been on guard8 ,yet ,i have constantly heard such an excuse made in the private house or institution1 and accepted3 viz41 that such a person had been let in or not let in1 and such a parcel had been wrongly delivered or lost because ,a and not ,b had opened the door6 #c ,there are many physical operations where coeteris paribus the danger is in a direct ratio to the time the operation lasts2 and coeteris paribus the operator's success will be in direct ratio to his quickness4 ,now there are many mental operations where exactly the same rule holds good with the sick2 coeteris paribus their capability of bearing such operations depends directly on the quickness1 without hurry1 with which they can be got through4 #d ,sidenote3 ,petty management better understood in institutions than in private houses4 ,so true is this that ,i could mention two cases of women of very high position1 both of whom died in the same way of the consequences of a surgical operation4 ,and in both cases1 ,i was told by the highest authority that the fatal result would not have happened in a ,london hospital4 ,sidenote3 ,what institutions are the exception8 ,but1 as far as regards the art of petty management in hospitals1 all the military hospitals ,i know must be excluded4 ,upon my own experience ,i stand1 and ,i solemnly declare that ,i have seen or known of fatal accidents1 such as suicides in delirium tremens1 bleedings to death1 dying patients dragged out of bed by drunken ,medical ,staff ,corps men1 and many other things less patent and striking1 which would not have happened in ,london civil hospitals nursed by women4 ,the medical officers should be absolved from all blame in these accidents4 ,how can a medical officer mount guard all day and all night over a patient 7say7 in delirium tremens8 ,the fault lies in there being no organized system of attendance4 ,were a trustworthy man in charge of each ward1 or set of wards1 not as office clerk1 but as head nurse1 7and head nurse the best hospital serjeant1 or ward master1 is not now and cannot be1 from default of the proper regulations17 the thing would not1 in all probability1 have happened4 ,but were a trustworthy woman in charge of the ward1 or set of wards1 the thing would not1 in all certainty1 have happened4 ,in other words1 it does not happen where a trustworthy woman is really in charge4 ,and1 in these remarks1 ,i by no means refer only to exceptional times of great emergency in war hospitals1 but also1 and quite as much1 to the ordinary run of military hospitals at home1 in time of peace2 or to a time in war when our army was actually more healthy than at home in peace1 and the pressure on our hospitals consequently much less4 ,sidenote3 ,nursing in ,regimental ,hospitals4 ,it is often said that1 in regimental hospitals1 patients ought to nurse each other1 because the number of sick altogether being1 say1 but thirty1 and out of these one only perhaps being seriously ill1 and the other twenty-nine having little the matter with them1 and nothing to do1 they should be set to nurse the one2 also1 that soldiers are so trained to obey1 that they will be the most obedient1 and therefore the best of nurses1 add to which they are always kind to their comrades4 ,now1 have those who say this1 considered that1 in order to obey1 you must know how to obey1 and that these soldiers certainly do not know how to obey in nursing4 ,i have seen these kind fellows 7and how kind they are no one knows so well as myself7 move a comrade so that1 in one case at least1 the man died in the act4 ,i have seen the comrades' kindness produce abundance of spirits1 to be drunk in secret4 ,let no one understand by this that female nurses ought to1 or could be introduced in regimental hospitals4 ,it would be most undesirable1 even were it not impossible4 ,but the head nurseship of a hospital serjeant is the more essential1 the more important1 the more inexperienced the nurses4 ,undoubtedly1 a ,london hospital sister does sometimes set relays of patients to watch a critical case2 but1 undoubtedly also1 always under her own superintendence2 and she is called to whenever there is something to be done1 and she knows how to do it4 ,the patients are not left to do it of their own unassisted genius1 however kind and willing they may be4 ,,iv4 ,,noise4 ,sidenote3 ,unnecessary noise4 ,unnecessary noise1 or noise that creates an expectation in the mind1 is that which hurts a patient4 ,it is rarely the loudness of the noise1 the effect upon the organ of the ear itself1 which appears to affect the sick4 ,how well a patient will generally bear1 e4 g41 the putting up of a scaffolding close to the house1 when he cannot bear the talking1 still less the whispering1 especially if it be of a familiar voice1 outside his door4 ,there are certain patients1 no doubt1 especially where there is slight concussion or other disturbance of the brain1 who are affected by mere noise4 ,but intermittent noise1 or sudden and sharp noise1 in these as in all other cases1 affects far more than continuous noise--noise with jar far more than noise without4 ,of one thing you may be certain1 that anything which wakes a patient suddenly out of his sleep will invariably put him into a state of greater excitement1 do him more serious1 aye1 and lasting mischief1 than any continuous noise1 however loud4 ,sidenote3 ,never let a patient be waked out of his first sleep4 ,never to allow a patient to be waked1 intentionally or accidentally1 is a sine qua non of all good nursing4 ,if he is roused out of his first sleep1 he is almost certain to have no more sleep4 ,it is a curious but quite intelligible fact that1 if a patient is waked after a few hours' instead of a few minutes' sleep1 he is much more likely to sleep again4 ,because pain1 like irritability of brain1 perpetuates and intensifies itself4 ,if you have gained a respite of either in sleep you have gained more than the mere respite4 ,both the probability of recurrence and of the same intensity will be diminished2 whereas both will be terribly increased by want of sleep4 ,this is the reason why sleep is so all-important4 ,this is the reason why a patient waked in the early part of his sleep loses not only his sleep1 but his power to sleep4 ,a healthy person who allows himself to sleep during the day will lose his sleep at night4 ,but it is exactly the reverse with the sick generally2 the more they sleep1 the better will they be able to sleep4 ,sidenote3 ,noise which excites expectation4 ,sidenote3 ,whispered conversation in the room4 ,i have often been surprised at the thoughtlessness1 7resulting in cruelty1 quite unintentionally7 of friends or of doctors who will hold a long conversation just in the room or passage adjoining to the room of the patient1 who is either every moment expecting them to come in1 or who has just seen them1 and knows they are talking about him4 ,if he is an amiable patient1 he will try to occupy his attention elsewhere and not to listen--and this makes matters worse--for the strain upon his attention and the effort he makes are so great that it is well if he is not worse for hours after4 ,if it is a whispered conversation in the same room1 then it is absolutely cruel2 for it is impossible that the patient's attention should not be involuntarily strained to hear4 ,walking on tip-toe1 doing any thing in the room very slowly1 are injurious1 for exactly the same reasons4 ,a firm light quick step1 a steady quick hand are the desiderata2 not the slow1 lingering1 shuffling foot1 the timid1 uncertain touch4 ,slowness is not gentleness1 though it is often mistaken for such3 quickness1 lightness1 and gentleness are quite compatible4 ,again1 if friends and doctors did but watch1 as nurses can and should watch1 the features sharpening1 the eyes growing almost wild1 of fever patients who are listening for the entrance from the corridor of the persons whose voices they are hearing there1 these would never run the risk again of creating such expectation1 or irritation of mind4--,such unnecessary noise has undoubtedly induced or aggravated delirium in many cases4 ,i have known such--in one case death ensued4 ,it is but fair to say that this death was attributed to fright4 ,it was the result of a long whispered conversation1 within sight of the patient1 about an impending operation2 but any one who has known the more than stoicism1 the cheerful coolness1 with which the certainty of an operation will be accepted by any patient1 capable of bearing an operation at all1 if it is properly communicated to him1 will hesitate to believe that it was mere fear which produced1 as was averred1 the fatal result in this instance4 ,it was rather the uncertainty1 the strained expectation as to what was to be decided upon4 ,sidenote3 ,or just outside the door4 ,i need hardly say that the other common cause1 namely1 for a doctor or friend to leave the patient and communicate his opinion on the result of his visit to the friends just outside the patient's door1 or in the adjoining room1 after the visit1 but within hearing or knowledge of the patient is1 if possible1 worst of all4 ,sidenote3 ,noise of female dress4 ,it is1 ,i think1 alarming1 peculiarly at this time1 when the female ink-bottles are perpetually impressing upon us woman's particular worth and general missionariness1 to see that the dress of women is daily more and more unfitting them for any mission1 or usefulness at all4 ,it is equally unfitted for all poetic and all domestic purposes4 ,a man is now a more handy and far less objectionable being in a sick room than a woman4 ,compelled by her dress1 every woman now either shuffles or waddles--only a man can cross the floor of a sick-room without shaking it6 ,what is become of woman's light step8--the firm1 light1 quick step we have been asking for8 ,unnecessary noise1 then1 is the most cruel absence of care which can be inflicted either on sick or well4 ,for1 in all these remarks1 the sick are only mentioned as suffering in a greater proportion than the well from precisely the same causes4 ,unnecessary 7although slight7 noise injures a sick person much more than necessary noise 7of a much greater amount74 ,sidenote3 ,patient's repulsion to nurses who rustle4 ,all doctrines about mysterious affinities and aversions will be found to resolve themselves very much1 if not entirely1 into presence or absence of care in these things4 ,a nurse who rustles 7,i am speaking of nurses professional and unprofessional7 is the horror of a patient1 though perhaps he does not know why4 ,the fidget of silk and of crinoline1 the rattling of keys1 the creaking of stays and of shoes1 will do a patient more harm than all the medicines in the world will do him good4 ,the noiseless step of woman1 the noiseless drapery of woman1 are mere figures of speech in this day4 ,her skirts 7and well if they do not throw down some piece of furniture7 will at least brush against every article in the room as she moves4#a ,again1 one nurse cannot open the door without making everything rattle4 ,or she opens the door unnecessarily often1 for want of remembering all the articles that might be brought in at once4 ,a good nurse will always make sure that no door or window in her patient's room shall rattle or creak2 that no blind or curtain shall1 by any change of wind through the open window be made to flap--especially will she be careful of all this before she leaves her patients for the night4 ,if you wait till your patients tell you1 or remind you of these things1 where is the use of their having a nurse8 ,there are more shy than exacting patients1 in all classes2 and many a patient passes a bad night1 time after time1 rather than remind his nurse every night of all the things she has forgotten4 ,if there are blinds to your windows1 always take care to have them well up1 when they are not being used4 ,a little piece slipping down1 and flapping with every draught1 will distract a patient4 ,sidenote3 ,hurry peculiarly hurtful to sick4 ,all hurry or bustle is peculiarly painful to the sick4 ,and when a patient has compulsory occupations to engage him1 instead of having simply to amuse himself1 it becomes doubly injurious4 ,the friend who remains standing and fidgetting about while a patient is talking business to him1 or the friend who sits and proses1 the one from an idea of not letting the patient talk1 the other from an idea of amusing him1 --each is equally inconsiderate4 ,always sit down when a sick person is talking business to you1 show no signs of hurry give complete attention and full consideration if your advice is wanted1 and go away the moment the subject is ended4 ,sidenote3 ,how to visit the sick and not hurt them4 ,always sit within the patient's view1 so that when you speak to him he has not painfully to turn his head round in order to look at you4 ,everybody involuntarily looks at the person speaking4 ,if you make this act a wearisome one on the part of the patient you are doing him harm4 ,so also if by continuing to stand you make him continuously raise his eyes to see you4 ,be as motionless as possible1 and never gesticulate in speaking to the sick4 ,never make a patient repeat a message or request1 especially if it be some time after4 ,occupied patients are often accused of doing too much of their own business4 ,they are instinctively right4 ,how often you hear the person1 charged with the request of giving the message or writing the letter1 say half an hour afterwards to the patient1 ,did you appoint #ab o'clock8 or1 ,what did you say was the address8 or ask perhaps some much more agitating question--thus causing the patient the effort of memory1 or worse still1 of decision1 all over again4 ,it is really less exertion to him to write his letters himself4 ,this is the almost universal experience of occupied invalids4 ,this brings us to another caution4 ,never speak to an invalid from behind1 nor from the door1 nor from any distance from him1 nor when he is doing anything4 ,the official politeness of servants in these things is so grateful to invalids1 that many prefer1 without knowing why1 having none but servants about them4 ,sidenote3 ,these things not fancy4 ,these things are not fancy4 ,if we consider that1 with sick as with well1 every thought decomposes some nervous matter1--that decomposition as well as re-composition of nervous matter is always going on1 and more quickly with the sick than with the well1--that1 to obtrude abruptly another thought upon the brain while it is in the act of destroying nervous matter by thinking1 is calling upon it to make a new exertion1-- if we consider these things1 which are facts1 not fancies1 we shall remember that we are doing positive injury by interrupting1 by startling a fanciful person1 as it is called4 ,alas6 it is no fancy4 ,sidenote3 ,interruption damaging to sick4 ,if the invalid is forced1 by his avocations1 to continue occupations requiring much thinking1 the injury is doubly great4 ,in feeding a patient suffering under delirium or stupor you may suffocate him1 by giving him his food suddenly1 but if you rub his lips gently with a spoon and thus attract his attention1 he will swallow the food unconsciously1 but with perfect safety4 ,thus it is with the brain4 ,if you offer it a thought1 especially one requiring a decision1 abruptly1 you do it a real not fanciful injury4 ,never speak to a sick person suddenly2 but1 at the same time1 do not keep his expectation on the tiptoe4 ,sidenote3 ,and to well4 ,this rule1 indeed1 applies to the well quite as much as to the sick4 ,i have never known persons who exposed themselves for years to constant interruption who did not muddle away their intellects by it at last4 ,the process with them may be accomplished without pain4 ,with the sick1 pain gives warning of the injury4 ,sidenote3 ,keeping a patient standing4 ,do not meet or overtake a patient who is moving about in order to speak to him1 or to give him any message or letter4 ,you might just as well give him a box on the ear4 ,i have seen a patient fall flat on the ground who was standing when his nurse came into the room4 ,this was an accident which might have happened to the most careful nurse4 ,but the other is done with intention4 ,a patient in such a state is not going to the ,east ,indies4 ,if you would wait ten seconds1 or walk ten yards further1 any promenade he could make would be over4 ,you do not know the effort it is to a patient to remain standing for even a quarter of a minute to listen to you4 ,if ,i had not seen the thing done by the kindest nurses and friends1 ,i should have thought this caution quite superfluous4#b ,sidenote3 ,patients dread surprise4 ,patients are often accused of being able to do much more when nobody is by4 ,it is quite true that they can4 ,unless nurses can be brought to attend to considerations of the kind of which we have given here but a few specimens1 a very weak patient finds it really much less exertion to do things for himself than to ask for them4 ,and he will1 in order to do them1 7very innocently and from instinct7 calculate the time his nurse is likely to be absent1 from a fear of her coming in upon him or speaking to him1 just at the moment when he finds it quite as much as he can do to crawl from his bed to his chair1 or from one room to another1 or down stairs1 or out of doors for a few minutes4 ,some extra call made upon his attention at that moment will quite upset him4 ,in these cases you may be sure that a patient in the state we have described does not make such exertions more than once or twice a day1 and probably much about the same hour every day4 ,and it is hard1 indeed1 if nurse and friends cannot calculate so as to let him make them undisturbed4 ,remember1 that many patients can walk who cannot stand or even sit up4 ,standing is1 of all positions1 the most trying to a weak patient4 ,everything you do in a patient's room1 after he is put up for the night1 increases tenfold the risk of his having a bad night4 ,but1 if you rouse him up after he has fallen asleep1 you do not risk1 you secure him a bad night4 ,one hint ,i would give to all who attend or visit the sick1 to all who have to pronounce an opinion upon sickness or its progress4 ,come back and look at your patient after he has had an hour's animated conversation with you4 ,it is the best test of his real state we know4 ,but never pronounce upon him from merely seeing what he does1 or how he looks1 during such a conversation4 ,learn also carefully and exactly1 if you can1 how he passed the night after it4 ,sidenote3 ,effects of over-exertion on sick4 ,people rarely1 if ever1 faint while making an exertion4 ,it is after it is over4 ,indeed1 almost every effect of over-exertion appears after1 not during such exertion4 ,it is the highest folly to judge of the sick1 as is so often done1 when you see them merely during a period of excitement4 ,people have very often died of that which1 it has been proclaimed at the time1 has done them no harm4#c ,remember never to lean against1 sit upon1 or unnecessarily shake1 or even touch the bed in which a patient lies4 ,this is invariably a painful annoyance4 ,if you shake the chair on which he sits1 he has a point by which to steady himself1 in his feet4 ,but on a bed or sofa1 he is entirely at your mercy1 and he feels every jar you give him all through him4 ,sidenote3 ,difference between real and fancy patients4 ,in all that we have said1 both here and elsewhere1 let it be distinctly understood that we are not speaking of hypochondriacs4 ,to distinguish between real and fancied disease forms an important branch of the education of a nurse4 ,to manage fancy patients forms an important branch of her duties4 ,but the nursing which real and that which fancied patients require is of different1 or rather of opposite1 character4 ,and the latter will not be spoken of here4 ,indeed1 many of the symptoms which are here mentioned are those which distinguish real from fancied disease4 ,it is true that hypochondriacs very often do that behind a nurse's back which they would not do before her face4 ,many such ,i have had as patients who scarcely ate anything at their regular meals2 but if you concealed food for them in a drawer1 they would take it at night or in secret4 ,but this is from quite a different motive4 ,they do it from the wish to conceal4 ,whereas the real patient will often boast to his nurse or doctor1 if these do not shake their heads at him1 of how much he has done1 or eaten or walked4 ,to return to real disease4 ,sidenote3 ,conciseness necessary with sick4 ,conciseness and decision are1 above all things1 necessary with the sick4 ,let your thought expressed to them be concisely and decidedly expressed4 ,what doubt and hesitation there may be in your own mind must never be communicated to theirs1 not even 7,i would rather say especially not7 in little things4 ,let your doubt be to yourself1 your decision to them4 ,people who think outside their heads1 the whole process of whose thought appears1 like ,homer's1 in the act of secretion1 who tell everything that led them towards this conclusion and away from that1 ought never to be with the sick4 ,sidenote3 ,irresolution most painful to them4 ,irresolution is what all patients most dread4 ,rather than meet this in others1 they will collect all their data1 and make up their minds for themselves4 ,a change of mind in others1 whether it is regarding an operation1 or re-writing a letter1 always injures the patient more than the being called upon to make up his mind to the most dreaded or difficult decision4 ,farther than this1 in very many cases1 the imagination in disease is far more active and vivid than it is in health4 ,if you propose to the patient change of air to one place one hour1 and to another the next1 he has1 in each case1 immediately constituted himself in imagination the tenant of the place1 gone over the whole premises in idea1 and you have tired him as much by displacing his imagination1 as if you had actually carried him over both places4 ,above all1 leave the sick room quickly and come into it quickly1 not suddenly1 not with a rush4 ,but don't let the patient be wearily waiting for when you will be out of the room or when you will be in it4 ,conciseness and decision in your movements1 as well as your words1 are necessary in the sick room1 as necessary as absence of hurry and