summaryrefslogtreecommitdiff
path: root/17366-h/17366-h.htm
blob: 8426409def525906237d19ba8a9fde75a7d01167 (plain) 
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
119
120
121
122
123
124
125
126
127
128
129
130
131
132
133
134
135
136
137
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
172
173
174
175
176
177
178
179
180
181
182
183
184
185
186
187
188
189
190
191
192
193
194
195
196
197
198
199
200
201
202
203
204
205
206
207
208
209
210
211
212
213
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
229
230
231
232
233
234
235
236
237
238
239
240
241
242
243
244
245
246
247
248
249
250
251
252
253
254
255
256
257
258
259
260
261
262
263
264
265
266
267
268
269
270
271
272
273
274
275
276
277
278
279
280
281
282
283
284
285
286
287
288
289
290
291
292
293
294
295
296
297
298
299
300
301
302
303
304
305
306
307
308
309
310
311
312
313
314
315
316
317
318
319
320
321
322
323
324
325
326
327
328
329
330
331
332
333
334
335
336
337
338
339
340
341
342
343
344
345
346
347
348
349
350
351
352
353
354
355
356
357
358
359
360
361
362
363
364
365
366
367
368
369
370
371
372
373
374
375
376
377
378
379
380
381
382
383
384
385
386
387
388
389
390
391
392
393
394
395
396
397
398
399
400
401
402
403
404
405
406
407
408
409
410
411
412
413
414
415
416
417
418
419
420
421
422
423
424
425
426
427
428
429
430
431
432
433
434
435
436
437
438
439
440
441
442
443
444
445
446
447
448
449
450
451
452
453
454
455
456
457
458
459
460
461
462
463
464
465
466
467
468
469
470
471
472
473
474
475
476
477
478
479
480
481
482
483
484
485
486
487
488
489
490
491
492
493
494
495
496
497
498
499
500
501
502
503
504
505
506
507
508
509
510
511
512
513
514
515
516
517
518
519
520
521
522
523
524
525
526
527
528
529
530
531
532
533
534
535
536
537
538
539
540
541
542
543
544
545
546
547
548
549
550
551
552
553
554
555
556
557
558
559
560
561
562
563
564
565
566
567
568
569
570
571
572
573
574
575
576
577
578
579
580
581
582
583
584
585
586
587
588
589
590
591
592
593
594
595
596
597
598
599
600
601
602
603
604
605
606
607
608
609
610
611
612
613
614
615
616
617
618
619
620
621
622
623
624
625
626
627
628
629
630
631
632
633
634
635
636
637
638
639
640
641
642
643
644
645
646
647
648
649
650
651
652
653
654
655
656
657
658
659
660
661
662
663
664
665
666
667
668
669
670
671
672
673
674
675
676
677
678
679
680
681
682
683
684
685
686
687
688
689
690
691
692
693
694
695
696
697
698
699
700
701
702
703
704
705
706
707
708
709
710
711
712
713
714
715
716
717
718
719
720
721
722
723
724
725
726
727
728
729
730
731
732
733
734
735
736
737
738
739
740
741
742
743
744
745
746
747
748
749
750
751
752
753
754
755
756
757
758
759
760
761
762
763
764
765
766
767
768
769
770
771
772
773
774
775
776
777
778
779
780
781
782
783
784
785
786
787
788
789
790
791
792
793
794
795
796
797
798
799
800
801
802
803
804
805
806
807
808
809
810
811
812
813
814
815
816
817
818
819
820
821
822
823
824
825
826
827
828
829
830
831
832
833
834
835
836
837
838
839
840
841
842
843
844
845
846
847
848
849
850
851
852
853
854
855
856
857
858
859
860
861
862
863
864
865
866
867
868
869
870
871
872
873
874
875
876
877
878
879
880
881
882
883
884
885
886
887
888
889
890
891
892
893
894
895
896
897
898
899
900
901
902
903
904
905
906
907
908
909
910
911
912
913
914
915
916
917
918
919
920
921
922
923
924
925
926
927
928
929
930
931
932
933
934
935
936
937
938
939
940
941
942
943
944
945
946
947
948
949
950
951
952
953
954
955
956
957
958
959
960
961
962
963
964
965
966
967
968
969
970
971
972
973
974
975
976
977
978
979
980
981
982
983
984
985
986
987
988
989
990
991
992
993
994
995
996
997
998
999
1000
1001
1002
1003
1004
1005
1006
1007
1008
1009
1010
1011
1012
1013
1014
1015
1016
1017
1018
1019
1020
1021
1022
1023
1024
1025
1026
1027
1028
1029
1030
1031
1032
1033
1034
1035
1036
1037
1038
1039
1040
1041
1042
1043
1044
1045
1046
1047
1048
1049
1050
1051
1052
1053
1054
1055
1056
1057
1058
1059
1060
1061
1062
1063
1064
1065
1066
1067
1068
1069
1070
1071
1072
1073
1074
1075
1076
1077
1078
1079
1080
1081
1082
1083
1084
1085
1086
1087
1088
1089
1090
1091
1092
1093
1094
1095
1096
1097
1098
1099
1100
1101
1102
1103
1104
1105
1106
1107
1108
1109
1110
1111
1112
1113
1114
1115
1116
1117
1118
1119
1120
1121
1122
1123
1124
1125
1126
1127
1128
1129
1130
1131
1132
1133
1134
1135
1136
1137
1138
1139
1140
1141
1142
1143
1144
1145
1146
1147
1148
1149
1150
1151
1152
1153
1154
1155
1156
1157
1158
1159
1160
1161
1162
1163
1164
1165
1166
1167
1168
1169
1170
1171
1172
1173
1174
1175
1176
1177
1178
1179
1180
1181
1182
1183
1184
1185
1186
1187
1188
1189
1190
1191
1192
1193
1194
1195
1196
1197
1198
1199
1200
1201
1202
1203
1204
1205
1206
1207
1208
1209
1210
1211
1212
1213
1214
1215
1216
1217
1218
1219
1220
1221
1222
1223
1224
1225
1226
1227
1228
1229
1230
1231
1232
1233
1234
1235
1236
1237
1238
1239
1240
1241
1242
1243
1244
1245
1246
1247
1248
1249
1250
1251
1252
1253
1254
1255
1256
1257
1258
1259
1260
1261
1262
1263
1264
1265
1266
1267
1268
1269
1270
1271
1272
1273
1274
1275
1276
1277
1278
1279
1280
1281
1282
1283
1284
1285
1286
1287
1288
1289
1290
1291
1292
1293
1294
1295
1296
1297
1298
1299
1300
1301
1302
1303
1304
1305
1306
1307
1308
1309
1310
1311
1312
1313
1314
1315
1316
1317
1318
1319
1320
1321
1322
1323
1324
1325
1326
1327
1328
1329
1330
1331
1332
1333
1334
1335
1336
1337
1338
1339
1340
1341
1342
1343
1344
1345
1346
1347
1348
1349
1350
1351
1352
1353
1354
1355
1356
1357
1358
1359
1360
1361
1362
1363
1364
1365
1366
1367
1368
1369
1370
1371
1372
1373
1374
1375
1376
1377
1378
1379
1380
1381
1382
1383
1384
1385
1386
1387
1388
1389
1390
1391
1392
1393
1394
1395
1396
1397
1398
1399
1400
1401
1402
1403
1404
1405
1406
1407
1408
1409
1410
1411
1412
1413
1414
1415
1416
1417
1418
1419
1420
1421
1422
1423
1424
1425
1426
1427
1428
1429
1430
1431
1432
1433
1434
1435
1436
1437
1438
1439
1440
1441
1442
1443
1444
1445
1446
1447
1448
1449
1450
1451
1452
1453
1454
1455
1456
1457
1458
1459
1460
1461
1462
1463
1464
1465
1466
1467
1468
1469
1470
1471
1472
1473
1474
1475
1476
1477
1478
1479
1480
1481
1482
1483
1484
1485
1486
1487
1488
1489
1490
1491
1492
1493
1494
1495
1496
1497
1498
1499
1500
1501
1502
1503
1504
1505
1506
1507
1508
1509
1510
1511
1512
1513
1514
1515
1516
1517
1518
1519
1520
1521
1522
1523
1524
1525
1526
1527
1528
1529
1530
1531
1532
1533
1534
1535
1536
1537
1538
1539
1540
1541
1542
1543
1544
1545
1546
1547
1548
1549
1550
1551
1552
1553
1554
1555
1556
1557
1558
1559
1560
1561
1562
1563
1564
1565
1566
1567
1568
1569
1570
1571
1572
1573
1574
1575
1576
1577
1578
1579
1580
1581
1582
1583
1584
1585
1586
1587
1588
1589
1590
1591
1592
1593
1594
1595
1596
1597
1598
1599
1600
1601
1602
1603
1604
1605
1606
1607
1608
1609
1610
1611
1612
1613
1614
1615
1616
1617
1618
1619
1620
1621
1622
1623
1624
1625
1626
1627
1628
1629
1630
1631
1632
1633
1634
1635
1636
1637
1638
1639
1640
1641
1642
1643
1644
1645
1646
1647
1648
1649
1650
1651
1652
1653
1654
1655
1656
1657
1658
1659
1660
1661
1662
1663
1664
1665
1666
1667
1668
1669
1670
1671
1672
1673
1674
1675
1676
1677
1678
1679
1680
1681
1682
1683
1684
1685
1686
1687
1688
1689
1690
1691
1692
1693
1694
1695
1696
1697
1698
1699
1700
1701
1702
1703
1704
1705
1706
1707
1708
1709
1710
1711
1712
1713
1714
1715
1716
1717
1718
1719
1720
1721
1722
1723
1724
1725
1726
1727
1728
1729
1730
1731
1732
1733
1734
1735
1736
1737
1738
1739
1740
1741
1742
1743
1744
1745
1746
1747
1748
1749
1750
1751
1752
1753
1754
1755
1756
1757
1758
1759
1760
1761
1762
1763
1764
1765
1766
1767
1768
1769
1770
1771
1772
1773
1774
1775
1776
1777
1778
1779
1780
1781
1782
1783
1784
1785
1786
1787
1788
1789
1790
1791
1792
1793
1794
1795
1796
1797
1798
1799
1800
1801
1802
1803
1804
1805
1806
1807
1808
1809
1810
1811
1812
1813
1814
1815
1816
1817
1818
1819
1820
1821
1822
1823
1824
1825
1826
1827
1828
1829
1830
1831
1832
1833
1834
1835
1836
1837
1838
1839
1840
1841
1842
1843
1844
1845
1846
1847
1848
1849
1850
1851
1852
1853
1854
1855
1856
1857
1858
1859
1860
1861
1862
1863
1864
1865
1866
1867
1868
1869
1870
1871
1872
1873
1874
1875
1876
1877
1878
1879
1880
1881
1882
1883
1884
1885
1886
1887
1888
1889
1890
1891
1892
1893
1894
1895
1896
1897
1898
1899
1900
1901
1902
1903
1904
1905
1906
1907
1908
1909
1910
1911
1912
1913
1914
1915
1916
1917
1918
1919
1920
1921
1922
1923
1924
1925
1926
1927
1928
1929
1930
1931
1932
1933
1934
1935
1936
1937
1938
1939
1940
1941
1942
1943
1944
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
2039
2040
2041
2042
2043
2044
2045
2046
2047
2048
2049
2050
2051
2052
2053
2054
2055
2056
2057
2058
2059
2060
2061
2062
2063
2064
2065
2066
2067
2068
2069
2070
2071
2072
2073
2074
2075
2076
2077
2078
2079
2080
2081
2082
2083
2084
2085
2086
2087
2088
2089
2090
2091
2092
2093
2094
2095
2096
2097
2098
2099
2100
2101
2102
2103
2104
2105
2106
2107
2108
2109
2110
2111
2112
2113
2114
2115
2116
2117
2118
2119
2120
2121
2122
2123
2124
2125
2126
2127
2128
2129
2130
2131
2132
2133
2134
2135
2136
2137
2138
2139
2140
2141
2142
2143
2144
2145
2146
2147
2148
2149
2150
2151
2152
2153
2154
2155
2156
2157
2158
2159
2160
2161
2162
2163
2164
2165
2166
2167
2168
2169
2170
2171
2172
2173
2174
2175
2176
2177
2178
2179
2180
2181
2182
2183
2184
2185
2186
2187
2188
2189
2190
2191
2192
2193
2194
2195
2196
2197
2198
2199
2200
2201
2202
2203
2204
2205
2206
2207
2208
2209
2210
2211
2212
2213
2214
2215
2216
2217
2218
2219
2220
2221
2222
2223
2224
2225
2226
2227
2228
2229
2230
2231
2232
2233
2234
2235
2236
2237
2238
2239
2240
2241
2242
2243
2244
2245
2246
2247
2248
2249
2250
2251
2252
2253
2254
2255
2256
2257
2258
2259
2260
2261
2262
2263
2264
2265
2266
2267
2268
2269
2270
2271
2272
2273
2274
2275
2276
2277
2278
2279
2280
2281
2282
2283
2284
2285
2286
2287
2288
2289
2290
2291
2292
2293
2294
2295
2296
2297
2298
2299
2300
2301
2302
2303
2304
2305
2306
2307
2308
2309
2310
2311
2312
2313
2314
2315
2316
2317
2318
2319
2320
2321
2322
2323
2324
2325
2326
2327
2328
2329
2330
2331
2332
2333
2334
2335
2336
2337
2338
2339
2340
2341
2342
2343
2344
2345
2346
2347
2348
2349
2350
2351
2352
2353
2354
2355
2356
2357
2358
2359
2360
2361
2362
2363
2364
2365
2366
2367
2368
2369
2370
2371
2372
2373
2374
2375
2376
2377
2378
2379
2380
2381
2382
2383
2384
2385
2386
2387
2388
2389
2390
2391
2392
2393
2394
2395
2396
2397
2398
2399
2400
2401
2402
2403
2404
2405
2406
2407
2408
2409
2410
2411
2412
2413
2414
2415
2416
2417
2418
2419
2420
2421
2422
2423
2424
2425
2426
2427
2428
2429
2430
2431
2432
2433
2434
2435
2436
2437
2438
2439
2440
2441
2442
2443
2444
2445
2446
2447
2448
2449
2450
2451
2452
2453
2454
2455
2456
2457
2458
2459
2460
2461
2462
2463
2464
2465
2466
2467
2468
2469
2470
2471
2472
2473
2474
2475
2476
2477
2478
2479
2480
2481
2482
2483
2484
2485
2486
2487
2488
2489
2490
2491
2492
2493
2494
2495
2496
2497
2498
2499
2500
2501
2502
2503
2504
2505
2506
2507
2508
2509
2510
2511
2512
2513
2514
2515
2516
2517
2518
2519
2520
2521
2522
2523
2524
2525
2526
2527
2528
2529
2530
2531
2532
2533
2534
2535
2536
2537
2538
2539
2540
2541
2542
2543
2544
2545
2546
2547
2548
2549
2550
2551
2552
2553
2554
2555
2556
2557
2558
2559
2560
2561
2562
2563
2564
2565
2566
2567
2568
2569
2570
2571
2572
2573
2574
2575
2576
2577
2578
2579
2580
2581
2582
2583
2584
2585
2586
2587
2588
2589
2590
2591
2592
2593
2594
2595
2596
2597
2598
2599
2600
2601
2602
2603
2604
2605
2606
2607
2608
2609
2610
2611
2612
2613
2614
2615
2616
2617
2618
2619
2620
2621
2622
2623
2624
2625
2626
2627
2628
2629
2630
2631
2632
2633
2634
2635
2636
2637
2638
2639
2640
2641
2642
2643
2644
2645
2646
2647
2648
2649
2650
2651
2652
2653
2654
2655
2656
2657
2658
2659
2660
2661
2662
2663
2664
2665
2666
2667
2668
2669
2670
2671
2672
2673
2674
2675
2676
2677
2678
2679
2680
2681
2682
2683
2684
2685
2686
2687
2688
2689
2690
2691
2692
2693
2694
2695
2696
2697
2698
2699
2700
2701
2702
2703
2704
2705
2706
2707
2708
2709
2710
2711
2712
2713
2714
2715
2716
2717
2718
2719
2720
2721
2722
2723
2724
2725
2726
2727
2728
2729
2730
2731
2732
2733
2734
2735
2736
2737
2738
2739
2740
2741
2742
2743
2744
2745
2746
2747
2748
2749
2750
2751
2752
2753
2754
2755
2756
2757
2758
2759
2760
2761
2762
2763
2764
2765
2766
2767
2768
2769
2770
2771
2772
2773
2774
2775
2776
2777
2778
2779
2780
2781
2782
2783
2784
2785
2786
2787
2788
2789
2790
2791
2792
2793
2794
2795
2796
2797
2798
2799
2800
2801
2802
2803
2804
2805
2806
2807
2808
2809
2810
2811
2812
2813
2814
2815
2816
2817
2818
2819
2820
2821
2822
2823
2824
2825
2826
2827
2828
2829
2830
2831
2832
2833
2834
2835
2836
2837
2838
2839
2840
2841
2842
2843
2844
2845
2846
2847
2848
2849
2850
2851
2852
2853
2854
2855
2856
2857
2858
2859
2860
2861
2862
2863
2864
2865
2866
2867
2868
2869
2870
2871
2872
2873
2874
2875
2876
2877
2878
2879
2880
2881
2882
2883
2884
2885
2886
2887
2888
2889
2890
2891
2892
2893
2894
2895
2896
2897
2898
2899
2900
2901
2902
2903
2904
2905
2906
2907
2908
2909
2910
2911
2912
2913
2914
2915
2916
2917
2918
2919
2920
2921
2922
2923
2924
2925
2926
2927
2928
2929
2930
2931
2932
2933
2934
2935
2936
2937
2938
2939
2940
2941
2942
2943
2944
2945
2946
2947
2948
2949
2950
2951
2952
2953
2954
2955
2956
2957
2958
2959
2960
2961
2962
2963
2964
2965
2966
2967
2968
2969
2970
2971
2972
2973
2974
2975
2976
2977
2978
2979
2980
2981
2982
2983
2984
2985
2986
2987
2988
2989
2990
2991
2992
2993
2994
2995
2996
2997
2998
2999
3000
3001
3002
3003
3004
3005
3006
3007
3008
3009
3010
3011
3012
3013
3014
3015
3016
3017
3018
3019
3020
3021
3022
3023
3024
3025
3026
3027
3028
3029
3030
3031
3032
3033
3034
3035
3036
3037
3038
3039
3040
3041
3042
3043
3044
3045
3046
3047
3048
3049
3050
3051
3052
3053
3054
3055
3056
3057
3058
3059
3060
3061
3062
3063
3064
3065
3066
3067
3068
3069
3070
3071
3072
3073
3074
3075
3076
3077
3078
3079
3080
3081
3082
3083
3084
3085
3086
3087
3088
3089
3090
3091
3092
3093
3094
3095
3096
3097
3098
3099
3100
3101
3102
3103
3104
3105
3106
3107
3108
3109
3110
3111
3112
3113
3114
3115
3116
3117
3118
3119
3120
3121
3122
3123
3124
3125
3126
3127
3128
3129
3130
3131
3132
3133
3134
3135
3136
3137
3138
3139
3140
3141
3142
3143
3144
3145
3146
3147
3148
3149
3150
3151
3152
3153
3154
3155
3156
3157
3158
3159
3160
3161
3162
3163
3164
3165
3166
3167
3168
3169
3170
3171
3172
3173
3174
3175
3176
3177
3178
3179
3180
3181
3182
3183
3184
3185
3186
3187
3188
3189
3190
3191
3192
3193
3194
3195
3196
3197
3198
3199
3200
