The Project Gutenberg eBook of Notes on Nursing: What It Is, and What It Is Not
    
This ebook is for the use of anyone anywhere in the United States and
most other parts of the world at no cost and with almost no restrictions
whatsoever. You may copy it, give it away or re-use it under the terms
of the Project Gutenberg License included with this ebook or online
at www.gutenberg.org. If you are not located in the United States,
you will have to check the laws of the country where you are located
before using this eBook.

Title: Notes on Nursing: What It Is, and What It Is Not

Author: Florence Nightingale

Release date: May 1, 2004 [eBook #12439]
                Most recently updated: December 14, 2020

Language: English

Credits: Produced by Carol David and PG Distributed Proofreaders


*** START OF THE PROJECT GUTENBERG EBOOK NOTES ON NURSING: WHAT IT IS, AND WHAT IT IS NOT ***




Produced by Carol David and PG Distributed Proofreaders




NOTES ON NURSING:

WHAT IT IS, AND WHAT IT IS NOT.

BY
FLORENCE NIGHTINGALE.


NEW YORK:
D. APPLETON AND COMPANY
72 FIFTH AVENUE
1898.




PREFACE.

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

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

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



TABLE OF CONTENTS.

VENTILATION AND WARMING
HEALTH OF HOUSES
PETTY MANAGEMENT
NOISE
VARIETY
TAKING FOOD
WHAT FOOD?
BED AND BEDDING
LIGHT
CLEANLINESS OF ROOMS AND WALLS
PERSONAL CLEANLINESS
CHATTERING HOPES AND ADVICES
OBSERVATION OF THE SICK
CONCLUSION
APPENDIX



NOTES ON NURSING:

WHAT IT IS, AND WHAT IT IS NOT.

* * * * *


[Sidenote: Disease a reparative process.]

Shall we begin by taking it as a general principle--that all disease, at
some period or other of its course, is more or less a reparative
process, not necessarily accompanied with suffering: an effort of
nature to remedy a process of poisoning or of decay, which has taken
place weeks, months, sometimes years beforehand, unnoticed, the
termination of the disease being then, while the antecedent process was
going on, determined?

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


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

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

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

If a patient is cold, if a patient is feverish, if a patient is faint,
if he is sick after taking food, if he has a bed-sore, it is generally
the fault not of the disease, but of the nursing.


[Sidenote: What nursing ought to do.]

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


[Sidenote: Nursing the sick little understood.]

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

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

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

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


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

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

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


[Sidenote: Nursing the well.]

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

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


[Sidenote: Little understood.]

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

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

But how much more extraordinary is it that, whereas what we might call
the coxcombries of education--_e.g._, the elements of astronomy--are now
taught to every school-girl, neither mothers of families of any class,
nor school-mistresses of any class, nor nurses of children, nor nurses
of hospitals, are taught anything about those laws which God has
assigned to the relations of our bodies with the world in which He has
put them. In other words, the laws which make these bodies, into which
He has put our minds, healthy or unhealthy organs of those minds, are
all but unlearnt. Not but that these laws--the laws of life--are in a
certain measure understood, but not even mothers think it worth their
while to study them--to study how to give their children healthy
existences. They call it medical or physiological knowledge, fit only
for doctors.

Another objection.

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

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


FOOTNOTES:

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

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

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




I. VENTILATION AND WARMING.


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

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

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

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

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

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


[Sidenote: Without chill.]

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

But a careless nurse, be her rank and education what it may, will stop
up every cranny and keep a hot-house heat when her patient is in bed,--
and, if he is able to get up, leave him comparatively unprotected. The
time when people take cold (and there are many ways of taking cold,
besides a cold in the nose,) is when they first get up after the
two-fold exhaustion of dressing and of having had the skin relaxed by
many hours, perhaps days, in bed, and thereby rendered more incapable of
re-action. Then the same temperature which refreshes the patient in bed
may destroy the patient just risen. And common sense will point out,
that, while purity of air is essential, a temperature must be secured
which shall not chill the patient. Otherwise the best that can be
expected will be a feverish re-action.

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

In the afternoon again, without care, the patient whose vital powers
have then risen often finds the room as close and oppressive as he found
it cold in the morning. Yet the nurse will be terrified, if a window is
opened.[2]


[Sidenote: Open windows.]

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

In a little book on nursing, published a short time ago, we are told,
that, "with proper care it is very seldom that the windows cannot be
opened for a few minutes twice in the day to admit fresh air from
without." I should think not; nor twice in the hour either. It only
shows how little the subject has been considered.


[Sidenote: What kind of warmth desirable.]

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

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


[Sidenote: Bedrooms almost universally foul.]

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


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

A careful nurse will keep a constant watch over her sick, especially
weak, protracted, and collapsed cases, to guard against the effects of
the loss of vital heat by the patient himself. In certain diseased
states much less heat is produced than in health; and there is a
constant tendency to the decline and ultimate extinction of the vital
powers by the call made upon them to sustain the heat of the body. Cases
where this occurs should be watched with the greatest care from hour to
hour, I had almost said from minute to minute. The feet and legs should
be examined by the hand from time to time, and whenever a tendency to
chilling is discovered, hot bottles, hot bricks, or warm flannels, with
some warm drink, should be made use of until the temperature is
restored. The fire should be, if necessary, replenished. Patients are
frequently lost in the latter stages of disease from want of attention
to such simple precautions. The nurse may be trusting to the patient's
diet, or to his medicine, or to the occasional dose of stimulant which
she is directed to give him, while the patient is all the while sinking
from want of a little external warmth. Such cases happen at all times,
even during the height of summer. This fatal chill is most apt to occur
towards early morning at the period of the lowest temperature of the
twenty-four hours, and at the time when the effect of the preceding
day's diets is exhausted.

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

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


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

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


[Sidenote: Night air.]

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


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

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


[Sidenote: Smoke.]

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


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

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 without, it
must not be forgotten that everything in the room which can give off
effluvia, besides the patient, evaporates itself into his air. And it
follows that there ought to be nothing in the room, excepting him, which
can give off effluvia or moisture. Out of all damp towels, &c., which
become dry in the room, the damp, of course, goes into the patient's
air. Yet this "of course" seems as little thought of, as if it were an
obsolete fiction. How very seldom you see a nurse who acknowledges by
her practice that nothing at all ought to be aired in the patient's
room, that nothing at all ought to be cooked at the patient's fire!
Indeed the arrangements often make this rule impossible to observe.

If the nurse be a very careful one, she will, when the patient leaves
his bed, but not his room, open the sheets wide, and throw the
bed-clothes back, in order to air his bed. And she will spread the wet
towels or flannels carefully out upon a horse, in order to dry them. Now
either these bed-clothes and towels are not dried and aired, or they dry
and air themselves into the patient's air. And whether the damp and
effluvia do him most harm in his air or in his bed, I leave to you to
determine, for I cannot.


[Sidenote: Effluvia from excreta.]

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

Of the fatal effects of the effluvia from the excreta it would seem
unnecessary to speak, were they not so constantly neglected. Concealing
the utensils behind the vallance to the bed seems all the precaution
which is thought necessary for safety in private nursing. Did you but
think for one moment of the atmosphere under that bed, the saturation of
the under side of the mattress with the warm evaporations, you would be
startled and frightened too!


[Sidenote: Chamber utensils without lids.]

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

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


[Sidenote: Abolish slop-pails.]

A slop pail should never be brought into a sick room. It should be a
rule invariable, rather more important in the private house than
elsewhere, that the utensil should be carried directly to the
water-closet, emptied there, rinsed there, and brought back. There
should always be water and a cock in every water-closet for rinsing. But
even if there is not, you must carry water there to rinse with. I have
actually seen, in the private sick room, the utensils emptied into the
foot-pan, and put back unrinsed under the bed. I can hardly say which is
most abominable, whether to do this or to rinse the utensil _in_ the
sick room. In the best hospitals it is now a rule that no slop-pail
shall ever be brought into the wards, but that the utensils, shall be
carried direct to be emptied and rinsed at the proper place. I would it
were so in the private house.


[Sidenote: Fumigations.]

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


FOOTNOTES:

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

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

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

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

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

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

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

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

But it is often observed that the nurses who make the greatest outcry
against open windows, are those who take the least pains to prevent
dangerous draughts. The door of the patients' room or ward _must_
sometimes stand open to allow of persons passing in and out, or heavy
things being carried in and out. The careful nurse will keep the door
shut while she shuts the windows, and then, and not before, set the door
open, so that a patient may not be left sitting up in bed, perhaps in a
profuse perspiration, directly in the draught between the open door and
window. Neither, of course, should a patient, while being washed, or in
any way exposed, remain in the draught of an open window or door.

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

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

If a nurse declines to do these kinds of things for her patient,
"because it is not her business," I should say that nursing was not her
calling. I have seen surgical "sisters," women whose hands were worth to
them two or three guineas a-week, down upon their knees scouring a room
or hut, because they thought it otherwise not fit for their patients to
go into. I am far from wishing nurses to scour. It is a waste of power.
But I do say that these women had the true nurse-calling--the good of
their sick first, and second only the consideration what it was their
"place" to do--and that women who wait for the housemaid to do this, or
for the charwoman to do that, when their patients are suffering, have
not the _making_ of a nurse in them.




II. HEALTH OF HOUSES.[1]


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

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

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

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


[Sidenote: Pure air.]

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


[Sidenote: Pure water.]

2. Pure water is more generally introduced into houses than it used to
be, thanks to the exertions of the sanitary reformers. Within the last
few years, a large part of London was in the daily habit of using water
polluted by the drainage of its sewers and water closets. This has
happily been remedied. But, in many parts of the country, well water of
a very impure kind is used for domestic purposes. And when epidemic
disease shows itself, persons using such water are almost sure to
suffer.


[Sidenote: Drainage.]

3. It would be curious to ascertain by inspection, how many houses in
London are really well drained. Many people would say, surely all or
most of them. But many people have no idea in what good drainage
consists. They think that a sewer in the street, and a pipe leading to
it from the house is good drainage. All the while the sewer may be
nothing but a laboratory from which epidemic disease and ill health is
being distilled into the house. No house with any untrapped drain pipe
communicating immediately with a sewer, whether it be from water closet,
sink, or gully-grate, can ever be healthy. An untrapped sink may at any
time spread fever or pyaemia among the inmates of a palace.


[Sidenote: Sinks.]

The ordinary oblong sink is an abomination. That great surface of stone,
which is always left wet, is always exhaling into the air. I have known
whole houses and hospitals smell of the sink. I have met just as strong
a stream of sewer air coming up the back staircase of a grand London
house from the sink, as I have ever met at Scutari; and I have seen the
rooms in that house all ventilated by the open doors, and the passages
all _un_ventilated by the closed windows, in order that as much of the
sewer air as possible might be conducted into and retained in the
bed-rooms. It is wonderful.

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


[Sidenote: Cleanliness.]

4. Without cleanliness, within and without your house, ventilation is
comparatively useless. In certain foul districts of London, poor people
used to object to open their windows and doors because of the foul
smells that came in. Rich people like to have their stables and dunghill
near their houses. But does it ever occur to them that with many
arrangements of this kind it would be safer to keep the windows shut
than open? You cannot have the air of the house pure with dung-heaps
under the windows. These are common all over London. And yet people are
surprised that their children, brought up in large "well-aired"
nurseries and bed-rooms suffer from children's epidemics. If they
studied Nature's laws in the matter of children's health, they would not
be so surprised.

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


[Sidenote: Light.]

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

People lose their health in a dark house, and if they get ill they
cannot get well again in it. More will be said about this farther on.


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

Three out of many "negligences, and ignorances" in managing the health
of houses generally, I will here mention as specimens--1. That the
female head in charge of any building does not think it necessary to
visit every hole and corner of it every day. How can she expect those
who are under her to be more careful to maintain her house in a healthy
condition than she who is in charge of it?--2. That it is not considered
essential to air, to sun, and to clean rooms while uninhabited; which is
simply ignoring the first elementary notion of sanitary things, and
laying the ground ready for all kinds of diseases.--3. That the window,
and one window, is considered enough to air a room. Have you never
observed that any room without a fire-place is always close? And, if you
have a fire-place, would you cram it up not only with a chimney-board,
but perhaps with a great wisp of brown paper, in the throat of the
chimney--to prevent the soot from coming down, you say? If your chimney
is foul, sweep it; but don't expect that you can ever air a room with
only one aperture; don't suppose that to shut up a room is the way to
keep it clean. It is the best way to foul the room and all that is in
it. Don't imagine that if you, who are in charge, don't look to all
these things yourself, those under you will be more careful than you
are. It appears as if the part of a mistress now is to complain of her
servants, and to accept their excuses--not to show them how there need
be neither complaints made nor excuses.


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

But again, to look to all these things yourself does not mean to do them
yourself. "I always open the windows," the head in charge often says. If
you do it, it is by so much the better, certainly, than if it were not
done at all. But can you not insure that it is done when not done by
yourself? Can you insure that it is not undone when your back is turned?
This is what being "in charge" means. And a very important meaning it
is, too. The former only implies that just what you can do with your own
hands is done. The latter that what ought to be done is always done.


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

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


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

[Sidenote: How does He teach His laws?]