bustle4 ,to possess yourself entirely will ensure you from either failing--either loitering or hurrying4 ,sidenote3 ,what a patient must not have to see to4 ,if a patient has to see1 not only to his own but also to his nurse's punctuality1 or perseverance1 or readiness1 or calmness1 to any or all of these things1 he is far better without that nurse than with her-- however valuable and handy her services may otherwise be to him1 and however incapable he may be of rendering them to himself4 ,sidenote3 ,reading aloud4 ,with regard to reading aloud in the sick room1 my experience is1 that when the sick are too ill to read to themselves1 they can seldom bear to be read to4 ,children1 eye-patients1 and uneducated persons are exceptions1 or where there is any mechanical difficulty in reading4 ,people who like to be read to1 have generally not much the matter with them2 while in fevers1 or where there is much irritability of brain1 the effort of listening to reading aloud has often brought on delirium4 ,i speak with great diffidence2 because there is an almost universal impression that it is sparing the sick to read aloud to them4 ,but two things are certain3-- ,sidenote3 ,read aloud slowly1 distinctly1 and steadily to the sick4 7#a47 ,if there is some matter which must be read to a sick person1 do it slowly4 ,people often think that the way to get it over with least fatigue to him is to get it over in least time4 ,they gabble2 they plunge and gallop through the reading4 ,there never was a greater mistake4 ,houdin1 the conjuror1 says that the way to make a story seem short is to tell it slowly4 ,so it is with reading to the sick4 ,i have often heard a patient say to such a mistaken reader1 ,don't read it to me2 tell it me4#d ,unconsciously he is aware that this will regulate the plunging1 the reading with unequal paces1 slurring over one part1 instead of leaving it out altogether1 if it is unimportant1 and mumbling another4 ,if the reader lets his own attention wander1 and then stops to read up to himself1 or finds he has read the wrong bit1 then it is all over with the poor patient's chance of not suffering4 ,very few people know how to read to the sick2 very few read aloud as pleasantly even as they speak4 ,in reading they sing1 they hesitate1 they stammer1 they hurry1 they mumble2 when in speaking they do none of these things4 ,reading aloud to the sick ought always to be rather slow1 and exceedingly distinct1 but not mouthing--rather monotonous1 but not sing song--rather loud but not noisy--and1 above all1 not too long4 ,be very sure of what your patient can bear4 ,sidenote3 ,never read aloud by fits and starts to the sick4 7#b47 ,the extraordinary habit of reading to oneself in a sick room1 and reading aloud to the patient any bits which will amuse him or more often the reader1 is unaccountably thoughtless4 ,what do you think the patient is thinking of during your gaps of non-reading8 ,do you think that he amuses himself upon what you have read for precisely the time it pleases you to go on reading to yourself1 and that his attention is ready for something else at precisely the time it pleases you to begin reading again8 ,whether the person thus read to be sick or well1 whether he be doing nothing or doing something else while being thus read to1 the self-absorption and want of observation of the person who does it1 is equally difficult to understand--although very often the readee is too amiable to say how much it hurts him4 ,sidenote3 ,people overhead4 ,one thing more3--,from1 the flimsy manner in which most modern houses are built1 where every step on the stairs1 and along the floors1 is felt all over the house2 the higher the story1 the greater the vibration4 ,it is inconceivable how much the sick suffer by having anybody overhead4 ,in the solidly built old houses1 which1 fortunately1 most hospitals are1 the noise and shaking is comparatively trifling4 ,but it is a serious cause of suffering1 in lightly built houses1 and with the irritability peculiar to some diseases4 ,better far put such patients at the top of the house1 even with the additional fatigue of stairs1 if you cannot secure the room above them being untenanted2 you may otherwise bring on a state of restlessness which no opium will subdue4 ,do not neglect the warning1 when a patient tells you that he ,feels every step above him to cross his heart4 ,remember that every noise a patient cannot see partakes of the character of suddenness to him2 and ,i am persuaded that patients with these peculiarly irritable nerves1 are positively less injured by having persons in the same room with them than overhead1 or separated by only a thin compartment4 ,any sacrifice to secure silence for these cases is worth while1 because no air1 however good1 no attendance1 however careful1 will do anything for such cases without quiet4 ,sidenote3 ,music4 ,,note4--,the effect of music upon the sick has been scarcely at all noticed4 ,in fact1 its expensiveness1 as it is now1 makes any general application of it quite out of the question4 ,i will only remark here1 that wind instruments1 including the human voice1 and stringed instruments1 capable of continuous sound1 have generally a beneficent effect--while the piano-forte1 with such instruments as have no continuity of sound1 has just the reverse4 ,the finest piano-forte playing will damage the sick1 while an air1 like ,home1 sweet home1 or ,assisa a pi d'un salice1 on the most ordinary grinding organ1 will sensibly soothe them--and this quite independent of association4 ,,footnotes3 #a ,sidenote3 ,burning of the crinolines4 ,fortunate it is if her skirts do not catch fire--and if the nurse does not give herself up a sacrifice together with her patient1 to be burnt in her own petticoats4 ,i wish the ,registrar-,general would tell us the exact number of deaths by burning occasioned by this absurd and hideous custom4 ,but if people will be stupid1 let them take measures to protect themselves from their own stupidity--measures which every chemist knows1 such as putting alum into starch1 which prevents starched articles of dress from blazing up4 ,sidenote3 ,indecency of the crinolines4 ,i wish1 too1 that people who wear crinoline could see the indecency of their own dress as other people see it4 ,a respectable elderly woman stooping forward1 invested in crinoline1 exposes quite as much of her own person to the patient lying in the room as any opera dancer does on the stage4 ,but no one will ever tell her this unpleasant truth4 #b ,sidenote3 ,never speak to a patient in the act of moving4 ,it is absolutely essential that a nurse should lay this down as a positive rule to herself1 never to speak to any patient who is standing or moving1 as long as she exercises so little observation as not to know when a patient cannot bear it4 ,i am satisfied that many of the accidents which happen from feeble patients tumbling down stairs1 fainting after getting up1 c41 happen solely from the nurse popping out of a door to speak to the patient just at that moment2 or from his fearing that she will do so4 ,and that if the patient were even left to himself1 till he can sit down1 such accidents would much seldomer occur4 ,if the nurse accompanies the patient1 let her not call upon him to speak4 ,it is incredible that nurses cannot picture to themselves the strain upon the heart1 the lungs1 and the brain1 which the act of moving is to any feeble patient4 #c ,sidenote3 ,careless observation of the results of careless ,visits4 ,as an old experienced nurse1 ,i do most earnestly deprecate all such careless words4 ,i have known patients delirious all night1 after seeing a visitor who called them better1 thought they only wanted a little amusement1 and who came again1 saying1 ,i hope you were not the worse for my visit1 neither waiting for an answer1 nor even looking at the case4 ,no real patient will ever say1 ,yes1 but ,i was a great deal the worse4 ,it is not1 however1 either death or delirium of which1 in these cases1 there is most danger to the patient4 ,unperceived consequences are far more likely to ensue4 ,you will have impunity--the poor patient will not4 ,that is1 the patient will suffer1 although neither he nor the inflictor of the injury will attribute it to its real cause4 ,it will not be directly traceable1 except by a very careful observant nurse4 ,the patient will often not even mention what has done him most harm4 #d ,sidenote3 ,the sick would rather be told a thing than have it read to them4 ,sick children1 if not too shy to speak1 will always express this wish4 ,they invariably prefer a story to be told to them1 rather than read to them4 ,v4 ,,variety4 ,sidenote3 ,variety a means of recovery4 ,to any but an old nurse1 or an old patient1 the degree would be quite inconceivable to which the nerves of the sick suffer from seeing the same walls1 the same ceiling1 the same surroundings during a long confinement to one or two rooms4 ,the superior cheerfulness of persons suffering severe paroxysms of pain over that of persons suffering from nervous debility has often been remarked upon1 and attributed to the enjoyment of the former of their intervals of respite4 ,i incline to think that the majority of cheerful cases is to be found among those patients who are not confined to one room1 whatever their suffering1 and that the majority of depressed cases will be seen among those subjected to a long monotony of objects about them4 ,the nervous frame really suffers as much from this as the digestive organs from long monotony of diet1 as e4g4 the soldier from his twenty-one years' boiled beef4 ,sidenote3 ,colour and form means of recovery4 ,the effect in sickness of beautiful objects1 of variety of objects1 and especially of brilliancy of colour is hardly at all appreciated4 ,such cravings are usually called the fancies of patients4 ,and often doubtless patients have fancies1 as e4g4 when they desire two contradictions4 ,but much more often1 their 7so called7 fancies are the most valuable indications of what is necessary for their recovery4 ,and it would be well if nurses would watch these 7so called7 fancies closely4 ,i have seen1 in fevers 7and felt1 when ,i was a fever patient myself71 the most acute suffering produced from the patient 7in a hut7 not being able to see out of window1 and the knots in the wood being the only view4 ,i shall never forget the rapture of fever patients over a bunch of bright-coloured flowers4 ,i remember 7in my own case7 a nosegay of wild flowers being sent me1 and from that moment recovery becoming more rapid4 ,sidenote3 ,this is no fancy4 ,people say the effect is only on the mind4 ,it is no such thing4 ,the effect is on the body1 too4 ,little as we know about the way in which we are affected by form1 by colour1 and light1 we do know this1 that they have an actual physical effect4 ,variety of form and brilliancy of colour in the objects presented to patients are actual means of recovery4 ,but it must be slow variety1 e4g41 if you shew a patient ten or twelve engravings successively1 ten-to-one that he does not become cold and faint1 or feverish1 or even sick2 but hang one up opposite him1 one on each successive day1 or week1 or month1 and he will revel in the variety4 ,sidenote3 ,flowers4 ,the folly and ignorance which reign too often supreme over the sick-room1 cannot be better exemplified than by this4 ,while the nurse will leave the patient stewing in a corrupting atmosphere1 the best ingredient of which is carbonic acid2 she will deny him1 on the plea of unhealthiness1 a glass of cut-flowers1 or a growing plant4 ,now1 no one ever saw overcrowding by plants in a room or ward4 ,and the carbonic acid they give off at nights would not poison a fly4 ,nay1 in overcrowded rooms1 they actually absorb carbonic acid and give off oxygen4 ,cut-flowers also decompose water and produce oxygen gas4 ,it is true there are certain flowers1 e4g4 lilies1 the smell of which is said to depress the nervous system4 ,these are easily known by the smell1 and can be avoided4 ,sidenote3 ,effect of body on mind4 ,volumes are now written and spoken upon the effect of the mind upon the body4 ,much of it is true4 ,but ,i wish a little more was thought of the effect of the body on the mind4 ,you who believe yourselves overwhelmed with anxieties1 but are able every day to walk up ,regent-street1 or out in the country1 to take your meals with others in other rooms1 c41 c41 you little know how much your anxieties are thereby lightened2 you little know how intensified they become to those who can have no change2#a how the very walls of their sick rooms seem hung with their cares2 how the ghosts of their troubles haunt their beds2 how impossible it is for them to escape from a pursuing thought without some help from variety4 ,a patient can just as much move his leg when it is fractured as change his thoughts when no external help from variety is given him4 ,this is1 indeed1 one of the main sufferings of sickness2 just as the fixed posture is one of the main sufferings of the broken limb4 ,sidenote3 ,help the sick to vary their thoughts4 ,it is an ever recurring wonder to see educated people1 who call themselves nurses1 acting thus4 ,they vary their own objects1 their own employments1 many times a day2 and while nursing 767 some bed-ridden sufferer1 they let him lie there staring at a dead wall1 without any change of object to enable him to vary his thoughts2 and it never even occurs to them1 at least to move his bed so that he can look out of window4 ,no1 the bed is to be always left in the darkest1 dullest1 remotest1 part of the room4#b ,i think it is a very common error among the well to think that with a little more self-control the sick might1 if they choose1 dismiss painful thoughts which aggravate their disease1 c4 ,believe me1 almost any sick person1 who behaves decently well1 exercises more self-control every moment of his day than you will ever know till you are sick yourself4 ,almost every step that crosses his room is painful to him2 almost every thought that crosses his brain is painful to him3 and if he can speak without being savage1 and look without being unpleasant1 he is exercising self-control4 ,suppose you have been up all night1 and instead of being allowed to have your cup of tea1 you were to be told that you ought to exercise self-control1 what should you say8 ,now1 the nerves of the sick are always in the state that yours are in after you have been up all night4 ,sidenote3 ,supply to the sick the defect of manual labour4 ,we will suppose the diet of the sick to be cared for4 ,then1 this state of nerves is most frequently to be relieved by care in affording them a pleasant view1 a judicious variety as to flowers1#c and pretty things4 ,light by itself will often relieve it4 ,the craving for the return of day1 which the sick so constantly evince1 is generally nothing but the desire for light1 the remembrance of the relief which a variety of objects before the eye affords to the harassed sick mind4 ,again1 every man and every woman has some amount of manual employment1 excepting a few fine ladies1 who do not even dress themselves1 and who are virtually in the same category1 as to nerves1 as the sick4 ,now1 you can have no idea of the relief which manual labour is to you--of the degree to which the deprivation of manual employment increases the peculiar irritability from which many sick suffer4 ,a little needle-work1 a little writing1 a little cleaning1 would be the greatest relief the sick could have1 if they could do it2 these are the greatest relief to you1 though you do not know it4 ,reading1 though it is often the only thing the sick can do1 is not this relief4 ,bearing this in mind1 bearing in mind that you have all these varieties of employment which the sick cannot have1 bear also in mind to obtain for them all the varieties which they can enjoy4 ,i need hardly say that ,i am well aware that excess in needle-work1 in writing1 in any other continuous employment1 will produce the same irritability that defect in manual employment 7as one cause7 produces in the sick4 ,,footnotes3 #a ,sidenote3 ,sick suffer to excess from mental as well as bodily pain4 ,it is a matter of painful wonder to the sick themselves1 how much painful ideas predominate over pleasurable ones in their impressions2 they reason with themselves2 they think themselves ungrateful2 it is all of no use4 ,the fact is1 that these painful impressions are far better dismissed by a real laugh1 if you can excite one by books or conversation1 than by any direct reasoning2 or if the patient is too weak to laugh1 some impression from nature is what he wants4 ,i have mentioned the cruelty of letting him stare at a dead wall4 ,in many diseases1 especially in convalescence from fever1 that wall will appear to make all sorts of faces at him2 now flowers never do this4 ,form1 colour1 will free your patient from his painful ideas better than any argument4 #b ,sidenote3 ,desperate desire in the sick to see out of window4 ,i remember a case in point4 ,a man received an injury to the spine1 from an accident1 which after a long confinement ended in death4 ,he was a workman--had not in his composition a single grain of what is called enthusiasm for nature--but he was desperate to see once more out of window4 ,his nurse actually got him on her back1 and managed to perch him up at the window for an instant1 to see out4 ,the consequence to the poor nurse was a serious illness1 which nearly proved fatal4 ,the man never knew it2 but a great many other people did4 ,yet the consequence in none of their minds1 so far as ,i know1 was the conviction that the craving for variety in the starving eye1 is just as desperate as that of food in the starving stomach1 and tempts the famishing creature in either case to steal for its satisfaction4 ,no other word will express it but desperation4 ,and it sets the seal of ignorance and stupidity just as much on the governors and attendants of the sick if they do not provide the sick-bed with a view of some kind1 as if they did not provide the hospital with a kitchen4 #c ,sidenote3 ,physical effect of colour4 ,no one who has watched the sick can doubt the fact1 that some feel stimulus from looking at scarlet flowers1 exhaustion from looking at deep blue1 c4 ,,vi4 ,,taking ,,food4 ,sidenote3 ,want of attention to hours of taking food4 ,every careful observer of the sick will agree in this that thousands of patients are annually starved in the midst of plenty1 from want of attention to the ways which alone make it possible for them to take food4 ,this want of attention is as remarkable in those who urge upon the sick to do what is quite impossible to them1 as in the sick themselves who will not make the effort to do what is perfectly possible to them4 ,for instance1 to the large majority of very weak patients it is quite impossible to take any solid food before #aa ,a4,m41 nor then1 if their strength is still further exhausted by fasting till that hour4 ,for weak patients have generally feverish nights and1 in the morning1 dry mouths2 and1 if they could eat with those dry mouths1 it would be the worse for them4 ,a spoonful of beef-tea1 of arrowroot and wine1 of egg flip1 every hour1 will give them the requisite nourishment1 and prevent them from being too much exhausted to take at a later hour the solid food1 which is necessary for their recovery4 ,and every patient who can swallow at all can swallow these liquid things1 if he chooses4 ,but how often do we hear a mutton-chop1 an egg1 a bit of bacon1 ordered to a patient for breakfast1 to whom 7as a moment's consideration would show us7 it must be quite impossible to masticate such things at that hour4 ,again1 a nurse is ordered to give a patient a tea-cup full of some article of food every three hours4 ,the patient's stomach rejects it4 ,if so1 try a table-spoon full every hour2 if this will not do1 a tea-spoon full every quarter of an hour4 ,i am bound to say1 that ,i think more patients are lost by want of care and ingenuity in these momentous minutiae in private nursing than in public hospitals4 ,and ,i think there is more of the entente cordiale to assist one another's hands between the doctor and his head nurse in the latter institutions1 than between the doctor and the patient's friends in the private house4 ,sidenote3 ,life often hangs upon minutes in taking food4 ,if we did but know the consequences which may ensue1 in very weak patients1 from ten minutes' fasting or repletion 7,i call it repletion when they are obliged to let too small an interval elapse between taking food and some other exertion1 owing to the nurse's unpunctuality71 we should be more careful never to let this occur4 ,in very weak patients there is often a nervous difficulty of swallowing1 which is so much increased by any other call upon their strength that1 unless they have their food punctually at the minute1 which minute again must be arranged so as to fall in with no other minute's occupation1 they can take nothing till the next respite occurs--so that an unpunctuality or delay of ten minutes may very well turn out to be one of two or three hours4 ,and why is it not as easy to be punctual to a minute8 ,life often literally hangs upon these minutes4 ,in acute cases1 where life or death is to be determined in a few hours1 these matters are very generally attended to1 especially in ,hospitals2 and the number of cases is large where the patient is1 as it were1 brought back to life by exceeding care on the part of the ,doctor or ,nurse1 or both1 in ordering and giving nourishment with minute selection and punctuality4 ,sidenote3 ,patients often starved to death in chronic cases4 ,but in chronic cases1 lasting over months and years1 where the fatal issue is often determined at last by mere protracted starvation1 ,i had rather not enumerate the instances which ,i have known where a little ingenuity1 and a great deal of perseverance1 might1 in all probability1 have averted the result4 ,the consulting the hours when the patient can take food1 the observation of the times1 often varying1 when he is most faint1 the altering seasons of taking food1 in order to anticipate and prevent such times--all this1 which requires observation1 ingenuity1 and perseverance 7and these really constitute the good ,nurse71 might save more lives than we wot of4 ,sidenote3 ,food never to be left by the patient's side4 ,to leave the patient's untasted food by his side1 from meal to meal1 in hopes that he will eat it in the interval is simply to prevent him from taking any food at all4 ,i have known patients literally incapacitated from taking one article of food after another1 by this piece of ignorance4 ,let the food come at the right time1 and be taken away1 eaten or uneaten1 at the right time2 but never let a patient have something always standing by him1 if you don't wish to disgust him of everything4 ,on the other hand1 ,i have known a patient's life saved 7he was sinking for want of food7 by the simple question1 put to him by the doctor1 ,but is there no hour when you feel you could eat8 ,oh1 yes1 he said1 ,i could always take something at ---- o'clock and ---- o'clock4 ,the thing was tried and succeeded4 ,patients very seldom1 however1 can tell this2 it is for you to watch and find it out4 ,sidenote3 ,patient had better not see more food than his own4 ,a patient should1 if possible1 not see or smell either the food of others1 or a greater amount of food than he himself can consume at one time1 or even hear food talked about or see it in the raw state4 ,i know of no exception to the above rule4 ,the breaking of it always induces a greater or less incapacity of taking food4 ,in hospital wards it is of course impossible to observe all this2 and in single wards1 where a patient must be continuously and closely watched1 it is frequently impossible to relieve the attendant1 so that his or her own meals can be taken out of the ward4 ,but it is not the less true that1 in such cases1 even where the patient is not himself aware of it1 his possibility of taking food is limited by seeing the attendant eating meals under his observation4 ,in some cases the sick are aware of it1 and complain4 ,a case where the patient was supposed to be insensible1 but complained as soon as able to speak1 is now present to my recollection4 ,remember1 however1 that the extreme punctuality in well-ordered hospitals1 the rule that nothing shall be done in the ward while the patients are having their meals1 go far to counterbalance what unavoidable evil there is in having patients together4 ,i have often seen the private nurse go on dusting or fidgeting about in a sick room all the while the patient is eating1 or trying to eat4 ,that the more alone an invalid can be when taking food1 the better1 is unquestionable2 and1 even if he must be fed1 the nurse should not allow him to talk1 or talk to him1 especially about food1 while eating4 ,when a person is compelled1 by the pressure of occupation1 to continue his business while sick1 it ought to be a rule ,,without ,,any ,,exception ,,whatever1 that no one shall bring business to him or talk to him while he is taking food1 nor go on talking to him on interesting subjects up to the last moment before his meals1 nor make an engagement with him immediately after1 so that there be any hurry of mind while taking them4 ,upon the observance of these rules1 especially the first1 often depends the patient's capability of taking food at all1 or1 if he is amiable and forces himself to take food1 of deriving any nourishment from it4 ,sidenote3 ,you cannot be too careful as to quality in sick diet4 ,a nurse should never put before a patient milk that is sour1 meat or soup that is turned1 an egg that is bad1 or vegetables underdone4 ,yet often ,i have seen these things brought in to the sick in a state perfectly perceptible to every nose or eye except the nurse's4 ,it is here that the clever nurse appears2 she will not bring in the peccant article1 but1 not to disappoint the patient1 she will whip up something else in a few minutes4 ,remember that sick cookery should half do the work of your poor patient's weak digestion4 ,but if you further impair it with your bad articles1 ,i know not what is to become of him or of it4 ,if the nurse is an intelligent being1 and not a mere carrier of diets to and from the patient1 let her exercise her intelligence in these things4 ,how often we have known a patient eat nothing at all in the day1 because one meal was left untasted 7at that time he was incapable of eating71 at another the milk was sour1 the third was spoiled by some other accident4 ,and it never occurred to the nurse to extemporize some expedient1--it never occurred to her that as he had had no solid food that day he might eat a bit of toast 7say7 with his tea in the evening1 or he might have some meal an hour earlier4 ,a patient who cannot touch his dinner at two1 will often accept it gladly1 if brought to him at seven4 ,but somehow nurses never think of these things4 ,one would imagine they did not consider themselves bound to exercise their judgment2 they leave it to the patient4 ,now ,i am quite sure that it is better for a patient rather to suffer these neglects than to try to teach his nurse to nurse him1 if she does not know how4 ,it ruffles him1 and if he is ill he is in no condition to teach1 especially upon himself4 ,the above remarks apply much more to private nursing than to hospitals4 ,sidenote3 ,nurse must have some rule of thought about her patient's diet4 ,i would say to the nurse1 have a rule of thought about your patient's diet2 consider1 remember how much he has had1 and how much he ought to have to-day4 ,generally1 the only rule of the private patient's diet is what the nurse has to give4 ,it is true she cannot give him what she has not got2 but his stomach does not wait for her convenience1 or even her necessity4#a ,if it is used to having its stimulus at one hour to-day1 and to-morrow it does not have it1 because she has failed in getting it1 he will suffer4 ,she must be always exercising her ingenuity to supply defects1 and to remedy accidents which will happen among the best contrivers1 but from which the patient does not suffer the less1 because they cannot be helped4 ,sidenote3 ,keep your patient's cup dry underneath4 ,one very minute caution1--take care not to spill into your patient's saucer1 in other words1 take care that the outside bottom rim of his cup shall be quite dry and clean2 if1 every time he lifts his cup to his lips1 he has to carry the saucer with it1 or else to drop the liquid upon1 and to soil his sheet1 or his bed-gown1 or pillow1 or if he is sitting up1 his dress1 you have no idea what a difference this minute want of care on your part makes to his comfort and even to his willingness for food4 ,,footnote3 #a ,sidenote3 ,nurse must have some rule of time about the patient's diet4 ,why1 because the nurse has not got some food to-day which the patient takes1 can the patient wait four hours for food to-day1 who could not wait two hours yesterday8 ,yet this is the only logic one generally hears4 ,on the other hand1 the other logic1 viz41 of the nurse giving a patient a thing because she has got it1 is equally fatal4 ,if she happens to have fresh jelly1 or fresh fruit1 she will frequently give it to the patient half an hour after his dinner1 or at his dinner1 when he cannot possibly eat that and the broth too--or worse still1 leave it by his bed-side till he is so sickened with the sight of it1 that he cannot eat it at all4 ,,vii4 ,,what ,,food8 ,sidenote3 ,common errors in diet4 ,sidenote3 ,beef tea4 ,sidenote3 ,eggs4 ,sidenote3 ,meat without vegetables4 ,sidenote3 ,arrowroot4 ,i will mention one or two of the most common errors among women in charge of sick respecting sick diet4 ,one is the belief that beef tea is the most nutritive of all articles4 ,now1 just try and boil down a lb4 of beef into beef tea1 evaporate your beef tea1 and see what is left of your beef4 ,you will find that there is barely a teaspoonful of solid nourishment to half a pint of water in beef tea2--nevertheless there is a certain reparative quality in it1 we do not know what1 as there is in tea2--but it may safely be given in almost any inflammatory disease1 and is as little to be depended upon with the healthy or convalescent where much nourishment is required4 ,again1 it is an ever ready saw that an egg is equivalent to a lb4 of meat1--whereas it is not at all so4 ,also1 it is seldom noticed with how many patients1 particularly of nervous or bilious temperament1 eggs disagree4 ,all puddings made with eggs1 are distasteful to them in consequence4 ,an egg1 whipped up with wine1 is often the only form in which they can take this kind of nourishment4 ,again1 if the patient has attained to eating meat1 it is supposed that to give him meat is the only thing needful for his recovery2 whereas scorbutic sores have been actually known to appear among sick persons living in the midst of plenty in ,england1 which could be traced to no other source than this1 viz43 that the nurse1 depending on meat alone1 had allowed the patient to be without vegetables for a considerable time1 these latter being so badly cooked that he always left them untouched4 ,arrowroot is another grand dependence of the nurse4 ,as a vehicle for wine1 and as a restorative quickly prepared1 it is all very well4 ,but it is nothing but starch and water4 ,flour is both more nutritive1 and less liable to ferment1 and is preferable wherever it can be used4 ,sidenote3 ,milk1 butter1 cream1 c4 ,again1 milk and the preparations from milk1 are a most important article of food for the sick4 ,butter is the lightest kind of animal fat1 and though it wants the sugar and some of the other elements which there are in milk1 yet it is most valuable both in itself and in enabling the patient to eat more bread4 ,flour1 oats1 groats1 barley1 and their kind1 are1 as we have already said1 preferable in all their preparations to all the preparations of arrowroot1 sago1 tapioca1 and their kind4 ,cream1 in many long chronic diseases1 is quite irreplaceable by any other article whatever4 ,it seems to act in the same manner as beef tea1 and to most it is much easier of digestion than milk4 ,in fact1 it seldom disagrees4 ,cheese is not usually digestible by the sick1 but it is pure nourishment for repairing waste2 and ,i have seen sick1 and not a few either1 whose craving for cheese shewed how much it was needed by them4#a ,but1 if fresh milk is so valuable a food for the sick1 the least change or sourness in it1 makes it of all articles1 perhaps1 the most injurious2 diarrhoea is a common result of fresh milk allowed to become at all sour4 ,the nurse therefore ought to exercise her utmost care in this4 ,in large institutions for the sick1 even the poorest1 the utmost care is exercised4 ,wenham ,lake ice is used for this express purpose every summer1 while the private patient1 perhaps1 never tastes a drop of milk that is not sour1 all through the hot weather1 so little does the private nurse understand the necessity of such care4 ,yet1 if you consider that the only drop of real nourishment in your patient's tea is the drop of milk1 and how much almost all ,english patients depend upon their tea1 you will see the great importance of not depriving your patient of this drop of milk4 ,buttermilk1 a totally different thing1 is often very useful1 especially in fevers4 ,sidenote3 ,sweet things4 ,in laying down rules of diet1 by the amounts of solid nutriment in different kinds of food1 it is constantly lost sight of what the patient requires to repair his waste1 what he can take and what he can't4 ,you cannot diet a patient from a book1 you cannot make up the human body as you would make up a prescription1--so many parts carboniferous1 so many parts nitrogenous will constitute a perfect diet for the patient4 ,the nurse's observation here will materially assist the doctor--the patient's fancies will materially assist the nurse4 ,for instance1 sugar is one of the most nutritive of all articles1 being pure carbon1 and is particularly recommended in some books4 ,but the vast majority of all patients in ,england1 young and old1 male and female1 rich and poor1 hospital and private1 dislike sweet things1--and while ,i have never known a person take to sweets when he was ill who disliked them when he was well1 ,i have known many fond of them when in health1 who in sickness would leave off anything sweet1 even to sugar in tea1--sweet puddings1 sweet drinks1 are their aversion2 the furred tongue almost always likes what is sharp or pungent4 ,scorbutic patients are an exception1 they often crave for sweetmeats and jams4 ,sidenote3 ,jelly4 ,jelly is another article of diet in great favour with nurses and friends of the sick2 even if it could be eaten solid1 it would not nourish1 but it is simply the height of folly to take #a_/h oz4 of gelatine and make it into a certain bulk by dissolving it in water and then to give it to the sick1 as if the mere bulk represented nourishment4 ,it is now known that jelly does not nourish1 that it has a tendency to produce diarrhoea1-- and to trust to it to repair the waste of a diseased constitution is simply to starve the sick under the guise of feeding them4 ,if #ajj spoonfuls of jelly were given in the course of the day1 you would have given one spoonful of gelatine1 which spoonful has no nutritive power whatever4 ,and1 nevertheless1 gelatine contains a large quantity of nitrogen1 which is one of the most powerful elements in nutrition2 on the other hand1 beef tea may be chosen as an illustration of great nutrient power in sickness1 co-existing with a very small amount of solid nitrogenous matter4 ,sidenote3 ,beef tea ,dr4 ,christison says that every one will be struck with the readiness with which certain classes of patients will often take diluted meat juice or beef tea repeatedly1 when they refuse all other kinds of food4 ,this is particularly remarkable in cases of gastric fever1 in which1 he says1 little or nothing else besides beef tea or diluted meat juice has been taken for weeks or even months1 and yet a pint of beef tea contains scarcely #a_/d oz4 of anything but water1--the result is so striking that he asks what is its mode of action8 ,not simply nutrient-- #a_/d oz4 of the most nutritive material cannot nearly replace the daily wear and tear of the tissues in any circumstances4 ,possibly1 he says1 it belongs to a new denomination of remedies4 ,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 matter4 ,the reason why jelly should be innutritious and beef tea nutritious to the sick1 is a secret yet undiscovered1 but it clearly shows that careful observation of the sick is the only clue to the best dietary4 ,sidenote3 ,observation1 not chemistry1 must decide sick diet4 ,chemistry has as yet afforded little insight into the dieting of sick4 ,all that chemistry can tell us is the amount of carboniferous or nitrogenous elements discoverable in different dietetic articles4 ,it has given us lists of dietetic substances1 arranged in the order of their richness in one or other of these principles2 but that is all4 ,in the great majority of cases1 the stomach of the patient is guided by other principles of selection than merely the amount of carbon or nitrogen in the diet4 ,no doubt1 in this as in other things1 nature has very definite rules for her guidance1 but these rules can only be ascertained by the most careful observation at the bedside4 ,she there teaches us that living chemistry1 the chemistry of reparation1 is something different from the chemistry of the laboratory4 ,organic chemistry is useful1 as all knowledge is1 when we come face to face with nature2 but it by no means follows that we should learn in the laboratory any one of the reparative processes going on in disease4 ,again1 the nutritive power of milk and of the preparations from milk1 is very much undervalued2 there is nearly as much nourishment in half a pint of milk as there is in a quarter of a lb4 of meat4 ,but this is not the whole question or nearly the whole4 ,the main question is what the patient's stomach can assimilate or derive nourishment from1 and of this the patient's stomach is the sole judge4 ,chemistry cannot tell this4 ,the patient's stomach must be its own chemist4 ,the diet which will keep the healthy man healthy1 will kill the sick one4 ,the same beef which is the most nutritive of all meat and which nourishes the healthy man1 is the least nourishing of all food to the sick man1 whose half-dead stomach can assimilate no part of it1 that is1 make no food out of it4 ,on a diet of beef tea healthy men on the other hand speedily lose their strength4 ,sidenote3 ,home-made bread4 ,i have known patients live for many months without touching bread1 because they could not eat baker's bread4 ,these were mostly country patients1 but not all4 ,home-made bread or brown bread is a most important article of diet for many patients4 ,the use of aperients may be entirely superseded by it4 ,oat cake is another4 ,sidenote3 ,sound observation has scarcely yet been brought to bear on sick diet4 ,to watch for the opinions1 then1 which the patient's stomach gives1 rather than to read analyses of foods1 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 breathe4 ,now the medical man who sees the patient only once a day or even only once or twice a week1 cannot possibly tell this without the assistance of the patient himself1 or of those who are in constant observation on the patient4 ,the utmost the medical man can tell is whether the patient is weaker or stronger at this visit than he was at the last visit4 ,i should therefore say that incomparably the most important office of the nurse1 after she has taken care of the patient's air1 is to take care to observe the effect of his food1 and report it to the medical attendant4 ,it is quite incalculable the good that would certainly come from such sound and close observation in this almost neglected branch of nursing1 or the help it would give to the medical man4 ,sidenote3 ,tea and coffee4 ,a great deal too much against tea#b is said by wise people1 and a great deal too much of tea is given to the sick by foolish people4 ,when you see the natural and almost universal craving in ,english sick for their tea1 you cannot but feel that nature knows what she is about4 ,but a little tea or coffee restores them quite as much as a great deal1 and a great deal of tea and especially of coffee impairs the little power of digestion they have4 ,yet a nurse1 because she sees how one or two cups of tea or coffee restores her patient1 thinks that three or four cups will do twice as much4 ,this is not the case at all2 it is however certain that there is nothing yet discovered which is a substitute to the ,english patient for his cup of tea2 he can take it when he can take nothing else1 and he often can't take anything else if he has it not4 ,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 night1 instead of tea4 ,if you give it at #e or #f o'clock in the morning1 he may even sometimes fall asleep after it1 and get perhaps his only two or three hours' sleep during the twenty-four4 ,at the same time you never should give tea or coffee to the sick1 as a rule1 after #e o'clock in the afternoon4 ,sleeplessness in the early night is from excitement generally and is increased by tea or coffee2 sleeplessness which continues to the early morning is from exhaustion often1 and is relieved by tea4 ,the only ,english patients ,i have ever known refuse tea1 have been typhus cases1 and the first sign of their getting better was their craving again for tea4 ,in general1 the dry and dirty tongue always prefers tea to coffee1 and will quite decline milk1 unless with tea4 ,coffee is a better restorative than tea1 but a greater impairer of the digestion4 ,let the patient's taste decide4 ,you will say that1 in cases of great thirst1 the patient's craving decides that it will drink a great deal of tea1 and that you cannot help it4 ,but in these cases be sure that the patient requires diluents for quite other purposes than quenching the thirst2 he wants a great deal of some drink1 not only of tea1 and the doctor will order what he is to have1 barley water or lemonade1 or soda water and milk1 as the case may be4 ,lehman1 quoted by ,dr4 ,christison1 says that1 among the well and active the infusion of #a oz4 of roasted coffee daily will diminish the waste going on in the body by one-fourth1 ,transcriber's note3 ,quotes as in the original and ,dr4 ,christison adds that tea has the same property4 ,now this is actual experiment4 ,lehman weighs the man and finds the fact from his weight4 ,it is not deduced from any analysis of food4 ,all experience among the sick shows the same thing4#c ,sidenote3 ,cocoa4 ,cocoa is often recommended to the sick in lieu of tea or coffee4 ,but independently of the fact that ,english sick very generally dislike cocoa1 it has quite a different effect from tea or coffee4 ,it is an oily starchy nut having no restorative power at all1 but simply increasing fat4 ,it is pure mockery of the sick1 therefore1 to call it a substitute for tea4 ,for any renovating stimulus it has1 you might just as well offer them chestnuts instead of tea4 ,sidenote3 ,bulk4 ,an almost universal error among nurses is in the bulk of the food and especially the drinks they offer to their patients4 ,suppose a patient ordered #d oz4 brandy during the day1 how is he to take this if you make it into four pints with diluting it8 ,the same with tea and beef tea1 with arrowroot1 milk1 c4 ,you have not increased the nourishment1 you have not increased the renovating power of these articles1 by increasing their bulk1--you have very likely diminished both by giving the patient's digestion more to do1 and most likely of all1 the patient will leave half of what he has been ordered to take1 because he cannot swallow the bulk with which you have been pleased to invest it4 ,it requires very nice observation and care 7and meets with hardly any7 to determine what will not be too thick or strong for the patient to take1 while giving him no more than the bulk which he is able to swallow4 ,,footnotes3 #a ,sidenote3 ,intelligent cravings of particular sick for particular articles of diet4 ,in the diseases produced by bad food1 such as scorbutic dysentery and diarrhoea1 the patient's stomach often craves for and digests things1 some of which certainly would be laid down in no dietary that ever was invented for sick1 and especially not for such sick4 ,these are fruit1 pickles1 jams1 gingerbread1 fat of ham or bacon1 suet1 cheese1 butter1 milk4 ,these cases ,i