3201
3202
3203
3204
3205
3206
3207
3208
3209
3210
3211
3212
3213
3214
3215
3216
3217
3218
3219
3220
3221
3222
3223
3224
3225
3226
3227
3228
3229
3230
3231
3232
3233
3234
3235
3236
3237
3238
3239
3240
3241
3242
3243
3244
3245
3246
3247
3248
3249
3250
3251
3252
3253
3254
3255
3256
3257
3258
3259
3260
3261
3262
3263
3264
3265
3266
3267
3268
3269
3270
3271
3272
3273
3274
3275
3276
3277
3278
3279
3280
3281
3282
3283
3284
3285
3286
3287
3288
3289
3290
3291
3292
3293
3294
3295
3296
3297
3298
3299
3300
3301
3302
3303
3304
3305
3306
3307
3308
3309
3310
3311
3312
3313
3314
3315
3316
3317
3318
3319
3320
3321
3322
3323
3324
3325
3326
3327
3328
3329
3330
3331
3332
3333
3334
3335
3336
3337
3338
3339
3340
3341
3342
3343
3344
3345
3346
3347
3348
3349
3350
3351
3352
3353
3354
3355
3356
3357
3358
3359
3360
3361
3362
3363
3364
3365
3366
3367
3368
3369
3370
3371
3372
3373
3374
3375
3376
3377
3378
3379
3380
3381
3382
3383
3384
3385
3386
3387
3388
3389
3390
3391
3392
3393
3394
3395
3396
3397
3398
3399
3400
3401
3402
3403
3404
3405
3406
3407
3408
3409
3410
3411
3412
3413
3414
3415
3416
3417
3418
3419
3420
3421
3422
3423
3424
3425
3426
3427
3428
3429
3430
3431
3432
3433
3434
3435
3436
3437
3438
3439
3440
3441
3442
3443
3444
3445
3446
3447
3448
3449
3450
3451
3452
3453
3454
3455
3456
3457
3458
3459
3460
3461
3462
3463
3464
3465
3466
3467
3468
3469
3470
3471
3472
3473
3474
3475
3476
3477
3478
3479
3480
3481
3482
3483
3484
3485
3486
3487
3488
3489
3490
3491
3492
3493
3494
3495
3496
3497
3498
3499
3500
3501
3502
3503
3504
3505
3506
3507
3508
3509
3510
3511
3512
3513
3514
3515
3516
3517
3518
3519
3520
3521
3522
3523
3524
3525
3526
3527
3528
3529
3530
3531
3532
3533
3534
3535
3536
3537
3538
3539
3540
3541
3542
3543
3544
3545
3546
3547
3548
3549
3550
3551
3552
3553
3554
3555
3556
3557
3558
3559
3560
3561
3562
3563
3564
3565
3566
3567
3568
3569
3570
3571
3572
3573
3574
3575
3576
3577
3578
3579
3580
3581
3582
3583
3584
3585
3586
3587
3588
3589
3590
3591
3592
3593
3594
3595
3596
3597
3598
3599
3600
3601
3602
3603
3604
3605
3606
3607
3608
3609
3610
3611
3612
3613
3614
3615
3616
3617
3618
3619
3620
3621
3622
3623
3624
3625
3626
3627
3628
3629
3630
3631
3632
3633
3634
3635
3636
3637
3638
3639
3640
3641
3642
3643
3644
3645
3646
3647
3648
3649
3650
3651
3652
3653
3654
3655
3656
3657
3658
3659
3660
3661
3662
3663
3664
3665
3666
3667
3668
3669
3670
3671
3672
3673
3674
3675
3676
3677
3678
3679
3680
3681
3682
3683
3684
3685
3686
3687
3688
3689
3690
3691
3692
3693
3694
3695
3696
3697
3698
3699
3700
3701
3702
3703
3704
3705
3706
3707
3708
3709
3710
3711
3712
3713
3714
3715
3716
3717
3718
3719
3720
3721
3722
3723
3724
3725
3726
3727
3728
3729
3730
3731
3732
3733
3734
3735
3736
3737
3738
3739
3740
3741
3742
3743
3744
3745
3746
3747
3748
3749
3750
3751
3752
3753
3754
3755
3756
3757
3758
3759
3760
3761
3762
3763
3764
3765
3766
3767
3768
3769
3770
3771
3772
3773
3774
3775
3776
3777
3778
3779
3780
3781
3782
3783
3784
3785
3786
3787
3788
3789
3790
3791
3792
3793
3794
3795
3796
3797
3798
3799
3800
3801
3802
3803
3804
3805
3806
3807
3808
3809
3810
3811
3812
3813
3814
3815
3816
3817
3818
3819
3820
3821
3822
3823
3824
3825
3826
3827
3828
3829
3830
3831
3832
3833
3834
3835
3836
3837
3838
3839
3840
3841
3842
3843
3844
3845
3846
3847
3848
3849
3850
3851
3852
3853
3854
3855
3856
3857
3858
3859
3860
3861
3862
3863
3864
3865
3866
3867
3868
3869
3870
3871
3872
3873
3874
3875
3876
3877
3878
3879
3880
3881
3882
3883
3884
3885
3886
3887
3888
3889
3890
3891
3892
3893
3894
3895
3896
3897
3898
3899
3900
3901
3902
3903
3904
3905
3906
3907
3908
3909
3910
3911
3912
3913
3914
3915
3916
3917
3918
3919
3920
3921
3922
3923
3924
3925
3926
3927
3928
3929
3930
3931
3932
3933
3934
3935
3936
3937
3938
3939
3940
3941
3942
3943
3944
3945
3946
3947
3948
3949
3950
3951
3952
3953
3954
3955
3956
3957
3958
3959
3960
3961
3962
3963
3964
3965
3966
3967
3968
3969
3970
3971
3972
3973
3974
3975
3976
3977
3978
3979
3980
3981
3982
3983
3984
3985
3986
3987
3988
3989
3990
3991
3992
3993
3994
3995
3996
3997
3998
3999
4000
4001
4002
4003
4004
4005
4006
4007
4008
4009
4010
4011
4012
4013
4014
4015
4016
4017
4018
4019
4020
4021
4022
4023
4024
4025
4026
4027
4028
4029
4030
4031
4032
4033
4034
4035
4036
4037
4038
4039
4040
4041
4042
4043
4044
4045
4046
4047
4048
4049
4050
4051
4052
4053
4054
4055
4056
4057
4058
4059
4060
4061
4062
4063
4064
4065
4066
4067
4068
4069
4070
4071
4072
4073
4074
4075
4076
4077
4078
4079
4080
4081
4082
4083
4084
4085
4086
4087
4088
4089
4090
4091
4092
4093
4094
4095
4096
4097
4098
4099
4100
4101
4102
4103
4104
4105
4106
4107
4108
4109
4110
4111
4112
4113
4114
4115
4116
4117
4118
4119
4120
4121
4122
4123
4124
4125
4126
4127
4128
4129
4130
4131
4132
4133
4134
4135
4136
4137
4138
4139
4140
4141
4142
4143
4144
4145
4146
4147
4148
4149
4150
4151
4152
4153
4154
4155
4156
4157
4158
4159
4160
4161
4162
4163
4164
4165
4166
4167
4168
4169
4170
4171
4172
4173
4174
4175
4176
4177
4178
4179
4180
4181
4182
4183
4184
4185
4186
4187
4188
4189
4190
4191
4192
4193
4194
4195
4196
4197
4198
4199
4200
4201
4202
4203
4204
4205
4206
4207
4208
4209
4210
4211
4212
4213
4214
4215
4216
4217
4218
4219
4220
4221
4222
4223
4224
4225
4226
4227
4228
4229
4230
4231
4232
4233
4234
4235
4236
4237
4238
4239
4240
4241
4242
4243
4244
4245
4246
4247
4248
4249
4250
4251
4252
4253
4254
4255
4256
4257
4258
4259
4260
4261
4262
4263
4264
4265
4266
4267
4268
4269
4270
4271
4272
4273
4274
4275
4276
4277
4278
4279
4280
4281
4282
4283
4284
4285
4286
4287
4288
4289
4290
4291
4292
4293
4294
4295
4296
4297
4298
4299
4300
4301
4302
4303
4304
4305
4306
4307
4308
4309
4310
4311
4312
4313
4314
4315
4316
4317
4318
4319
4320
4321
4322
4323
4324
4325
4326
4327
4328
4329
4330
4331
4332
4333
4334
4335
4336
4337
4338
4339
4340
4341
4342
4343
4344
4345
4346
4347
4348
4349
4350
4351
4352
4353
4354
4355
4356
4357
4358
4359
4360
4361
4362
4363
4364
4365
4366
4367
4368
4369
4370
4371
4372
4373
4374
4375
4376
4377
4378
4379
4380
4381
4382
4383
4384
4385
4386
4387
4388
4389
4390
4391
4392
4393
4394
4395
4396
4397
4398
4399
4400
4401
4402
4403
4404
4405
4406
4407
4408
4409
4410
4411
4412
4413
4414
4415
4416
4417
4418
4419
4420
4421
4422
4423
4424
4425
4426
4427
4428
4429
4430
4431
4432
4433
4434
4435
4436
4437
4438
4439
4440
4441
4442
4443
4444
4445
4446
4447
4448
4449
4450
4451
4452
4453
4454
4455
4456
4457
4458
4459
4460
4461
4462
4463
4464
4465
4466
4467
4468
4469
4470
4471
4472
4473
4474
4475
4476
4477
4478
4479
4480
4481
4482
4483
4484
4485
4486
4487
4488
4489
4490
4491
4492
4493
4494
4495
4496
4497
4498
4499
4500
4501
4502
4503
4504
4505
4506
4507
4508
4509
4510
4511
4512
4513
4514
4515
4516
4517
4518
4519
4520
4521
4522
4523
4524
4525
4526
4527
4528
4529
4530
4531
4532
4533
4534
4535
4536
4537
4538
4539
4540
4541
4542
4543
4544
4545
4546
4547
4548
4549
4550
4551
4552
4553
4554
4555
4556
4557
4558
4559
4560
4561
4562
4563
4564
4565
4566
4567
4568
4569
4570
4571
4572
4573
4574
4575
4576
4577
4578
4579
4580
4581
4582
4583
4584
4585
4586
4587
4588
4589
4590
4591
4592
4593
4594
4595
4596
4597
4598
4599
4600
4601
4602
4603
4604
4605
4606
4607
4608
4609
4610
4611
4612
4613
4614
4615
4616
4617
4618
4619
4620
4621
4622
4623
4624
4625
4626
4627
4628
4629
4630
4631
4632
4633
4634
4635
4636
4637
4638
4639
4640
4641
4642
4643
4644
4645
4646
4647
4648
4649
4650
4651
4652
4653
4654
4655
4656
4657
4658
4659
4660
4661
4662
4663
4664
4665
4666
4667
4668
4669
4670
4671
4672
4673
4674
4675
4676
4677
4678
4679
4680
4681
4682
4683
4684
4685
4686
4687
4688
4689
4690
4691
4692
4693
4694
4695
4696
4697
4698
4699
4700
4701
4702
4703
4704
4705
4706
4707
4708
4709
4710
4711
4712
4713
4714
4715
4716
4717
4718
4719
4720
4721
4722
4723
4724
4725
4726
4727
4728
4729
4730
4731
4732
4733
4734
4735
4736
4737
4738
4739
4740
4741
4742
4743
4744
4745
4746
4747
4748
4749
4750
4751
4752
4753
4754
4755
4756
4757
4758
4759
4760
4761
4762
4763
4764
4765
4766
4767
4768
4769
4770
4771
4772
4773
4774
4775
4776
4777
4778
4779
4780
4781
4782
4783
4784
4785
4786
4787
4788
4789
4790
4791
4792
4793
4794
4795
4796
4797
4798
4799
4800
4801
4802
4803
4804
4805
4806
4807
4808
4809
4810
4811
4812
4813
4814
4815
4816
4817
4818
4819
4820
4821
4822
4823
4824
4825
4826
4827
4828
4829
4830
4831
4832
4833
4834
4835
4836
4837
4838
4839
4840
4841
4842
4843
4844
4845
4846
4847
4848
4849
4850
4851
4852
4853
4854
4855
4856
4857
4858
4859
4860
4861
4862
4863
4864
4865
4866
4867
4868
4869
4870
4871
4872
4873
4874
4875
4876
4877
4878
4879
4880
4881
4882
4883
4884
4885
4886
4887
4888
4889
4890
4891
4892
4893
4894
4895
4896
4897
4898
4899
4900
4901
4902
4903
4904
4905
4906
4907
4908
4909
4910
4911
4912
4913
4914
4915
4916
4917
4918
4919
4920
4921
4922
4923
4924
4925
4926
4927
4928
4929
4930
4931
4932
4933
4934
4935
4936
4937
4938
4939
4940
4941
4942
4943
4944
4945
4946
4947
4948
4949
4950
4951
4952
4953
4954
4955
4956
4957
4958
4959
4960
4961
4962
4963
4964
4965
4966
4967
4968
4969
4970
4971
4972
4973
4974
4975
4976
4977
4978
4979
4980
4981
4982
4983
4984
4985
4986
4987
4988
4989
4990
4991
4992
4993
4994
4995
4996
4997
4998
4999
5000
5001
5002
5003
5004
5005
5006
5007
5008
5009
5010
5011
5012
5013
5014
5015
5016
5017
5018
5019
5020
5021
5022
5023
5024
5025
5026
5027
5028
5029
5030
5031
5032
5033
5034
5035
5036
5037
5038
5039
5040
5041
5042
5043
5044
5045
5046
5047
5048
5049
5050
5051
5052
5053
5054
5055
5056
5057
5058
5059
5060
5061
5062
5063
5064
5065
5066
5067
5068
5069
5070
5071
5072
5073
5074
5075
5076
5077
5078
5079
5080
5081
5082
5083
5084
5085
5086
5087
5088
5089
5090
5091
5092
5093
5094
5095
5096
5097
5098
5099
5100
5101
5102
5103
5104
5105
5106
5107
5108
5109
5110
5111
5112
5113
5114
5115
5116
5117
5118
5119
5120
5121
5122
5123
5124
5125
5126
5127
5128
5129
5130
5131
5132
5133
5134
5135
5136
5137
5138
5139
5140
5141
5142
5143
5144
5145
5146
5147
5148
5149
5150
5151
5152
5153
5154
5155
5156
5157
5158
5159
5160
5161
5162
5163
5164
5165
5166
5167
5168
5169
5170
5171
5172
5173
5174
5175
5176
5177
5178
5179
5180
5181
5182
5183
5184
5185
5186
5187
5188
5189
5190
5191
5192
5193
5194
5195
5196
5197
5198
5199
5200
5201
5202
5203
5204
5205
5206
5207
5208
5209
5210
5211
5212
5213
5214
5215
5216
5217
5218
5219
5220
5221
5222
5223
5224
5225
5226
5227
5228
5229
5230
5231
5232
5233
5234
5235
5236
5237
5238
5239
5240
5241
5242
5243
5244
5245
5246
5247
5248
5249
5250
5251
5252
5253
5254
5255
5256
5257
5258
5259
5260
5261
5262
5263
5264
5265
5266
5267
5268
5269
5270
5271
5272
5273
5274
5275
5276
5277
5278
5279
5280
5281
5282
5283
5284
5285
5286
5287
5288
5289
5290
5291
5292
5293
5294
5295
5296
5297
5298
5299
5300
5301
5302
5303
5304
5305
5306
5307
5308
5309
5310
5311
5312
5313
5314
5315
5316
5317
5318
5319
5320
5321
5322
5323
5324
5325
5326
5327
5328
5329
5330
5331
5332
5333
5334
5335
5336
5337
5338
5339
5340
5341
5342
5343
5344
5345
5346
5347
5348
5349
5350
5351
5352
5353
5354
5355
5356
5357
5358
5359
5360
5361
5362
5363
5364
5365
5366
5367
5368
5369
5370
5371
5372
5373
5374
5375
5376
5377
5378
5379
5380
5381
5382
5383
5384
5385
5386
5387
5388
5389
5390
5391
5392
5393
5394
5395
5396
5397
5398
5399
5400
5401
5402
5403
5404
5405
5406
5407
5408
5409
5410
5411
5412
5413
5414
5415
5416
5417
5418
5419
5420
5421
5422
5423
5424
5425
5426
5427
5428
5429
5430
5431
5432
5433
5434
5435
5436
5437
5438
5439
5440
5441
5442
5443
5444
5445
5446
5447
5448
5449
5450
5451
5452
5453
5454
5455
5456
5457
5458
5459
5460
5461
5462
5463
5464
5465
5466
5467
5468
5469
5470
5471
5472
5473
5474
5475
5476
5477
5478
5479
5480
5481
5482
5483
5484
5485
5486
5487
5488
5489
5490
5491
5492
5493
5494
5495
5496
5497
5498
5499
5500
5501
5502
5503
5504
5505
5506
5507
5508
5509
5510
5511
5512
5513
5514
5515
5516
5517
5518
5519
5520
5521
5522
5523
5524
5525
5526
5527
5528
5529
5530
5531
5532
5533
5534
5535
5536
5537
5538
5539
5540
5541
5542
5543
5544
5545
5546
5547
5548
5549
5550
5551
5552
5553
5554
5555
5556
5557
5558
5559
5560
5561
5562
5563
5564
5565
5566
5567
5568
5569
5570
5571
5572
5573
5574
5575
5576
5577
5578
5579
5580
5581
5582
5583
5584
5585
5586
5587
5588
5589
5590
5591
5592
5593
5594
5595
5596
5597
5598
5599
5600
5601
5602
5603
5604
5605
5606
5607
5608
5609
5610
5611
5612
5613
5614
5615
5616
5617
5618
5619
5620
5621
5622
5623
5624
5625
5626
5627
5628
5629
5630
5631
5632
5633
5634
5635
5636
5637
5638
5639
5640
5641
5642
5643
5644
5645
5646
5647
5648
5649
5650
5651
5652
5653
5654
5655
5656
5657
5658
5659
5660
5661
5662
5663
5664
5665
5666
5667
5668
5669
5670
5671
5672
5673
5674
5675
5676
5677
5678
5679
5680
5681
5682
5683
5684
5685
5686
5687
5688
5689
5690
5691
5692
5693
5694
5695
5696
5697
5698
5699
5700
5701
5702
5703
5704
5705
5706
5707
5708
5709
5710
5711
5712
5713
5714
5715
5716
5717
5718
5719
5720
5721
5722
5723
5724
5725
5726
5727
5728
5729
5730
5731
5732
5733
5734
5735
5736
5737
5738
5739
5740
5741
5742
5743
5744
5745
5746
5747
5748
5749
5750
5751
5752
5753
5754
5755
5756
5757
5758
5759
5760
5761
5762
5763
5764
5765
5766
5767
5768
5769
5770
5771
5772
5773
5774
5775
5776
5777
5778
5779
5780
5781
5782
5783
5784
5785
5786
5787
5788
5789
5790
5791
5792
5793
5794
5795
5796
5797
5798
5799
5800
5801
5802
5803
5804
5805
5806
5807
5808
5809
5810
5811
5812
5813
5814
5815
5816
5817
5818
5819
5820
5821
5822
5823
5824
5825
5826
5827
5828
5829
5830
5831
5832
5833
5834
5835
5836
5837
5838
5839
5840
5841
5842
5843
5844
5845
5846
5847
5848
5849
5850
5851
5852
5853
5854
5855
5856
5857
5858
5859
5860
5861
5862
5863
5864
5865
5866
5867
5868
5869
5870
5871
5872
5873
5874
5875
5876
5877
5878
5879
5880
5881
5882
5883
5884
5885
5886
5887
5888
5889
5890
5891
5892
5893
5894
5895
5896
5897
5898
5899
5900
5901
5902
5903
5904
5905
5906
5907
5908
5909
5910
5911
5912
5913
5914
5915
5916
5917
5918
5919
5920
5921
5922
5923
5924
5925
5926
5927
5928
5929
5930
5931
5932
5933
5934
5935
5936
5937
5938
5939
5940
5941
5942
5943
5944
5945
5946
5947
5948
5949
5950
5951
5952
5953
5954
5955
5956
5957
5958
5959
5960
5961
5962
5963
5964
5965
5966
5967
5968
5969
5970
5971
5972
5973
5974
5975
5976
5977
5978
5979
5980
5981
5982
5983
5984
5985
5986
5987
5988
5989
5990
5991
5992
5993
5994
5995
5996
5997
5998
5999
6000
6001
6002
6003
6004
6005
6006
6007
6008
6009
6010
6011
6012
6013
6014
6015
6016
6017
6018
6019
6020
6021
6022
6023
6024
6025
6026
6027
6028
6029
6030
6031
6032
6033
6034
6035
6036
6037
6038
6039