I will tell you what was the cause of this hospital pyaemia being in
that large private house. It was that the sewer air from an ill-placed
sink was carefully conducted into all the rooms by sedulously opening
all the doors, and closing all the passage windows. It was that the
slops were emptied into the foot pans!--it was that the utensils were
never properly rinsed;--it was that the chamber crockery was rinsed with
dirty water;--it was that the beds were never properly shaken, aired,
picked to pieces, or changed. It was that the carpets and curtains were
always musty;--it was that the furniture was always dusty;--it was that
the papered walls were saturated with dirt;--it was that the floors were
never cleaned;--it was that the uninhabited rooms were never sunned, or
cleaned, or aired;--it was that the cupboards were always reservoirs of
foul air;--it was that the windows were always tight shut up at night;--
it was that no window was ever systematically opened even in the day, or
that the right window was not opened. A person gasping for air might
open a window for himself. But the servants were not taught to open the
windows, to shut the doors; or they opened the windows upon a dank well
between high walls, not upon the airier court; or they opened the room
doors into the unaired halls and passages, by way of airing the rooms.
Now all this is not fancy, but fact. In that handsome house I have known
in one summer three cases of hospital pyaemia, one of phlebitis, two of
consumptive cough; all the _immediate_ products of foul air. When, in
temperate climates, a house is more unhealthy in summer than in winter,
it is a certain sign of something wrong. Yet nobody learns the lesson.
Yes, God always justifies His ways. He is teaching while you are not
learning. This poor body loses his finger, that one loses his life. And
all from the most easily preventible causes.[3]


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

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


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

With regard to the health of houses where there is a sick person, it
often happens that the sick room is made a ventilating shaft for the
rest of the house. For while the house is kept as close, unaired, and
dirty as usual, the window of the sick room is kept a little open
always, and the door occasionally. Now, there are certain sacrifices
which a house with one sick person in it does make to that sick person:
it ties up its knocker; it lays straw before it in the street. Why can't
it keep itself thoroughly clean and unusually well aired, in deference
to the sick person?


[Sidenote: Infection.]

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

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

Wise and humane management of the patient is the best safeguard against
infection.


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

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

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

Oh because, you say, we cannot keep it from infection--other children
have measles--and it must take them--and it is safer that it should.

But why must other children have measles? And if they have, why must
yours have them too?

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


FOOTNOTES:

[1]
[Sidenote: Health of carriages.]

The health of carriages, especially close carriages, is not of
sufficient universal importance to mention here, otherwise than
cursorily. Children, who are always the most delicate test of sanitary
conditions, generally cannot enter a close carriage without being sick--
and very lucky for them that it is so. A close carriage, with the
horse-hair cushions and linings always saturated with organic matter, if
to this be added the windows up, is one of the most unhealthy of human
receptacles. The idea of taking an _airing_ in it is something
preposterous. Dr. Angus Smith has shown that a crowded railway carriage,
which goes at the rate of 30 miles an hour, is as unwholesome as the
strong smell of a sewer, or as a back yard in one of the most unhealthy
courts off one of the most unhealthy streets in Manchester.

[2]
God lays down certain physical laws. Upon His carrying out such laws
depends our responsibility (that much abused word), for how could we
have any responsibility for actions, the results of which we could not
foresee--which would be the case if the carrying out of His laws were
not certain. Yet we seem to be continually expecting that He will work a
miracle--i.e., break His own laws expressly to relieve us of
responsibility.

[3]
[Sidenote: Servants rooms.]

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

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

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

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

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

I have seen, for instance, with a little overcrowding, continued fever
grow up; and with a little more, typhoid fever; and with a little more,
typhus, and all in the same ward or hut.

Would it not be far better, truer, and more practical, if we looked upon
disease in this light?

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




III. PETTY MANAGEMENT.


[Sidenote: Petty management.]

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

It is as impossible in a book to teach a person in charge of sick how to
_manage_, as it is to teach her how to nurse. Circumstances must vary
with each different case. But it _is_ possible to press upon her to
think for herself: Now what does happen during my absence? I am obliged
to be away on Tuesday. But fresh air, or punctuality is not less
important to my patient on Tuesday than it was on Monday. Or: At 10 P.M.
I am never with my patient; but quiet is of no less consequence to him
at 10 than it was at 5 minutes to 10.

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


[Sidenote: Illustrations of the want of it.]

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


[Sidenote: Strangers coming into the sick room.]

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


[Sidenote: Sick room airing the whole house.]

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


[Sidenote: Uninhabited room fouling the whole house.]

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


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

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

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

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


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

It is never thought that the patient remembers these things if you do
not. He has not only to think whether the visit or letter may arrive,
but whether you will be in the way at the particular day and hour when
it may arrive. So that your _partial_ measures for "being in the way"
yourself, only increase the necessity for his thought.

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

For the above reasons, whatever a patient _can_ do for himself, it is
better, i.e. less anxiety, for him to do for himself, unless the person
in charge has the spirit of management.

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

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

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

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


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

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

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

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

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


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

How few men, or even women, understand, either in great or in little
things, what it is the being "in charge"--I mean, know how to carry out
a "charge." From the most colossal calamities, down to the most trifling
accidents, results are often traced (or rather _not_ traced) to such
want of some one "in charge" or of his knowing how to be "in charge." A
short time ago the bursting of a funnel-casing on board the finest and
strongest ship that ever was built, on her trial trip, destroyed several
lives and put several hundreds in jeopardy--not from any undetected flaw
in her new and untried works--but from a tap being closed which ought
not to have been closed--from what every child knows would make its
mother's tea-kettle burst. And this simply because no one seemed to know
what it is to be "in charge," or _who_ was in charge. Nay more, the jury
at the inquest actually altogether ignored the same, and apparently
considered the tap "in charge," for they gave as a verdict "accidental
death."

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

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

It is often said that there are few good servants now; I say there are
few good mistresses now. As the jury seems to have thought the tap was
in charge of the ship's safety, so mistresses now seem to think the
house is in charge of itself. They neither know how to give orders, nor
how to teach their servants to obey orders--_i.e._, to obey
intelligently, which is the real meaning of all discipline.

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


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

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


FOOTNOTES:

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

That excellent paper, the _Builder_, mentions the lingering of the smell
of paint for a month about a house as a proof of want of ventilation.
Certainly--and, where there are ample windows to open, and these are
never opened to get rid of the smell of paint, it is a proof of want of
management in using the means of ventilation. Of course the smell will
then remain for months. Why should it go?

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

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

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

[3]
There are many physical operations where _coeteris paribus_ the danger
is in a direct ratio to the time the operation lasts; and _coeteris
paribus_ the operator's success will be in direct ratio to his
quickness. Now there are many mental operations where exactly the same
rule holds good with the sick; _coeteris paribus_ their capability of
bearing such operations depends directly on the quickness, _without
hurry_, with which they can be got through.

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

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


[Sidenote: What institutions are the exception?]

But, as far as regards the art of petty management in hospitals, all the
military hospitals I know must be excluded. Upon my own experience I
stand, and I solemnly declare that I have seen or known of fatal
accidents, such as suicides in _delirium tremens,_ bleedings to death,
dying patients dragged out of bed by drunken Medical Staff Corps men,
and many other things less patent and striking, which would not have
happened in London civil hospitals nursed by women. The medical officers
should be absolved from all blame in these accidents. How can a medical
officer mount guard all day and all night over a patient (say) in
_delirium tremens?_ The fault lies in there being no organized system
of attendance. Were a trustworthy _man_ in charge of each ward, or set
of wards, not as office clerk, but as head nurse, (and head nurse the
best hospital serjeant, or ward master, is not now and cannot be, from
default of the proper regulations,) the thing would not, in all
probability, have happened. But were a trustworthy _woman_ in charge of
the ward, or set of wards, the thing would not, in all certainty, have
happened. In other words, it does not happen where a trustworthy woman
is really in charge. And, in these remarks, I by no means refer only to
exceptional times of great emergency in war hospitals, but also, and
quite as much, to the ordinary run of military hospitals at home, in
time of peace; or to a time in war when our army was actually more
healthy than at home in peace, and the pressure on our hospitals
consequently much less.


[Sidenote: Nursing in Regimental Hospitals.]

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

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




IV. NOISE.


[Sidenote: Unnecessary noise.]

Unnecessary noise, or noise that creates an expectation in the mind, is
that which hurts a patient. It is rarely the loudness of the noise, the
effect upon the organ of the ear itself, which appears to affect the
sick. How well a patient will generally bear, _e. g._, the putting up of
a scaffolding close to the house, when he cannot bear the talking, still
less the whispering, especially if it be of a familiar voice, outside
his door.

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


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

Never to allow a patient to be waked, intentionally or accidentally, is
a _sine qua non_ of all good nursing. If he is roused out of his first
sleep, he is almost certain to have no more sleep. It is a curious but
quite intelligible fact that, if a patient is waked after a few hours'
instead of a few minutes' sleep, he is much more likely to sleep again.
Because pain, like irritability of brain, perpetuates and intensifies
itself. If you have gained a respite of either in sleep you have gained
more than the mere respite. Both the probability of recurrence and of
the same intensity will be diminished; whereas both will be terribly
increased by want of sleep. This is the reason why sleep is so
all-important. This is the reason why a patient waked in the early part
of his sleep loses not only his sleep, but his power to sleep. A healthy
person who allows himself to sleep during the day will lose his sleep at
night. But it is exactly the reverse with the sick generally; the more
they sleep, the better will they be able to sleep.


[Sidenote: Noise which excites expectation.]

[Sidenote: Whispered conversation in the room.]

I have often been surprised at the thoughtlessness, (resulting in
cruelty, quite unintentionally) of friends or of doctors who will hold a
long conversation just in the room or passage adjoining to the room of
the patient, who is either every moment expecting them to come in, or
who has just seen them, and knows they are talking about him. If he is
an amiable patient, he will try to occupy his attention elsewhere and
not to listen--and this makes matters worse--for the strain upon his
attention and the effort he makes are so great that it is well if he is
not worse for hours after. If it is a whispered conversation in the same
room, then it is absolutely cruel; for it is impossible that the
patient's attention should not be involuntarily strained to hear.
Walking on tip-toe, doing any thing in the room very slowly, are
injurious, for exactly the same reasons. A firm light quick step, a
steady quick hand are the desiderata; not the slow, lingering, shuffling
foot, the timid, uncertain touch. Slowness is not gentleness, though it
is often mistaken for such: quickness, lightness, and gentleness are
quite compatible. Again, if friends and doctors did but watch, as nurses
can and should watch, the features sharpening, the eyes growing almost
wild, of fever patients who are listening for the entrance from the
corridor of the persons whose voices they are hearing there, these would
never run the risk again of creating such expectation, or irritation of
mind.--Such unnecessary noise has undoubtedly induced or aggravated
delirium in many cases. I have known such--in one case death ensued. It
is but fair to say that this death was attributed to fright. It was the
result of a long whispered conversation, within sight of the patient,
about an impending operation; but any one who has known the more than
stoicism, the cheerful coolness, with which the certainty of an
operation will be accepted by any patient, capable of bearing an
operation at all, if it is properly communicated to him, will hesitate
to believe that it was mere fear which produced, as was averred, the
fatal result in this instance. It was rather the uncertainty, the
strained expectation as to what was to be decided upon.


[Sidenote: Or just outside the door.]

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


[Sidenote: Noise of female dress.]

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

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

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


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

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

A nurse who rustles (I am speaking of nurses professional and
unprofessional) is the horror of a patient, though perhaps he does not
know why.

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

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

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

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

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


[Sidenote: Hurry peculiarly hurtful to sick.]

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


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

Always sit within the patient's view, so that when you speak to him he
has not painfully to turn his head round in order to look at you.
Everybody involuntarily looks at the person speaking. If you make this
act a wearisome one on the part of the patient you are doing him harm.
So also if by continuing to stand you make him continuously raise his
eyes to see you. Be as motionless as possible, and never gesticulate in
speaking to the sick.

Never make a patient repeat a message or request, especially if it be
some time after. Occupied patients are often accused of doing too much
of their own business. They are instinctively right. How often you hear
the person, charged with the request of giving the message or writing
the letter, say half an hour afterwards to the patient, "Did you appoint
12 o'clock?" or, "What did you say was the address?" or ask perhaps some
much more agitating question--thus causing the patient the effort of
memory, or worse still, of decision, all over again. It is really less
exertion to him to write his letters himself. This is the almost
universal experience of occupied invalids.

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

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


[Sidenote: These things not fancy.]

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


[Sidenote: Interruption damaging to sick.]

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


[Sidenote: And to well.]

This rule, indeed, applies to the well quite as much as to the sick. I
have never known persons who exposed themselves for years to constant
interruption who did not muddle away their intellects by it at last. The
process with them may be accomplished without pain. With the sick, pain
gives warning of the injury.


[Sidenote: Keeping a patient standing.]

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


[Sidenote: Patients dread surprise.]

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

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

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


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

People rarely, if ever, faint while making an exertion. It is after it
is over. Indeed, almost every effect of over-exertion appears after, not
during such exertion. It is the highest folly to judge of the sick, as
is so often done, when you see them merely during a period of
excitement. People have very often died of that which, it has been
proclaimed at the time, has "done them no harm."[3]

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


[Sidenote: Difference between real and fancy patients.]

In all that we have said, both here and elsewhere, let it be distinctly
understood that we are not speaking of hypochondriacs. To distinguish
between real and fancied disease forms an important branch of the
education of a nurse. To manage fancy patients forms an important branch
of her duties. But the nursing which real and that which fancied
patients require is of different, or rather of opposite, character. And
the latter will not be spoken of here. Indeed, many of the symptoms
which are here mentioned are those which distinguish real from fancied
disease.