have seen not by ones1 nor by tens1 but by hundreds4 ,and the patient's stomach was right and the book was wrong4 ,the articles craved for1 in these cases1 might have been principally arranged under the two heads of fat and vegetable acids4 ,there is often a marked difference between men and women in this matter of sick feeding4 ,women's digestion is generally slower4 #b ,it is made a frequent recommendation to persons about to incur great exhaustion1 either from the nature of the service1 or from their being not in a state fit for it1 to eat a piece of bread before they go4 ,i wish the recommenders would themselves try the experiment of substituting a piece of bread for a cup of tea or coffee1 or beef-tea1 as a refresher4 ,they would find it a very poor comfort4 ,when soldiers have to set out fasting on fatiguing duty1 when nurses have to go fasting in to their patients1 it is a hot restorative they want1 and ought to have1 before they go1 not a cold bit of bread4 ,and dreadful have been the consequences of neglecting this4 ,if they can take a bit of bread with the hot cup of tea1 so much the better1 but not instead of it4 ,the fact that there is more nourishment in bread than in almost anything else1 has probably induced the mistake4 ,that it is a fatal mistake1 there is no doubt4 ,it seems1 though very little is known on the subject1 that what assimilates itself directly1 and with the least trouble of digestion with the human body1 is the best for the above circumstances4 ,bread requires two or three processes of assimilation1 before it becomes like the human body4 ,the almost universal testimony of ,english men and women who have undergone great fatigue1 such as riding long journeys without stopping1 or sitting up for several nights in succession1 is that they could do it best upon an occasional cup of tea--and nothing else4 ,let experience1 not theory1 decide upon this as upon all other things4 #c ,in making coffee1 it is absolutely necessary to buy it in the berry and grind it at home4 ,otherwise you may reckon upon its containing a certain amount of chicory1 at least4 ,this is not a question of the taste1 or of the wholesomeness of chicory4 ,it is that chicory has nothing at all of the properties for which you give coffee4 ,and therefore you may as well not give it4 ,again1 all laundresses1 mistresses of dairy-farms1 head nurses1 7,i speak of the good old sort only--women who unite a good deal of hard manual labour with the head-work necessary for arranging the day's business1 so that none of it shall tread upon the heels of something else17 set great value1 ,i have observed1 upon having a high-priced tea4 ,this is called extravagant4 ,but these women are extravagant in nothing else4 ,and they are right in this4 ,real tea-leaf tea alone contains the restorative they want2 which is not to be found in sloe-leaf tea4 ,the mistresses of houses1 who cannot even go over their own house once a day1 are incapable of judging for these women4 ,for they are incapable themselves1 to all appearance1 of the spirit of arrangement 7no small task7 necessary for managing a large ward or dairy4 ,,viii4 ,,bed ,,and ,,bedding4 ,sidenote3 ,feverishness a symptom of bedding4 ,a few words upon bedsteads and bedding2 and principally as regards patients who are entirely1 or almost entirely1 confined to bed4 ,feverishness is generally supposed to be a symptom of fever--in nine cases out of ten it is a symptom of bedding4#a ,the patient has had re-introduced into the body the emanations from himself which day after day and week after week saturate his unaired bedding4 ,how can it be otherwise8 ,look at the ordinary bed in which a patient lies4 ,sidenote3 ,uncleanliness of ordinary bedding4 ,if ,i were looking out for an example in order to show what not to do1 ,i should take the specimen of an ordinary bed in a private house3 a wooden bedstead1 two or even three mattresses piled up to above the height of a table2 a vallance attached to the frame--nothing but a miracle could ever thoroughly dry or air such a bed and bedding4 ,the patient must inevitably alternate between cold damp after his bed is made1 and warm damp before1 both saturated with organic matter#b1 and this from the time the mattresses are put under him till the time they are picked to pieces1 if this is ever done4 ,sidenote3 ,air your dirty sheets1 not only your clean ones4 ,if you consider that an adult in health exhales by the lungs and skin in the twenty-four hours three pints at least of moisture1 loaded with organic matter ready to enter into putrefaction2 that in sickness the quantity is often greatly increased1 the quality is always more noxious --just ask yourself next where does all this moisture go to8 ,chiefly into the bedding1 because it cannot go anywhere else4 ,and it stays there2 because1 except perhaps a weekly change of sheets1 scarcely any other airing is attempted4 ,a nurse will be careful to fidgetiness about airing the clean sheets from clean damp1 but airing the dirty sheets from noxious damp will never even occur to her4 ,besides this1 the most dangerous effluvia we know of are from the excreta of the sick--these are placed1 at least temporarily1 where they must throw their effluvia into the under side of the bed1 and the space under the bed is never aired2 it cannot be1 with our arrangements4 ,must not such a bed be always saturated1 and be always the means of re-introducing into the system of the unfortunate patient who lies in it1 that excrementitious matter to eliminate which from the body nature had expressly appointed the disease8 ,my heart always sinks within me when ,i hear the good house-wife1 of every class1 say1 ,i assure you the bed has been well slept in1 and ,i can only hope it is not true4 ,what8 is the bed already saturated with somebody else's damp before my patient comes to exhale in it his own damp8 ,has it not had a single chance to be aired8 ,no1 not one4 ,it has been slept in every night4 ,sidenote3 ,iron spring bedsteads the best4 ,sidenote3 ,comfort and cleanliness of two beds4 ,the only way of really nursing a real patient is to have an iron bedstead1 with rheocline springs1 which are permeable by the air up to the very mattress 7no vallance1 of course71 the mattress to be a thin hair one2 the bed to be not above #c-a_/b feet wide4 ,if the patient be entirely confined to his bed1 there should be two such bedsteads2 each bed to be made with mattress1 sheets1 blankets1 c41 complete--the patient to pass twelve hours in each bed2 on no account to carry his sheets with him4 ,the whole of the bedding to be hung up to air for each intermediate twelve hours4 ,of course there are many cases where this cannot be done at all--many more where only an approach to it can be made4 ,i am indicating the ideal of nursing1 and what ,i have actually had done4 ,but about the kind of bedstead there can be no doubt1 whether there be one or two provided4 ,sidenote3 ,bed not to be too wide4 ,there is a prejudice in favour of a wide bed--,i believe it to be a prejudice4 ,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 bed2 and a patient who is really very ill does not stray far in bed4 ,but it is said there is no room to put a tray down on a narrow bed4 ,no good nurse will ever put a tray on a bed at all4 ,if the patient can turn on his side1 he will eat more comfortably from a bed-side table2 and on no account whatever should a bed ever be higher than a sofa4 ,otherwise the patient feels himself out of humanity's reach2 he can get at nothing for himself3 he can move nothing for himself4 ,if the patient cannot turn1 a table over the bed is a better thing4 ,i need hardly say that a patient's bed should never have its side against the wall4 ,the nurse must be able to get easily to both sides of the bed1 and to reach easily every part of the patient without stretching--a thing impossible if the bed be either too wide or too high4 ,sidenote3 ,bed not to be too high4 ,when ,i see a patient in a room nine or ten feet high upon a bed between four and five feet high1 with his head1 when he is sitting up in bed1 actually within two or three feet of the ceiling1 ,i ask myself1 is this expressly planned to produce that peculiarly distressing feeling common to the sick1 viz41 as if the walls and ceiling were closing in upon them1 and they becoming sandwiches between floor and ceiling1 which imagination is not1 indeed1 here so far from the truth8 ,if1 over and above this1 the window stops short of the ceiling1 then the patient's head may literally be raised above the stratum of fresh air1 even when the window is open4 ,can human perversity any farther go1 in unmaking the process of restoration which ,god has made8 ,the fact is1 that the heads of sleepers or of sick should never be higher than the throat of the chimney1 which ensures their being in the current of best air4 ,and we will not suppose it possible that you have closed your chimney with a chimney-board4 ,if a bed is higher than a sofa1 the difference of the fatigue of getting in and out of bed will just make the difference1 very often1 to the patient 7who can get in and out of bed at all7 of being able to take a few minutes' exercise1 either in the open air or in another room4 ,it is so very odd that people never think of this1 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 are1 who only1 it is to be hoped1 get into bed once and out of bed once during the twenty-four hours4 ,sidenote3 ,nor in a dark place4 ,a patient's bed should always be in the lightest spot in the room2 and he should be able to see out of window4 ,sidenote3 ,nor a four poster with curtains4 ,i need scarcely say that the old four-post bed with curtains is utterly inadmissible1 whether for sick or well4 ,hospital bedsteads are in many respects very much less objectionable than private ones4 ,sidenote3 ,scrofula often a result of disposition of bed clothes4 ,there is reason to believe that not a few of the apparently unaccountable cases of scrofula among children proceed from the habit of sleeping with the head under the bed clothes1 and so inhaling air already breathed1 which is farther contaminated by exhalations from the skin4 ,patients are sometimes given to a similar habit1 and it often happens that the bed clothes are so disposed that the patient must necessarily breathe air more or less contaminated by exhalations from his skin4 ,a good nurse will be careful to attend to this4 ,it is an important part1 so to speak1 of ventilation4 ,sidenote3 ,bed sores4 ,it may be worth while to remark1 that where there is any danger of bed-sores a blanket should never be placed under the patient4 ,it retains damp and acts like a poultice4 ,sidenote3 ,heavy and impervious bed clothes4 ,never use anything but light ,whitney blankets as bed covering for the sick4 ,the heavy cotton impervious counterpane is bad1 for the very reason that it keeps in the emanations from the sick person1 while the blanket allows them to pass through4 ,weak patients are invariably distressed by a great weight of bed clothes1 which often prevents their getting any sound sleep whatever4 ,,note4--,one word about pillows4 ,every weak patient1 be his illness what it may1 suffers more or less from difficulty in breathing4 ,to take the weight of the body off the poor chest1 which is hardly up to its work as it is1 ought therefore to be the object of the nurse in arranging his pillows4 ,now what does she do and what are the consequences8 ,she piles the pillows one a-top of the other like a wall of bricks4 ,the head is thrown upon the chest4 ,and the shoulders are pushed forward1 so as not to allow the lungs room to expand4 ,the pillows1 in fact1 lean upon the patient1 not the patient upon the pillows4 ,it is impossible to give a rule for this1 because it must vary with the figure of the patient4 ,and tall patients suffer much more than short ones1 because of the drag of the long limbs upon the waist4 ,but the object is to support1 with the pillows1 the back below the breathing apparatus1 to allow the shoulders room to fall back1 and to support the head1 without throwing it forward4 ,the suffering of dying patients is immensely increased by neglect of these points4 ,and many an invalid1 too weak to drag about his pillows himself1 slips his book or anything at hand behind the lower part of his back to support it4 ,,footnotes3 #a ,sidenote3 ,nurses often do not think the sick room any business of theirs1 but only1 the sick4 ,i once told a very good nurse that the way in which her patient's room was kept was quite enough to account for his sleeplessness2 and she answered quite good-humouredly she was not at all surprised at it--as if the state of the room were1 like the state of the weather1 entirely out of her power4 ,now in what sense was this woman to be called a nurse8 #b ,for the same reason if1 after washing a patient1 you must put the same night-dress on him again1 always give it a preliminary warm at the fire4 ,the night-gown he has worn must be1 to a certain extent1 damp4 ,it has now got cold from having been off him for a few minutes4 ,the fire will dry and at the same time air it4 ,this is much more important than with clean things4 ,,ix4 ,,light4 ,sidenote3 ,light essential to both health and recovery4 ,it is the unqualified result of all my experience with the sick1 that second only to their need of fresh air is their need of light2 that1 after a close room1 what hurts them most is a dark room4 ,and that it is not only light but direct sun-light they want4 ,i had rather have the power of carrying my patient about after the sun1 according to the aspect of the rooms1 if circumstances permit1 than let him linger in a room when the sun is off4 ,people think the effect is upon the spirits only4 ,this is by no means the case4 ,the sun is not only a painter but a sculptor4 ,you admit that he does the photograph4 ,without going into any scientific exposition we must admit that light has quite as real and tangible effects upon the human body4 ,but this is not all4 ,who has not observed the purifying effect of light1 and especially of direct sunlight1 upon the air of a room8 ,here is an observation within everybody's experience4 ,go into a room where the shutters are always shut 7in a sick room or a bedroom there should never be shutters shut71 and though the room be uninhabited1 though the air has never been polluted by the breathing of human beings1 you will observe a close1 musty smell of corrupt air1 of air i4e4 unpurified by the effect of the sun's rays4 ,the mustiness of dark rooms and corners1 indeed1 is proverbial4 ,the cheerfulness of a room1 the usefulness of light in treating disease is all-important4 ,sidenote3 ,aspect1 view1 and sunlight matters of first importance to the sick4 ,a very high authority in hospital construction has said that people do not enough consider the difference between wards and dormitories in planning their buildings4 ,but ,i go farther1 and say1 that healthy people never remember the difference between bed-rooms and sick-rooms in making arrangements for the sick4 ,to a sleeper in health it does not signify what the view is from his bed4 ,he ought never to be in it excepting when asleep1 and at night4 ,aspect does not very much signify either 7provided the sun reach his bed-room some time in every day1 to purify the air71 because he ought never to be in his bed-room except during the hours when there is no sun4 ,but the case is exactly reversed with the sick1 even should they be as many hours out of their beds as you are in yours1 which probably they are not4 ,therefore1 that they should be able1 without raising themselves or turning in bed1 to see out of window from their beds1 to see sky and sun-light at least1 if you can show them nothing else1 ,i assert to be1 if not of the very first importance for recovery1 at least something very near it4 ,and you should therefore look to the position of the beds of your sick one of the very first things4 ,if they can see out of two windows instead of one1 so much the better4 ,again1 the morning sun and the mid-day sun-- the hours when they are quite certain not to be up1 are of more importance to them1 if a choice must be made1 than the afternoon sun4 ,perhaps you can take them out of bed in the afternoon and set them by the window1 where they can see the sun4 ,but the best rule is1 if possible1 to give them direct sunlight from the moment he rises till the moment he sets4 ,another great difference between the bed-room and the sick-room is1 that the sleeper has a very large balance of fresh air to begin with1 when he begins the night1 if his room has been open all day as it ought to be2 the sick man has not1 because all day he has been breathing the air in the same room1 and dirtying it by the emanations from himself4 ,far more care is therefore necessary to keep up a constant change of air in the sick room4 ,it is hardly necessary to add that there are acute cases 7particularly a few ophthalmic cases1 and diseases where the eye is morbidly sensitive71 where a subdued light is necessary4 ,but a dark north room is inadmissible even for these4 ,you can always moderate the light by blinds and curtains4 ,heavy1 thick1 dark window or bed curtains should1 however1 hardly ever be used for any kind of sick in this country4 ,a light white curtain at the head of the bed is1 in general1 all that is necessary1 and a green blind to the window1 to be drawn down only when necessary4 ,sidenote3 ,without sunlight1 we degenerate body and mind4 ,one of the greatest observers of human things 7not physiological71 says1 in another language1 ,where there is sun there is thought4 ,all physiology goes to confirm this4 ,where is the shady side of deep vallies1 there is cretinism4 ,where are cellars and the unsunned sides of narrow streets1 there is the degeneracy and weakliness of the human race--mind and body equally degenerating4 ,put the pale withering plant and human being into the sun1 and1 if not too far gone1 each will recover health and spirit4 ,sidenote3 ,almost all patients lie with their faces to the light4 ,it is a curious thing to observe how almost all patients lie with their faces turned to the light1 exactly as plants always make their way towards the light2 a patient will even complain that it gives him pain lying on that side4 ,then why do you lie on that side8 ,he does not know1--but we do4 ,it is because it is the side towards the window4 ,a fashionable physician has recently published in a government report that he always turns his patient's faces from the light4 ,yes1 but nature is stronger than fashionable physicians1 and depend upon it she turns the faces back and towards such light as she can get4 ,walk through the wards of a hospital1 remember the bed sides of private patients you have seen1 and count how many sick you ever saw lying with their faces towards the wall4 ,x4 ,,cleanliness ,,of ,,rooms ,,and ,,walls4 ,sidenote3 ,cleanliness of carpets and furniture4 ,it cannot be necessary to tell a nurse that she should be clean1 or that she should keep her patient clean1--seeing that the greater part of nursing consists in preserving cleanliness4 ,no ventilation can freshen a room or ward where the most scrupulous cleanliness is not observed4 ,unless the wind be blowing through the windows at the rate of twenty miles an hour1 dusty carpets1 dirty wainscots1 musty curtains and furniture1 will infallibly produce a close smell4 ,i have lived in a large and expensively furnished ,london house1 where the only constant inmate in two very lofty rooms1 with opposite windows1 was myself1 and yet1 owing to the above-mentioned dirty circumstances1 no opening of windows could ever keep those rooms free from closeness2 but the carpet and curtains having been turned out of the rooms altogether1 they became instantly as fresh as could be wished4 ,it is pure nonsense to say that in ,london a room cannot be kept clean4 ,many of our hospitals show the exact reverse4 ,sidenote3 ,dust never removed now4 ,but no particle of dust is ever or can ever be removed or really got rid of by the present system of dusting4 ,dusting in these days means nothing but flapping the dust from one part of a room on to another with doors and windows closed4 ,what you do it for ,i cannot think4 ,you had much better leave the dust alone1 if you are not going to take it away altogether4 ,for from the time a room begins to be a room up to the time when it ceases to be one1 no one atom of dust ever actually leaves its precincts4 ,tidying a room means nothing now but removing a thing from one place1 which it has kept clean for itself1 on to another and a dirtier one4#a ,flapping by way of cleaning is only admissible in the case of pictures1 or anything made of paper4 ,the only way ,i know to remove dust1 the plague of all lovers of fresh air1 is to wipe everything with a damp cloth4 ,and all furniture ought to be so made as that it may be wiped with a damp cloth without injury to itself1 and so polished as that it may be damped without injury to others4 ,to dust1 as it is now practised1 truly means to distribute dust more equally over a room4 ,sidenote3 ,floors4 ,as to floors1 the only really clean floor ,i know is the ,berlin lackered floor1 which is wet rubbed and dry rubbed every morning to remove the dust4 ,the ,french parquet is always more or less dusty1 although infinitely superior in point of cleanliness and healthiness to our absorbent floor4 ,for a sick room1 a carpet is perhaps the worst expedient which could by any possibility have been invented4 ,if you must have a carpet1 the only safety is to take it up two or three times a year1 instead of once4 ,a dirty carpet literally infects the room4 ,and if you consider the enormous quantity of organic matter from the feet of people coming in1 which must saturate it1 this is by no means surprising4 ,sidenote3 ,papered1 plastered1 oil-painted walls4 ,as for walls1 the worst is the papered wall2 the next worst is plaster4 ,but the plaster can be redeemed by frequent lime-washing2 the paper requires frequent renewing4 ,a glazed paper gets rid of a good deal of the danger4 ,but the ordinary bed-room paper is all that it ought not to be4#b ,the close connection between ventilation and cleanliness is shown in this4 ,an ordinary light paper will last clean much longer if there is an ,arnott's