<!DOCTYPE html PUBLIC "-//W3C//DTD XHTML 1.0 Strict//EN"
    "http://www.w3.org/TR/xhtml1/DTD/xhtml1-strict.dtd">

<html xmlns="http://www.w3.org/1999/xhtml">
  <head>
    <meta http-equiv="Content-Type" content="text/html;charset=iso-8859-1" />
    <title>
      The Project Gutenberg eBook of Notes On Nursing, by Florence Nightingale.
    </title>
    <style type="text/css">
/*<![CDATA[  XML blockout */
<!--
    p {  margin-top: .75em;
         text-align: justify;
         margin-bottom: .75em;
         }
    h1,h2,h3,h4,h5,h6 {
         text-align: center; /* all headings centered */
         clear: both;
         }
    hr { width: 33%;
	 margin-top: 2em;
	 margin-bottom: 2em;
         margin-left: auto;
         margin-right: auto;
         clear: both;
       }

    table {margin-left: auto; margin-right: auto;}

    body{margin-left: 8%;
         margin-right: 25%;
        }

    .linenum  {position: absolute; top: auto; left: 4%;} /* poetry number */
    .blockquot{margin-left: 5%; margin-right: 10%;}
    .pagenum {
      font-size: smaller;
      text-align: right;
      padding: 0 0 0 0 ;
      margin: 0 0 0 0;
      position: absolute; right: 1%;
      color: #778899;
    }
    .sidenote {
		/* sidenote box appearance controls: */
                        position: absolute; right: 25%;
			width: 15em; 		/* ..fixed width, */
			float: right;		/* ..float to the right, */
			margin-right: -16em;	/* ..exdent into body margin */
			margin-top: 0; /* top even with following <p>'s top */
			text-align: left;	/* ..right align text in box */
		}