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


[Sidenote: Conciseness necessary with sick.]

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


[Sidenote: Irresolution most painful to them.]

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

Above all, leave the sick room quickly and come into it quickly, not
suddenly, not with a rush. But don't let the patient be wearily waiting
for when you will be out of the room or when you will be in it.
Conciseness and decision in your movements, as well as your words, are
necessary in the sick room, as necessary as absence of hurry and bustle.
To possess yourself entirely will ensure you from either failing--either
loitering or hurrying.


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

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


[Sidenote: Reading aloud.]

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


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

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


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

(2.) The extraordinary habit of reading to oneself in a sick room, and
reading aloud to the patient any bits which will amuse him or more often
the reader, is unaccountably thoughtless. What _do_ you think the
patient is thinking of during your gaps of non-reading? Do you think
that he amuses himself upon what you have read for precisely the time it
pleases you to go on reading to yourself, and that his attention is
ready for something else at precisely the time it pleases you to begin
reading again? Whether the person thus read to be sick or well, whether
he be doing nothing or doing something else while being thus read to,
the self-absorption and want of observation of the person who does it,
is equally difficult to understand--although very often the read_ee_ is
too amiable to say how much it hurts him.


[Sidenote: People overhead.]

One thing more:--From, the flimsy manner in which most modern houses are
built, where every step on the stairs, and along the floors, is felt all
over the house; the higher the story, the greater the vibration. It is
inconceivable how much the sick suffer by having anybody overhead. In
the solidly built old houses, which, fortunately, most hospitals are,
the noise and shaking is comparatively trifling. But it is a serious
cause of suffering, in lightly built houses, and with the irritability
peculiar to some diseases. Better far put such patients at the top of
the house, even with the additional fatigue of stairs, if you cannot
secure the room above them being untenanted; you may otherwise bring on
a state of restlessness which no opium will subdue. Do not neglect the
warning, when a patient tells you that he "Feels every step above him to
cross his heart." Remember that every noise a patient cannot _see_
partakes of the character of suddenness to him; and I am persuaded that
patients with these peculiarly irritable nerves, are positively less
injured by having persons in the same room with them than overhead, or
separated by only a thin compartment. Any sacrifice to secure silence
for these cases is worth while, because no air, however good, no
attendance, however careful, will do anything for such cases without
quiet.


[Sidenote: Music.]

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


FOOTNOTES:

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

Fortunate it is if her skirts do not catch fire--and if the nurse does
not give herself up a sacrifice together with her patient, to be burnt
in her own petticoats. I wish the Registrar-General would tell us the
exact number of deaths by burning occasioned by this absurd and hideous
custom. But if people will be stupid, let them take measures to protect
themselves from their own stupidity--measures which every chemist
knows, such as putting alum into starch, which prevents starched
articles of dress from blazing up.


[Sidenote: Indecency of the crinolines.]

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

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

It is absolutely essential that a nurse should lay this down as a
positive rule to herself, never to speak to any patient who is standing
or moving, as long as she exercises so little observation as not to know
when a patient cannot bear it. I am satisfied that many of the accidents
which happen from feeble patients tumbling down stairs, fainting after
getting up, &c., happen solely from the nurse popping out of a door to
speak to the patient just at that moment; or from his fearing that she
will do so. And that if the patient were even left to himself, till he
can sit down, such accidents would much seldomer occur. If the nurse
accompanies the patient, let her not call upon him to speak. It is
incredible that nurses cannot picture to themselves the strain upon the
heart, the lungs, and the brain, which the act of moving is to any
feeble patient.

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

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

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

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

Sick children, if not too shy to speak, will always express this wish.
They invariably prefer a story to be _told_ to them, rather than read to
them.




V. VARIETY.


[Sidenote: Variety a means of recovery.]

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

The superior cheerfulness of persons suffering severe paroxysms of pain
over that of persons suffering from nervous debility has often been
remarked upon, and attributed to the enjoyment of the former of their
intervals of respite. I incline to think that the majority of cheerful
cases is to be found among those patients who are not confined to one
room, whatever their suffering, and that the majority of depressed cases
will be seen among those subjected to a long monotony of objects about
them.

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


[Sidenote: Colour and form means of recovery.]

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

Such cravings are usually called the "fancies" of patients. And often
doubtless patients have "fancies," as e.g. when they desire two
contradictions. But much more often, their (so called) "fancies" are the
most valuable indications of what is necessary for their recovery. And
it would be well if nurses would watch these (so called) "fancies"
closely.

I have seen, in fevers (and felt, when I was a fever patient myself),
the most acute suffering produced from the patient (in a hut) not being
able to see out of window, and the knots in the wood being the only
view. I shall never forget the rapture of fever patients over a bunch of
bright-coloured flowers. I remember (in my own case) a nosegay of wild
flowers being sent me, and from that moment recovery becoming more
rapid.


[Sidenote: This is no fancy.]

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

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

But it must be _slow_ variety, e.g., if you shew a patient ten or twelve
engravings successively, ten-to-one that he does not become cold and
faint, or feverish, or even sick; but hang one up opposite him, one on
each successive day, or week, or month, and he will revel in the
variety.


[Sidenote: Flowers.]

The folly and ignorance which reign too often supreme over the
sick-room, cannot be better exemplified than by this. While the nurse
will leave the patient stewing in a corrupting atmosphere, the best
ingredient of which is carbonic acid; she will deny him, on the plea of
unhealthiness, a glass of cut-flowers, or a growing plant. Now, no one
ever saw "overcrowding" by plants in a room or ward. And the carbonic
acid they give off at nights would not poison a fly. Nay, in overcrowded
rooms, they actually absorb carbonic acid and give off oxygen.
Cut-flowers also decompose water and produce oxygen gas. It is true there
are certain flowers, e.g. lilies, the smell of which is said to depress
the nervous system. These are easily known by the smell, and can be
avoided.


[Sidenote: Effect of body on mind.]

Volumes are now written and spoken upon the effect of the mind upon the
body. Much of it is true. But I wish a little more was thought of the
effect of the body on the mind. You who believe yourselves overwhelmed
with anxieties, but are able every day to walk up Regent-street, or out
in the country, to take your meals with others in other rooms, &c., &c.,
you little know how much your anxieties are thereby lightened; you
little know how intensified they become to those who can have no
change;[1] how the very walls of their sick rooms seem hung with their
cares; how the ghosts of their troubles haunt their beds; how impossible
it is for them to escape from a pursuing thought without some help from
variety.

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


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

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

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

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


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

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

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

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

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


FOOTNOTES:

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

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


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

I remember a case in point. A man received an injury to the spine, from
an accident, which after a long confinement ended in death. He was a
workman--had not in his composition a single grain of what is called
"enthusiasm for nature"--but he was desperate to "see once more out of
window." His nurse actually got him on her back, and managed to perch
him up at the window for an instant, "to see out." The consequence to
the poor nurse was a serious illness, which nearly proved fatal. The man
never knew it; but a great many other people did. Yet the consequence in
none of their minds, so far as I know, was the conviction that the
craving for variety in the starving eye, is just as desperate as that of
food in the starving stomach, and tempts the famishing creature in
either case to steal for its satisfaction. No other word will express it
but "desperation." 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 kind, as if they did not
provide the hospital with a kitchen.

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

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




VI. TAKING FOOD.


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

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

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

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

I am bound to say, that I think more patients are lost by want of care
and ingenuity in these momentous minutiae in private nursing than in
public hospitals. 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 institutions, than between the doctor and the patient's friends
in the private house.


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

If we did but know the consequences which may ensue, in very weak
patients, from ten minutes' fasting or repletion (I call it repletion
when they are obliged to let too small an interval elapse between taking
food and some other exertion, owing to the nurse's unpunctuality), we
should be more careful never to let this occur. In very weak patients
there is often a nervous difficulty of swallowing, which is so much
increased by any other call upon their strength that, unless they have
their food punctually at the minute, which minute again must be arranged
so as to fall in with no other minute's occupation, they can take
nothing 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 hours.
And why is it not as easy to be punctual to a minute? Life often
literally hangs upon these minutes.

In acute cases, where life or death is to be determined in a few hours,
these matters are very generally attended to, especially in Hospitals;
and the number of cases is large where the patient is, as it were,
brought back to life by exceeding care on the part of the Doctor or
Nurse, or both, in ordering and giving nourishment with minute selection
and punctuality.


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

But in chronic cases, lasting over months and years, where the fatal
issue is often determined at last by mere protracted starvation, I had
rather not enumerate the instances which I have known where a little
ingenuity, and a great deal of perseverance, might, in all probability,
have averted the result. The consulting the hours when the patient can
take food, the observation of the times, often varying, when he is most
faint, the altering seasons of taking food, in order to anticipate and
prevent such times--all this, which requires observation, ingenuity, and
perseverance (and these really constitute the good Nurse), might save
more lives than we wot of.


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

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

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


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

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

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

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

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

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

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


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

A nurse should never put before a patient milk that is sour, meat or
soup that is turned, an egg that is bad, or vegetables underdone. Yet
often I have seen these things brought in to the sick in a state
perfectly perceptible to every nose or eye except the nurse's. It is
here that the clever nurse appears; she will not bring in the peccant
article, but, not to disappoint the patient, she will whip up something
else in a few minutes. Remember that sick cookery should half do the
work of your poor patient's weak digestion. But if you further impair it
with your bad articles, I know not what is to become of him or of it.

If the nurse is an intelligent being, and not a mere carrier of diets to
and from the patient, let her exercise her intelligence in these things.
How often we have known a patient eat nothing at all in the day, because
one meal was left untasted (at that time he was incapable of eating), at
another the milk was sour, the third was spoiled by some other accident.
And it never occurred to the nurse to extemporize some expedient,--it
never occurred to her that as he had had no solid food that day he might
eat a bit of toast (say) with his tea in the evening, or he might have
some meal an hour earlier. A patient who cannot touch his dinner at two,
will often accept it gladly, if brought to him at seven. But somehow
nurses never "think of these things." One would imagine they did not
consider themselves bound to exercise their judgment; they leave it to
the patient. Now I am quite sure that it is better for a patient rather
to suffer these neglects than to try to teach his nurse to nurse him, if
she does not know how. It ruffles him, and if he is ill he is in no
condition to teach, especially upon himself. The above remarks apply
much more to private nursing than to hospitals.


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

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


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

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


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

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




VII. WHAT FOOD?


[Sidenote: Common errors in diet.]

[Sidenote: Beef tea.]

[Sidenote: Eggs.]

[Sidenote: Meat without vegetables.]

[Sidenote: Arrowroot.]

I will mention one or two of the most common errors among women in
charge of sick respecting sick diet. One is the belief that beef tea is
the most nutritive of all articles. Now, just try and boil down a lb. of
beef into beef tea, evaporate your beef tea, and see what is left of
your beef. You will find that there is barely a teaspoonful of solid
nourishment to half a pint of water in beef tea;--nevertheless there is
a certain reparative quality in it, we do not know what, as there is in
tea;--but it may safely be given in almost any inflammatory disease, and
is as little to be depended upon with the healthy or convalescent where
much nourishment is required. Again, it is an ever ready saw that an egg
is equivalent to a lb. of meat,--whereas it is not at all so. Also, it
is seldom noticed with how many patients, particularly of nervous or
bilious temperament, eggs disagree. All puddings made with eggs, are
distasteful to them in consequence. An egg, whipped up with wine, is
often the only form in which they can take this kind of nourishment.
Again, if the patient has attained to eating meat, it is supposed that
to give him meat is the only thing needful for his recovery; whereas
scorbutic sores have been actually known to appear among sick persons
living in the midst of plenty in England, which could be traced to no
other source than this, viz.: that the nurse, depending on meat alone,
had allowed the patient to be without vegetables for a considerable
time, these latter being so badly cooked that he always left them
untouched. Arrowroot is another grand dependence of the nurse. As a
vehicle for wine, and as a restorative quickly prepared, it is all very
well. But it is nothing but starch and water. Flour is both more
nutritive, and less liable to ferment, and is preferable wherever it can
be used.


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

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

But, if fresh milk is so valuable a food for the sick, the least change
or sourness in it, makes it of all articles, perhaps, the most
injurious; diarrhoea is a common result of fresh milk allowed to become
at all sour. The nurse therefore ought to exercise her utmost care in
this. In large institutions for the sick, even the poorest, the utmost
care is exercised. Wenham Lake ice is used for this express purpose
every summer, while the private patient, perhaps, never tastes a drop of
milk that is not sour, all through the hot weather, so little does the
private nurse understand the necessity of such care. Yet, if you
consider that the only drop of real nourishment in your patient's tea is
the drop of milk, and how much almost all English patients depend upon
their tea, you will see the great importance of not depriving your
patient of this drop of milk. Buttermilk, a totally different thing, is
often very useful, especially in fevers.


[Sidenote: Sweet things.]

In laying down rules of diet, by the amounts of "solid nutriment" in
different kinds of food, it is constantly lost sight of what the patient
requires to repair his waste, what he can take and what he can't. You
cannot diet a patient from a book, you cannot make up the human body as
you would make up a prescription,--so many parts "carboniferous," so
many parts "nitrogenous" will constitute a perfect diet for the patient.
The nurse's observation here will materially assist the doctor--the
patient's "fancies" will materially assist the nurse. For instance,
sugar is one of the most nutritive of all articles, being pure carbon,
and is particularly recommended in some books. But the vast majority of
all patients in England, young and old, male and female, rich and poor,
hospital and private, dislike sweet things,--and while I have never
known a person take to sweets when he was ill who disliked them when he
was well, I have known many fond of them when in health, who in sickness
would leave off anything sweet, even to sugar in tea,--sweet puddings,
sweet drinks, are their aversion; the furred tongue almost always likes
what is sharp or pungent. Scorbutic patients are an exception, they
often crave for sweetmeats and jams.