ventilator in the chimney than it otherwise would4 ,the best wall now extant is oil paint4 ,from this you can wash the animal exuvi4#c ,these are what make a room musty4 ,sidenote3 ,best kind of wall for a sick-room4 ,the best wall for a sick-room or ward that could be made is pure white non-absorbent cement or glass1 or glazed tiles1 if they were made sightly enough4 ,air can be soiled just like water4 ,if you blow into water you will soil it with the animal matter from your breath4 ,so it is with air4 ,air is always soiled in a room where walls and carpets are saturated with animal exhalations4 ,want of cleanliness1 then1 in rooms and wards1 which you have to guard against1 may arise in three ways4 ,sidenote3 ,dirty air from without4 #a4 ,dirty air coming in from without1 soiled by sewer emanations1 the evaporation from dirty streets1 smoke1 bits of unburnt fuel1 bits of straw1 bits of horse dung4 ,sidenote3 ,best kind of wall for a house4 ,if people would but cover the outside walls of their houses with plain or encaustic tiles1 what an incalculable improvement would there be in light1 cleanliness1 dryness1 warmth1 and consequently economy4 ,the play of a fire-engine would then effectually wash the outside of a house4 ,this kind of walling would stand next to paving in improving the health of towns4 ,sidenote3 ,dirty air from within4 #b4 ,dirty air coming from within1 from dust1 which you often displace1 but never remove4 ,and this recalls what ought to be a sine qua non4 ,have as few ledges in your room or ward as possible4 ,and under no pretence have any ledge whatever out-of sight4 ,dust accumulates there1 and will never be wiped off4 ,this is a certain way to soil the air4 ,besides this1 the animal exhalations from your inmates saturate your furniture4 ,and if you never clean your furniture properly1 how can your rooms or wards be anything but musty8 ,ventilate as you please1 the rooms will never be sweet4 ,besides this1 there is a constant degradation1 as it is called1 taking place from everything except polished or glazed articles--,e4g4 in colouring certain green papers arsenic is used4 ,now in the very dust even1 which is lying about in rooms hung with this kind of green paper1 arsenic has been distinctly detected4 ,you see your dust is anything but harmless2 yet you will let such dust lie about your ledges for months1 your rooms for ever4 ,again1 the fire fills the room with coal-dust4 ,sidenote3 ,dirty air from the carpet4 #c4 ,dirty air coming from the carpet4 ,above all1 take care of the carpets1 that the animal dirt left there by the feet of visitors does not stay there4 ,floors1 unless the grain is filled up and polished1 are just as bad4 ,the smell from the floor of a school-room or ward1 when any moisture brings out the organic matter by which it is saturated1 might alone be enough to warn us of the mischief that is going on4 ,sidenote3 ,remedies4 ,the outer air1 then1 can only be kept clean by sanitary improvements1 and by consuming smoke4 ,the expense in soap1 which this single improvement would save1 is quite incalculable4 ,the inside air can only be kept clean by excessive care in the ways mentioned above--to rid the walls1 carpets1 furniture1 ledges1 c41 of the organic matter and dust--dust consisting greatly of this organic matter--with which they become saturated1 and which is what really makes the room musty4 ,without cleanliness1 you cannot have all the effect of ventilation2 without ventilation1 you can have no thorough cleanliness4 ,very few people1 be they of what class they may1 have any idea of the exquisite cleanliness required in the sick-room4 ,for much of what ,i have said applies less to the hospital than to the private sick-room4 ,the smoky chimney1 the dusty furniture1 the utensils emptied but once a day1 often keep the air of the sick constantly dirty in the best private houses4 ,the well have a curious habit of forgetting that what is to them but a trifling inconvenience1 to be patiently put up with1 is to the sick a source of suffering1 delaying recovery1 if not actually hastening death4 ,the well are scarcely ever more than eight hours1 at most1 in the same room4 ,some change they can always make1 if only for a few minutes4 ,even during the supposed eight hours1 they can change their posture or their position in the room4 ,but the sick man who never leaves his bed1 who cannot change by any movement of his own his air1 or his light1 or his warmth2 who cannot obtain quiet1 or get out of the smoke1 or the smell1 or the dust2 he is really poisoned or depressed by what is to you the merest trifle4 ,what can't be cured must be endured1 is the very worst and most dangerous maxim for a nurse which ever was made4 ,patience and resignation in her are but other words for carelessness or indifference --contemptible1 if in regard to herself2 culpable1 if in regard to her sick4 ,,footnotes3 #a ,sidenote3 ,how a room is dusted4 ,if you like to clean your furniture by laying out your clean clothes upon your dirty chairs or sofa1 this is one way certainly of doing it4 ,having witnessed the morning process called tidying the room1 for many years1 and with ever-increasing astonishment1 ,i can describe what it is4 ,from the chairs1 tables1 or sofa1 upon which the things have lain during the night1 and which are therefore comparatively clean from dust or blacks1 the poor things having caught it1 they are removed to other chairs1 tables1 sofas1 upon which you could write your name with your finger in the dust or blacks4 ,the other side of the things is therefore now evenly dirtied or dusted4 ,the housemaid then flaps everything1 or some things1 not out of her reach1 with a thing called a duster--the dust flies up1 then re-settles more equally than it lay before the operation4 ,the room has now been put to rights4 #b ,sidenote3 ,atmosphere in painted and papered rooms quite distinguishable4 ,i am sure that a person who has accustomed her senses to compare atmospheres proper and improper1 for the sick and for children1 could tell1 blindfold1 the difference of the air in old painted and in old papered rooms1 coeteris paribus4 ,the latter will always be dusty1 even with all the windows open4 #c ,sidenote3 ,how to keep your wall clean at the expense of your clothes4 ,if you like to wipe your dirty door1 or some portion of your dirty wall1 by hanging up your clean gown or shawl against it on a peg1 this is one way certainly1 and the most usual way1 and generally the only way of cleaning either door or wall in a bed room6 ,,xi4 ,,personal ,,cleanliness4 ,sidenote3 ,poisoning by the skin4 ,in almost all diseases1 the function of the skin is1 more or less1 disordered2 and in many most important diseases nature relieves herself almost entirely by the skin4 ,this is particularly the case with children4 ,but the excretion1 which comes from the skin1 is left there1 unless removed by washing or by the clothes4 ,every nurse should keep this fact constantly in mind1--for1 if she allow her sick to remain unwashed1 or their clothing to remain on them after being saturated with perspiration or other excretion1 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 mouth4 ,poisoning by the skin is no less certain than poisoning by the mouth--only it is slower in its operation4 ,sidenote3 ,ventilation and skin-cleanliness equally essential4 ,the amount of relief and comfort experienced by sick after the skin has been carefully washed and dried1 is one of the commonest observations made at a sick bed4 ,but it must not be forgotten that the comfort and relief so obtained are not all4 ,they are1 in fact1 nothing more than a sign that the vital powers have been relieved by removing something that was oppressing them4 ,the nurse1 therefore1 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 relief1 which can be quite as well given later4 ,in all well-regulated hospitals this ought to be1 and generally is1 attended to4 ,but it is very generally neglected with private sick4 ,just as it is necessary to renew the air round a sick person frequently1 to carry off morbid effluvia from the lungs and skin1 by maintaining free ventilation1 so is it necessary to keep the pores of the skin free from all obstructing excretions4 ,the object1 both of ventilation and of skin-cleanliness1 is pretty much the same1--to wit1 removing noxious matter from the system as rapidly as possible4 ,care should be taken in all these operations of sponging1 washing1 and cleansing the skin1 not to expose too great a surface at once1 so as to check the perspiration1 which would renew the evil in another form4 ,the various ways of washing the sick need not here be specified1--the less so as the doctors ought to say which is to be used4 ,in several forms of diarrhoea1 dysentery1 c41 where the skin is hard and harsh1 the relief afforded by washing with a great deal of soft soap is incalculable4 ,in other cases1 sponging with tepid soap and water1 then with tepid water and drying with a hot towel will be ordered4 ,every nurse ought to be careful to wash her hands very frequently during the day4 ,if her face too1 so much the better4 ,one word as to cleanliness merely as cleanliness4 ,sidenote3 ,steaming and rubbing the skin4 ,compare the dirtiness of the water in which you have washed when it is cold without soap1 cold with soap1 hot with soap4 ,you will find the first has hardly removed any dirt at all1 the second a little more1 the third a great deal more4 ,but hold your hand over a cup of hot water for a minute or two1 and then1 by merely rubbing with the finger1 you will bring off flakes of dirt or dirty skin4 ,after a vapour bath you may peel your whole self clean in this way4 ,what ,i mean is1 that by simply washing or sponging with water you do not really clean your skin4 ,take a rough towel1 dip one corner in very hot water1--if a little spirit be added to it it will be more effectual1--and then rub as if you were rubbing the towel into your skin with your fingers4 ,the black flakes which will come off will convince you that you were not clean before1 however much soap and water you have used4 ,these flakes are what require removing4 ,and you can really keep yourself cleaner with a tumbler of hot water and a rough towel and rubbing1 than with a whole apparatus of bath and soap and sponge1 without rubbing4 ,it is quite nonsense to say that anybody need be dirty4 ,patients have been kept as clean by these means on a long voyage1 when a basin full of water could not be afforded1 and when they could not be moved out of their berths1 as if all the appurtenances of home had been at hand4 ,washing1 however1 with a large quantity of water has quite other effects than those of mere cleanliness4 ,the skin absorbs the water and becomes softer and more perspirable4 ,to wash with soap and soft water is1 therefore1 desirable from other points of view than that of cleanliness4 ,,xii4 ,,chattering ,,hopes ,,and ,,advices4 ,sidenote3 ,advising the sick4 ,the sick man to his advisers4 ,my advisers6 ,their name is legion4 99 99 99 ,somehow or other1 it seems a provision of the universal destinies1 that every man1 woman1 and child should consider him1 her1 or itself privileged especially to advise me4 ,why8 ,that is precisely what ,i want to know4 ,and this is what ,i have to say to them4 ,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 cart1 carriage---yes1 and even swing 767 and dumb-bell 767 in existence2 to imbibe every different kind of stimulus that ever has been invented2 ,and this when those best fitted to know1 viz41 medical men1 after long and close attendance1 had declared any journey out of the question1 had prohibited any kind of motion whatever1 had closely laid down the diet and drink4 ,what would my advisers say1 were they the medical attendants1 and ,i the patient left their advice1 and took the casual adviser's8 ,but the singularity in ,legion's mind is this3 it never occurs to him that everybody else is doing the same thing1 and that ,i the patient must perforce say1 in sheer self-defence1 like ,rosalind1 ,i could not do with all4 ,sidenote3 ,chattering hopes the bane of the sick4 ,chattering ,hopes may seem an odd heading4 ,but ,i really believe there is scarcely a greater worry which invalids have to endure than the incurable hopes of their friends4 ,there is no one practice against which ,i can speak more strongly from actual personal experience1 wide and long1 of its effects during sickness observed both upon others and upon myself4 ,i would appeal most seriously to all friends1 visitors1 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 recovery4 ,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 state4 ,how intense is the folly1 then1 to say the least of it1 of the friend1 be he even a medical man1 who thinks that his opinion1 given after a cursory observation1 will weigh with the patient1 against the opinion of the medical attendant1 given1 perhaps1 after years of observation1 after using every help to diagnosis afforded by the stethoscope1 the examination of pulse1 tongue1 c42 and certainly after much more observation than the friend can possibly have had4 ,supposing the patient to be possessed of common sense1--how can the favourable opinion1 if it is to be called an opinion at all1 of the casual visitor cheer him1--when different from that of the experienced attendant8 ,unquestionably the latter may1 and often does1 turn out to be wrong4 ,but which is most likely to be wrong8 ,sidenote3 ,patient does not want to talk of himself4 ,the fact is1 that the patient#a is not cheered at all by these well-meaning1 most tiresome friends4 ,on the contrary1 he is depressed and wearied4 ,if1 on the one hand1 he exerts himself to tell each successive member of this too numerous conspiracy1 whose name is legion1 why he does not think as they do1--in what respect he is worse1--what symptoms exist that they know nothing of1--he is fatigued instead of cheered1 and his attention is fixed upon himself4 ,in general1 patients who are really ill1 do not want to talk about themselves4 ,hypochondriacs do1 but again ,i say we are not on the subject of hypochondriacs4 ,sidenote3 ,absurd consolations put forth for the benefit of the sick4 ,if1 on the other hand1 and which is much more frequently the case1 the patient says nothing but the ,shakespearian ,oh6 ,ah6 ,go to6 and ,in good sooth6 in order to escape from the conversation about himself the sooner1 he is depressed by want of sympathy4 ,he feels isolated in the midst of friends4 ,he feels what a convenience it would be1 if there were any single person to whom he could speak simply and openly1 without pulling the string upon himself of this shower-bath of silly hopes and encouragements2 to whom he could express his wishes and directions without that person persisting in saying1 ,i hope that it will please ,god yet to give you twenty years1 or1 ,you have a long life of activity before you4 ,how often we see at the end of biographies or of cases recorded in medical papers1 after a long illness ,a4 died rather suddenly1 or1 unexpectedly both to himself and to others4 ,unexpectedly to others1 perhaps1 who did not see1 because they did not look2 but by no means unexpectedly to himself1 as ,i feel entitled to believe1 both from the internal evidence in such stories1 and from watching similar cases2 there was every reason to expect that ,a4 would die1 and he knew it2 but he found it useless to insist upon his own knowledge to his friends4 ,in these remarks ,i am alluding neither to acute cases which terminate rapidly nor to nervous cases4 ,by the first much interest in1 their own danger is very rarely felt4 ,in writings of fiction1 whether novels or biographies1 these death-beds are generally depicted as almost seraphic in lucidity of intelligence4 ,sadly large has been my experience in death-beds1 and ,i can only say that ,i have seldom or never seen such4 ,indifference1 excepting with regard to bodily suffering1 or to some duty the dying man desires to perform1 is the far more usual state4 ,the nervous case1 on the other hand1 delights in figuring to himself and others a fictitious danger4 ,but the long chronic case1 who knows too well himself1 and who has been told by his physician that he will never enter active life again1 who feels that every month he has to give up something he could do the month before--oh6 spare such sufferers your chattering hopes4 ,you do not know how you worry and weary them4 ,such real sufferers cannot bear to talk of themselves1 still less to hope for what they cannot at all expect4 ,so also as to all the advice showered so profusely upon such sick1 to leave off some occupation1 to try some other doctor1 some other house1 climate1 pill1 powder1 or specific2 ,i say nothing of the inconsistency-- for these advisers are sure to be the same persons who exhorted the sick man not to believe his own doctor's prognostics1 because doctors are always mistaken1 but to believe some other doctor1 because this doctor is always right4 ,sure also are these advisers to be the persons to bring the sick man fresh occupation1 while exhorting him to leave his own4 ,sidenote3 ,wonderful presumption of the advisers of the sick4 ,wonderful is the face with which friends1 lay and medical1 will come in and worry the patient with recommendations to do something or other1 having just as little knowledge as to its being feasible1 or even safe for him1 as if they were to recommend a man to take exercise1 not knowing he had broken his leg4 ,what would the friend say1 if he were the medical attendant1 and if the patient1 because some other friend had come in1 because somebody1 anybody1 nobody1 had recommended something1 anything1 nothing1 were to disregard his orders1 and take that other body's recommendation8 ,but people never think of this4 ,sidenote3 ,advisers the same now as two hundred years ago4 ,a celebrated historical personage has related the commonplaces which1 when on the eve of executing a remarkable resolution1 were showered in nearly the same words by every one around successively for a period of six months4 ,to these the personage states that it was found least trouble always to reply the same thing1 viz41 that it could not be supposed that such a resolution had been taken without sufficient previous consideration4 ,to patients enduring every day for years from every friend or acquaintance1 either by letter or viva voce1 some torment of this kind1 ,i would suggest the same answer4 ,it would indeed be spared1 if such friends and acquaintances would but consider for one moment1 that it is probable the patient has heard such advice at least fifty times before1 and that1 had it been practicable1 it would have been practised long ago4 ,but of such consideration there appears to be no chance4 ,strange1 though true1 that people should be just the same in these things as they were a few hundred years ago6 ,to me these commonplaces1 leaving their smear upon the cheerful1 single-hearted1 constant devotion to duty1 which is so often seen in the decline of such sufferers1 recall the slimy trail left by the snail on the sunny southern garden-wall loaded with fruit4 ,sidenote3 ,mockery of the advice given to sick4 ,no mockery in the world is so hollow as the advice showered upon the sick4 ,it is of no use for the sick to say anything1 for what the adviser wants is1 not to know the truth about the state of the patient1 but to turn whatever the sick may say to the support of his own argument1 set forth1 it must be repeated1 without any inquiry whatever into the patient's real condition4 ,but it would be impertinent or indecent in me to make such an inquiry1 says the adviser4 ,true2 and how much more impertinent is it to give your advice when you can know nothing about the truth1 and admit you could not inquire into it4 ,to nurses ,i say--these are the visitors who do your patient harm4 ,when you hear him told3--#a4 ,that he has nothing the matter with him1 and that he wants cheering4 #b4 ,that he is committing suicide1 and that he wants preventing4 #c4 ,that he is the tool of somebody who makes use of him for a purpose4 #d4 ,that he will listen to nobody1 but is obstinately bent upon his own way2 and #e4 ,that1 he ought to be called to a sense of duty1 and is flying in the face of ,providence2--then know that your patient is receiving all the injury that he can receive from a visitor4 ,how little the real sufferings of illness are known or understood4 ,how little does any one in good health fancy him or even herself into the life of a sick person4 ,sidenote3 ,means of giving pleasure to the sick4 ,do1 you who are about the sick or who visit the sick1 try and give them pleasure1 remember to tell them what will do so4 ,how often in such visits the sick person has to do the whole conversation1 exerting his own imagination and memory1 while you would take the visitor1 absorbed in his own anxieties1 making no effort of memory or imagination1 for the sick person4 ,oh6 my dear1 ,i have so much to think of1 ,i really quite forgot to tell him that2 besides1 ,i thought he would know it1 says the visitor to another friend4 ,how could he know it8 ,depend upon it1 the people who say this are really those who have little to think of4 ,there are many burthened with business who always manage to keep a pigeon-hole in their minds1 full of things to tell the invalid4 ,i do not say1 don't tell him your anxieties--,i believe it is good for him and good for you too2 but if you tell him what is anxious1 surely you can remember to tell him what is pleasant too4 ,a sick person does so enjoy hearing good news3--for instance1 of a love and courtship1 while in progress to a good ending4 ,if you tell him only when the marriage takes place1 he loses half the pleasure1 which ,god knows he has little enough of2 and ten to one but you have told him of some love-making with a bad ending4 ,a sick person also intensely enjoys hearing of any material good1 any positive or practical success of the right4 ,he has so much of books and fiction1 of principles1 and precepts1 and theories2 do1 instead of advising him with advice he has heard at least fifty times before1 tell him of one benevolent act which has really succeeded practically1--it is like a day's health to him4#b ,you have no idea what the craving of sick with undiminished power of thinking1 