    .bb       {border-bottom: solid 2px;}
    .bl       {border-left: solid 2px;}
    .bt       {border-top: solid 2px;}
    .br       {border-right: solid 2px;}
    .bbox     {border: solid 2px;}

    .center   {text-align: center;}
    .smcap    {font-variant: small-caps;}
    .u        {text-decoration: underline;}

    .caption  {font-weight: bold;}

    .figcenter   {margin: auto; text-align: center;}

    .figleft     {float: left; clear: left; margin-left: 0; margin-bottom: 1em; margin-top:
                 1em; margin-right: 1em; padding: 0; text-align: center;}

    .figright    {float: right; clear: right; margin-left: 1em; margin-bottom: 1em;
                 margin-top: 1em; margin-right: 0; padding: 0; text-align: center;}

    .footnotes        {border: dashed 1px;}
    .footnote         {margin-left: 10%; margin-right: 10%;}
    .footnote .label  {position: absolute; right: 86%; text-align: right;}
    .fnanchor         {vertical-align: super; font-size: .8em; text-decoration: none;}

    .poem             {margin-left:10%; margin-right:10%; text-align: left;}
    .poem br          {display: none;}
    .poem .stanza     {margin: 1em 0em 1em 0em;}
    .poem span.i0     {display: block; margin-left: 0em; padding-left: 3em; text-indent: -3em;}
    .poem span.i2     {display: block; margin-left: 2em; padding-left: 3em; text-indent: -3em;}
    .poem span.i4     {display: block; margin-left: 4em; padding-left: 3em; text-indent: -3em;}
    // -->
    /* XML end  ]]>*/
    </style>
  </head>
<body>


<pre>

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: December 21, 2005 [EBook #17366]

Language: English

Character set encoding: ISO-8859-1

*** START OF THIS PROJECT GUTENBERG EBOOK NOTES ON NURSING ***




Produced by Jonathan Ingram, Susan Skinner and the Online
Distributed Proofreading Team at https://www.pgdp.net (This
file was produced from images generously made available
by The Internet Archive/Canadian Libraries)






</pre>

<p><a name="Page_1" id="Page_1"></a><span class='pagenum'>[Pg 1]</span></p>

<h1>NOTES ON NURSING:<br />
<br />
<span style="font-size: 75%;">WHAT IT IS, AND WHAT IT IS NOT.</span></h1>
<p><br /></p>
<h3>BY</h3>
<p><br /></p>
<h2>FLORENCE NIGHTINGALE.</h2>

<p><br /></p>

<p class="center">LONDON:<br />
HARRISON, 59, PALL MALL,<br />
BOOKSELLER TO THE QUEEN.</p>


<p class="center">[<i>The right of Translation is reserved.</i>]</p>

<p><a name="Page_2" id="Page_2"></a><span class='pagenum'>[Pg 2]</span></p>
<p class="center">PRINTED BY HARRISON AND SONS,</p>

<p class="center">ST. MARTIN'S LANE, W.C.</p><p><a name="Page_3" id="Page_3"></a><span class='pagenum'>[Pg 3]</span>
</p>



<hr style="width: 65%;" />
<h2><a name="PREFACE" id="PREFACE"></a>PREFACE.</h2>


<p>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,&mdash;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&mdash;distinct from medical knowledge,
which only a profession can have.</p>

<p>If, then, every woman must, at some time or other of her
life, become a nurse, <i>i.e.</i>, 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.</p>

<p>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.</p><p><a name="Page_4" id="Page_4"></a><span class='pagenum'>[Pg 4]</span></p>



<hr style="width: 65%;" />
<h2><a name="TABLE_OF_CONTENTS" id="TABLE_OF_CONTENTS"></a>TABLE OF CONTENTS.</h2>

<div class='center'>
<table border="0" cellpadding="4" cellspacing="0" summary="">
<tr><td align='left'></td><td align='center'>PAGES</td></tr>
<tr><td align='left'><span class="smcap"><a href="#I_VENTILATION_AND_WARMING">Ventilation and Warming</a></span></td><td align='right'><a href="#Page_8">8</a></td></tr>
<tr><td align='left'><span class="smcap"><a href="#II_HEALTH_OF_HOUSES7">Health of Houses</a></span></td><td align='right'><a href="#Page_14">14</a></td></tr>
<tr><td align='left'><span class="smcap"><a href="#III_PETTY_MANAGEMENT">Petty Management</a></span></td><td align='right'><a href="#Page_20">20</a></td></tr>
<tr><td align='left'><span class="smcap"><a href="#IV_NOISE">Noise</a></span></td><td align='right'><a href="#Page_25">25</a></td></tr>
<tr><td align='left'><span class="smcap"><a href="#V_VARIETY">Variety</a></span></td><td align='right'><a href="#Page_33">33</a></td></tr>
<tr><td align='left'><span class="smcap"><a href="#VI_TAKING_FOOD">Taking Food</a></span></td><td align='right'><a href="#Page_36">36</a></td></tr>
<tr><td align='left'><span class="smcap"><a href="#VII_WHAT_FOOD">What Food?</a></span></td><td align='right'><a href="#Page_39">39</a></td></tr>
<tr><td align='left'><span class="smcap"><a href="#VIII_BED_AND_BEDDING">Bed and Bedding</a></span></td><td align='right'><a href="#Page_45">45</a></td></tr>
<tr><td align='left'><span class="smcap"><a href="#IX_LIGHT">Light</a></span></td><td align='right'><a href="#Page_47">47</a></td></tr>
<tr><td align='left'><span class="smcap"><a href="#X_CLEANLINESS_OF_ROOMS_AND_WALLS">Cleanliness of Rooms and Walls</a></span></td><td align='right'><a href="#Page_49">49</a></td></tr>
<tr><td align='left'><span class="smcap"><a href="#XI_PERSONAL_CLEANLINESS">Personal Cleanliness</a></span></td><td align='right'><a href="#Page_52">52</a></td></tr>
<tr><td align='left'><span class="smcap"><a href="#XII_CHATTERING_HOPES_AND_ADVICES">Chattering Hopes and Advices</a></span></td><td align='right'><a href="#Page_54">54</a></td></tr>
<tr><td align='left'><span class="smcap"><a href="#XIII_OBSERVATION_OF_THE_SICK">Observation of the Sick</a></span></td><td align='right'><a href="#Page_59">59</a></td></tr>
<tr><td align='left'><span class="smcap"><a href="#CONCLUSION">Conclusion</a></span></td><td align='right'><a href="#Page_71">71</a></td></tr>
<tr><td align='left'><span class="smcap"><a href="#APPENDIX">Appendix</a></span></td><td align='right'><a href="#Page_77">77</a></td></tr>
</table></div>

<p><a name="Page_5" id="Page_5"></a><span class='pagenum'>[Pg 5]</span></p>



<hr style="width: 65%;" />
<h2>NOTES ON NURSING:<br />
<br/>
<span style="font-size: 75%;">WHAT IT IS, AND WHAT IT IS NOT.</span></h2>

<hr style='width: 45%;' />

<div class="sidenote">Disease a
reparative
process.</div>

<p>Shall we begin by taking it as a general principle&mdash;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?</p>

<p>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&mdash;all the climates of the earth are
meant to be made habitable for man, by the efforts of man&mdash;the
objection would be immediately raised,&mdash;Will the top of Mont Blanc
ever be made habitable? Our answer would be, it will be many
thousands of years before we have reached the bottom of Mont Blanc
in making the earth healthy. Wait till we have reached the bottom
before we discuss the top.</p>

<div class="sidenote">Of the sufferings
of disease,
disease not always the
cause.</div>

<p>In watching disease, 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&mdash;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.</p>

<p>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.</p><p><a name="Page_6" id="Page_6"></a><span class='pagenum'>[Pg 6]</span></p>

<p>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.</p>

<div class="sidenote">What nursing
ought to do.</div>

<p>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&mdash;all at the least expense of vital power to the
patient.</p>

<div class="sidenote">Nursing the
sick little
understood.</div>

<p>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.</p>

<p>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.</p>

<p>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.</p>

<div class="sidenote">Nursing ought
to assist the
reparative process.</div>

<p>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?&mdash;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.</p>

<p>Another and the commonest exclamation which will be instantly
made is&mdash;Would you do nothing, then, in cholera, fever, &amp;c.?&mdash;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, &amp;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.</p>

<div class="sidenote">Nursing the
well.</div>

<p>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,&mdash;and
this sometimes, not always.</p>

<p>It is constantly objected,&mdash;"But how can I obtain this medical
knowledge? I am not a doctor. I must leave this to doctors."</p>

<div class="sidenote">Little understood.</div>

<p>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<a name="Page_7" id="Page_7"></a><span class='pagenum'>[Pg 7]</span>
England, nearly one out of two?<a name="FNanchor_1_1" id="FNanchor_1_1"></a><a href="#Footnote_1_1" class="fnanchor">[1]</a> "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?</p>

<p>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.</p>

<p>But how much more extraordinary is it that, whereas what we
might call the coxcombries of education&mdash;<i>e.g.</i>, the elements of astronomy&mdash;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&mdash;the laws of life&mdash;are in a certain measure understood,
but not even mothers think it worth their while to study them&mdash;to
study how to give their children healthy existences. They call it
medical or physiological knowledge, fit only for doctors.</p>

<p>Another objection.</p>

<p>We are constantly told,&mdash;"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."</p>

<p><a name="Page_8" id="Page_8"></a><span class='pagenum'>[Pg 8]</span></p>

<p>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, &amp;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.</p>



<hr style="width: 65%;" />
<h2><a name="I_VENTILATION_AND_WARMING" id="I_VENTILATION_AND_WARMING"></a>I. VENTILATION AND WARMING.</h2>

<div class="sidenote">First rule of
nursing, to
keep the air
within as pure
as the air
without.</div>

<p>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 the
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:
<span class="smcap">To keep the air he breathes as pure as the external air,
without chilling him.</span> 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&mdash;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.</p>

<p>Again, a thing I have often seen both in private houses and institutions.
A room remains uninhabited; the fire place 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.<a name="FNanchor_2_2" id="FNanchor_2_2"></a><a href="#Footnote_2_2" class="fnanchor">[2]</a></p>

<p>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.</p>

<p>A short time ago a man walked into a back-kitchen in Queen
<a name="Page_9" id="Page_9"></a><span class='pagenum'>[Pg 9]</span>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.</p>

<p>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."</p>

<div class="sidenote">Without chill.</div>

<p>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.</p>

<p>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,&mdash;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.</p>

<p>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.</p>

<p>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<a name="FNanchor_3_3" id="FNanchor_3_3"></a><a href="#Footnote_3_3" class="fnanchor">[3]</a>.</p>

<div class="sidenote">Open windows.</div>

<p>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.</p>

<p>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
<a name="Page_10" id="Page_10"></a><span class='pagenum'>[Pg 10]</span>air from without." I should think not; nor twice in the hour either.
It only shows how little the subject has been considered.</p>

<div class="sidenote">What kind of
warmth
desirable.</div>

<p>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.</p>

<p>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.</p>

<div class="sidenote">Bedrooms
almost universally
foul.</div>

<p>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.<a name="FNanchor_4_4" id="FNanchor_4_4"></a><a href="#Footnote_4_4" class="fnanchor">[4]</a></p>

<p><a name="Page_11" id="Page_11"></a><span class='pagenum'>[Pg 11]</span></p>

<div class="sidenote">When warmth
must be most
carefully
looked to.</div>

<p>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.</p>

<p>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.</p>

<p>All these things require common sense and care. Yet perhaps
in no one single thing is so little common sense shewn, in all ranks,
as in nursing.<a name="FNanchor_5_5" id="FNanchor_5_5"></a><a href="#Footnote_5_5" class="fnanchor">[5]</a></p>

<div class="sidenote">Cold air not
ventilation,
nor fresh air a
method of
chill.</div>

<p>The extraordinary confusion between cold and ventilation, in
the minds of even 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.<a name="Page_12" id="Page_12"></a><span class='pagenum'>[Pg 12]</span>
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.</p>

<div class="sidenote">Night air.</div>

<p>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.</p>

<div class="sidenote">Air from the
outside.
Open your
windows, shut
your doors.</div>

<p>Always air your room, then, from the outside air, if possible.
Windows are made to open; doors are made to shut&mdash;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&mdash;every passage from without. But the fewer
passages there are in a hospital the better.</p>

<div class="sidenote">Smoke.</div>

<p>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&mdash;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.</p>