[Sidenote: Jelly.]

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

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


[Sidenote: Beef tea]

Dr. 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 repeatedly, when they refuse all other kinds of food."
This is particularly remarkable in "cases of gastric fever, in which,"
he says, "little or nothing else besides beef tea or diluted meat juice"
has been taken for weeks or even months, "and yet a pint of beef tea
contains scarcely 1/4 oz. of anything but water,"--the result is so
striking that he asks what is its mode of action? "Not simply nutrient--
1/4 oz. of the most nutritive material cannot nearly replace the daily
wear and tear of the tissues in any circumstances. Possibly," he says,
"it belongs to a new denomination of remedies."

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

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


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

Chemistry has as yet afforded little insight into the dieting of sick.
All that chemistry can tell us is the amount of "carboniferous" or
"nitrogenous" elements discoverable in different dietetic articles. It
has given us lists of dietetic substances, arranged in the order of
their richness in one or other of these principles; but that is all. In
the great majority of cases, the stomach of the patient is guided by
other principles of selection than merely the amount of carbon or
nitrogen in the diet. No doubt, in this as in other things, nature has
very definite rules for her guidance, but these rules can only be
ascertained by the most careful observation at the bedside. She there
teaches us that living chemistry, the chemistry of reparation, is
something different from the chemistry of the laboratory. Organic
chemistry is useful, as all knowledge is, when we come face to face with
nature; but it by no means follows that we should learn in the
laboratory any one of the reparative processes going on in disease.

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


[Sidenote: Home-made bread.]

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


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

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

Now the medical man who sees the patient only once a day or even only
once or twice a week, cannot possibly tell this without the assistance
of the patient himself, or of those who are in constant observation on
the patient. The utmost the medical man can tell is whether the patient
is weaker or stronger at this visit than he was at the last visit. I
should therefore say that incomparably the most important office of the
nurse, after she has taken care of the patient's air, is to take care to
observe the effect of his food, and report it to the medical attendant.

It is quite incalculable the good that would certainly come from such
_sound_ and close observation in this almost neglected branch of
nursing, or the help it would give to the medical man.


[Sidenote: Tea and coffee.]

A great deal too much against tea[2] is said by wise people, and a great
deal too much of tea is given to the sick by foolish people. When you
see the natural and almost universal craving in English sick for their
"tea," you cannot but feel that nature knows what she is about. But a
little tea or coffee restores them quite as much as a great deal, and a
great deal of tea and especially of coffee impairs the little power of
digestion they have. Yet a nurse, because she sees how one or two cups
of tea or coffee restores her patient, thinks that three or four cups
will do twice as much. This is not the case at all; it is however
certain that there is nothing yet discovered which is a substitute to
the English patient for his cup of tea; he can take it when he can take
nothing else, and he often can't take anything else if he has it not. I
should be very glad if any of the abusers of tea would point out what to
give to an English patient after a sleepless night, instead of tea. If
you give it at 5 or 6 o'clock in the morning, he may even sometimes fall
asleep after it, and get perhaps his only two or three hours' sleep
during the twenty-four. At the same time you never should give tea or
coffee to the sick, as a rule, after 5 o'clock in the afternoon.
Sleeplessness in the early night is from excitement generally and is
increased by tea or coffee; sleeplessness which continues to the early
morning is from exhaustion often, and is relieved by tea. The only
English patients I have ever known refuse tea, have been typhus cases,
and the first sign of their getting better was their craving again for
tea. In general, the dry and dirty tongue always prefers tea to coffee,
and will quite decline milk, unless with tea. Coffee is a better
restorative than tea, but a greater impairer of the digestion. Let the
patient's taste decide. You will say that, in cases of great thirst, the
patient's craving decides that it will drink _a great deal_ of tea, and
that you cannot help it. But in these cases be sure that the patient
requires diluents for quite other purposes than quenching the thirst; he
wants a great deal of some drink, not only of tea, and the doctor will
order what he is to have, barley water or lemonade, or soda water and
milk, as the case may be.

Lehman, quoted by Dr. Christison, says that, among the well and active
"the infusion of 1 oz. of roasted coffee daily will diminish the waste"
going on in the body" "by one-fourth," [Transcriber's note: Quotes as in
the original] and Dr. Christison adds that tea has the same property.
Now this is actual experiment. Lehman weighs the man and finds the fact
from his weight. It is not deduced from any "analysis" of food. All
experience among the sick shows the same thing.[3]


[Sidenote: Cocoa.]

Cocoa is often recommended to the sick in lieu of tea or coffee. But
independently of the fact that English sick very generally dislike
cocoa, it has quite a different effect from tea or coffee. It is an oily
starchy nut having no restorative power at all, but simply increasing
fat. It is pure mockery of the sick, therefore, to call it a substitute
for tea. For any renovating stimulus it has, you might just as well
offer them chestnuts instead of tea.


[Sidenote: Bulk.]

An almost universal error among nurses is in the bulk of the food and
especially the drinks they offer to their patients. Suppose a patient
ordered 4 oz. brandy during the day, how is he to take this if you make
it into four pints with diluting it? The same with tea and beef tea,
with arrowroot, milk, &c. You have not increased the nourishment, you
have not increased the renovating power of these articles, by increasing
their bulk,--you have very likely diminished both by giving the
patient's digestion more to do, and most likely of all, the patient will
leave half of what he has been ordered to take, because he cannot
swallow the bulk with which you have been pleased to invest it. It
requires very nice observation and care (and meets with hardly any) to
determine what will not be too thick or strong for the patient to take,
while giving him no more than the bulk which he is able to swallow.


FOOTNOTES:

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

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

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

[2]
It is made a frequent recommendation to persons about to incur great
exhaustion, either from the nature of the service, or from their being
not in a state fit for it, to eat a piece of bread before they go. I
wish the recommenders would themselves try the experiment of
substituting a piece of bread for a cup of tea or coffee, or beef-tea,
as a refresher. They would find it a very poor comfort. When soldiers
have to set out fasting on fatiguing duty, when nurses have to go
fasting in to their patients, it is a hot restorative they want, and
ought to have, before they go, not a cold bit of bread. And dreadful
have been the consequences of neglecting this. If they can take a bit of
bread _with_ the hot cup of tea, so much the better, but not _instead_
of it. The fact that there is more nourishment in bread than in almost
anything else, has probably induced the mistake. That it is a fatal
mistake, there is no doubt. It seems, though very little is known on the
subject, that what "assimilates" itself directly, and with the least
trouble of digestion with the human body, is the best for the above
circumstances. Bread requires two or three processes of assimilation,
before it becomes like the human body.

The almost universal testimony of English men and women who have
undergone great fatigue, such as riding long journeys without stopping,
or sitting up for several nights in succession, is that they could do it
best upon an occasional cup of tea--and nothing else.

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

[3]
In making coffee, it is absolutely necessary to buy it in the berry and
grind it at home. Otherwise you may reckon upon its containing a certain
amount of chicory, _at least_. This is not a question of the taste, or
of the wholesomeness of chicory. It is that chicory has nothing at all
of the properties for which you give coffee. And therefore you may as
well not give it.

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

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




VIII. BED AND BEDDING.


[Sidenote: Feverishness a symptom of bedding.]

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

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


[Sidenote: Uncleanliness of ordinary bedding.]

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


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

If you consider that an adult in health exhales by the lungs and skin in
the twenty-four hours three pints at least of moisture, loaded with
organic matter ready to enter into putrefaction; that in sickness the
quantity is often greatly increased, the quality is always more noxious
--just ask yourself next where does all this moisture go to? Chiefly
into the bedding, because it cannot go anywhere else. And it stays
there; because, except perhaps a weekly change of sheets, scarcely any
other airing is attempted. A nurse will be careful to fidgetiness about
airing the clean sheets from clean damp, but airing the dirty sheets
from noxious damp will never even occur to her. Besides this, the most
dangerous effluvia we know of are from the excreta of the sick--these
are placed, at least temporarily, where they must throw their effluvia
into the under side of the bed, and the space under the bed is never
aired; it cannot be, with our arrangements. Must not such a bed be
always saturated, and be always the means of re-introducing into the
system of the unfortunate patient who lies in it, that excrementitious
matter to eliminate which from the body nature had expressly appointed
the disease?

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


[Sidenote: Iron spring bedsteads the best.]

[Sidenote: Comfort and cleanliness of _two_ beds.]

The only way of really nursing a real patient is to have an _iron_
bedstead, with rheocline springs, which are permeable by the air up to
the very mattress (no vallance, of course), the mattress to be a thin
hair one; the bed to be not above 3-1/2 feet wide. If the patient be
entirely confined to his bed, there should be _two_ such bedsteads; each
bed to be "made" with mattress, sheets, blankets, &c., complete--the
patient to pass twelve hours in each bed; on no account to carry his
sheets with him. The whole of the bedding to be hung up to air for each
intermediate twelve hours. Of course there are many cases where this
cannot be done at all--many more where only an approach to it can be
made. I am indicating the ideal of nursing, and what I have actually had
done. But about the kind of bedstead there can be no doubt, whether
there be one or two provided.


[Sidenote: Bed not to be too wide.]

There is a prejudice in favour of a wide bed--I believe it to be a
prejudice. All the refreshment of moving a patient from one side to the
other of his bed is far more effectually secured by putting him into a
fresh bed; and a patient who is really very ill does not stray far in
bed. But it is said there is no room to put a tray down on a narrow bed.
No good nurse will ever put a tray on a bed at all. If the patient can
turn on his side, he will eat more comfortably from a bed-side table;
and on no account whatever should a bed ever be higher than a sofa.
Otherwise the patient feels himself "out of humanity's reach;" he can
get at nothing for himself: he can move nothing for himself. If the
patient cannot turn, a table over the bed is a better thing. I need
hardly say that a patient's bed should never have its side against the
wall. The nurse must be able to get easily to both sides of the bed, and
to reach easily every part of the patient without stretching--a thing
impossible if the bed be either too wide or too high.


[Sidenote: Bed not to be too high.]

When I see a patient in a room nine or ten feet high upon a bed between
four and five feet high, with his head, when he is sitting up in bed,
actually within two or three feet of the ceiling, I ask myself, is this
expressly planned to produce that peculiarly distressing feeling common
to the sick, viz., as if the walls and ceiling were closing in upon
them, and they becoming sandwiches between floor and ceiling, which
imagination is not, indeed, here so far from the truth? If, over and
above this, the window stops short of the ceiling, then the patient's
head may literally be raised above the stratum of fresh air, even when
the window is open. Can human perversity any farther go, in unmaking the
process of restoration which God has made? The fact is, that the heads
of sleepers or of sick should never be higher than the throat of the
chimney, which ensures their being in the current of best air. And we
will not suppose it possible that you have closed your chimney with a
chimney-board.

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


[Sidenote: Nor in a dark place.]

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


[Sidenote: Nor a four poster with curtains.]

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


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

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


[Sidenote: Bed sores.]

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


[Sidenote: Heavy and impervious bed clothes.]

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


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


FOOTNOTES:

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

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 sleeplessness; and she
answered quite good-humouredly she was not at all surprised at it--as if
the state of the room were, like the state of the weather, entirely out
of her power. Now in what sense was this woman to be called a "nurse?"

[2]
For the same reason if, after washing a patient, you must put the same
night-dress on him again, always give it a preliminary warm at the fire.
The night-gown he has worn must be, to a certain extent, damp. It has
now got cold from having been off him for a few minutes. The fire will
dry and at the same time air it. This is much more important than with
clean things.




IX. LIGHT.


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

It is the unqualified result of all my experience with the sick, that
second only to their need of fresh air is their need of light; that,
after a close room, what hurts them most is a dark room. And that it is
not only light but direct sun-light they want. I had rather have the
power of carrying my patient about after the sun, according to the
aspect of the rooms, if circumstances permit, than let him linger in a
room when the sun is off. People think the effect is upon the spirits
only. This is by no means the case. The sun is not only a painter but a
sculptor. You admit that he does the photograph. Without going into any
scientific exposition we must admit that light has quite as real and
tangible effects upon the human body. But this is not all. Who has not
observed the purifying effect of light, and especially of direct
sunlight, upon the air of a room? Here is an observation within
everybody's experience. Go into a room where the shutters are always
shut (in a sick room or a bedroom there should never be shutters shut),
and though the room be uninhabited, though the air has never been
polluted by the breathing of human beings, you will observe a close,
musty smell of corrupt air, of air _i.e._ unpurified by the effect of
the sun's rays. The mustiness of dark rooms and corners, indeed, is
proverbial. The cheerfulness of a room, the usefulness of light in
treating disease is all-important.


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

A very high authority in hospital construction has said that people do
not enough consider the difference between wards and dormitories in
planning their buildings. But I go farther, and say, that healthy people
never remember the difference between _bed_-rooms and _sick_-rooms in
making arrangements for the sick. To a sleeper in health it does not
signify what the view is from his bed. He ought never to be in it
excepting when asleep, and at night. Aspect does not very much signify
either (provided the sun reach his bed-room some time in every day, to
purify the air), because he ought never to be in his bed-room except
during the hours when there is no sun. But the case is exactly reversed
with the sick, even should they be as many hours out of their beds as
you are in yours, which probably they are not. Therefore, that they
should be able, without raising themselves or turning in bed, to see out
of window from their beds, to see sky and sun-light at least, if you can
show them nothing else, I assert to be, if not of the very first
importance for recovery, at least something very near it.