but little power of doing1 is to hear of good practical action1 when they can no longer partake in it4 ,do observe these things with the sick4 ,do remember how their life is to them disappointed and incomplete4 ,you see them lying there with miserable disappointments1 from which they can have no escape but death1 and you can't remember to tell them of what would give them so much pleasure1 or at least an hour's variety4 ,they don't want you to be lachrymose and whining with them1 they like you to be fresh and active and interested1 but they cannot bear absence of mind1 and they are so tired of the advice and preaching they receive from everybody1 no matter whom it is1 they see4 ,there is no better society than babies and sick people for one another4 ,of course you must manage this so that neither shall suffer from it1 which is perfectly possible4 ,if you think the air of the sick room bad for the baby1 why it is bad for the invalid too1 and1 therefore1 you will of course correct it for both4 ,it freshens up a sick person's whole mental atmosphere to see the baby4 ,and a very young child1 if unspoiled1 will generally adapt itself wonderfully to the ways of a sick person1 if the time they spend together is not too long4 ,if you knew how unreasonably sick people suffer from reasonable causes of distress1 you would take more pains about all these things4 ,an infant laid upon the sick bed will do the sick person1 thus suffering1 more good than all your logic4 ,a piece of good news will do the same4 ,perhaps you are afraid of disturbing him4 ,you say there is no comfort for his present cause of affliction4 ,it is perfectly reasonable4 ,the distinction is this1 if he is obliged to act1 do not disturb him with another subject of thought just yet2 help him to do what he wants to do2 but1 if he has done this1 or if nothing can be done1 then disturb him by all means4 ,you will relieve1 more effectually1 unreasonable suffering from reasonable causes by telling him the news1 showing him the baby1 or giving him something new to think of or to look at than by all the logic in the world4 ,it has been very justly said that the sick are like children in this1 that there is no proportion in events to them4 ,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 doing4 ,how can they find it out otherwise8 ,you will find them far more open to conviction than children in this4 ,and you will find that their unreasonable intensity of suffering from unkindness1 from want of sympathy1 c41 will disappear with their freshened interest in the big world's events4 ,but then you must be able to give them real interests1 not gossip4 ,sidenote3 ,two new classes of patients peculiar to this generation4 ,,note4--,there are two classes of patients which are unfortunately becoming more common every day1 especially among women of the richer orders1 to whom all these remarks are pre-eminently inapplicable4 #a4 ,those who make health an excuse for doing nothing1 and at the same time allege that the being able to do nothing is their only grief4 #b4 ,those who have brought upon themselves ill-health by over pursuit of amusement1 which they and their friends have most unhappily called intellectual activity4 ,i scarcely know a greater injury that can be inflicted than the advice too often given to the first class to vegetate--or than the admiration too often bestowed on the latter class for pluck4 ,,footnotes3 #a ,sidenote3 ,absurd statistical comparisons made in common conversation by the most sensible people for the benefit of the sick4 ,there are1 of course1 cases1 as in first confinements1 when an assurance from the doctor or experienced nurse to the frightened suffering woman that there is nothing unusual in her case1 that she has nothing to fear but a few hours' pain1 may cheer her most effectually4 ,this is advice of quite another order4 ,it is the advice of experience to utter inexperience4 ,but the advice we have been referring to is the advice of inexperience to bitter experience2 and1 in general1 amounts to nothing more than this1 that you think ,i shall recover from consumption because somebody knows somebody somewhere who has recovered from fever4 ,i have heard a doctor condemned whose patient did not1 alas6 recover1 because another doctor's patient of a different sex1 of a different age1 recovered from a different disease1 in a different place4 ,yes1 this is really true4 ,if people who make these comparisons did but know 7only they do not care to know71 the care and preciseness with which such comparisons require to be made1 7and are made17 in order to be of any value whatever1 they would spare their tongues4 ,in comparing the deaths of one hospital with those of another1 any statistics are justly considered absolutely valueless which do not give the ages1 the sexes1 and the diseases of all the cases4 ,it does not seem necessary to mention this4 ,it does not seem necessary to say that there can be no comparison between old men with dropsies and young women with consumptions4 ,yet the cleverest men and the cleverest women are often heard making such comparisons1 ignoring entirely sex1 age1 disease1 place--in fact1 all the conditions essential to the question4 ,it is the merest gossip4 #b ,a small pet animal is often an excellent companion for the sick1 for long chronic cases especially4 ,a pet bird in a cage is sometimes the only pleasure of an invalid confined for years to the same room4 ,if he can feed and clean the animal himself1 he ought always to be encouraged to do so4 ,,xiii4 ,,observation ,,of ,,the ,,sick4 ,sidenote3 ,what is the use of the question1 ,is he better8 ,there is no more silly or universal question scarcely asked than this1 ,is he better8 ,ask it of the medical attendant1 if you please4 ,but of whom else1 if you wish for a real answer to your question1 would you ask8 ,certainly not of the casual visitor2 certainly not of the nurse1 while the nurse's observation is so little exercised as it is now4 ,what you want are facts1 not opinions--for who can have any opinion of any value as to whether the patient is better or worse1 excepting the constant medical attendant1 or the really observing nurse8 ,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 neglect4 ,all this is what ought to make part1 and an essential part1 of the training of every nurse4 ,at present how few there are1 either professional or unprofessional1 who really know at all whether any sick person they may be with is better or worse4 ,the vagueness and looseness of the information one receives in answer to that much abused question1 ,is he better8 would be ludicrous1 if it were not painful4 ,the only sensible answer 7in the present state of knowledge about sickness7 would be ,how can ,i know8 ,i cannot tell how he was when ,i was not with him4 ,i can record but a very few specimens of the answers#a which ,i have heard made by friends and nurses1 and accepted by physicians and surgeons at the very bed-side of the patient1 who could have contradicted every word1 but did not--sometimes from amiability1 often from shyness1 oftenest from languor6 ,how often have the bowels acted1 nurse8 ,once1 sir4 ,this generally means that the utensil has been emptied once1 it having been used perhaps seven or eight times4 ,do you think the patient is much weaker than he was six weeks ago8 ,oh no1 sir2 you know it is very long since he has been up and dressed1 and he can get across the room now4 ,this means that the nurse has not observed that whereas six weeks ago he sat up and occupied himself in bed1 he now lies still doing nothing2 that1 although he can get across the room1 he cannot stand for five seconds4 ,another patient who is eating well1 recovering steadily1 although slowly1 from fever1 but cannot walk or stand1 is represented to the doctor as making no progress at all4 ,sidenote3 ,leading questions useless or misleading4 ,questions1 too1 as asked now 7but too generally7 of or about patients1 would obtain no information at all about them1 even if the person asked of had every information to give4 ,the question is generally a leading question2 and it is singular that people never think what must be the answer to this question before they ask it3 for instance1 ,has he had a good night8 ,now1 one patient will think he has a bad night if he has not slept ten hours without waking4 ,another does not think he has a bad night if he has had intervals of dosing occasionally4 ,the same answer has1 actually been given as regarded two patients--one who had been entirely sleepless for five times twenty-four hours1 and died of it1 and another who had not slept the sleep of a regular night1 without waking4 ,why cannot the question be asked1 ,how many hours' sleep has ---- had8 and at what hours of the night8#b ,i have never closed my eyes all night1 an answer as frequently made when the speaker has had several hours' sleep as when he has had none1 would then be less often said4 ,lies1 intentional and unintentional1 are much seldomer told in answer to precise than to leading questions4 ,another frequent error is to inquire whether one cause remains1 and not whether the effect which may be produced by a great many different causes1 not inquired after1 remains4 ,as when it is asked1 whether there was noise in the street last night2 and if there were not1 the patient is reported1 without more ado1 to have had a good night4 ,patients are completely taken aback by these kinds of leading questions1 and give only the exact amount of information asked for1 even when they know it to be completely misleading4 ,the shyness of patients is seldom allowed for4 ,how few there are who1 by five or six pointed questions1 can elicit the whole case1 and get accurately to know and to be able to report where the patient is4 ,sidenote3 ,means of obtaining inaccurate information4 ,i knew a very clever physician1 of large dispensary and hospital practice1 who invariably began his examination of each patient with ,put your finger where you be bad4 ,that man would never waste his time with collecting inaccurate information from nurse or patient4 ,leading questions always collect inaccurate information4 ,at a recent celebrated trial1 the following leading question was put successively to nine distinguished medical men4 ,can you attribute these symptoms to anything else but poison8 ,and out of the nine1 eight answered ,no6 without any qualification whatever4 ,it appeared1 upon cross-examination3--#a4 ,that none of them had ever seen a case of the kind of poisoning supposed4 #b4 ,that none of them had ever seen a case of the kind of disease to which the death1 if not to poison1 was attributable4 #c4 ,that none of them were even aware of the main fact of the disease and condition to which the death was attributable4 ,surely nothing stronger can be adduced to prove what use leading questions are of1 and what they lead to4 ,i had rather not say how many instances ,i have known1 where1 owing to this system of leading questions1 the patient has died1 and the attendants have been actually unaware of the principal feature of the case4 ,sidenote3 ,as to food patient takes or does not take4 ,it is useless to go through all the particulars1 besides sleep1 in which people have a peculiar talent for gleaning inaccurate information4 ,as to food1 for instance1 ,i often think that most common question1 ,how is your appetite8 can only be put because the questioner believes the questioned has really nothing the matter with him1 which is very often the case4 ,but where there is1 the remark holds good which has been made about sleep4 ,the same answer will often be made as regards a patient who cannot take two ounces of solid food per diem1 and a patient who does not enjoy five meals a day as much as usual4 ,again1 the question1 ,how is your appetite8 is often put when ,how is your digestion8 is the question meant4 ,no doubt the two things depend on one another4 ,but they are quite different4 ,many a patient can eat1 if you can only tempt his appetite4 ,the fault lies in your not having got him the thing that he fancies4 ,but many another patient does not care between grapes and turnips--everything is equally distasteful to him4 ,he would try to eat anything which would do him good2 but everything makes him worse4 ,the fault here generally lies in the cooking4 ,it is not his appetite which requires tempting1 it is his digestion which requires sparing4 ,and good sick cookery will save the digestion half its work4 ,there may be four different causes1 any one of which will produce the same result1 viz41 the patient slowly starving to death from want of nutrition3 #a4 ,defect in cooking2 #b4 ,defect in choice of diet2 #c4 ,defect in choice of hours for taking diet2 #d4 ,defect of appetite in patient4 ,yet all these are generally comprehended in the one sweeping assertion that the patient has no appetite4 ,surely many lives might be saved by drawing a closer distinction2 for the remedies are as diverse as the causes4 ,the remedy for the first is to cook better2 for the second1 to choose other articles of diet2 for the third1 to watch for the hours when the patient is in want of food2 for the fourth1 to show him what he likes1 and sometimes unexpectedly4 ,but no one of these remedies will do for any other of the defects not corresponding with it4 ,i cannot too often repeat that patients are generally either too languid to observe these things1 or too shy to speak about them2 nor is it well that they should be made to observe them1 it fixes their attention upon themselves4 ,again1 ,i say1 what is the nurse or friend there for except to take note of these things1 instead of the patient doing so8#c ,sidenote3 ,as to diarrhoea ,again1 the question is sometimes put1 ,is there diarrhoea8 ,and the answer will be the same1 whether it is just merging into cholera1 whether it is a trifling degree brought on by some trifling indiscretion1 which will cease the moment the cause is removed1 or whether there is no diarrhoea at all1 but simply relaxed bowels4 ,it is useless to multiply instances of this kind4 ,as long as observation is so little cultivated as it is now1 ,i do believe that it is better for the physician not to see the friends of the patient at all4 ,they will oftener mislead him than not4 ,and as often by making the patient out worse as better than he really is4 ,in the case of infants1 everything must depend upon the accurate observation of the nurse or mother who has to report4 ,and how seldom is this condition of accuracy fulfilled4 ,sidenote3 ,means of cultivating sound and ready observation4 ,a celebrated man1 though celebrated only for foolish things1 has told us that one of his main objects in the education of his son1 was to give him a ready habit of accurate observation1 a certainty of perception1 and that for this purpose one of his means was a month's course as follows3--he took the boy rapidly past a toy-shop2 the father and son then described to each other as many of the objects as they could1 which they had seen in passing the windows1 noting them down with pencil and paper1 and returning afterwards to verify their own accuracy4 ,the boy always succeeded best1 e4g41 if the father described #cj objects1 the boy did #dj1 and scarcely ever made a mistake4 ,i have often thought how wise a piece of education this would be for much higher objects2 and in our calling of nurses the thing itself is essential4 ,for it may safely be said1 not that the habit of ready and correct observation will by itself make us useful nurses1 but that without it we shall be useless with all our devotion4 ,i have known a nurse in charge of a set of wards1 who not only carried in her head all the little varieties in the diets which each patient was allowed to fix for himself1 but also exactly what each patient had taken during each day4 ,i have known another nurse in charge of one single patient1 who took away his meals day after day all but untouched1 and never knew it4 ,if you find it helps you to note down such things on a bit of paper1 in pencil1 by all means do so4 ,i think it more often lames than strengthens the memory and observation4 ,but if you cannot get the habit of observation one way or other1 you had better give up the being a nurse1 for it is not your calling1 however kind and anxious you may be4 ,surely you can learn at least to judge with the eye how much an oz4 of solid food is1 how much an oz4 of liquid4 ,you will find this helps your observation and memory very much1 you will then say to yourself1 ,a4 took about an oz4 of his meat to day2 ,b4 took three times in #bd hours about #a_/d pint of beef tea2 instead of saying ,b4 has taken nothing all day1 or ,i gave ,a4 his dinner as usual4 ,sidenote3 ,sound and ready observation essential in a nurse4 ,i have known several of our real old-fashioned hospital sisters1 who could1 as accurately as a measuring glass1 measure out all their patients' wine and medicine by the eye1 and never be wrong4 ,i do not recommend this1 one must be very sure of one's self to do it4 ,i only mention it1 because if a nurse can by practice measure medicine by the eye1 surely she is no nurse who cannot measure by the eye about how much food 7in oz47 her patient has taken4#d ,in hospitals those who cut up the diets give with sufficient accuracy1 to each patient1 his #ab oz4 or his #f oz4 of meat without weighing4 ,yet a nurse will often have patients loathing all food and incapable of any will to get well1 who just tumble over the contents of the plate or dip the spoon in the cup to deceive the nurse1 and she will take it away without ever seeing that there is just the same quantity of food as when she brought it1 and she will tell the doctor1 too1 that the patient has eaten all his diets as usual1 when all she ought to have meant is that she has taken away his diets as usual4 ,now what kind of a nurse is this8 ,sidenote3 ,difference of excitable and accumulative temperaments4 ,i would call attention to something else1 in which nurses frequently fail in observation4 ,there is a well-marked distinction between the excitable and what ,i will call the accumulative temperament in patients4 ,one will blaze up at once1 under any shock or anxiety1 and sleep very comfortably after it2 another will seem quite calm and even torpid1 under the same shock1 and people say1 ,he hardly felt it at all1 yet you will find him some time after slowly sinking4 ,the same remark applies to the action of narcotics1 of aperients1 which1 in the one1 take effect directly1 in the other not perhaps for twenty-four hours4 ,a journey1 a visit1 an unwonted exertion1 will affect the one immediately1 but he recovers after it2 the other bears it very well at the time1 apparently1 and dies or is prostrated for life by it4 ,people often say how difficult the excitable temperament is to manage4 ,i say how difficult is the accumulative temperament4 ,with the first you have an out-break which you could anticipate1 and it is all over4 ,with the second you never know where you are--you never know when the consequences are over4 ,and it requires your closest observation to know what are the consequences of what--for the consequent by no means follows immediately upon the antecedent--and coarse observation is utterly at fault4 ,sidenote3 ,superstition the fruit of bad observation4 ,almost all superstitions are owing to bad observation1 to the post hoc1 ergo propter hoc2 and bad observers are almost all superstitious4 ,farmers used to attribute disease among cattle to witchcraft2 weddings have been attributed to seeing one magpie1 deaths to seeing three2 and ,i have heard the most highly educated now-a-days draw consequences for the sick closely resembling these4 ,sidenote3 ,physiognomy of disease little shewn by the face4 ,another remark3 although there is unquestionably a physiognomy of disease as well as of health2 of all parts of the body1 the face is perhaps the one which tells the least to the common observer or the casual visitor4 ,because1 of all parts of the body1 it is the one most exposed to other influences1 besides health4 ,and people never1 or scarcely ever1 observe enough to know how to distinguish between the effect of exposure1 of robust health1 of a tender skin1 of a tendency to congestion1 of suffusion1 flushing1 or many other things4 ,again1 the face is often the last to shew emaciation4 ,i should say that the hand was a much surer test than the face1 both as to flesh1 colour1 circulation1 c41 c4 ,it is true that there are some diseases which are only betrayed at all by something in the face1 e4g41 the eye or the tongue1 as great irritability of brain by the appearance of the pupil of the eye4 ,but we are talking of casual1 not minute1 observation4 ,and few minute observers will hesitate to say that far more untruth than truth is conveyed by the oft repeated words1 ,he looks well1 or ill1 or better or worse4 ,wonderful is the way in which people will go upon the slightest observation1 or often upon no observation at all1 or upon some saw which the world's experience1 if it had any1 would have pronounced utterly false long ago4 ,i have known patients dying of sheer pain1 exhaustion1 and want of sleep1 from one of the most lingering and painful diseases known1 preserve1 till within a few days of death1 not only the healthy colour of the cheek1 but the mottled appearance of a robust child4 ,and scores of times have ,i heard these unfortunate creatures assailed with1 ,i am glad to see you looking so well4 ,i see no reason why you should not live till ninety years of age4 ,why don't you take a little more exercise and amusement1 with all the other commonplaces with which we are so familiar4 ,there is1 unquestionably1 a physiognomy of disease4 ,let the nurse learn it4 ,the experienced nurse can always tell that a person has taken a narcotic the night before by the patchiness of the colour about the face1 when the re-action of depression has set in2 that very colour which the inexperienced will point to as a proof of health4 ,there is1 again1 a faintness1 which does not betray itself by the colour at all1 or in which the patient becomes brown instead of white4 ,there is a faintness of another kind which1 it is true1 can always be seen by the paleness4 ,but the nurse seldom distinguishes4 ,she will talk to the patient who is too faint to move1 without