<div class="sidenote">Airing damp
things in a
patient's room.</div>

<p>In laying down the principle that the first object of the nurse
must be to keep the air breathed by her patient as pure as the air
without, it must not be forgotten that everything in the room which
can give off effluvia, besides the patient, evaporates itself into his
air. And it follows that there ought to be nothing in the room,
excepting him, which can give off effluvia or moisture. Out of all
damp towels, &amp;c., which become dry in the room, the damp, of
<a name="Page_13" id="Page_13"></a><span class='pagenum'>[Pg 13]</span>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.</p>

<p>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.</p>

<div class="sidenote">Effluvia from
excreta.</div>

<p>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.</p>

<p>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!</p>

<div class="sidenote">Chamber utensils
without
lids.</div>

<p>The use of any chamber utensil <i>without a lid</i><a name="FNanchor_6_6" id="FNanchor_6_6"></a><a href="#Footnote_6_6" class="fnanchor">[6]</a> 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<a name="Page_14" id="Page_14"></a><span class='pagenum'>[Pg 14]</span>
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?</p>

<p>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.</p>

<div class="sidenote">Abolish slop-pails.</div>

<p>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 <i>in</i> 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.</p>

<div class="sidenote">Fumigations</div>

<p>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.</p>



<hr style="width: 65%;" />
<h2><a name="II_HEALTH_OF_HOUSES7" id="II_HEALTH_OF_HOUSES7"></a>II.&mdash;HEALTH OF HOUSES.<a name="FNanchor_7_7" id="FNanchor_7_7"></a><a href="#Footnote_7_7" class="fnanchor">[7]</a></h2>


<div class="sidenote">Health of
houses. Five
points essential.</div>

<p>There are five essential points in securing the health of
houses:&mdash;</p>


<ol><li>Pure air.</li>
<li>Pure water.</li>
<li>Efficient drainage.</li>
<li>Cleanliness.</li>
<li>Light.</li>
</ol>
<p><a name="Page_15" id="Page_15"></a><span class='pagenum'>[Pg 15]</span></p>
<p>Without these, no house can be healthy. And it will be unhealthy
just in proportion as they are deficient.</p>

<div class="sidenote">Pure air.</div>

<p>1. To have pure air, your house must 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 unhealthily 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<a name="FNanchor_8_8" id="FNanchor_8_8"></a><a href="#Footnote_8_8" class="fnanchor">[8]</a> 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.</p>

<div class="sidenote">Pure water.</div>

<p>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.</p>

<div class="sidenote">Drainage.</div>

<p>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 py&aelig;mia among the inmates of a palace.</p>

<div class="sidenote">Sinks.</div>

<p>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<a name="Page_16" id="Page_16"></a><span class='pagenum'>[Pg 16]</span>
Scutari; and I have seen the rooms in that house all ventilated by
the open doors, and the passages all <i>un</i>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.</p>

<p>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.</p>

<div class="sidenote">Cleanliness.</div>

<p>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.</p>

<p>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.</p>

<div class="sidenote">Light.</div>

<p>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, &amp;c., among the children.</p>

<p>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.</p>

<div class="sidenote">Three common
errors in
managing the
health of
houses.</div>

<p>Three out of many "negligences and ignorances" in managing the
health of houses generally, I will here mention as specimens&mdash;1. That
the female head in charge of any building does not think it necessary to
<a name="Page_17" id="Page_17"></a><span class='pagenum'>[Pg 17]</span>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?&mdash;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.&mdash;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&mdash;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&mdash;not to show them how
there need be neither complaints made nor excuses.</p>

<div class="sidenote">Head in charge
must see to
House Hygiene, not do
it herself.</div>

<p>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.</p>

<div class="sidenote">Does God
think of these
things so
seriously?</div>

<p>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 py&aelig;mia 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 <i>anything</i> at all from
it. They went on <i>thinking</i>&mdash;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&mdash;leading <i>not</i> 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?</p>

<div class="sidenote">How does He
carry out His
laws?</div>

<p>I will tell you what was the cause of this hospital py&aelig;mia 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;&mdash;it was that the
utensils were never properly rinsed;&mdash;it was that the chamber
<a name="Page_18" id="Page_18"></a><span class='pagenum'>[Pg 18]</span>crockery was rinsed with dirty water;&mdash;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;&mdash;it was that the
furniture was always dusty; it was that the papered walls were saturated
with dirt;&mdash;it was that the floors were never cleaned;&mdash;it was
that the uninhabited rooms were never sunned, or cleaned, or aired;&mdash;it
was that the cupboards were always reservoirs of foul air;&mdash;it
was that the windows were always tight shut up at night;&mdash;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.
<span class="sidenote">How does He
teach His
laws?</span>In that handsome house I have known in one summer three
cases of hospital py&aelig;mia, one of phlebitis, two of consumptive
cough: all the <i>immediate</i> 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.<a name="FNanchor_9_9" id="FNanchor_9_9"></a><a href="#Footnote_9_9" class="fnanchor">[9]</a></p>

<div class="sidenote">Physical degeneration
in
families. Its
causes.</div>

<p>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&mdash;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
<a name="Page_19" id="Page_19"></a><span class='pagenum'>[Pg 19]</span>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.</p>

<div class="sidenote">Don't make
your sick-room
into a
ventilating
shaft for the
whole house.</div>

<p>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?</p>

<div class="sidenote">Infection.</div>

<p>We must not forget what, in ordinary language, is called
"Infection;"<a name="FNanchor_10_10" id="FNanchor_10_10"></a><a href="#Footnote_10_10" class="fnanchor">[10]</a>&mdash;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 <i>r&eacute;gime</i>, 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&mdash;scarlet fever, measles, &amp;c.&mdash;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
<a name="Page_20" id="Page_20"></a><span class='pagenum'>[Pg 20]</span>not so even now, in some of the European lazarets&mdash;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!</p>

<p>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.</p>

<p>Wise and humane management of the patient is the best safeguard
against infection.</p>

<div class="sidenote">Why must
children have
measles, &amp;c.?</div>

<p>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," &amp;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.</p>

<p>Now, do tell us, why must a child have measles?</p>

<p>Oh because, you say, we cannot keep it from infection&mdash;other
children have measles&mdash;and it must take them&mdash;and it is safer that
it should.</p>

<p>But why must other children have measles? And if they have,
why must yours have them too?</p>

<p>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, <i>are laws</i>, 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?</p>



<hr style="width: 65%;" />
<h2><a name="III_PETTY_MANAGEMENT" id="III_PETTY_MANAGEMENT"></a>III. PETTY MANAGEMENT.</h2>


<div class="sidenote">Petty
management.</div>

<p>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 <i>there</i>. 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&mdash;that is to say, the patient of the
first will not really be so well cared for, as the patient of the second.</p>

<p>It is as impossible in a book to teach a person in charge of sick
how to <i>manage</i>, as it is to teach her how to nurse. Circumstances
must vary with each different case. But it <i>is</i> 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<a name="Page_21" id="Page_21"></a><span class='pagenum'>[Pg 21]</span>
Monday. Or: At 10 <span class="smcap">p.m.</span> 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.</p>

<p>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&mdash;not to arrange so as that no minute and no hour
shall be for her patient without the essentials of her nursing.</p>

<div class="sidenote">Illustrations of
the want of it.</div>

<p>A very few instances will be sufficient, not as precepts, but
as illustrations.</p>

<div class="sidenote">Strangers
coming into
the sick room.</div>

<p>A strange washerwoman, coming late at night for the "things,"
will burst in by mistake to the patient's sick-room, after he has
fallen into his first 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.</p>

<div class="sidenote">Sick room
airing the
whole house.</div>

<p>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.</p>

<div class="sidenote">Uninhabited
room fouling
the whole
house.</div>

<p>An uninhabited room, a newly painted room,<a name="FNanchor_11_11" id="FNanchor_11_11"></a><a href="#Footnote_11_11" class="fnanchor">[11]</a> an uncleaned
closet or cupboard, may often become a reservoir of foul air for the
whole house, because the person in charge never thinks of arranging
that these places shall be always aired, always cleaned; she merely
opens the window herself "when she goes in."</p>

<div class="sidenote">Delivery and
non-delivery
of letters and
messages.</div>

<p>An agitating letter or message may be delivered, or an important
letter or message <i>not</i> delivered; a visitor whom it was of consequence
to see, may be refused, or one whom it was of still more consequence
<i>not</i> to see may be admitted&mdash;because the person in charge has never
asked herself this question, What is done when I am not there?<a name="FNanchor_12_12" id="FNanchor_12_12"></a><a href="#Footnote_12_12" class="fnanchor">[12]</a></p>

<p>At all events, one may safely say, a nurse cannot be with the
<a name="Page_22" id="Page_22"></a><span class='pagenum'>[Pg 22]</span>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.</p>

<p>Add to this that the <i>attempting</i> this impossibility does more to
increase the poor Patient's hurry and nervousness than anything else.</p>

<div class="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.</div>

<p>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 <i>partial</i> 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.</p>

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

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

<p>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.<a name="FNanchor_13_13" id="FNanchor_13_13"></a><a href="#Footnote_13_13" class="fnanchor">[13]</a></p>

<p>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.</p>

<p>No such thing. You <i>ought</i> 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.</p>

<div class="sidenote">What is the
cause of half
the accidents
which
happen?</div>

<p>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
<a name="Page_23" id="Page_23"></a><span class='pagenum'>[Pg 23]</span>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 "<i>there</i>", 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.</p>

<p>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.<a name="FNanchor_14_14" id="FNanchor_14_14"></a><a href="#Footnote_14_14" class="fnanchor">[14]</a></p>

<p><a name="Page_24" id="Page_24"></a><span class='pagenum'>[Pg 24]</span></p>

<p>But in both, let whoever is in charge keep this simple question in
her head (<i>not</i>, how can I always do this right thing myself, but) how
can I provide for this right thing to be always done?</p>

<p>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 (<i>not</i>, how can I provide against any
more of such absences? which is neither possible nor desirable, but)
how can I provide against any thing wrong arising out of my
absence?</p>

<div class="sidenote">What it is to be "in charge."</div>

<p>How few men, or even women, understand, either in great or in
little things, what it is the being "in charge"&mdash;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 <i>not</i> 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&mdash;not
from any undetected flaw in her new and untried works&mdash;but
from a tap being closed which ought not to have been closed&mdash;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 <i>who</i> 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."</p>

<p>This is the meaning of the word, on a large scale. On a much
smaller scale, it happened, a short time ago, that an insane person
burnt herself slowly and intentionally to death, while in her doctor's
charge and almost in 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.</p>

<p>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.)"</p><p><a name="Page_25" id="Page_25"></a><span class='pagenum'>[Pg 25]</span></p>

<p>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&mdash;<i>i.e.</i> to
obey intelligently, which is the real meaning of all discipline.</p>

<p>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, &amp;c., but themselves.
It seems to me that the pride is rather in carrying on a
system, in keeping stores, closets, books, accounts, &amp;c., so that any
body can understand and carry them on&mdash;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.</p>

<div class="sidenote">Why hired
nurses give so
much trouble.</div>

<div class="blockquot"><p><span class="smcap">Note</span>.&mdash;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&mdash;things with a little management
quite compatible, and indeed only attainable together. It is certainly not
for the nurse to "order about" the servants.</p></div>



<hr style="width: 65%;" />
<h2><a name="IV_NOISE" id="IV_NOISE"></a>IV. NOISE.</h2>


<div class="sidenote">Unnecessary
noise.</div>

<p>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, <i>e.g.</i>, 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.</p>

<p>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&mdash;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.</p>

<div class="sidenote">Never let a
patient be
waked out of
his first sleep.</div>

<p>Never to allow a patient to be waked, intentionally or accidentally,
is a <i>sine qu&acirc; non</i> 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
<a name="Page_26" id="Page_26"></a><span class='pagenum'>[Pg 26]</span>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.</p>

<div class="sidenote">Noise which
excites expectation.</div>
<p>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&mdash;and this makes
matters worse&mdash;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.<span class="sidenote">Whispered
conversation
in the room</span> 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.&mdash;Such unnecessary noise has undoubtedly induced
or aggravated delirium in many cases. I have known such&mdash;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.</p>

<div class="sidenote">Or just outside
the door.</div>

<p>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.</p>

<div class="sidenote">Noise of
female dress.</div>

<p>It is, I think, alarming, peculiarly at this time, when the female
ink-bottles are perpetually impressing upon us "woman's" "parti<a name="Page_27" id="Page_27"></a><span class='pagenum'>[Pg 27]</span>cular
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&mdash;only a man can cross
the floor of a sick-room without shaking it! What is become of
woman's light step?&mdash;the firm, light, quick step we have been
asking for?</p>

<p>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.</p>

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

<div class="sidenote">Patient's repulsion
to nurses who
rustle.</div>

<p>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.</p>

<p>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.</p>

<p>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.</p>

<p>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.<a name="FNanchor_15_15" id="FNanchor_15_15"></a><a href="#Footnote_15_15" class="fnanchor">[15]</a></p>

<p>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.</p>

<p>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&mdash;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 name="Page_28" id="Page_28"></a><span class='pagenum'>[Pg 28]</span>a patient passes a bad night, time after time, rather than remind
his nurse every night of all the things she has forgotten.</p>

<p>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.</p>

<div class="sidenote">Hurry peculiarly
hurtful
to sick.</div>

<p>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,&mdash;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.</p>

<div class="sidenote">How to visit
the sick and
not hurt them.</div>

<p>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.</p>

<p>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&mdash;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.</p>

<p>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.</p>

<p>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.</p>

<div class="sidenote">These things
not fancy.</div>

<p>These things are not fancy. If we consider that, with sick as
with well, every thought decomposes some nervous matter,&mdash;that
decomposition as well as re-composition of nervous matter is always
going on, and more quickly with the sick than with the well,&mdash;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,&mdash;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.</p>

