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+*** START OF THE PROJECT GUTENBERG EBOOK 12439 ***
+
+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 12439 ***
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+The Project Gutenberg EBook of Notes on Nursing, by Florence Nightingale
+
+This eBook is for the use of anyone anywhere 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
+
+
+Title: Notes on Nursing
+       What It Is, and What It Is Not
+
+Author: Florence Nightingale
+
+Release Date: May 26, 2004 [EBook #12439]
+[Date last updated: December 21, 2005]
+
+Language: English
+
+Character set encoding: ISO-8859-1
+
+*** START OF THIS PROJECT GUTENBERG EBOOK NOTES ON NURSING ***
+
+
+
+
+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
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+The Project Gutenberg EBook of Notes on Nursing, by Florence Nightingale
+
+This eBook is for the use of anyone anywhere 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
+
+
+Title: Notes on Nursing
+       What It Is, and What It Is Not
+
+Author: Florence Nightingale
+
+Release Date: May 26, 2004 [EBook #12439]
+[Date last updated: December 21, 2005]
+
+Language: English
+
+Character set encoding: ASCII
+
+*** START OF THIS PROJECT GUTENBERG EBOOK NOTES ON NURSING ***
+
+
+
+
+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 pie 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
+exuviae.[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 Mere Angelique of Port Royal, what would
+our own Mrs. Fry have said to this?
+
+
+NOTE.--I would earnestly ask my sisters to keep clear of both the
+jargons now current 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
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