the least scruple1 unless he is pale and unless1 luckily for him1 the muscles of the throat are affected and he loses his voice4 ,yet these two faintnesses are perfectly distinguishable1 by the mere countenance of the patient4 ,sidenote3 ,peculiarities of patients4 ,again1 the nurse must distinguish between the idiosyncracies of patients4 ,one likes to suffer out all his suffering alone1 to be as little looked after as possible4 ,another likes to be perpetually made much of and pitied1 and to have some one always by him4 ,both these peculiarities might be observed and indulged much more than they are4 ,for quite as often does it happen that a busy attendance is forced upon the first patient1 who wishes for nothing but to be let alone1 as that the second is left to think himself neglected4 ,sidenote3 ,nurse must observe for herself increase of patient's weakness1 patient will not tell her4 ,again1 ,i think that few things press so heavily on one suffering from long and incurable illness1 as the necessity of recording in words from time to time1 for the information of the nurse1 who will not otherwise see1 that he cannot do this or that1 which he could do a month or a year ago4 ,what is a nurse there for if she cannot observe these things for herself8 ,yet ,i have known--and known too among those--and chiefly among those--whom money and position put in possession of everything which money and position could give--,i have known1 ,i say1 more accidents 7fatal1 slowly or rapidly7 arising from this want of observation among nurses than from almost anything else4 ,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 ago1 the nurse concludes that he can do so now4 ,she has never observed the change2 and the patient is lost from being left in a helpless state of exhaustion1 till some one accidentally comes in4 ,and this not from any unexpected apoplectic1 paralytic1 or fainting fit 7though even these could be expected far more1 at least1 than they are now1 if we did but observe74 ,no1 from the unexpected1 or to be expected1 inevitable1 visible1 calculable1 uninterrupted increase of weakness1 which none need fail to observe4 ,sidenote3 ,accidents arising from the nurse's want of observation4 ,again1 a patient not usually confined to bed1 is compelled by an attack of diarrhoea1 vomiting1 or other accident1 to keep his bed for a few days2 he gets up for the first time1 and the nurse lets him go into another room1 without coming in1 a few minutes afterwards1 to look after him4 ,it never occurs to her that he is quite certain to be faint1 or cold1 or to want something4 ,she says1 as her excuse1 ,oh1 he does not like to be fidgetted after4 ,yes1 he said so some weeks ago2 but he never said he did not like to be fidgetted after1 when he is in the state he is in now2 and if he did1 you ought to make some excuse to go in to him4 ,more patients have been lost in this way than is at all generally known1 viz41 from relapses brought on by being left for an hour or two faint1 or cold1 or hungry1 after getting up for the first time4 ,sidenote3 ,is the faculty of observing on the decline8 ,yet it appears that scarcely any improvement in the faculty of observing is being made4 ,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 signs of the change while in progress4 ,or1 rather1 is it not to be feared that observation1 as an essential part of medicine1 has been declining8 ,which of us has not heard fifty times1 from one or another1 a nurse1 or a friend of the sick1 aye1 and a medical friend too1 the following remark3--,so ,a is worse1 or ,b is dead4 ,i saw him the day before2 ,i thought him so much better2 there certainly was no appearance from which one could have expected so sudden 787 a change4 ,i have never heard any one say1 though one would think it the more natural thing1 ,there must have been some appearance1 which ,i should have seen if ,i had but looked2 let me try and remember what there was1 that ,i may observe another time4 ,no1 this is not what people say4 ,they boldly assert that there was nothing to observe1 not that their observation was at fault4 ,let people who have to observe sickness and death look back and try to register in their observation the appearances which have preceded relapse1 attack1 or death1 and not assert that there were none1 or that there were not the right ones4#e ,sidenote3 ,observation of general conditions4 ,a want of the habit of observing conditions and an inveterate habit of taking averages are each of them often equally misleading4 ,men whose profession like that of medical men leads them to observe only1 or chiefly1 palpable and permanent organic changes are often just as wrong in their opinion of the result as those who do not observe at all4 ,for instance1 there is a broken leg2 the surgeon has only to look at it once to know2 it will not be different if he sees it in the morning to what it would have been had he seen it in the evening4 ,and in whatever conditions the patient is1 or is likely to be1 there will still be the broken leg1 until it is set4 ,the same with many organic diseases4 ,an experienced physician has but to feel the pulse once1 and he knows that there is aneurism which will kill some time or other4 ,but with the great majority of cases1 there is nothing of the kind2 and the power of forming any correct opinion as to the result must entirely depend upon an enquiry into all the conditions in which the patient lives4 ,in a complicated state of society in large towns1 death1 as every one of great experience knows1 is far less often produced by any one organic disease than by some illness1 after many other diseases1 producing just the sum of exhaustion necessary for death4 ,there is nothing so absurd1 nothing so misleading as the verdict one so often hears3 ,so-and-so has no organic disease1--there is no reason why he should not live to extreme old age2 sometimes the clause is added1 sometimes not3 ,provided he has quiet1 good food1 good air1 c41 c41 c43 the verdict is repeated by ignorant people without the latter clause2 or there is no possibility of the conditions of the latter clause being obtained2 and this1 the only essential part of the whole1 is made of no effect4 ,i have heard a physician1 deservedly eminent1 assure the friends of a patient of his recovery4 ,why8 ,because he had now prescribed a course1 every detail of which the patient had followed for years4 ,and because he had forbidden a course which the patient could not by any possibility alter4#f ,undoubtedly a person of no scientific knowledge whatever but of observation and experience in these kinds of conditions1 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 house1 than the most scientific physician to whom the same persons are brought to have their pulse felt2 no enquiry being made into their conditions4 ,in ,life ,insurance and such like societies1 were they instead of having the person examined by the medical man1 to have the houses1 conditions1 ways of life1 of these persons examined1 at how much truer results would they arrive6 ,w4 ,smith appears a fine hale man1 but it might be known that the next cholera epidemic he runs a bad chance4 ,mr4 and ,mrs4 ,j4 are a strong healthy couple1 but it might be known that they live in such a house1 in such a part of ,london1 so near the river that they will kill four-fifths of their children2 which of the children will be the ones to survive might also be known4 ,sidenote3 ,average rate of mortality tells us only that so many per cent4 will die4 ,observation must tell us which in the hundred they will be who will die4 ,averages again seduce us away from minute observation4 ,average mortalities merely tell that so many per cent4 die in this town and so many in that1 per annum4 ,but whether ,a or ,b will be among these1 the average rate of course does not tell4 ,we know1 say1 that from #bb to #bd per #a1jjj will die in ,london next year4 ,but minute enquiries into conditions enable us to know that in such a district1 nay1 in such a street1--or even on one side of that street1 in such a particular house1 or even on one floor of that particular house1 will be the excess of mortality1 that is1 the person will die who ought not to have died before old age4 ,now1 would it not very materially alter the opinion of whoever were endeavouring to form one1 if he knew that from that floor1 of that house1 of that street the man came4 ,much more precise might be our observations even than this1 and much more correct our conclusions4 ,it is well known that the same names may be seen constantly recurring on workhouse books for generations4 ,that is1 the persons were born and brought up1 and will be born and brought up1 generation after generation1 in the conditions which make paupers4 ,death and disease are like the workhouse1 they take from the same family1 the same house1 or in other words1 the same conditions4 ,why will we not observe what they are8 ,the close observer may safely predict that such a family1 whether its members marry or not1 will become extinct2 that such another will degenerate morally and physically4 ,but who learns the lesson8 ,on the contrary1 it may be well known that the children die in such a house at the rate of #h out of #aj2 one would think that nothing more need be said2 for how could ,providence speak more distinctly8 yet nobody listens1 the family goes on living there till it dies out1 and then some other family takes it4 ,neither would they listen if one rose from the dead4 ,sidenote3 ,what observation is for4 ,in dwelling upon the vital importance of sound observation1 it must never be lost sight of what observation is for4 ,it is not for the sake of piling up miscellaneous information or curious facts1 but for the sake of saving life and increasing health and comfort4 ,the caution may seem useless1 but it is quite surprising how many men 7some women do it too71 practically behave as if the scientific end were the only one in view1 or as if the sick body were but a reservoir for stowing medicines into1 and the surgical disease only a curious case the sufferer has made for the attendant's special information4 ,this is really no exaggeration4 ,you think1 if you suspected your patient was being poisoned1 say1 by a copper kettle1 you would instantly1 as you ought1 cut off all possible connection between him and the suspected source of injury1 without regard to the fact that a curious mine of observation is thereby lost4 ,but it is not everybody who does so1 and it has actually been made a question of medical ethics1 what should the medical man do if he suspected poisoning8 ,the answer seems a very simple one1--insist on a confidential nurse being placed with the patient1 or give up the case4 ,sidenote3 ,what a confidential nurse should be4 ,and remember every nurse should be one who is to be depended upon1 in other words1 capable of being1 a confidential nurse4 ,she does not know how soon she may find herself placed in such a situation2 she must be no gossip1 no vain talker2 she should never answer questions about her sick except to those who have a right to ask them2 she must1 ,i need not say1 be strictly sober and honest2 but more than this1 she must be a religious and devoted woman2 she must have a respect for her own calling1 because ,god's precious gift of life is often literally placed in her hands2 she must be a sound1 and close1 and quick observer2 and she must be a woman of delicate and decent feeling4 ,sidenote3 ,observation is for practical purposes4 ,to return to the question of what observation is for3--,it would really seem as if some had considered it as its own end1 as if detection1 not cure1 was their business2 nay more1 in a recent celebrated trial1 three medical men1 according to their own account1 suspected poison1 prescribed for dysentery1 and left the patient to the poisoner4 ,this is an extreme case4 ,but in a small way1 the same manner of acting falls under the cognizance of us all4 ,how often the attendants of a case have stated that they knew perfectly well that the patient could not get well in such an air1 in such a room1 or under such circumstances1 yet have gone on dosing him with medicine1 and making no effort to remove the poison from him1 or him from the poison which they knew was killing him2 nay1 more1 have sometimes not so much as mentioned their conviction in the right quarter--that is1 to the only person who could act in the matter4 ,,footnotes3 #a ,it is a much more difficult thing to speak the truth than people commonly imagine4 ,there is the want of observation simple1 and the want of observation compound1 compounded1 that is1 with the imaginative faculty4 ,both may equally intend to speak the truth4 ,the information of the first is simply defective4 ,that of the second is much more dangerous4 ,the first gives1 in answer to a question asked about a thing that has been before his eyes perhaps for years1 information exceedingly imperfect1 or says1 he does not know4 ,he has never observed4 ,and people simply think him stupid4 ,the second has observed just as little1 but imagination immediately steps in1 and he describes the whole thing from imagination merely1 being perfectly convinced all the while that he has seen or heard it2 or he will repeat a whole conversation1 as if it were information which had been addressed to him2 whereas it is merely what he has himself said to somebody else4 ,this is the commonest of all4 ,these people do not even observe that they have not observed1 nor remember that they have forgotten4 ,courts of justice seem to think that anybody can speak the whole truth1 and nothing but the truth1 if he does but intend it4 ,it requires many faculties combined of observation and memory to speak the whole truth1 and to say nothing but the truth4 ,i knows ,i fibs dreadful2 but believe me1 ,miss1 ,i never finds out ,i have fibbed until they tells me so1 was a remark actually made4 ,it is also one of much more extended application than most people have the least idea of4 ,concurrence of testimony1 which is so often adduced as final proof1 may prove nothing more1 as is well known to those accustomed to deal with the unobservant imaginative1 than that one person has told his story a great many times4 ,i have heard thirteen persons concur in declaring that fourteenth1 who had never left his bed1 went to a distant chapel every morning at seven o'clock4 ,i have heard persons in perfect good faith declare1 that a man came to dine every day at the house where they lived1 who had never dined there once2 that a person had never taken the sacrament1 by whose side they had twice at least knelt at ,communion2 that but one meal a day came out of a hospital kitchen1 which for six weeks they had seen provide from three to five and six meals a day4 ,such instances might be multiplied ad infinitum if necessary4 #b ,this is important1 because on this depends what the remedy will be4 ,if a patient sleeps two or three hours early in the night1 and then does not sleep again at all1 ten to one it is not a narcotic he wants1 but food or stimulus1 or perhaps only warmth4 ,if1 on the other hand1 he is restless and awake all night1 and is drowsy in the morning1 he probably wants sedatives1 either quiet1 coolness1 or medicine1 a lighter diet1 or all four4 ,now the doctor should be told this1 or how can he judge what to give8 #c ,sidenote3 ,more important to spare the patient thought than physical exertion4 ,it is commonly supposed that the nurse is there to spare the patient from making physical exertion for himself--,i would rather say that she ought to be there to spare him from taking thought for himself4 ,and ,i am quite sure1 that if the patient were spared all thought for himself1 and not spared all physical exertion1 he would be infinitely the gainer4 ,the reverse is generally the case in the private house4 ,in the hospital it is the relief from all anxiety1 afforded by the rules of a well-regulated institution1 which has often such a beneficial effect upon the patient4 #d ,sidenote3 ,english women have great capacity of1 but little practice in close observation4 ,it may be too broad an assertion1 and it certainly sounds like a paradox4 ,but ,i think that in no country are women to be found so deficient in ready and sound observation as in ,england1 while peculiarly capable of being trained to it4 ,the ,french or ,irish woman is too quick of perception to be so sound an observer--the ,teuton is too slow to be so ready an observer as the ,english woman might be4 ,yet ,english women lay themselves open to the charge so often made against them by men1 viz41 that they are not to be trusted in handicrafts to which their strength is quite equal1 for want of a practised and steady observation4 ,in countries where women 7with average intelligence certainly not superior to that of ,english women7 are employed1 e4g41 in dispensing1 men responsible for what these women do 7not theorizing about man's and woman's missions17 have stated that they preferred the service of women to that of men1 as being more exact1 more careful1 and incurring fewer mistakes of inadvertence4 ,now certainly ,english women are peculiarly capable of attaining to this4 ,i remember when a child1 hearing the story of an accident1 related by some one who sent two girls to fetch a bottle of salvolatile from her room2 ,mary could not stir1 she said1 ,fanny ran and fetched a bottle that was not salvolatile1 and that was not in my room4 ,now this sort of thing pursues every one through life4 ,a woman is asked to fetch a large new bound red book1 lying on the table by the window1 and she fetches five small old boarded brown books lying on the shelf by the fire4 ,and this1 though she has put that room to rights every day for a month perhaps1 and must have observed the books every day1 lying in the same places1 for a month1 if she had any observation4 ,habitual observation is the more necessary1 when any sudden call arises4 ,if ,fanny had observed the bottle of salvolatile in the aunt's room1 every day she was there1 she would more probably have found it when it was suddenly wanted4 ,there are two causes for these mistakes of inadvertence4 #a4 ,a want of ready attention2 only a part of the request is heard at all4 #b4 ,a want of the habit of observation4 ,to a nurse ,i would add1 take care that you always put the same things in the same places2 you don't know how suddenly you may be called on some day to find something1 and may not be able to remember in your haste where you yourself had put it1 if your memory is not in the habit of seeing the thing there always4 #e ,sidenote3 ,approach of death1 paleness by no means an invariable effect1 as we find in novels4 ,it falls to few ever to have had the opportunity of observing the different aspects which the human face puts on at the sudden approach of certain forms of death by violence2 and as it is a knowledge of little use1 ,i only mention it here as being the most startling example of what ,i mean4 ,in the nervous temperament the face becomes pale 7this is the only recognised effect72 in the sanguine temperament purple2 in the bilious yellow1 or every manner of colour in patches4 ,now1 it is generally supposed that paleness is the one indication of almost any violent change in the human being1 whether from terror1 disease1 or anything else4 ,there can be no more false observation4 ,granted1 it is the one recognised livery1 as ,i have said--de rigueur in novels1 but nowhere else4 #f ,i have known two cases1 the one of a man who intentionally and repeatedly displaced a dislocation1 and was kept and petted by all the surgeons2 the other of one who was pronounced to have nothing the matter with him1 there being no organic change perceptible1 but who died within the week4 ,in both these cases1 it was the nurse who1 by accurately pointing out what she had accurately observed1 to the doctors1 saved the one case from persevering in a fraud1 the other from being discharged when actually in a dying state4 ,i will even go further and say1 that in diseases which have their origin in the feeble or irregular action of some function1 and not in organic change1 it is quite an accident if the doctor who sees the case only once a day1 and generally at the same time1 can form any but a negative idea of its real condition4 ,in the middle of the day1 when such a patient has been refreshed by light and air1 by his tea1 his beef-tea1 and his brandy1 by hot bottles to his feet1 by being washed and by clean linen1 you can scarcely believe that he is the same person as lay with a rapid fluttering pulse1 with puffed eye-lids1 with short breath1 cold limbs1 and unsteady hands1 this morning4 ,now what is a nurse to do in such a case8 ,not cry1 ,lord1 bless you1 sir1 why you'd have thought he were a dying all night4 ,this may be true1 but it is not the way to impress with the truth a doctor1 more capable of forming a judgment from the facts1 if he did but know them1 than you are4 ,what he wants is not your opinion1 however respectfully given1 but your facts4 ,in all diseases it is important1 but in diseases which do not run a distinct and fixed course1 it is not only important1 it is essential that the facts the nurse alone can observe1 should be accurately observed1 and accurately reported to the doctor4 ,i must direct the nurse's attention to the extreme variation there is not unfrequently in the pulse of such patients during the day4 ,a very common case is this3 ,between #c and #d ,a4,m41 the pulse become quick1 perhaps #acj1 and so thready it is not like a pulse at all1 but like a string vibrating just underneath the skin4 ,after this the patient gets no more sleep4 ,about mid-day the pulse has come down to #hj2 and though feeble and compressible1 is a very respectable pulse4 ,at night1 if the patient has had a day of excitement1 it is almost imperceptible4 ,but1 if the patient has had a good day1 it is stronger and steadier1 and not quicker than at mid-day4 ,this is a common history of a common pulse2 and others1 equally varying during the day1 might be given4 ,now1 in inflammation1 which may almost always be detected by the pulse1 in typhoid fever1 which is accompanied by the low pulse that nothing will raise1 there is no such great variation4 ,and doctors and nurses become accustomed not to look for it4 ,the doctor indeed cannot4 ,but the