<div class="sidenote">Interruption
damaging to sick.</div>

<p>If the invalid is forced, by his avocations, to continue occupations
<a name="Page_29" id="Page_29"></a><span class='pagenum'>[Pg 29]</span>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.</p>

<div class="sidenote">And to well.</div>

<p>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.</p>

<div class="sidenote">Keeping a
patient
standing.</div>

<p>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.<a name="FNanchor_16_16" id="FNanchor_16_16"></a><a href="#Footnote_16_16" class="fnanchor">[16]</a></p>

<div class="sidenote">Patients dread
surprise.</div>

<p>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
<a name="Page_30" id="Page_30"></a><span class='pagenum'>[Pg 30]</span>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.</p>

<p>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.</p>

<p>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 <i>after</i> 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.</p>

<div class="sidenote">Effects of over-exertion
on
sick.</div>

<p>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."<a name="FNanchor_17_17" id="FNanchor_17_17"></a><a href="#Footnote_17_17" class="fnanchor">[17]</a></p>

<p>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.</p>

<div class="sidenote">Difference
between real
and fancy
patients.</div>

<p>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.</p>
<p><a name="Page_31" id="Page_31"></a><span class='pagenum'>[Pg 31]</span></p>

<p>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.</p>

<div class="sidenote">Conciseness
necessary with
Sick.</div>

<p>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.</p>

<div class="sidenote">Irresolution
most painful
to them.</div>

<p>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.</p>

<p>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&mdash;either loitering or hurrying.</p>

<div class="sidenote">What a patient
must not have
to see to.</div>

<p>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&mdash;however
valuable and handy her services may otherwise be to him,
and however incapable he may be of rendering them to himself.</p>

<div class="sidenote">Reading
aloud.</div>

<p>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
<a name="Page_32" id="Page_32"></a><span class='pagenum'>[Pg 32]</span>brought on delirium. I speak with great diffidence; because there
is an almost universal impression that it is <i>sparing</i> the sick to read
aloud to them. But two things are certain:&mdash;</p>

<div class="sidenote">Read aloud
slowly,
distinctly, and
steadily to the
sick.</div>

<p>(1.) If there is some matter which <i>must</i> 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."<a name="FNanchor_18_18" id="FNanchor_18_18"></a><a href="#Footnote_18_18" class="fnanchor">[18]</a> 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&mdash;rather monotonous, but not sing song&mdash;rather
loud, but not noisy&mdash;and, above all, not too long. Be very
sure of what your patient can bear.</p>

<div class="sidenote">Never read
aloud by fits
and starts to
the sick.</div>

<p>(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 <i>do</i> 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&mdash;although
very often the read<i>ee</i> is too amiable to say how much it
disturbs him.</p>

<div class="sidenote">People
overhead.</div>

<p>One thing more:&mdash;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
<a name="Page_33" id="Page_33"></a><span class='pagenum'>[Pg 33]</span>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 <i>see</i> 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.</p>

<div class="sidenote">Music.</div>

<div class="blockquot"><p><span class="smcap">Note</span>.&mdash;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&mdash;while the piano-forte, with such instruments as have
<i>no</i> 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 pi&egrave; d'un
salice," on the most ordinary grinding organ will sensibly soothe them&mdash;and this
quite independent of association.</p></div>



<hr style="width: 65%;" />
<h2><a name="V_VARIETY" id="V_VARIETY"></a>V. VARIETY.</h2>


<div class="sidenote">Variety a
means of
recovery.</div>

<p>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.</p>

<p>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.</p>

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

<div class="sidenote">Colour and
form means of
recovery.</div>

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

<p>Such cravings are usually called the "fancies" of patients. And
often doubtless patients have "fancies," as, <i>e.g.</i> 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.</p>

<p>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
<a name="Page_34" id="Page_34"></a><span class='pagenum'>[Pg 34]</span>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.</p>

<div class="sidenote">This is no
fancy.</div>

<p>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.</p>

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

<p>But it must be <i>slow</i> variety, <i>e.g.</i>, 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.</p>

<div class="sidenote">Flowers.</div>

<p>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, <i>e.g.</i>, lilies, the smell
of which is said to depress the nervous system. These are easily
known by the smell, and can be avoided.</p>

<div class="sidenote">Effect of body
on mind.</div>

<p>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, &amp;c., &amp;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;<a name="FNanchor_19_19" id="FNanchor_19_19"></a><a href="#Footnote_19_19" class="fnanchor">[19]</a> 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.</p>

<p>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
<a name="Page_35" id="Page_35"></a><span class='pagenum'>[Pg 35]</span>as the fixed posture is one of the main sufferings of the broken
limb.</p>

<div class="sidenote">Help the sick
to vary their
thoughts.</div>

<p>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.<a name="FNanchor_20_20" id="FNanchor_20_20"></a><a href="#Footnote_20_20" class="fnanchor">[20]</a></p>

<p>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," &amp;c.
Believe me, almost <i>any</i> 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.</p>

<p>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.</p>

<div class="sidenote">Supply to the
sick the defect
of manual
labour.</div>

<p>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,<a name="FNanchor_21_21" id="FNanchor_21_21"></a><a href="#Footnote_21_21" class="fnanchor">[21]</a> 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.</p>

<p>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&mdash;of the degree to which the deprivation of manual
<a name="Page_36" id="Page_36"></a><span class='pagenum'>[Pg 36]</span>employment increases the peculiar irritability from which many sick
suffer.</p>

<p>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 <i>are</i> 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.</p>

<p>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.</p>



<hr style="width: 65%;" />
<h2><a name="VI_TAKING_FOOD" id="VI_TAKING_FOOD"></a>VI. TAKING FOOD.</h2>


<div class="sidenote">Want of attention
to hours
of taking food.</div>

<p>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.</p>

<p>For instance, to the large majority of very weak patients it is
quite impossible to take any solid food before 11 <span class="smcap">a.m.</span>, 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.</p>

<p>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.</p>

<p>I am bound to say, that I think more patients are lost by want of
care and ingenuity in these momentous minuti&aelig; in private nursing
than in public hospitals. And I think there is more of the <i>entente
cordiale</i> 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.</p>

<div class="sidenote">Life often
hangs upon
minutes in
taking food.</div>

<p>If we did but know the consequences which may ensue, in very
weak patients, from ten minutes' fasting or repletion, (I call it repletion
<a name="Page_37" id="Page_37"></a><span class='pagenum'>[Pg 37]</span>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&mdash;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.</p>

<p>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.</p>

<div class="sidenote">Patients often
starved to
death in
chronic cases.</div>

<p>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&mdash;all this, which requires observation,
ingenuity, and perseverance (and these really constitute the good
Nurse), might save more lives than we wot of.</p>

<div class="sidenote">Food never to
be left by the
patient's side.</div>

<p>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.</p>

<p>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 &mdash; o'clock and &mdash; 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.</p>

<div class="sidenote">Patient had
better not see
more food than
his own.</div>

<p>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.</p>

<p>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
<a name="Page_38" id="Page_38"></a><span class='pagenum'>[Pg 38]</span>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.</p>

<p>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.</p>

<p>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.</p>

<p>When a person is compelled, by the pressure of occupation, to
continue his business while sick, it ought to be a rule <span class="smcap">without any
exception whatever</span>, 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.</p>

<p>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.</p>

<div class="sidenote">You cannot be
too careful as
to quality in
sick diet.</div>

<p>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.</p>

<p>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,&mdash;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
<a name="Page_39" id="Page_39"></a><span class='pagenum'>[Pg 39]</span>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.</p>

<div class="sidenote">Nurse must
have some rule
of thought
about her
patients diet.</div>

<p>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.<a name="FNanchor_22_22" id="FNanchor_22_22"></a><a href="#Footnote_22_22" class="fnanchor">[22]</a> 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."</p>

<div class="sidenote">Keep your
patient's cup
dry underneath.</div>

<p>One very minute caution,&mdash;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.</p>




<hr style="width: 65%;" />
<h2><a name="VII_WHAT_FOOD" id="VII_WHAT_FOOD"></a>VII. WHAT FOOD?</h2>


<div class="sidenote">Common
errors in diet.</div>

<p>I will mention one or two of the most common errors among
women in charge of sick respecting sick diet. <span class="sidenote">Beef tea.</span>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;&mdash;nevertheless
there is a certain reparative quality in it, we do not know
what, as there is in tea;&mdash;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,&mdash;whereas
it is not at all so.<span class="sidenote">Eggs.</span> Also, it is seldom noticed with how many
<a name="Page_40" id="Page_40"></a><span class='pagenum'>[Pg 40]</span>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.<span class="sidenote">Meat without
vegetables.</span> 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.
<span class="sidenote">Arrowroot.</span>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.</p>

<div class="sidenote">Milk, butter,
cream, &amp;c.</div>

<p>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 arrow root, 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.<a name="FNanchor_23_23" id="FNanchor_23_23"></a><a href="#Footnote_23_23" class="fnanchor">[23]</a></p>

<p>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;
diarrh&#339;a 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
<a name="Page_41" id="Page_41"></a><span class='pagenum'>[Pg 41]</span>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.</p>

<div class="sidenote">Sweet things.</div>

<p>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,&mdash;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&mdash;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,&mdash;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,&mdash;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.</p>

<div class="sidenote">Jelly.</div>

<p>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 <sup style="font-size: 75%;">1</sup><span style="font-size: 75%;">/</span><sub style="font-size: 75%;">8</sub> 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 diarrh&#339;a,&mdash;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.</p>

<p>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.</p>

<div class="sidenote">Beef tea.</div>

<p>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 &frac14; oz. of anything but water,"&mdash;the
result is so striking that he asks what is its mode of action? "Not
simply nutrient&mdash;&frac14; 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."</p>

<p>It has been observed that a small quantity of beef tea, added to
<a name="Page_42" id="Page_42"></a><span class='pagenum'>[Pg 42]</span>other articles of nutrition augments their power out of all proportion
to the additional amount of solid matter.</p>

<p>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.</p>

<div class="sidenote">Observation,
not chemistry,
must decide
sick diet.</div>

<p>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 bed-side. 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.</p>

<p>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 <i>assimilate</i> 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.</p>

<div class="sidenote">Home-made
bread.</div>

<p>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.</p>

<div class="sidenote">Sound observation
has
scarcely yet
been brought
to bear on sick
diet.</div>

<p>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&mdash;perhaps the most
important thing to be provided for him after the air he is to breathe.</p>

<p>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
<a name="Page_43" id="Page_43"></a><span class='pagenum'>[Pg 43]</span>air, is to take care to observe the effect of his food, and report it to
the medical attendant.</p>

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

<div class="sidenote">Tea and coffee.</div>

<p>A great deal too much against tea<a name="FNanchor_24_24" id="FNanchor_24_24"></a><a href="#Footnote_24_24" class="fnanchor">[24]</a> 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
<a name="Page_44" id="Page_44"></a><span class='pagenum'>[Pg 44]</span>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 <i>a great deal</i> 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.</p>

<p>Lehmann, 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," and Dr. Christison
adds that tea has the same property. Now this is actual experiment.
Lehmann 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.<a name="FNanchor_25_25" id="FNanchor_25_25"></a><a href="#Footnote_25_25" class="fnanchor">[25]</a></p>

<div class="sidenote">Cocoa.</div>

<p>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 chesnuts instead of tea.</p>

<div class="sidenote">Bulk.</div>

<p>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, &amp;c. You have not increased the
nourishment, you have not increased the renovating power of these
articles, by increasing their bulk,&mdash;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.</p>
<p><a name="Page_45" id="Page_45"></a><span class='pagenum'>[Pg 45]</span></p>



<hr style="width: 65%;" />
<h2><a name="VIII_BED_AND_BEDDING" id="VIII_BED_AND_BEDDING"></a>VIII. BED AND BEDDING.</h2>


<div class="sidenote">Feverishness
a symptom of
bedding.</div>

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

<p>Feverishness is generally supposed to be a symptom of fever&mdash;in
nine cases out of ten it is a symptom of bedding.<a name="FNanchor_26_26" id="FNanchor_26_26"></a><a href="#Footnote_26_26" class="fnanchor">[26]</a> The patient
has had re-introduced into the body the emanations from himself
which day after day and week after week saturate his unaired bedding.
How can it be otherwise? Look at the ordinary bed in which
a patient lies.</p>

<div class="sidenote">Uncleanliness
of ordinary
bedding.</div>

<p>If I were looking out for an example in order to show what <i>not</i>
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&mdash;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,<a name="FNanchor_27_27" id="FNanchor_27_27"></a><a href="#Footnote_27_27" class="fnanchor">[27]</a> and this from the time the mattresses are put
under him till the time they are picked to pieces, if this is ever done.</p>

<div class="sidenote">Air your dirty
sheets, not
only your
clean ones.</div>

<p>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&mdash;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&mdash;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?</p>

<p>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
<a name="Page_46" id="Page_46"></a><span class='pagenum'>[Pg 46]</span>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 into it his own damp? Has it not had a single chance to be
aired? No, not one. "It has been slept in every night."</p>

<div class="sidenote">Iron spring
bedstead the
best.</div>

<p>The only way of really nursing a real patient is to have an <i>iron</i>
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&frac12; feet wide.<span class="sidenote">Comfort and
cleanliness of
<i>two</i> beds.</span> If the patient
be entirely confined to his bed, there should be <i>two</i> such bedsteads;
each bed to be "made" with mattress, sheets, blankets, &amp;c., complete&mdash;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&mdash;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.</p>

<div class="sidenote">Bed not to be
too wide.</div>

<p>There is a prejudice in favour of a wide bed&mdash;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 the bed, and to reach easily every
part of the patient without stretching&mdash;a thing impossible if the bed
be either too wide or too high.</p>