And you should therefore look to the position of the beds of your sick
one of the very first things. If they can see out of two windows instead
of one, so much the better. Again, the morning sun and the mid-day sun--
the hours when they are quite certain not to be up, are of more
importance to them, if a choice must be made, than the afternoon sun.
Perhaps you can take them out of bed in the afternoon and set them by
the window, where they can see the sun. But the best rule is, if
possible, to give them direct sunlight from the moment he rises till the
moment he sets.

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

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

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


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

One of the greatest observers of human things (not physiological), says,
in another language, "Where there is sun there is thought." All
physiology goes to confirm this. Where is the shady side of deep
vallies, there is cretinism. Where are cellars and the unsunned sides of
narrow streets, there is the degeneracy and weakliness of the human
race--mind and body equally degenerating. Put the pale withering plant
and human being into the sun, and, if not too far gone, each will
recover health and spirit.


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

It is a curious thing to observe how almost all patients lie with their
faces turned to the light, exactly as plants always make their way
towards the light; a patient will even complain that it gives him pain
"lying on that side." "Then why _do_ you lie on that side?" He does not
know,--but we do. It is because it is the side towards the window. A
fashionable physician has recently published in a government report that
he always turns his patient's faces from the light. Yes, but nature is
stronger than fashionable physicians, and depend upon it she turns the
faces back and _towards_ such light as she can get. Walk through the
wards of a hospital, remember the bed sides of private patients you have
seen, and count how many sick you ever saw lying with their faces
towards the wall.




X. CLEANLINESS OF ROOMS AND WALLS.


[Sidenote: Cleanliness of carpets and furniture.]

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


[Sidenote: Dust never removed now.]

But no particle of dust is ever or can ever be removed or really got rid
of by the present system of dusting. Dusting in these days means nothing
but flapping the dust from one part of a room on to another with doors
and windows closed. What you do it for I cannot think. You had much
better leave the dust alone, if you are not going to take it away
altogether. For from the time a room begins to be a room up to the time
when it ceases to be one, no one atom of dust ever actually leaves its
precincts. Tidying a room means nothing now but removing a thing from
one place, which it has kept clean for itself, on to another and a
dirtier one.[1] Flapping by way of cleaning is only admissible in the
case of pictures, or anything made of paper. The only way I know to
_remove_ dust, the plague of all lovers of fresh air, is to wipe
everything with a damp cloth. And all furniture ought to be so made as
that it may be wiped with a damp cloth without injury to itself, and so
polished as that it may be damped without injury to others. To dust, as
it is now practised, truly means to distribute dust more equally over a
room.


[Sidenote: Floors.]

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

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


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

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

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

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

These are what make a room musty.


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

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

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

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


[Sidenote: Dirty air from without.]

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


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

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


[Sidenote: Dirty air from within.]

2. Dirty air coming from within, from dust, which you often displace,
but never remove. And this recalls what ought to be a _sine qua non_.
Have as few ledges in your room or ward as possible. And under no
pretence have any ledge whatever out-of sight. Dust accumulates there,
and will never be wiped off. This is a certain way to soil the air.
Besides this, the animal exhalations from your inmates saturate your
furniture. And if you never clean your furniture properly, how can your
rooms or wards be anything but musty? Ventilate as you please, the rooms
will never be sweet. Besides this, there is a constant _degradation_, as
it is called, taking place from everything except polished or glazed
articles--_E.g._ in colouring certain green papers arsenic is used. Now
in the very dust even, which is lying about in rooms hung with this kind
of green paper, arsenic has been distinctly detected. You see your dust
is anything but harmless; yet you will let such dust lie about your
ledges for months, your rooms for ever.

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


[Sidenote: Dirty air from the carpet.]

3. Dirty air coming from the carpet. Above all, take care of the
carpets, that the animal dirt left there by the feet of visitors does
not stay there. Floors, unless the grain is filled up and polished, are
just as bad. The smell from the floor of a school-room or ward, when any
moisture brings out the organic matter by which it is saturated, might
alone be enough to warn us of the mischief that is going on.


[Sidenote: Remedies.]

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

The inside air can only be kept clean by excessive care in the ways
mentioned above--to rid the walls, carpets, furniture, ledges, &c., of
the organic matter and dust--dust consisting greatly of this organic
matter--with which they become saturated, and which is what really makes
the room musty.

Without cleanliness, you cannot have all the effect of ventilation;
without ventilation, you can have no thorough cleanliness.

Very few people, be they of what class they may, have any idea of the
exquisite cleanliness required in the sick-room. For much of what I have
said applies less to the hospital than to the private sick-room. The
smoky chimney, the dusty furniture, the utensils emptied but once a day,
often keep the air of the sick constantly dirty in the best private
houses.

The well have a curious habit of forgetting that what is to them but a
trifling inconvenience, to be patiently "put up" with, is to the sick a
source of suffering, delaying recovery, if not actually hastening death.
The well are scarcely ever more than eight hours, at most, in the same
room. Some change they can always make, if only for a few minutes. Even
during the supposed eight hours, they can change their posture or their
position in the room. But the sick man who never leaves his bed, who
cannot change by any movement of his own his air, or his light, or his
warmth; who cannot obtain quiet, or get out of the smoke, or the smell,
or the dust; he is really poisoned or depressed by what is to you the
merest trifle.

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


FOOTNOTES:

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

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

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

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

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

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




XI. PERSONAL CLEANLINESS.


[Sidenote: Poisoning by the skin.]

In almost all diseases, the function of the skin is, more or less,
disordered; and in many most important diseases nature relieves herself
almost entirely by the skin. This is particularly the case with
children. But the excretion, which comes from the skin, is left there,
unless removed by washing or by the clothes. Every nurse should keep
this fact constantly in mind,--for, if she allow her sick to remain
unwashed, or their clothing to remain on them after being saturated with
perspiration or other excretion, she is interfering injuriously with the
natural processes of health just as effectually as if she were to give
the patient a dose of slow poison by the mouth. Poisoning by the skin is
no less certain than poisoning by the mouth--only it is slower in its
operation.


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

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

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

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

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

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

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

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

One word as to cleanliness merely as cleanliness.


[Sidenote: Steaming and rubbing the skin.]

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

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




XII. CHATTERING HOPES AND ADVICES.


[Sidenote: Advising the sick.]

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


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

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

Far more now than formerly does the medical attendant tell the truth to
the sick who are really desirous to hear it about their own state.

How intense is the folly, then, to say the least of it, of the friend,
be he even a medical man, who thinks that his opinion, given after a
cursory observation, will weigh with the patient, against the opinion of
the medical attendant, given, perhaps, after years of observation, after
using every help to diagnosis afforded by the stethoscope, the
examination of pulse, tongue, &c.; and certainly after much more
observation than the friend can possibly have had.

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


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

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


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

If, on the other hand, and which is much more frequently the case, the
patient says nothing but the Shakespearian "Oh!" "Ah!" "Go to!" and "In
good sooth!" in order to escape from the conversation about himself the
sooner, he is depressed by want of sympathy. He feels isolated in the
midst of friends. He feels what a convenience it would be, if there were
any single person to whom he could speak simply and openly, without
pulling the string upon himself of this shower-bath of silly hopes and
encouragements; to whom he could express his wishes and directions
without that person persisting in saying, "I hope that it will please
God yet to give you twenty years," or, "You have a long life of activity
before you." How often we see at the end of biographies or of cases
recorded in medical papers, "after a long illness A. died rather
suddenly," or, "unexpectedly both to himself and to others."
"Unexpectedly" to others, perhaps, who did not see, because they did not
look; but by no means "unexpectedly to himself," as I feel entitled to
believe, both from the internal evidence in such stories, and from
watching similar cases; there was every reason to expect that A. would
die, and he knew it; but he found it useless to insist upon his own
knowledge to his friends.

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

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

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

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

So also as to all the advice showered so profusely upon such sick, to
leave off some occupation, to try some other doctor, some other house,
climate, pill, powder, or specific; I say nothing of the inconsistency--
for these advisers are sure to be the same persons who exhorted the sick
man not to believe his own doctor's prognostics, because "doctors are
always mistaken," but to believe some other doctor, because "this doctor
is always right." Sure also are these advisers to be the persons to
bring the sick man fresh occupation, while exhorting him to leave his
own.


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

Wonderful is the face with which friends, lay and medical, will come in
and worry the patient with recommendations to do something or other,
having just as little knowledge as to its being feasible, or even safe
for him, as if they were to recommend a man to take exercise, not
knowing he had broken his leg. What would the friend say, if _he_ were
the medical attendant, and if the patient, because some _other_ friend
had come in, because somebody, anybody, nobody, had recommended
something, anything, nothing, were to disregard _his_ orders, and take
that other body's recommendation? But people never think of this.


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

A celebrated historical personage has related the commonplaces which,
when on the eve of executing a remarkable resolution, were showered in
nearly the same words by every one around successively for a period of
six months. To these the personage states that it was found least
trouble always to reply the same thing, viz., that it could not be
supposed that such a resolution had been taken without sufficient
previous consideration. To patients enduring every day for years from
every friend or acquaintance, either by letter or _viva voce_, some
torment of this kind, I would suggest the same answer. It would indeed
be spared, if such friends and acquaintances would but consider for one
moment, that it is probable the patient has heard such advice at least
fifty times before, and that, had it been practicable, it would have
been practised long ago. But of such consideration there appears to be
no chance. Strange, though true, that people should be just the same in
these things as they were a few hundred years ago!

To me these commonplaces, leaving their smear upon the cheerful,
single-hearted, constant devotion to duty, which is so often seen in the
decline of such sufferers, recall the slimy trail left by the snail on
the sunny southern garden-wall loaded with fruit.


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

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

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

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


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

Do, you who are about the sick or who visit the sick, try and give them
pleasure, remember to tell them what will do so. How often in such
visits the sick person has to do the whole conversation, exerting his
own imagination and memory, while you would take the visitor, absorbed
in his own anxieties, making no effort of memory or imagination, for the
sick person. "Oh! my dear, I have so much to think of, I really quite
forgot to tell him that; besides, I thought he would know it," says the
visitor to another friend. How could "he know it?" Depend upon it, the
people who say this are really those who have little "to think of."
There are many burthened with business who always manage to keep a
pigeon-hole in their minds, full of things to tell the "invalid."

I do not say, don't tell him your anxieties--I believe it is good for
him and good for you too; but if you tell him what is anxious, surely
you can remember to tell him what is pleasant too.

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

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

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

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

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

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

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

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


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

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


FOOTNOTES:

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

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

I have heard a doctor condemned whose patient did not, alas! recover,
because another doctor's patient of a _different_ sex, of a _different_
age, recovered from a _different_ disease, in a _different_ place. Yes,
this is really true. If people who make these comparisons did but know
(only they do not care to know), the care and preciseness with which
such comparisons require to be made, (and are made,) in order to be of
any value whatever, they would spare their tongues. In comparing the
deaths of one hospital with those of another, any statistics are justly
considered absolutely valueless which do not give the ages, the sexes,
and the diseases of all the cases. It does not seem necessary to mention
this. It does not seem necessary to say that there can be no comparison
between old men with dropsies and young women with consumptions. Yet the
cleverest men and the cleverest women are often heard making such
comparisons, ignoring entirely sex, age, disease, place--in fact, _all_
the conditions essential to the question. It is the merest _gossip_.

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




XIII. OBSERVATION OF THE SICK.


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

There is no more silly or universal question scarcely asked than this,
"Is he better?" Ask it of the medical attendant, if you please. But of
whom else, if you wish for a real answer to your question, would you
ask? Certainly not of the casual visitor; certainly not of the nurse,
while the nurse's observation is so little exercised as it is now. What
you want are facts, not opinions--for who can have any opinion of any
value as to whether the patient is better or worse, excepting the
constant medical attendant, or the really observing nurse?

The most important practical lesson that can be given to nurses is to
teach them what to observe--how to observe--what symptoms indicate
improvement--what the reverse--which are of importance--which are of
none--which are the evidence of neglect--and of what kind of neglect.

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

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

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

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

"Do you think the patient is much weaker than he was six weeks ago?" "Oh
no, sir; you know it is very long since he has been up and dressed, and
he can get across the room now." This means that the nurse has not
observed that whereas six weeks ago he sat up and occupied himself in
bed, he now lies still doing nothing; that, although he can "get across
the room," he cannot stand for five seconds.

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


[Sidenote: Leading questions useless or misleading.]

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

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


[Sidenote: Means of obtaining inaccurate information.]

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

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

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

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


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

It is useless to go through all the particulars, besides sleep, in which
people have a peculiar talent for gleaning inaccurate information. As to
food, for instance, I often think that most common question, How is your
appetite? can only be put because the questioner believes the questioned
has really nothing the matter with him, which is very often the case.
But where there is, the remark holds good which has been made about
sleep. The _same_ answer will often be made as regards a patient who
cannot take two ounces of solid food per diem, and a patient who does
not enjoy five meals a day as much as usual.