variation is in itself an important feature4 ,cases like the above often go off rather suddenly1 as it is called1 from some trifling ailment of a few days1 which just makes up the sum of exhaustion necessary to produce death4 ,and everybody cries1 ,who would have thought it8 except the observing nurse1 if there is one1 who had always expected the exhaustion to come1 from which there would be no rally1 because she knew the patient had no capital in strength on which to draw1 if he failed for a few days to make his barely daily income in sleep and nutrition4 ,i have often seen really good nurses distressed1 because they could not impress the doctor with the real danger of their patient2 and quite provoked because the patient would look either so much better or so much worse than he really is when the doctor was there4 ,the distress is very legitimate1 but it generally arises from the nurse not having the power of laying clearly and shortly before the doctor the facts from which she derives her opinion1 or from the doctor being hasty and inexperienced1 and not capable of eliciting them4 ,a man who really cares for his patients1 will soon learn to ask for and appreciate the information of a nurse1 who is at once a careful observer and a clear reporter4 ,,conclusion4 ,sidenote3 ,sanitary nursing as essential in surgical as in medical cases1 but not to supersede surgical nursing4 ,the whole of the preceding remarks apply even more to children and to puerperal woman than to patients in general4 ,they also apply to the nursing of surgical1 quite as much as to that of medical cases4 ,indeed1 if it be possible1 cases of external injury require such care even more than sick4 ,in surgical wards1 one duty of every nurse certainly is prevention4 ,fever1 or hospital gangrene1 or pyaemia1 or purulent discharge of some kind may else supervene4 ,has she a case of compound fracture1 of amputation1 or of erysipelas1 it may depend very much on how she looks upon the things enumerated in these notes1 whether one or other of these hospital diseases attacks her patient or not4 ,if she allows her ward to become filled with the peculiar close foetid smell1 so apt to be produced among surgical cases1 especially where there is great suppuration and discharge1 she may see a vigorous patient in the prime of life gradually sink and die where1 according to all human probability1 he ought to have recovered4 ,the surgical nurse must be ever on the watch1 ever on her guard1 against want of cleanliness1 foul air1 want of light1 and of warmth4 ,nevertheless let no one think that because sanitary nursing is the subject of these notes1 therefore1 what may be called the handicraft of nursing is to be undervalued4 ,a patient may be left to bleed to death in a sanitary palace4 ,another who cannot move himself may die of bed-sores1 because the nurse does not know how to change and clean him1 while he has every requisite of air1 light1 and quiet4 ,but nursing1 as a handicraft1 has not been treated of here for three reasons3 #a4 ,that these notes do not pretend to be a manual for nursing1 any more than for cooking for the sick2 #b4 ,that the writer1 who has herself seen more of what may be called surgical nursing1 i4e4 practical manual nursing1 than1 perhaps1 any one in ,europe1 honestly believes that it is impossible to learn it from any book1 and that it can only be thoroughly learnt in the wards of a hospital2 and she also honestly believes that the perfection of surgical nursing may be seen practised by the old-fashioned ,sister of a ,london hospital1 as it can be seen nowhere else in ,europe4 #c4 ,while thousands die of foul air1 c41 who have this surgical nursing to perfection1 the converse is comparatively rare4 ,sidenote3 ,children3 their greater susceptibility to the same things4 ,to revert to children4 ,they are much more susceptible than grown people to all noxious influences4 ,they are affected by the same things1 but much more quickly and seriously1 viz41 by want of fresh air1 of proper warmth1 want of cleanliness in house1 clothes1 bedding1 or body1 by startling noises1 improper food1 or want of punctuality1 by dulness and by want of light1 by too much or too little covering in bed1 or when up1 by want of the spirit of management generally in those in charge of them4 ,one can1 therefore1 only press the importance1 as being yet greater in the case of children1 greatest in the case of sick children1 of attending to these things4 ,that which1 however1 above all1 is known to injure children seriously is foul air1 and most seriously at night4 ,keeping the rooms where they sleep tight shut up1 is destruction to them4 ,and1 if the child's breathing be disordered by disease1 a few hours only of such foul air may endanger its life1 even where no inconvenience is felt by grown-up persons in the same room4 ,the following passages1 taken out of an excellent ,lecture on ,sudden ,death in ,infancy and ,childhood1 just published1 show the vital importance of careful nursing of children4 ,in the great majority of instances1 when death suddenly befalls the infant or young child1 it is an accident2 it is not a necessary result of any disease from which it is suffering4 ,it may be here added1 that it would be very desirable to know how often death is1 with adults1 not a necessary1 inevitable result of any disease4 ,omit the word sudden2 7for sudden death is comparatively rare in middle age27 and the sentence is almost equally true for all ages4 ,the following causes of accidental death in sick children are enumerated3--,sudden noises1 which startle--a rapid change of temperature1 which chills the surface1 though only for a moment--a rude awakening from sleep--or even an over-hasty1 or an overfull meal--any sudden impression on the nervous system--any hasty alteration of posture--in short1 any cause whatever by which the respiratory process may be disturbed4 ,it may again be added1 that1 with very weak adult patients1 these causes are also 7not often suddenly fatal1 it is true1 but7 very much oftener than is at all generally known1 irreparable in their consequences4 ,both for children and for adults1 both for sick and for well 7although more certainly in the case of sick children than in any others71 ,i would here again repeat1 the most frequent and most fatal cause of all is sleeping1 for even a few hours1 much more for weeks and months1 in foul air1 a condition which1 more than any other condition1 disturbs the respiratory process1 and tends to produce accidental death in disease4 ,i need hardly here repeat the warning against any confusion of ideas between cold and fresh air4 ,you may chill a patient fatally without giving him fresh air at all4 ,and you can quite well1 nay1 much better1 give him fresh air without chilling him4 ,this is the test of a good nurse4 ,in cases of long recurring faintnesses from disease1 for instance1 especially disease which affects the organs of breathing1 fresh air to the lungs1 warmth to the surface1 and often 7as soon as the patient can swallow7 hot drink1 these are the right remedies and the only ones4 ,yet1 oftener than not1 you see the nurse or mother just reversing this2 shutting up every cranny through which fresh air can enter1 and leaving the body cold1 or perhaps throwing a greater weight of clothes upon it1 when already it is generating too little heat4 ,breathing carefully1 anxiously1 as though respiration were a function which required all the attention for its performance1 is cited as a not unusual state in children1 and as one calling for care in all the things enumerated above4 ,that breathing becomes an almost voluntary act1 even in grown up patients who are very weak1 must often have been remarked4 ,disease having interfered with the perfect accomplishment of the respiratory function1 some sudden demand for its complete exercise1 issues in the sudden standstill of the whole machinery1 is given as one process3--life goes out for want of nervous power to keep the vital functions in activity1 is given as another1 by which accidental death is most often brought to pass in infancy4 ,also in middle age1 both these processes may be seen ending in death1 although generally not suddenly4 ,and ,i have seen1 even in middle age1 the sudden stand-still here mentioned1 and from the same causes4 ,sidenote3 ,summary4 ,to sum up3--the answer to two of the commonest objections urged1 one by women themselves1 the other by men1 against the desirableness of sanitary knowledge for women1 plus a caution1 comprises the whole argument for the art of nursing4 ,sidenote3 ,reckless amateur physicking by women4 ,real knowledge of the laws of health alone can check this4 7#a47 ,it is often said by men1 that it is unwise to teach women anything about these laws of health1 because they will take to physicking1--that there is a great deal too much of amateur physicking as it is1 which is indeed true4 ,one eminent physician told me that he had known more calomel given1 both at a pinch and for a continuance1 by mothers1 governesses1 and nurses1 to children than he had ever heard of a physician prescribing in all his experience4 ,another says1 that women's only idea in medicine is calomel and aperients4 ,this is undeniably too often the case4 ,there is nothing ever seen in any professional practice like the reckless physicking by amateur females4#a ,but this is just what the really experienced and observing nurse does not do2 she neither physics herself nor others4 ,and to cultivate in things pertaining to health observation and experience in women who are mothers1 governesses or nurses1 is just the way to do away with amateur physicking1 and if the doctors did but know it1 to make the nurses obedient to them1--helps to them instead of hindrances4 ,such education in women would indeed diminish the doctor's work--but no one really believes that doctors wish that there should be more illness1 in order to have more work4 ,sidenote3 ,what pathology teaches4 ,what observation alone teaches4 ,what medicine does4 ,what nature alone does4 7#b47 ,it is often said by women1 that they cannot know anything of the laws of health1 or what to do to preserve their children's health1 because they can know nothing of ,pathology1 or cannot dissect1--a confusion of ideas which it is hard to attempt to disentangle4 ,pathology teaches the harm that disease has done4 ,but it teaches nothing more4 ,we know nothing of the principle of health1 the positive of which pathology is the negative1 except from observation and experience4 ,and nothing but observation and experience will teach us the ways to maintain or to bring back the state of health4 ,it is often thought that medicine is the curative process4 ,it is no such thing2 medicine is the surgery of functions1 as surgery proper is that of limbs and organs4 ,neither can do anything but remove obstructions2 neither can cure2 nature alone cures4 ,surgery removes the bullet out of the limb1 which is an obstruction to cure1 but nature heals the wound4 ,so it is with medicine2 the function of an organ becomes obstructed2 medicine1 so far as we know1 assists nature to remove the obstruction1 but does nothing more4 ,and what nursing has to do in either case1 is to put the patient in the best condition for nature to act upon him4 ,generally1 just the contrary is done4 ,you think fresh air1 and quiet and cleanliness extravagant1 perhaps dangerous1 luxuries1 which should be given to the patient only when quite convenient1 and medicine the sine qua non1 the panacea4 ,if ,i have succeeded in any measure in dispelling this illusion1 and in showing what true nursing is1 and what it is not1 my object will have been answered4 ,now for the caution3-- 7#c47 ,it seems a commonly received idea among men and even among women themselves that it requires nothing but a disappointment in love1 the want of an object1 a general disgust1 or incapacity for other things1 to turn a woman into a good nurse4 ,this reminds one of the parish where a stupid old man was set to be schoolmaster because he was past keeping the pigs4 ,apply the above receipt for making a good nurse to making a good servant4 ,and the receipt will be found to fail4 ,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 lovers1 and when found1 forthwith abandoning their sick-ward for their lover1 as might be expected4 ,yet in the estimation of the authors1 these ladies were none the worse for that1 but on the contrary were heroines of nursing4 ,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 deal4 ,the everyday management of a large ward1 let alone of a hospital--the knowing what are the laws of life and death for men1 and what the laws of health for wards--7and wards are healthy or unhealthy1 mainly according to the knowledge or ignorance of the nurse7--are not these matters of sufficient importance and difficulty to require learning by experience and careful inquiry1 just as much as any other art8 ,they do not come by inspiration to the lady disappointed in love1 nor to the poor workhouse drudge hard up for a livelihood4 ,and terrible is the injury which has followed to the sick from such wild notions6 ,in this respect 7and why is it so871 in ,roman ,catholic countries1 both writers and workers are1 in theory at least1 far before ours4 ,they would never think of such a beginning for a good working ,superior or ,sister of ,charity4 ,and many a ,superior has refused to admit a ,postulant who appeared to have no better vocation or reasons for offering herself than these4 ,it is true we make no vows4 ,but is a vow necessary to convince us that the true spirit for learning any art1 most especially an art of charity1 aright1 is not a disgust to everything or something else8 ,do we really place the love of our kind 7and of nursing1 as one branch of it7 so low as this8 ,what would the ,mre ,anglique of ,port ,royal1 what would our own ,mrs4 ,fry have said to this8 ,,note4--,i would earnestly ask my sisters to keep clear of both the jargons now current every where 7for they are equally jargons72 of the jargon1 namely1 about the rights of women1 which urges women to do all that men do1 including the medical and other professions1 merely because men do it1 and without regard to whether this is the best that women1 can do2 and of the jargon which urges women to do nothing that men do1 merely because they are women1 and should be recalled to a sense of their duty as women1 and because this is women's work1 and that is men's1 and these are things which women should not do1 which is all assertion1 and nothing more4 ,surely woman should bring the best she has1 whatever that is1 to the work of ,god's world1 without attending to either of these cries4 ,for what are they1 both of them1 the one just as much as the other1 but listening to the what people will say1 to opinion1 to the voices from without8 ,and as a wise man has said1 no one has ever done anything great or useful by listening to the voices from without4 ,you do not want the effect of your good things to be1 ,how wonderful for a woman6 nor would you be deterred from good things by hearing it said1 ,yes1 but she ought not to have done this1 because it is not suitable for a woman4 ,but you want to do the thing that is good1 whether it is suitable for a woman or not4 ,it does not make a thing good1 that it is remarkable that a woman should have been able to do it4 ,neither does it make a thing bad1 which would have been good had a man done it1 that it has been done by a woman4 ,oh1 leave these jargons1 and go your way straight to ,god's work1 in simplicity and singleness of heart4 ,,footnotes3 #a ,sidenote3 ,danger of physicking by amateur females4 ,i have known many ladies who1 having once obtained a blue pill prescription from a physician1 gave and took it as a common aperient two or three times a week--with what effect may be supposed4 ,in one case ,i happened to be the person to inform the physician of it1 who substituted for the prescription a comparatively harmless aperient pill4 ,the lady came to me and complained that it did not suit her half so well4 ,if women will take or give physic1 by far the safest plan is to send for the doctor every time--for ,i have known ladies who both gave and took physic1 who would not take the pains to learn the names of the commonest medicines1 and confounded1 e4g41 colocynth with colchicum4 ,this is playing with sharp-edged tools with a vengeance4 ,there are excellent women who will write to ,london to their physician that there is much sickness in their neighbourhood in the country1 and ask for some prescription from him1 which they used to like themselves1 and then give it to all their friends and to all their poorer neighbours who will take it4 ,now1 instead of giving medicine1 of which you cannot possibly know the exact and proper application1 nor all its consequences1 would it not be better if you were to persuade and help your poorer neighbours to remove the dung-hill from before the door1 to put in a window which opens1 or an ,arnott's ventilator1 or to cleanse and lime-wash the cottages8 ,of these things the benefits are sure4 ,the benefits of the inexperienced administration of medicines are by no means so sure4 ,homoeopathy has introduced one essential amelioration in the practice of physic by amateur females2 for its rules are excellent1 its physicking comparatively harmless--the globule is the one grain of folly which appears to be necessary to make any good thing acceptable4 ,let then women1 if they will give medicine1 give homoeopathic medicine4 ,it won't do any harm4 ,an almost universal error among women is the supposition that everybody must have the bowels opened once in every twenty-four hours1 or must fly immediately to aperients4 ,the reverse is the conclusion of experience4 ,this is a doctor's subject1 and ,i will not enter more into it2 but will simply repeat1 do not go on taking or giving to your children your abominable courses of aperients1 without calling in the doctor4 ,it is very seldom indeed1 that by choosing your diet1 you cannot regulate your own bowels2 and every woman may watch herself to know what kind of diet will do this2 ,i have known deficiency of meat produce constipation1 quite as often as deficiency of vegetables2 baker's bread much oftener than either4 ,home made brown bread will oftener cure it than anything else4 ,,appendix4 ,transcriber's note3 ,these tables have been transposed to fit the page width4 ,the figures in the left hand column1 ,table ,b3 ,nurse 7not ,domestic ,servant7 do not add up4 ,there is probably a typographical error in this column since it cannot be accounted for by errors in transcription4 ,,table ,a4 ,,great ,,britain4 ,,ages4 ,,nurses4 ,nurse 7not ,domestic ,nurse 7,domestic ,servant7 ,servant7 ,all ,ages4 #be1dff #ci1aci ,under #e years 444 444 #e- 444 #ejh #aj- 444 #g1bei #ae- 444 #aj1cee #bj- #fbd #f1ecg #be- #hag #d1agd #cj- #a1aah #b1die #ce- #a1cei #a1fha #dj- #b1bbc #a1dfh #de- #b1gdh #a1bjf #ej- #c1ihb #a1aif #ee- #c1def #hcc #fj- #c1hbe #gab #fe- #b1edb #cfi #gj- #a1efh #bjd #ge- #gdf #aja #hj- #caa #be #he and upwards #adg #af ,,table ,b4 ,,aged #bj ,,years1 ,,and ,,upwards4 ,,nurses4 ,nurse 7not ,domestic ,nurse 7,domestic ,servant7 ,servant7 ,great ,britain and #be1dff #ba1jag ,islands in the ,british ,seas4 ,england and ,wales4 #bc1gea #ah1ide ,scotland4 #a1edc #a1ibb ,islands in the ,british ,seas4 #agb #aej #ast ,division4 ,london4 #g1hjg #e1jfa #bnd ,division4 ,south ,eastern4 #b1hgh #b1ead #crd ,division4 ,south ,midland4 #b1bhf #a1beb #dth ,division4 ,eastern ,counties4 #b1djh #iei #eth ,division4 ,south ,western ,counties4 #c1jee #a1gcg #fth ,division4 ,west ,midland ,counties4 #a1bbe #b1bhc #gth ,division4 ,north ,midland ,counties4 #a1jjc #ieg #hth ,division4 ,north ,western ,counties4 #igj #b1ace #ith ,division4 ,yorkshire4 #a1jgd #a1jbc #ajth ,division4 ,northern ,counties4 #dfb #daj #aath ,division4 ,monmouth and ,wales4 #cdc #fad ,,note ,,as ,,to ,,the ,,number ,,of ,,women ,,employed ,,as ,,nurses ,,in ,,great ,,britain4 #be1dff were returned1 at the census of #ahea1 as nurses by profession1 #ci1aci nurses in domestic service1#a and #b1hbb midwives4 ,the numbers of different ages are shown in table ,a1 and in table ,b their distribution over ,great ,britain4 ,to increase the efficiency of this class1 and to make as many of them as possible the disciples of the true doctrines of health1 would be a great national work4 ,for there the material exists1 and will be used for nursing1 whether the real conclusion of the matter be to nurse or to poison the sick4 ,a man1 who stands perhaps at the head of our medical profession1 once said to me1 ,i send a nurse into a private family to nurse the sick1 but ,i know that it is only to do them harm4 ,now a nurse means any person in charge of the personal health of another4 ,and1 in the preceding notes1 the term nurse is used indiscriminately for amateur and professional nurses4 ,for1 besides nurses of the sick and nurses of children1 the numbers of whom are here given1 there are friends or relations who take temporary charge of a sick person1 there are mothers of families4 ,it appears as if these unprofessional nurses were just as much in want of knowledge of the laws of health as professional ones4 ,then there are the schoolmistresses of all national and other schools throughout the kingdom4 ,how many of children's epidemics originate in these6 ,then the proportion of girls in these schools1 who become mothers or members among the #fd1fjj nurses recorded above1 or schoolmistresses in their turn4 ,if the laws of health1 as far as regards fresh air1 cleanliness1 light1 c41 were taught to these1 would this not prevent some children being killed1 some evil being perpetuated8 ,on women we must depend1 first and last1 for personal and household hygiene--for preventing the race from degenerating in as far as these things are concerned4 ,would not the true way of infusing the art of preserving its own health into the human race be to teach the female part of it in schools and hospitals1 both by practical teaching and by simple experiments1 in as far as these illustrate what may be called the theory of it8 #a ,a curious fact will be shown by ,table ,a1 viz41 that #ah1abb out of #ci1aci1 or nearly one-half of all the nurses1 in domestic service1 are between #e and #bj years of age4