<div class="sidenote">Bed not to be
too high.</div>

<p>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.</p>

<p>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
<a name="Page_47" id="Page_47"></a><span class='pagenum'>[Pg 47]</span>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.</p>

<div class="sidenote">Nor in a dark
place.</div>

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

<div class="sidenote">Nor a four
poster with
curtains.</div>

<p>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.</p>

<div class="sidenote">Scrofula often
a result of disposition
of
bedclothes.</div>

<p>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.</p>

<div class="sidenote">Bed sores.</div>

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

<div class="sidenote">Heavy and impervious
bedclothes.</div>

<p>Never use anything but light Witney 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.</p>

<div class="blockquot"><p><span class="smcap">Note.</span>&mdash;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 <i>drag</i> of the long limbs
upon the waist. But the object is to support, with the pillows, the back <i>below</i>
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.</p></div>



<hr style="width: 65%;" />
<h2><a name="IX_LIGHT" id="IX_LIGHT"></a>IX. LIGHT.</h2>


<div class="sidenote">Light essential
to both health
and recovery.</div>

<p>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;
<a name="Page_48" id="Page_48"></a><span class='pagenum'>[Pg 48]</span>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>i.e.</i> 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.</p>

<div class="sidenote">Aspect, view
and sunlight
matters of first
importance
to the sick.</div>

<p>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 <i>bed</i>-rooms
and <i>sick</i>-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&mdash;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 sun-light from the moment he rises till
the moment he sets.</p>

<p>Another great difference between the <i>bed</i>-room and the <i>sick</i>-room
is, that the <i>sleeper</i> 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 <i>sick</i> man has not, because all day he has been<a name="Page_49" id="Page_49"></a><span class='pagenum'>[Pg 49]</span>
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.</p>

<p>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.</p>

<p>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.</p>

<div class="sidenote">Without sunlight,
we degenerate
body and mind</div>

<p>One of the greatest observers of human things (not physiological),
says, in another language, "Where there is sun there is thought."
All physiology goes to confirm this. Where is the shady side of
deep valleys, there is cretinism. Where are cellars and the
unsunned sides of narrow streets, there is the degeneracy and weakliness
of the human race&mdash;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.</p>

<div class="sidenote">Almost all
patients lie
with their
faces to the
light.</div>

<p>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
faces turned to the light; a patient will even complain that it gives
him pain "lying on that side." "Then why <i>do</i> you lie on that
side?" He does not know,&mdash;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 patients' faces from
the light. Yes, but nature is stronger than fashionable physicians, and
depend upon it she turns the faces back and <i>towards</i> 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.</p>



<hr style="width: 65%;" />
<h2><a name="X_CLEANLINESS_OF_ROOMS_AND_WALLS" id="X_CLEANLINESS_OF_ROOMS_AND_WALLS"></a>X. CLEANLINESS OF ROOMS AND WALLS.</h2>


<div class="sidenote">Cleanliness of
carpets and
furniture.</div>

<p>It cannot be necessary to tell a nurse that she should be clean,
or that she should keep her patient clean,&mdash;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 abovementioned
dirty circumstances, no opening of windows could ever keep those
<a name="Page_50" id="Page_50"></a><span class='pagenum'>[Pg 50]</span>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.</p>

<div class="sidenote">Dust never removed
now.</div>

<p>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.<a name="FNanchor_28_28" id="FNanchor_28_28"></a><a href="#Footnote_28_28" class="fnanchor">[28]</a> Flapping
by way of cleaning is only admissible in the case of pictures, or
anything made of paper. The only way I know to <i>remove</i> 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.</p>

<div class="sidenote">Floors.</div>

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

<p>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.</p>

<div class="sidenote">Papered,
plastered, oil-painted
walls.</div>

<p>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
<a name="Page_51" id="Page_51"></a><span class='pagenum'>[Pg 51]</span>good deal of the danger. But the ordinary bed-room paper is all
that it ought <i>not</i> to be.<a name="FNanchor_29_29" id="FNanchor_29_29"></a><a href="#Footnote_29_29" class="fnanchor">[29]</a></p>

<p>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.</p>

<p>The best wall now extant is oil paint. From this you can wash
the animal exuvi&aelig;.<a name="FNanchor_30_30" id="FNanchor_30_30"></a><a href="#Footnote_30_30" class="fnanchor">[30]</a></p>

<p>These are what make a room musty.</p>

<div class="sidenote">Best kind of
wall for a
sick-room.</div>

<p>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.</p>

<p>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.</p>

<p>Want of cleanliness, then, in rooms and wards, which you have
to guard against, may arise in three ways.</p>

<div class="sidenote">Dirty air from
without.</div>

<p>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.</p>

<div class="sidenote">Best kind of
wall for a
house.</div>

<p>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 <i>walling</i> would stand next to paving
in improving the health of towns.</p>

<div class="sidenote">Dirty air from
within.</div>

<p>2. Dirty air coming from within, from dust, which you often
displace, but never remove. And this recalls what ought to be a
<i>sine qu&acirc; non</i>. 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 <i>degradation</i>, as it is called, taking
place from everything except polished or glazed articles&mdash;<i>E.g.</i>, 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.</p>
<p><a name="Page_52" id="Page_52"></a><span class='pagenum'>[Pg 52]</span></p>

<p>Again, the fire fills the room with coal-dust.</p>

<div class="sidenote">Dirty air from
the carpet.</div>

<p>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.</p>

<div class="sidenote">Remedies.</div>

<p>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.</p>

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

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

<p>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.</p>

<p>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.</p>

<p>"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&mdash;contemptible, if in regard to herself; culpable, if in
regard to her sick.</p>



<hr style="width: 65%;" />
<h2><a name="XI_PERSONAL_CLEANLINESS" id="XI_PERSONAL_CLEANLINESS"></a>XI. PERSONAL CLEANLINESS.</h2>


<div class="sidenote">Poisoning by
the skin.</div>

<p>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
<a name="Page_53" id="Page_53"></a><span class='pagenum'>[Pg 53]</span>should keep this fact constantly in mind,&mdash;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&mdash;only
it is slower in its operation.</p>

<div class="sidenote">Ventilation
and skin-cleanliness
equally
essential.</div>

<p>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.</p>

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

<p>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.</p>

<p>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.</p>

<p>The various ways of washing the sick need not here be specified,&mdash;the
less so as the doctors ought to say which is to be used.</p>

<p>In several forms of diarrh&#339;a, dysentery, &amp;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.</p>

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

<p>One word as to cleanliness merely as cleanliness.</p>

<div class="sidenote">Steaming and
rubbing the
skin.</div>

<p>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,&mdash;if a little spirit be added to it it will be more effectual,&mdash;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
<a name="Page_54" id="Page_54"></a><span class='pagenum'>[Pg 54]</span>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.</p>

<p>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.</p>



<hr style="width: 65%;" />
<h2><a name="XII_CHATTERING_HOPES_AND_ADVICES" id="XII_CHATTERING_HOPES_AND_ADVICES"></a>XII. CHATTERING HOPES AND ADVICES.</h2>


<div class="sidenote">Advising the
sick.</div>

<p>The sick man to his advisers.</p>

<p>"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&mdash;to
take every kind of exercise by every kind of cart, carriage&mdash;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 <i>best</i> 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 <i>must</i> perforce say, in sheer self-defence, like Rosalind,
"I could not do with all."</p>

<div class="sidenote">Chattering
hopes the bane
of the sick.</div>

<p>"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.</p>

<p>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.</p><p><a name="Page_55" id="Page_55"></a><span class='pagenum'>[Pg 55]</span></p>

<p>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, &amp;c.; and certainly after much more
observation than the friend can possibly have had.</p>

<p>Supposing the patient to be possessed of common sense,&mdash;how
can the "favourable" opinion, if it is to be called an opinion at all,
of the casual visitor "cheer" him,&mdash;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?</p>

<div class="sidenote">Patient does
not want to
talk of himself.</div>

<p>The fact is, that the patient<a name="FNanchor_31_31" id="FNanchor_31_31"></a><a href="#Footnote_31_31" class="fnanchor">[31]</a> 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,&mdash;in what respect
he is worse,&mdash;what symptoms exist that they know nothing of,&mdash;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.</p>

<div class="sidenote">Absurd consolations
put
forth for the
benefit of the
sick.</div>

<p>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
<a name="Page_56" id="Page_56"></a><span class='pagenum'>[Pg 56]</span>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.</p>

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

<p>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.</p>

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

<p>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&mdash;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.</p>

<p>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&mdash;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.</p>

<div class="sidenote">Wonderful presumption
of
the advisers of
the sick.</div>

<p>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 <i>he</i> were the medical attendant, and if
the patient, because some <i>other</i> friend had come in, because somebody,
anybody, nobody, had recommended something, anything,
nothing, were to disregard <i>his</i> orders, and take that other body's
recommendation? But people never think of this.</p><p><a name="Page_57" id="Page_57"></a><span class='pagenum'>[Pg 57]</span></p>

<div class="sidenote">Advisers the
same now as
two hundred
years ago.</div>

<p>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 <i>viv&acirc; voce</i>, 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!</p>

<p>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.</p>

<div class="sidenote">Mockery of
the advice
given to sick.</div>

<p>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, <i>not</i> 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.</p>

<p>To nurses I say&mdash;these are the visitors who do your patient
harm. When you hear him told:&mdash;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 the sense of duty, and is flying
in the face of Providence;&mdash;then know that your patient is receiving
all the injury that he can receive from a visitor.</p>

<p>How little the real sufferings of illness are known or understood.
How little does any one in good health fancy him or even <i>her</i>self into
the life of a sick person.</p>

<div class="sidenote">Means of
giving pleasure
to the
sick.</div>

<p>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
<a name="Page_58" id="Page_58"></a><span class='pagenum'>[Pg 58]</span>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."</p>

<p>I do not say, don't tell him your anxieties&mdash;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.</p>

<p>A sick person does so enjoy hearing good news:&mdash;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.</p>

<p>A sick person also intensely enjoys hearing of any <i>material</i> 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,&mdash;it is like a day's health to him.<a name="FNanchor_32_32" id="FNanchor_32_32"></a><a href="#Footnote_32_32" class="fnanchor">[32]</a></p>

<p>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.</p>

<p>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.</p>

<p>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 every body, no matter whom it is, they see.</p>

<p>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.</p>

<p>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<a name="Page_59" id="Page_59"></a><span class='pagenum'>[Pg 59]</span>
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 <i>has</i> done this, or if nothing
<i>can</i> 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.</p>

<p>It has been very justly said that the sick are like children in this,
that there is no <i>proportion</i> in events to them. Now it is your business
as their visitor to restore this right proportion for them&mdash;to
shew 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, &amp;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.</p>

<div class="sidenote">Two new
classes of
patients peculiar
to this
generation.</div>

<div class="blockquot"><p><span class="smcap">Note.</span>&mdash;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"&mdash;or
than the admiration too often bestowed on the latter class for "pluck."</p></div>



<hr style="width: 65%;" />
<h2><a name="XIII_OBSERVATION_OF_THE_SICK" id="XIII_OBSERVATION_OF_THE_SICK"></a>XIII. OBSERVATION OF THE SICK.</h2>


<div class="sidenote">What is the
use of the
question, Is he
better?</div>

<p>There is no more silly or universal question scarcely asked than
this, "Is he better?" Ask it of the medical attendant, if you please.
But of whom else, if you wish for a real answer to your question,
would you ask it? Certainly not of the casual visitor; certainly
not of the nurse, while the nurse's observation is so little exercised
as it is now. What you want are facts, not opinions&mdash;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?</p>

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

<p>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.</p>

<p>The vagueness and looseness of the information one receives in
answer to that much abused question, "Is he better?" would be
<a name="Page_60" id="Page_60"></a><span class='pagenum'>[Pg 60]</span>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."</p>

<p>I can record but a very few specimens of the answers<a name="FNanchor_33_33" id="FNanchor_33_33"></a><a href="#Footnote_33_33" class="fnanchor">[33]</a> 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&mdash;sometimes from amiability,
often from shyness, oftenest from languor!</p>

<p>"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.</p>

<p>"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.</p>

<p>Another patient who is eating well, recovering steadily, although
slowly, from a fever, but cannot walk or stand, is represented to the
doctor as making no progress at all.</p>
<p><a name="Page_61" id="Page_61"></a><span class='pagenum'>[Pg 61]</span></p>

<div class="sidenote">Leading questions
useless
or misleading.</div>

<p>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&mdash;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 &mdash;&mdash; had? and
at what hours of the night?<a name="FNanchor_34_34" id="FNanchor_34_34"></a><a href="#Footnote_34_34" class="fnanchor">[34]</a> "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, <i>not</i> 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.</p>

<p>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 <i>where</i> the patient is.</p>

<div class="sidenote">Means of
obtaining
inaccurate
information.</div>

<p>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.</p>

<p>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:&mdash;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
<a name="Page_62" id="Page_62"></a><span class='pagenum'>[Pg 62]</span>of the main fact of the disease and condition to which the death
was attributable.</p>

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

<p>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.</p>

<div class="sidenote">As to food
patient takes
or does not
take.</div>

<p>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 <i>same</i> 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.</p>

<p>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,&mdash;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.</p>

<p>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:</p>


<ol><li>Defect in cooking;</li>
<li>Defect in choice of diet;</li>
<li>Defect in choice of hours for taking diet;</li>
<li>Defect of appetite in patient.</li>
</ol>

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

<p>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.</p>

<p>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.</p><p><a name="Page_63" id="Page_63"></a><span class='pagenum'>[Pg 63]</span></p>

<p>Again, I say, what <i>is</i> the nurse or friend there for except to take
note of these things, instead of the patient doing so?<a name="FNanchor_35_35" id="FNanchor_35_35"></a><a href="#Footnote_35_35" class="fnanchor">[35]</a></p>