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

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

1. Defect in cooking;

2. Defect in choice of diet;

3. Defect in choice of hours for taking diet;

4. Defect of appetite in patient.

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

Surely many lives might be saved by drawing a closer distinction; for
the remedies are as diverse as the causes. The remedy for the first is
to cook better; for the second, to choose other articles of diet; for
the third, to watch for the hours when the patient is in want of food;
for the fourth, to show him what he likes, and sometimes unexpectedly.
But no one of these remedies will do for any other of the defects not
corresponding with it.

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

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


[Sidenote: As to diarrhoea]

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

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

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


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

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

I have often thought how wise a piece of education this would be for
much higher objects; and in our calling of nurses the thing itself is
essential. For it may safely be said, not that the habit of ready and
correct observation will by itself make us useful nurses, but that
without it we shall be useless with all our devotion.

I have known a nurse in charge of a set of wards, who not only carried
in her head all the little varieties in the diets which each patient was
allowed to fix for himself, but also exactly what each patient had taken
during each day. I have known another nurse in charge of one single
patient, who took away his meals day after day all but untouched, and
never knew it.

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

Surely you can learn at least to judge with the eye how much an oz. of
solid food is, how much an oz. of liquid. You will find this helps your
observation and memory very much, you will then say to yourself, "A.
took about an oz. of his meat to day;" "B. took three times in 24 hours
about 1/4 pint of beef tea;" instead of saying "B. has taken nothing all
day," or "I gave A. his dinner as usual."


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

I have known several of our real old-fashioned hospital "sisters," who
could, as accurately as a measuring glass, measure out all their
patients' wine and medicine by the eye, and never be wrong. I do not
recommend this, one must be very sure of one's self to do it. I only
mention it, because if a nurse can by practice measure medicine by the
eye, surely she is no nurse who cannot measure by the eye about how much
food (in oz.) her patient has taken.[4] In hospitals those who cut up
the diets give with sufficient accuracy, to each patient, his 12 oz. or
his 6 oz. of meat without weighing. Yet a nurse will often have patients
loathing all food and incapable of any will to get well, who just tumble
over the contents of the plate or dip the spoon in the cup to deceive
the nurse, and she will take it away without ever seeing that there is
just the same quantity of food as when she brought it, and she will tell
the doctor, too, that the patient has eaten all his diets as usual, when
all she ought to have meant is that she has taken away his diets as
usual.

Now what kind of a nurse is this?


[Sidenote: Difference of excitable and _accumulative_ temperaments.]

I would call attention to something else, in which nurses frequently
fail in observation. There is a well-marked distinction between the
excitable and what I will call the _accumulative_ temperament in
patients. One will blaze up at once, under any shock or anxiety, and
sleep very comfortably after it; another will seem quite calm and even
torpid, under the same shock, and people say, "He hardly felt it at
all," yet you will find him some time after slowly sinking. The same
remark applies to the action of narcotics, of aperients, which, in the
one, take effect directly, in the other not perhaps for twenty-four
hours. A journey, a visit, an unwonted exertion, will affect the one
immediately, but he recovers after it; the other bears it very well at
the time, apparently, and dies or is prostrated for life by it. People
often say how difficult the excitable temperament is to manage. I say
how difficult is the _accumulative_ temperament. With the first you have
an out-break which you could anticipate, and it is all over. With the
second you never know where you are--you never know when the
consequences are over. And it requires your closest observation to know
what _are_ the consequences of what--for the consequent by no means
follows immediately upon the antecedent--and coarse observation is
utterly at fault.


[Sidenote: Superstition the fruit of bad observation.]

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


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

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

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

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

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

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

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

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

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


[Sidenote: Peculiarities of patients.]

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


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

Again, I think that few things press so heavily on one suffering from
long and incurable illness, as the necessity of recording in words from
time to time, for the information of the nurse, who will not otherwise
see, that he cannot do this or that, which he could do a month or a year
ago. What is a nurse there for if she cannot observe these things for
herself? Yet I have known--and known too among those--and _chiefly_
among those--whom money and position put in possession of everything
which money and position could give--I have known, I say, more accidents
(fatal, slowly or rapidly) arising from this want of observation among
nurses than from almost anything else. Because a patient could get out
of a warm-bath alone a month ago--because a patient could walk as far as
his bell a week ago, the nurse concludes that he can do so now. She has
never observed the change; and the patient is lost from being left in a
helpless state of exhaustion, till some one accidentally comes in. And
this not from any unexpected apoplectic, paralytic, or fainting fit
(though even these could be expected far more, at least, than they are
now, if we did but _observe_). No, from the unexpected, or to be
expected, inevitable, visible, calculable, uninterrupted increase of
weakness, which none need fail to observe.


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

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


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

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

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

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


[Sidenote: Observation of general conditions.]

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

Men whose profession like that of medical men leads them to observe
only, or chiefly, palpable and permanent organic changes are often just
as wrong in their opinion of the result as those who do not observe at
all. For instance, there is a broken leg; the surgeon has only to look
at it once to know; it will not be different if he sees it in the
morning to what it would have been had he seen it in the evening. And in
whatever conditions the patient is, or is likely to be, there will still
be the broken leg, until it is set. The same with many organic diseases.
An experienced physician has but to feel the pulse once, and he knows
that there is aneurism which will kill some time or other.

But with the great majority of cases, there is nothing of the kind; and
the power of forming any correct opinion as to the result must entirely
depend upon an enquiry into all the conditions in which the patient
lives. In a complicated state of society in large towns, death, as every
one of great experience knows, is far less often produced by any one
organic disease than by some illness, after many other diseases,
producing just the sum of exhaustion necessary for death. There is
nothing so absurd, nothing so misleading as the verdict one so often
hears: So-and-so has no organic disease,--there is no reason why he
should not live to extreme old age; sometimes the clause is added,
sometimes not: Provided he has quiet, good food, good air, &c., &c.,
&c.: the verdict is repeated by ignorant people _without_ the latter
clause; or there is no possibility of the conditions of the latter
clause being obtained; and this, the _only_ essential part of the whole,
is made of no effect. I have heard a physician, deservedly eminent,
assure the friends of a patient of his recovery. Why? Because he had now
prescribed a course, every detail of which the patient had followed for
years. And because he had forbidden a course which the patient could not
by any possibility alter.[6]

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

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


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

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

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

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

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

The close observer may safely predict that such a family, whether its
members marry or not, will become extinct; that such another will
degenerate morally and physically. But who learns the lesson? On the
contrary, it may be well known that the children die in such a house at
the rate of 8 out of 10; one would think that nothing more need be said;
for how could Providence speak more distinctly? yet nobody listens, the
family goes on living there till it dies out, and then some other family
takes it. Neither would they listen "if one rose from the dead."


[Sidenote: What observation is for.]

In dwelling upon the vital importance of _sound_ observation, it must
never be lost sight of what observation is for. It is not for the sake
of piling up miscellaneous information or curious facts, but for the
sake of saving life and increasing health and comfort. The caution may
seem useless, but it is quite surprising how many men (some women do it
too), practically behave as if the scientific end were the only one in
view, or as if the sick body were but a reservoir for stowing medicines
into, and the surgical disease only a curious case the sufferer has made
for the attendant's special information. This is really no exaggeration.
You think, if you suspected your patient was being poisoned, say, by a
copper kettle, you would instantly, as you ought, cut off all possible
connection between him and the suspected source of injury, without
regard to the fact that a curious mine of observation is thereby lost.
But it is not everybody who does so, and it has actually been made a
question of medical ethics, what should the medical man do if he
suspected poisoning? The answer seems a very simple one,--insist on a
confidential nurse being placed with the patient, or give up the case.


[Sidenote: What a confidential nurse should be.]

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


[Sidenote: Observation is for practical purposes.]

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


FOOTNOTES:
[1]
It is a much more difficult thing to speak the truth than people
commonly imagine. There is the want of observation _simple_, and the
want of observation _compound_, compounded, that is, with the
imaginative faculty. Both may equally intend to speak the truth. The
information of the first is simply defective. That of the second is much
more dangerous. The first gives, in answer to a question asked about a
thing that has been before his eyes perhaps for years, information
exceedingly imperfect, or says, he does not know. He has never observed.
And people simply think him stupid.

The second has observed just as little, but imagination immediately
steps in, and he describes the whole thing from imagination merely,
being perfectly convinced all the while that he has seen or heard it; or
he will repeat a whole conversation, as if it were information which had
been addressed to him; whereas it is merely what he has himself said to
somebody else. This is the commonest of all. These people do not even
observe that they have _not_ observed, nor remember that they have
forgotten.

Courts of justice seem to think that anybody can speak "the whole truth,
and nothing but the truth," if he does but intend it. It requires many
faculties combined of observation and memory to speak "the whole truth,"
and to say "nothing but the truth."

"I knows I fibs dreadful; but believe me, Miss, I never finds out I have
fibbed until they tells me so," was a remark actually made. It is also
one of much more extended application than most people have the least
idea of.

Concurrence of testimony, which is so often adduced as final proof, may
prove nothing more, as is well known to those accustomed to deal with
the unobservant imaginative, than that one person has told his story a
great many times.

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

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

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

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

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


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

It may be too broad an assertion, and it certainly sounds like a
paradox. But I think that in no country are women to be found so
deficient in ready and sound observation as in England, while peculiarly
capable of being trained to it. The French or Irish woman is too quick
of perception to be so sound an observer--the Teuton is too slow to be
so ready an observer as the English woman might be. Yet English women
lay themselves open to the charge so often made against them by men,
viz., that they are not to be trusted in handicrafts to which their
strength is quite equal, for want of a practised and steady observation.
In countries where women (with average intelligence certainly not
superior to that of English women) are employed, e.g., in dispensing,
men responsible for what these women do (not theorizing about man's and
woman's "missions,") have stated that they preferred the service of
women to that of men, as being more exact, more careful, and incurring
fewer mistakes of inadvertence.

Now certainly English women are peculiarly capable of attaining to this.

I remember when a child, hearing the story of an accident, related by
some one who sent two girls to fetch a "bottle of salvolatile from her
room;" "Mary could not stir," she said, "Fanny ran and fetched a bottle
that was not salvolatile, and that was not in my room."

Now this sort of thing pursues every one through life. A woman is asked
to fetch a large new bound red book, lying on the table by the window,
and she fetches five small old boarded brown books lying on the shelf by
the fire. And this, though she has "put that room to rights" every day
for a month perhaps, and must have observed the books every day, lying
in the same places, for a month, if she had any observation.

Habitual observation is the more necessary, when any sudden call arises.
If "Fanny" had observed "the bottle of salvolatile" in "the aunt's
room," every day she was there, she would more probably have found it
when it was suddenly wanted.

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

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

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

It falls to few ever to have had the opportunity of observing the
different aspects which the human face puts on at the sudden approach of
certain forms of death by violence; and as it is a knowledge of little
use, I only mention it here as being the most startling example of what
I mean. In the nervous temperament the face becomes pale (this is the
only _recognised_ effect); in the sanguine temperament purple; in the
bilious yellow, or every manner of colour in patches. Now, it is
generally supposed that paleness is the one indication of almost any
violent change in the human being, whether from terror, disease, or
anything else. There can be no more false observation. Granted, it is
the one recognised livery, as I have said--_de rigueur_ in novels, but
nowhere else.

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

I will even go further and say, that in diseases which have their origin
in the feeble or irregular action of some function, and not in organic
change, it is quite an accident if the doctor who sees the case only
once a day, and generally at the same time, can form any but a negative
idea of its real condition. In the middle of the day, when such a
patient has been refreshed by light and air, by his tea, his beef-tea,
and his brandy, by hot bottles to his feet, by being washed and by clean
linen, you can scarcely believe that he is the same person as lay with a
rapid fluttering pulse, with puffed eye-lids, with short breath, cold
limbs, and unsteady hands, this morning. Now what is a nurse to do in
such a case? Not cry, "Lord, bless you, sir, why you'd have thought he
were a dying all night." This may be true, but it is not the way to
impress with the truth a doctor, more capable of forming a judgment from
the facts, if he did but know them, than you are. What he wants is not
your opinion, however respectfully given, but your facts. In all
diseases it is important, but in diseases which do not run a distinct
and fixed course, it is not only important, it is essential that the
facts the nurse alone can observe, should be accurately observed, and
accurately reported to the doctor.

I must direct the nurse's attention to the extreme variation there is
not unfrequently in the pulse of such patients during the day. A very
common case is this: Between 3 and 4 A.M., the pulse become quick,
perhaps 130, and so thready it is not like a pulse at all, but like a
string vibrating just underneath the skin. After this the patient gets
no more sleep. About mid-day the pulse has come down to 80; and though
feeble and compressible, is a very respectable pulse. At night, if the
patient has had a day of excitement, it is almost imperceptible. But, if
the patient has had a good day, it is stronger and steadier, and not
quicker than at mid-day. This is a common history of a common pulse; and
others, equally varying during the day, might be given. Now, in
inflammation, which may almost always be detected by the pulse, in
typhoid fever, which is accompanied by the low pulse that nothing will
raise, there is no such great variation. And doctors and nurses become
accustomed not to look for it. The doctor indeed cannot. But the
variation is in itself an important feature.

Cases like the above often "go off rather suddenly," as it is called,
from some trifling ailment of a few days, which just makes up the sum of
exhaustion necessary to produce death. And everybody cries, Who would
have thought it? except the observing nurse, if there is one, who had
always expected the exhaustion to come, from which there would be no
rally, because she knew the patient had no capital in strength on which
to draw, if he failed for a few days to make his barely daily income in
sleep and nutrition.

I have often seen really good nurses distressed, because they could not
impress the doctor with the real danger of their patient; and quite
provoked because the patient "would look" either "so much better" or "so
much worse" than he really is "when the doctor was there." The distress
is very legitimate, but it generally arises from the nurse not having
the power of laying clearly and shortly before the doctor the facts from
which she derives her opinion, or from the doctor being hasty and
inexperienced, and not capable of eliciting them. A man who really cares
for his patients, will soon learn to ask for and appreciate the
information of a nurse, who is at once a careful observer and a clear
reporter.




CONCLUSION.


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

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

Nevertheless let no one think that because _sanitary_ nursing is the
subject of these notes, therefore, what may be called the handicraft of
nursing is to be undervalued. A patient may be left to bleed to death in
a sanitary palace. Another who cannot move himself may die of bed-sores,
because the nurse does not know how to change and clean him, while he
has every requisite of air, light, and quiet. But nursing, as a
handicraft, has not been treated of here for three reasons: 1. That
these notes do not pretend to be a manual for nursing, any more than for
cooking for the sick; 2. That the writer, who has herself seen more of
what may be called surgical nursing, i.e. practical manual nursing,
than, perhaps, any one in Europe, honestly believes that it is
impossible to learn it from any book, and that it can only be thoroughly
learnt in the wards of a hospital; and she also honestly believes that
the perfection of surgical nursing may be seen practised by the
old-fashioned "Sister" of a London hospital, as it can be seen nowhere
else in Europe. 3. While thousands die of foul air, &c., who have this
surgical nursing to perfection, the converse is comparatively rare.


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

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

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

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

It may be here added, that it would be very desirable to know how often
death is, with adults, "not a necessary, inevitable result of any
disease." Omit the word "sudden;" (for _sudden_ death is comparatively
rare in middle age;) and the sentence is almost equally true for all
ages.

The following causes of "accidental" death in sick children are
enumerated:--"Sudden noises, which startle--a rapid change of
temperature, which chills the surface, though only for a moment--a rude
awakening from sleep--or even an over-hasty, or an overfull meal"--"any
sudden impression on the nervous system--any hasty alteration of
posture--in short, any cause whatever by which the respiratory process
may be disturbed."

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

Both for children and for adults, both for sick and for well (although
more certainly in the case of sick children than in any others), I would
here again repeat, the most frequent and most fatal cause of all is
sleeping, for even a few hours, much more for weeks and months, in foul
air, a condition which, more than any other condition, disturbs the
respiratory process, and tends to produce "accidental" death in disease.

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

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

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

"Breathing carefully, anxiously, as though respiration were a function
which required all the attention for its performance," is cited as a not
unusual state in children, and as one calling for care in all the things
enumerated above. That breathing becomes an almost voluntary act, even
in grown up patients who are very weak, must often have been remarked.

"Disease having interfered with the perfect accomplishment of the
respiratory function, some sudden demand for its complete exercise,
issues in the sudden standstill of the whole machinery," is given as one
process:--"life goes out for want of nervous power to keep the vital
functions in activity," is given as another, by which "accidental" death
is most often brought to pass in infancy.

Also in middle age, both these processes may be seen ending in death,
although generally not suddenly. And I have seen, even in middle age,
the "_sudden_ stand-still" here mentioned, and from the same causes.


[Sidenote: Summary.]

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


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

(1.) It is often said by men, that it is unwise to teach women anything
about these laws of health, because they will take to physicking,--that
there is a great deal too much of amateur physicking as it is, which is
indeed true. One eminent physician told me that he had known more
calomel given, both at a pinch and for a continuance, by mothers,
governesses, and nurses, to children than he had ever heard of a
physician prescribing in all his experience. Another says, that women's
only idea in medicine is calomel and aperients. This is undeniably too
often the case. There is nothing ever seen in any professional practice
like the reckless physicking by amateur females.[1] But this is just
what the really experienced and observing nurse does _not_ do; she
neither physics herself nor others. And to cultivate in things
pertaining to health observation and experience in women who are
mothers, governesses or nurses, is just the way to do away with amateur
physicking, and if the doctors did but know it, to make the nurses
obedient to them,--helps to them instead of hindrances. Such education
in women would indeed diminish the doctor's work--but no one really
believes that doctors wish that there should be more illness, in order
to have more work.


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

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

Pathology teaches the harm that disease has done. But it teaches nothing
more. We know nothing of the principle of health, the positive of which
pathology is the negative, except from observation and experience. And
nothing but observation and experience will teach us the ways to
maintain or to bring back the state of health. It is often thought that
medicine is the curative process. It is no such thing; medicine is the
surgery of functions, as surgery proper is that of limbs and organs.
Neither can do anything but remove obstructions; neither can cure;
nature alone cures. Surgery removes the bullet out of the limb, which is
an obstruction to cure, but nature heals the wound. So it is with
medicine; the function of an organ becomes obstructed; medicine, so far
as we know, assists nature to remove the obstruction, but does nothing
more. And what nursing has to do in either case, is to put the patient
in the best condition for nature to act upon him. Generally, just the
contrary is done. You think fresh air, and quiet and cleanliness
extravagant, perhaps dangerous, luxuries, which should be given to the
patient only when quite convenient, and medicine the _sine qua non_, the
panacea. If I have succeeded in any measure in dispelling this illusion,
and in showing what true nursing is, and what it is not, my object will
have been answered.

Now for the caution:--

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

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

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

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

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

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

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

In this respect (and why is it so?), in Roman Catholic countries, both
writers and workers are, in theory at least, far before ours. They would
never think of such a beginning for a good working Superior or Sister of
Charity. And many a Superior has refused to admit a _Postulant_ who
appeared to have no better "vocation" or reasons for offering herself
than these.

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


NOTE.--I would earnestly ask my sisters to keep clear of both the
jargons now current every where (for they _are_ equally jargons); of the
jargon, namely, about the "rights" of women, which urges women to do all
that men do, including the medical and other professions, merely because
men do it, and without regard to whether this _is_ the best that women,
can do; and of the jargon which urges women to do nothing that men do,
merely because they are women, and should be "recalled to a sense of
their duty as women," and because "this is women's work," and "that is
men's," and "these are things which women should not do," which is all
assertion, and nothing more. Surely woman should bring the best she has,
_whatever_ that is, to the work of God's world, without attending to
either of these cries. For what are they, both of them, the one _just_
as much as the other, but listening to the "what people will say," to
opinion, to the "voices from without?" And as a wise man has said, no
one has ever done anything great or useful by listening to the voices
from without.

You do not want the effect of your good things to be, "How wonderful for
a _woman_!" nor would you be deterred from good things by hearing it
said, "Yes, but she ought not to have done this, because it is not
suitable for a woman." But you want to do the thing that is good,
whether it is "suitable for a woman" or not.

It does not make a thing good, that it is remarkable that a woman should
have been able to do it. Neither does it make a thing bad, which would
have been good had a man done it, that it has been done by a woman.

Oh, leave these jargons, and go your way straight to God's work, in
simplicity and singleness of heart.


FOOTNOTES:

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

I have known many ladies who, having once obtained a "blue pill"
prescription from a physician, gave and took it as a common aperient two
or three times a week--with what effect may be supposed. In one case I
happened to be the person to inform the physician of it, who substituted
for the prescription a comparatively harmless aperient pill. The lady
came to me and complained that it "did not suit her half so well."

If women will take or give physic, by far the safest plan is to send for
"the doctor" every time--for I have known ladies who both gave and took
physic, who would not take the pains to learn the names of the commonest
medicines, and confounded, _e.g._, colocynth with colchicum. This _is_
playing with sharp-edged tools "with a vengeance."

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

Homoeopathy has introduced one essential amelioration in the practice of
physic by amateur females; for its rules are excellent, its physicking
comparatively harmless--the "globule" is the one grain of folly which
appears to be necessary to make any good thing acceptable. Let then
women, if they will give medicine, give homoeopathic medicine. It won't
do any harm.

An almost universal error among women is the supposition that everybody
_must_ have the bowels opened once in every twenty-four hours, or must
fly immediately to aperients. The reverse is the conclusion of
experience.

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

It is very seldom indeed, that by choosing your diet, you cannot
regulate your own bowels; and every woman may watch herself to know what
kind of diet will do this; I have known deficiency of meat produce
constipation, quite as often as deficiency of vegetables; baker's bread
much oftener than either. Home made brown bread will oftener cure it
than anything else.




APPENDIX.

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

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



TABLE A.

GREAT BRITAIN.

AGES.

NURSES.        Nurse (not Domestic   Nurse (Domestic
               Servant)              Servant)
All Ages.      25,466                39,139
Under 5 years     ...                   ...
5-                ...                   508
10-               ...                 7,259
15-               ...                10,355
20-               624                 6,537
25-               817                 4,174
30-             1,118                 2,495
35-             1,359                 1,681
40-             2,223                 1,468
45-             2,748                 1,206
50-             3,982                 1,196
55-             3,456                   833
60-             3,825                   712
65-             2,542                   369
70-             1,568                   204
75-               746                   101
80-               311                    25
85 and upwards    147                    16



TABLE  B.

AGED 20 YEARS, AND UPWARDS.

NURSES.              Nurse (not Domestic   Nurse (Domestic
                     Servant)              Servant)
Great Britain and    25,466                21,017
Islands in the
British Seas.
England and Wales.   23,751                18,945
Scotland.             1,543                 1,922
Islands in the
British Seas.           172                   150
1st Division.
London.               7,807                 5,061
2nd Division.
South Eastern.        2,878                 2,514
3rd Division.
South Midland.        2,286                 1,252
4th Division.
Eastern Counties.     2,408                   959
5th Division.
South Western
Counties.             3,055                 1,737
6th Division.
West Midland
Counties.             1,225                 2,283
7th Division.
North Midland
Counties.             1,003                   957
8th Division.
North Western
Counties.               970                 2,135
9th Division.
Yorkshire.            1,074                 1,023
10th Division.
Northern
Counties.               462                   410
11th Division.
Monmouth
and Wales.              343                   614


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

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

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

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

Now a nurse means any person in charge of the personal health of
another. And, in the preceding notes, the term _nurse_ is used
indiscriminately for amateur and professional nurses. For, besides
nurses of the sick and nurses of children, the numbers of whom are here
given, there are friends or relations who take temporary charge of a
sick person, there are mothers of families. It appears as if these
unprofessional nurses were just as much in want of knowledge of the laws
of health as professional ones.

Then there are the schoolmistresses of all national and other schools
throughout the kingdom. How many of children's epidemics originate in
these! Then the proportion of girls in these schools, who become
mothers or members among the 64,600 nurses recorded above, or
schoolmistresses in their turn. If the laws of health, as far as regards
fresh air, cleanliness, light, &c., were taught to these, would this not
prevent some children being killed, some evil being perpetuated? On
women we must depend, first and last, for personal and household
hygiene--for preventing the race from degenerating in as far as these
things are concerned. Would not the true way of infusing the art of
preserving its own health into the human race be to teach the female
part of it in schools and hospitals, both by practical teaching and by
simple experiments, in as far as these illustrate what may be called the
theory of it?

[1] A curious fact will be shown by Table A, viz., that 18,122 out of
39,139, or nearly one-half of all the nurses, in domestic service, are
between 5 and 20 years of age.





End of Project Gutenberg's Notes on Nursing, by Florence Nightingale



*** END OF THE PROJECT GUTENBERG EBOOK NOTES ON NURSING: WHAT IT IS, AND WHAT IT IS NOT ***


    

Updated editions will replace the previous one—the old editions will
be renamed.

Creating the works from print editions not protected by U.S. copyright
law means that no one owns a United States copyright in these works,
so the Foundation (and you!) can copy and distribute it in the United
States without permission and without paying copyright
royalties. Special rules, set forth in the General Terms of Use part
of this license, apply to copying and distributing Project
Gutenberg™ electronic works to protect the PROJECT GUTENBERG™
concept and trademark. Project Gutenberg is a registered trademark,
and may not be used if you charge for an eBook, except by following
the terms of the trademark license, including paying royalties for use
of the Project Gutenberg trademark. If you do not charge anything for
copies of this eBook, complying with the trademark license is very
easy. You may use this eBook for nearly any purpose such as creation
of derivative works, reports, performances and research. Project
Gutenberg eBooks may be modified and printed and given away—you may
do practically ANYTHING in the United States with eBooks not protected
by U.S. copyright law. Redistribution is subject to the trademark
license, especially commercial redistribution.


START: FULL LICENSE

THE FULL PROJECT GUTENBERG LICENSE

PLEASE READ THIS BEFORE YOU DISTRIBUTE OR USE THIS WORK

To protect the Project Gutenberg™ mission of promoting the free
distribution of electronic works, by using or distributing this work
(or any other work associated in any way with the phrase “Project
Gutenberg”), you agree to comply with all the terms of the Full
Project Gutenberg™ License available with this file or online at
www.gutenberg.org/license.

Section 1. General Terms of Use and Redistributing Project Gutenberg™
electronic works

1.A. By reading or using any part of this Project Gutenberg™
electronic work, you indicate that you have read, understand, agree to
and accept all the terms of this license and intellectual property
(trademark/copyright) agreement. If you do not agree to abide by all
the terms of this agreement, you must cease using and return or
destroy all copies of Project Gutenberg™ electronic works in your
possession. If you paid a fee for obtaining a copy of or access to a
Project Gutenberg™ electronic work and you do not agree to be bound
by the terms of this agreement, you may obtain a refund from the person
or entity to whom you paid the fee as set forth in paragraph 1.E.8.

1.B. “Project Gutenberg” is a registered trademark. It may only be
used on or associated in any way with an electronic work by people who
agree to be bound by the terms of this agreement. There are a few
things that you can do with most Project Gutenberg™ electronic works
even without complying with the full terms of this agreement. See
paragraph 1.C below. There are a lot of things you can do with Project
Gutenberg™ electronic works if you follow the terms of this
agreement and help preserve free future access to Project Gutenberg™
electronic works. See paragraph 1.E below.

1.C. The Project Gutenberg Literary Archive Foundation (“the
Foundation” or PGLAF), owns a compilation copyright in the collection
of Project Gutenberg™ electronic works. Nearly all the individual
works in the collection are in the public domain in the United
States. If an individual work is unprotected by copyright law in the
United States and you are located in the United States, we do not
claim a right to prevent you from copying, distributing, performing,
displaying or creating derivative works based on the work as long as
all references to Project Gutenberg are removed. Of course, we hope
that you will support the Project Gutenberg™ mission of promoting
free access to electronic works by freely sharing Project Gutenberg™
works in compliance with the terms of this agreement for keeping the
Project Gutenberg™ name associated with the work. You can easily
comply with the terms of this agreement by keeping this work in the
same format with its attached full Project Gutenberg™ License when
you share it without charge with others.

1.D. The copyright laws of the place where you are located also govern
what you can do with this work. Copyright laws in most countries are
in a constant state of change. If you are outside the United States,
check the laws of your country in addition to the terms of this
agreement before downloading, copying, displaying, performing,
distributing or creating derivative works based on this work or any
other Project Gutenberg™ work. The Foundation makes no
representations concerning the copyright status of any work in any
country other than the United States.

1.E. Unless you have removed all references to Project Gutenberg:

1.E.1. The following sentence, with active links to, or other
immediate access to, the full Project Gutenberg™ License must appear
prominently whenever any copy of a Project Gutenberg™ work (any work
on which the phrase “Project Gutenberg” appears, or with which the
phrase “Project Gutenberg” is associated) is accessed, displayed,
performed, viewed, copied or distributed:

    This eBook is for the use of anyone anywhere in the United States and most
    other parts of the world at no cost and with almost no restrictions
    whatsoever. You may copy it, give it away or re-use it under the terms
    of the Project Gutenberg License included with this eBook or online
    at www.gutenberg.org. If you
    are not located in the United States, you will have to check the laws
    of the country where you are located before using this eBook.
  
1.E.2. If an individual Project Gutenberg™ electronic work is
derived from texts not protected by U.S. copyright law (does not
contain a notice indicating that it is posted with permission of the
copyright holder), the work can be copied and distributed to anyone in
the United States without paying any fees or charges. If you are
redistributing or providing access to a work with the phrase “Project
Gutenberg” associated with or appearing on the work, you must comply
either with the requirements of paragraphs 1.E.1 through 1.E.7 or
obtain permission for the use of the work and the Project Gutenberg™
trademark as set forth in paragraphs 1.E.8 or 1.E.9.

1.E.3. If an individual Project Gutenberg™ electronic work is posted
with the permission of the copyright holder, your use and distribution
must comply with both paragraphs 1.E.1 through 1.E.7 and any
additional terms imposed by the copyright holder. Additional terms
will be linked to the Project Gutenberg™ License for all works
posted with the permission of the copyright holder found at the
beginning of this work.

1.E.4. Do not unlink or detach or remove the full Project Gutenberg™
License terms from this work, or any files containing a part of this
work or any other work associated with Project Gutenberg™.

1.E.5. Do not copy, display, perform, distribute or redistribute this
electronic work, or any part of this electronic work, without
prominently displaying the sentence set forth in paragraph 1.E.1 with
active links or immediate access to the full terms of the Project
Gutenberg™ License.

1.E.6. You may convert to and distribute this work in any binary,
compressed, marked up, nonproprietary or proprietary form, including
any word processing or hypertext form. However, if you provide access
to or distribute copies of a Project Gutenberg™ work in a format
other than “Plain Vanilla ASCII” or other format used in the official
version posted on the official Project Gutenberg™ website
(www.gutenberg.org), you must, at no additional cost, fee or expense
to the user, provide a copy, a means of exporting a copy, or a means
of obtaining a copy upon request, of the work in its original “Plain
Vanilla ASCII” or other form. Any alternate format must include the
full Project Gutenberg™ License as specified in paragraph 1.E.1.

1.E.7. Do not charge a fee for access to, viewing, displaying,
performing, copying or distributing any Project Gutenberg™ works
unless you comply with paragraph 1.E.8 or 1.E.9.

1.E.8. You may charge a reasonable fee for copies of or providing
access to or distributing Project Gutenberg™ electronic works
provided that:

    • You pay a royalty fee of 20% of the gross profits you derive from
        the use of Project Gutenberg™ works calculated using the method
        you already use to calculate your applicable taxes. The fee is owed
        to the owner of the Project Gutenberg™ trademark, but he has
        agreed to donate royalties under this paragraph to the Project
        Gutenberg Literary Archive Foundation. Royalty payments must be paid
        within 60 days following each date on which you prepare (or are
        legally required to prepare) your periodic tax returns. Royalty
        payments should be clearly marked as such and sent to the Project
        Gutenberg Literary Archive Foundation at the address specified in
        Section 4, “Information about donations to the Project Gutenberg
        Literary Archive Foundation.”
    
    • You provide a full refund of any money paid by a user who notifies
        you in writing (or by e-mail) within 30 days of receipt that s/he
        does not agree to the terms of the full Project Gutenberg™
        License. You must require such a user to return or destroy all
        copies of the works possessed in a physical medium and discontinue
        all use of and all access to other copies of Project Gutenberg™
        works.
    
    • You provide, in accordance with paragraph 1.F.3, a full refund of
        any money paid for a work or a replacement copy, if a defect in the
        electronic work is discovered and reported to you within 90 days of
        receipt of the work.
    
    • You comply with all other terms of this agreement for free
        distribution of Project Gutenberg™ works.
    

1.E.9. If you wish to charge a fee or distribute a Project
Gutenberg™ electronic work or group of works on different terms than
are set forth in this agreement, you must obtain permission in writing
from the Project Gutenberg Literary Archive Foundation, the manager of
the Project Gutenberg™ trademark. Contact the Foundation as set
forth in Section 3 below.

1.F.

1.F.1. Project Gutenberg volunteers and employees expend considerable
effort to identify, do copyright research on, transcribe and proofread
works not protected by U.S. copyright law in creating the Project
Gutenberg™ collection. Despite these efforts, Project Gutenberg™
electronic works, and the medium on which they may be stored, may
contain “Defects,” such as, but not limited to, incomplete, inaccurate
or corrupt data, transcription errors, a copyright or other
intellectual property infringement, a defective or damaged disk or
other medium, a computer virus, or computer codes that damage or
cannot be read by your equipment.

1.F.2. LIMITED WARRANTY, DISCLAIMER OF DAMAGES - Except for the “Right
of Replacement or Refund” described in paragraph 1.F.3, the Project
Gutenberg Literary Archive Foundation, the owner of the Project
Gutenberg™ trademark, and any other party distributing a Project
Gutenberg™ electronic work under this agreement, disclaim all
liability to you for damages, costs and expenses, including legal
fees. YOU AGREE THAT YOU HAVE NO REMEDIES FOR NEGLIGENCE, STRICT
LIABILITY, BREACH OF WARRANTY OR BREACH OF CONTRACT EXCEPT THOSE
PROVIDED IN PARAGRAPH 1.F.3. YOU AGREE THAT THE FOUNDATION, THE
TRADEMARK OWNER, AND ANY DISTRIBUTOR UNDER THIS AGREEMENT WILL NOT BE
LIABLE TO YOU FOR ACTUAL, DIRECT, INDIRECT, CONSEQUENTIAL, PUNITIVE OR
INCIDENTAL DAMAGES EVEN IF YOU GIVE NOTICE OF THE POSSIBILITY OF SUCH
DAMAGE.

1.F.3. LIMITED RIGHT OF REPLACEMENT OR REFUND - If you discover a
defect in this electronic work within 90 days of receiving it, you can
receive a refund of the money (if any) you paid for it by sending a
written explanation to the person you received the work from. If you
received the work on a physical medium, you must return the medium
with your written explanation. The person or entity that provided you
with the defective work may elect to provide a replacement copy in
lieu of a refund. If you received the work electronically, the person
or entity providing it to you may choose to give you a second
opportunity to receive the work electronically in lieu of a refund. If
the second copy is also defective, you may demand a refund in writing
without further opportunities to fix the problem.

1.F.4. Except for the limited right of replacement or refund set forth
in paragraph 1.F.3, this work is provided to you ‘AS-IS’, WITH NO
OTHER WARRANTIES OF ANY KIND, EXPRESS OR IMPLIED, INCLUDING BUT NOT
LIMITED TO WARRANTIES OF MERCHANTABILITY OR FITNESS FOR ANY PURPOSE.

1.F.5. Some states do not allow disclaimers of certain implied
warranties or the exclusion or limitation of certain types of
damages. If any disclaimer or limitation set forth in this agreement
violates the law of the state applicable to this agreement, the
agreement shall be interpreted to make the maximum disclaimer or
limitation permitted by the applicable state law. The invalidity or
unenforceability of any provision of this agreement shall not void the
remaining provisions.

1.F.6. INDEMNITY - You agree to indemnify and hold the Foundation, the
trademark owner, any agent or employee of the Foundation, anyone
providing copies of Project Gutenberg™ electronic works in
accordance with this agreement, and any volunteers associated with the
production, promotion and distribution of Project Gutenberg™
electronic works, harmless from all liability, costs and expenses,
including legal fees, that arise directly or indirectly from any of
the following which you do or cause to occur: (a) distribution of this
or any Project Gutenberg™ work, (b) alteration, modification, or
additions or deletions to any Project Gutenberg™ work, and (c) any
Defect you cause.

Section 2. Information about the Mission of Project Gutenberg™

Project Gutenberg™ is synonymous with the free distribution of
electronic works in formats readable by the widest variety of
computers including obsolete, old, middle-aged and new computers. It
exists because of the efforts of hundreds of volunteers and donations
from people in all walks of life.

Volunteers and financial support to provide volunteers with the
assistance they need are critical to reaching Project Gutenberg™’s
goals and ensuring that the Project Gutenberg™ collection will
remain freely available for generations to come. In 2001, the Project
Gutenberg Literary Archive Foundation was created to provide a secure
and permanent future for Project Gutenberg™ and future
generations. To learn more about the Project Gutenberg Literary
Archive Foundation and how your efforts and donations can help, see
Sections 3 and 4 and the Foundation information page at www.gutenberg.org.

Section 3. Information about the Project Gutenberg Literary Archive Foundation

The Project Gutenberg Literary Archive Foundation is a non-profit
501(c)(3) educational corporation organized under the laws of the
state of Mississippi and granted tax exempt status by the Internal
Revenue Service. The Foundation’s EIN or federal tax identification
number is 64-6221541. Contributions to the Project Gutenberg Literary
Archive Foundation are tax deductible to the full extent permitted by
U.S. federal laws and your state’s laws.

The Foundation’s business office is located at 809 North 1500 West,
Salt Lake City, UT 84116, (801) 596-1887. Email contact links and up
to date contact information can be found at the Foundation’s website
and official page at www.gutenberg.org/contact

Section 4. Information about Donations to the Project Gutenberg
Literary Archive Foundation

Project Gutenberg™ depends upon and cannot survive without widespread
public support and donations to carry out its mission of
increasing the number of public domain and licensed works that can be
freely distributed in machine-readable form accessible by the widest
array of equipment including outdated equipment. Many small donations
($1 to $5,000) are particularly important to maintaining tax exempt
status with the IRS.

The Foundation is committed to complying with the laws regulating
charities and charitable donations in all 50 states of the United
States. Compliance requirements are not uniform and it takes a
considerable effort, much paperwork and many fees to meet and keep up
with these requirements. We do not solicit donations in locations
where we have not received written confirmation of compliance. To SEND
DONATIONS or determine the status of compliance for any particular state
visit www.gutenberg.org/donate.

While we cannot and do not solicit contributions from states where we
have not met the solicitation requirements, we know of no prohibition
against accepting unsolicited donations from donors in such states who
approach us with offers to donate.

International donations are gratefully accepted, but we cannot make
any statements concerning tax treatment of donations received from
outside the United States. U.S. laws alone swamp our small staff.

Please check the Project Gutenberg web pages for current donation
methods and addresses. Donations are accepted in a number of other
ways including checks, online payments and credit card donations. To
donate, please visit: www.gutenberg.org/donate.

Section 5. General Information About Project Gutenberg™ electronic works

Professor Michael S. Hart was the originator of the Project
Gutenberg™ concept of a library of electronic works that could be
freely shared with anyone. For forty years, he produced and
distributed Project Gutenberg™ eBooks with only a loose network of
volunteer support.

Project Gutenberg™ eBooks are often created from several printed
editions, all of which are confirmed as not protected by copyright in
the U.S. unless a copyright notice is included. Thus, we do not
necessarily keep eBooks in compliance with any particular paper
edition.

Most people start at our website which has the main PG search
facility: www.gutenberg.org.

This website includes information about Project Gutenberg™,
including how to make donations to the Project Gutenberg Literary
Archive Foundation, how to help produce our new eBooks, and how to
subscribe to our email newsletter to hear about new eBooks.