<div class="sidenote">As to diarrh&#339;a.</div>

<p>Again, the question is sometimes put, Is there diarrh&#339;a? 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 diarrh&#339;a at all, but simply relaxed bowels.</p>

<p>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 <i>not</i> 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.</p>

<p>In the case of infants, <i>everything</i> must depend upon the accurate
observation of the nurse or mother who has to report. And how
seldom is this condition of accuracy fulfilled.</p>

<div class="sidenote">Means of
cultivating
sound and
ready observation.</div>

<p>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:&mdash;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, <i>e.g.</i>, if the father
described 30 objects, the boy did 40, and scarcely ever made a
mistake.</p>

<p>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.</p>

<p>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.</p>

<p>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.</p>
<p><a name="Page_64" id="Page_64"></a><span class='pagenum'>[Pg 64]</span></p>

<p>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 &frac14; pint of beef tea;" instead of saying "B.
has taken nothing all day," or "I gave A. his dinner as usual."</p>

<div class="sidenote">Sound and
ready observation
essential
in a nurse.</div>

<p>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.<a name="FNanchor_36_36" id="FNanchor_36_36"></a><a href="#Footnote_36_36" class="fnanchor">[36]</a> In hospitals
those who cut up the diets give with quite 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
<a name="Page_65" id="Page_65"></a><span class='pagenum'>[Pg 65]</span>has eaten all his diets as usual, when all she ought to have meant is
that she has taken away his diets as usual.</p>

<p>Now what kind of a nurse is this?</p>

<div class="sidenote">Difference of
excitable and
<i>accumulative</i>
temperaments.</div>

<p>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 <i>accumulative</i> 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 <i>accumulative</i>
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&mdash;you never know when the consequences are over. And it
requires your closest observation to know what <i>are</i> the consequences
of what&mdash;for the consequent by no means follows immediately upon
the antecedent&mdash;and coarse observation is utterly at fault.</p>

<div class="sidenote">Superstition
the fruit of
bad observation.</div>

<p>Almost all superstitions are owing to bad observation, to the <i>post
hoc, ergo propter hoc</i>; 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.</p>

<div class="sidenote">Physiognomy
of disease
little shown
by the face.</div>

<p>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
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, &amp;c., &amp;c. It is true that there are
<i>some</i> diseases which are only betrayed at all by something in the
face, <i>e.g.</i>, 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 <i>looks</i> well, or ill, or better or worse.</p>

<p>Wonderful is the way in which people will go upon the slightest
observation, or often upon no observation at all, or upon some <i>saw</i>
which the world's experience, if it had any, would have pronounced
utterly false long ago.</p><p><a name="Page_66" id="Page_66"></a><span class='pagenum'>[Pg 66]</span></p>

<p>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.</p>

<p>There is, unquestionably, a physiognomy of disease. Let the
nurse learn it.</p>

<p>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.</p>

<p>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.</p>

<p>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.</p>

<p>Yet these two faintnesses are perfectly distinguishable, by the
mere countenance of the patient.</p>

<div class="sidenote">Peculiarities
of patients.</div>

<p>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.</p>

<div class="sidenote">Nurse must
observe for
herself increase
of
patient's weakness,
patient
will not tell
her.</div>

<p>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&mdash;and known
too among those&mdash;and <i>chiefly</i> among those&mdash;whom money and
position put in possession of everything which money and position
could give&mdash;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&mdash;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
<a name="Page_67" id="Page_67"></a><span class='pagenum'>[Pg 67]</span>least, than they are now, if we did but <i>observe</i>). No, from the
expected, or to be expected, inevitable, visible, calculable, uninterrupted
increase of weakness, which none need fail to observe.</p>

<div class="sidenote">Accidents
arising from
the nurse's
want of observation.</div>

<p>Again, a patient not usually confined to bed, is compelled by an
attack of diarrh&#339;a, 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.</p>

<div class="sidenote">Is the faculty
of observing
on the decline.</div>

<p>Yet it appears that scarcely any improvement in the faculty
of observing is being made. Vast has been the increase of knowledge
in pathology&mdash;that science which teaches us the final change
produced by disease on the human frame&mdash;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?</p>

<p>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:&mdash;"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 <i>must</i> have
been <i>some</i> 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.</p>

<p>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 <i>right</i> ones.<a name="FNanchor_37_37" id="FNanchor_37_37"></a><a href="#Footnote_37_37" class="fnanchor">[37]</a></p>

<div class="sidenote">Observation
of general
conditions.</div>

<p>A want of the habit of observing conditions and an inveterate
habit of taking averages are each of them often equally misleading.</p>
<p><a name="Page_68" id="Page_68"></a><span class='pagenum'>[Pg 68]</span></p>

<p>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.</p>

<p>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,&mdash;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,
&amp;c., &amp;c., &amp;c.; the verdict is repeated by ignorant people <i>without</i> the
latter clause; or there is no possibility of the conditions of the
latter clause being obtained; and this, the <i>only</i> 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.<a name="FNanchor_38_38" id="FNanchor_38_38"></a><a href="#Footnote_38_38" class="fnanchor">[38]</a></p>
<p><a name="Page_69" id="Page_69"></a><span class='pagenum'>[Pg 69]</span></p>

<p>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.</p>

<p>In Life Insurance and such like societies, were they instead of
having the persons examined by a medical man, to have the houses,
conditions, ways of life, of these persons examined, at how much
truer results would they arrive! W. Smith appears a fine 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.</p>

<div class="sidenote">"Average rate
of mortality"
tells us only
that so many
per cent. will
die. Observation
must tell
us <i>which</i> in the
hundred they
will be who
will die.</div>

<p>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,&mdash;or even on one side of that street, in
such a particular house, or even on one floor of that particular
<a name="Page_70" id="Page_70"></a><span class='pagenum'>[Pg 70]</span>house, will be the excess of mortality, that is, the person will die
who ought not to have died before old age.</p>

<p>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?</p>

<p>Much more precise might be our observations even than this and
much more correct our conclusions.</p>

<p>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?</p>

<p>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."</p>

<div class="sidenote">What observation is for.</div>

<p>In dwelling upon the vital importance of <i>sound</i> 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,&mdash;insist on a confidential nurse being placed with the
patient, or give up the case.</p>

<div class="sidenote">What a confidential nurse should be.</div>

<p>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,
<a name="Page_71" id="Page_71"></a><span class='pagenum'>[Pg 71]</span>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.</p>

<div class="sidenote">Observation is
for practical
purposes.</div>

<p>To return to the question of what observation is for:&mdash;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&mdash;that
is, to the only person who could act in the matter.</p>



<hr style="width: 65%;" />
<h2><a name="CONCLUSION" id="CONCLUSION"></a>CONCLUSION.</h2>


<div class="sidenote">Sanitary
nursing as
essential in
surgical as in
medical cases,
but not to supersede
surgical
nursing.</div>

<p>The whole of the preceding remarks apply even more to children
and to puerperal women than to patients in general. They also
apply to the nursing of surgical, quite as much as to that of medical
cases. Indeed, if it be possible, cases of external injury require such
care even more than sick. In surgical wards, one duty of every nurse
certainly is <i>prevention</i>. Fever, or hospital gangrene, or py&aelig;mia, 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 f&#339;tid 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.</p>

<p>Nevertheless let no one think that because <i>sanitary</i> 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>i.e.</i>, practical manual nursing, than, perhaps, any one in Europe,
<a name="Page_72" id="Page_72"></a><span class='pagenum'>[Pg 72]</span>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, &amp;c., who have this surgical nursing to perfection, the
converse is comparatively rare.</p>

<div class="sidenote">Children:
their greater
susceptibility
to the same
things.</div>

<p>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.</p>

<p>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.</p>

<p>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 <i>accident</i>; it is not a necessary, inevitable result of any
disease from which it is suffering."</p>

<p>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 <i>sudden</i> death is
comparatively rare in middle age;) and the sentence is almost equally
true for all ages.</p>

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

<p>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.</p>

<p>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
<a name="Page_73" id="Page_73"></a><span class='pagenum'>[Pg 73]</span>other condition, disturbs the respiratory process, and tends to produce
"accidental" death in disease.</p>

<p>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.</p>

<p>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.</p>

<p>"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.</p>

<p>"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:&mdash;"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.</p>

<p>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 "<i>sudden</i> stand-still" here mentioned, and from the
same causes.</p>

<div class="sidenote">Summary.</div>

<p>To sum up:&mdash;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, <i>plus</i> a caution,
comprises the whole argument for the art of nursing.</p>

<div class="sidenote">Reckless amateur
physicking
by women.
Real knowledge
of the
laws of health
alone can
check this.</div>

<p>(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,&mdash;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.<a name="FNanchor_39_39" id="FNanchor_39_39"></a><a href="#Footnote_39_39" class="fnanchor">[39]</a> But this is just what the really experienced and
<a name="Page_74" id="Page_74"></a><span class='pagenum'>[Pg 74]</span>observing nurse does <i>not</i> 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,&mdash;helps to them
instead of hindrances. Such education in women would indeed
diminish the doctor's work&mdash;but no one really believes that
doctors wish that there should be more illness, in order to have more
work.</p>

<div class="sidenote">What pathology
teaches.
What observation
alone
teaches. What
medicine does.
What nature
alone does.</div>

<p>(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,"&mdash;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
<a name="Page_75" id="Page_75"></a><span class='pagenum'>[Pg 75]</span>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 <i>sine qu&acirc; non</i>, 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.</p>

<p>Now for the caution:&mdash;</p>

<p>(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.</p>

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

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

<p>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.</p>

<p>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.</p>

<p>The everyday management of a large ward, let alone of a hospital&mdash;the
knowing what are the laws of life and death for men, and
what the laws of health for wards&mdash;(and wards are healthy or unhealthy,
mainly according to the knowledge or ignorance of the
nurse)&mdash;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.</p>

<p>And terrible is the injury which has followed to the sick from
such wild notions!</p>

<p>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 <i>Postulant</i> who appeared to have no better "vocation" or
reasons for offering herself than these.</p>

<p>It is true <i>we</i> 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
<a name="Page_76" id="Page_76"></a><span class='pagenum'>[Pg 76]</span>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 M&egrave;re Ang&eacute;lique
of Port Royal, what would our own Mrs. Fry have said to this?</p>

<div class="blockquot"><p><span class="smcap">Note.</span>&mdash;I would earnestly ask my sisters to keep clear of both the jargons
now current everywhere (for they <i>are</i> 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 <i>is</i> 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,
<i>whatever</i> 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 <i>just</i> 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.</p>

<p>You do not want the effect of your good things to be, "How wonderful for a
<i>woman</i>!" 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.</p>

<p>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.</p>

<p>Oh, leave these jargons, and go your way straight to God's work, in simplicity
and singleness of heart.</p></div><p><a name="Page_77" id="Page_77"></a><span class='pagenum'>[Pg 77]</span></p>


<hr style="width: 65%;" />
<p><a name="Page_78" id="Page_78"></a><span class='pagenum'>[Pg 78]</span></p>
<h2><a name="APPENDIX" id="APPENDIX"></a>APPENDIX.</h2>

<p>[Transcriber's Note: The tables below have been rotated through 90&deg; for easier display.]</p>

<h3><span class="smcap">Table A.</span></h3>

<h4>GREAT BRITAIN.<br />
<br />
AGES.</h4>

<div class='center'>
<table border="0" cellpadding="4" cellspacing="0" summary="">
<tr><td align='right'><span class="smcap">Nurses.</span></td><td align='center'>Nurse</td><td align='center'>Nurse</td></tr>
<tr><td align='right'></td><td align='center'>(not Domestic Servant)</td><td align='center'>(Domestic Servant)</td></tr>
<tr><td align='right'>All Ages</td><td align='center'>25,466</td><td align='center'>39,139</td></tr>
<tr><td align='right'>Under 5 Years.</td><td align='center'>...</td><td align='center'>...</td></tr>
<tr><td align='right'>5&mdash;</td><td align='center'>...</td><td align='center'>508</td></tr>
<tr><td align='right'>10&mdash;</td><td align='center'>...</td><td align='center'>7,259</td></tr>
<tr><td align='right'>15&mdash;</td><td align='center'>...</td><td align='center'>10,355</td></tr>
<tr><td align='right'>20&mdash;</td><td align='center'>624</td><td align='center'>6,537</td></tr>
<tr><td align='right'>25&mdash;</td><td align='center'>817</td><td align='center'>4,174</td></tr>
<tr><td align='right'>30&mdash;</td><td align='center'>1,118</td><td align='center'>2,495</td></tr>
<tr><td align='right'>35&mdash;</td><td align='center'>1,359</td><td align='center'>1,681</td></tr>
<tr><td align='right'>40&mdash;</td><td align='center'>2,223</td><td align='center'>1,468</td></tr>
<tr><td align='right'>45&mdash;</td><td align='center'>2,748</td><td align='center'>1,206</td></tr>
<tr><td align='right'>50&mdash;</td><td align='center'>3,982</td><td align='center'>1,196</td></tr>
<tr><td align='right'>55&mdash;</td><td align='center'>3,456</td><td align='center'>833</td></tr>
<tr><td align='right'>60&mdash;</td><td align='center'>3,825</td><td align='center'>712</td></tr>
<tr><td align='right'>65&mdash;</td><td align='center'>2,542</td><td align='center'>369</td></tr>
<tr><td align='right'>70&mdash;</td><td align='center'>1,568</td><td align='center'>204</td></tr>
<tr><td align='right'>75&mdash;</td><td align='center'>746</td><td align='center'>101</td></tr>
<tr><td align='right'>80&mdash;</td><td align='center'>311</td><td align='center'>25</td></tr>
<tr><td align='right'>85 and Upwards</td><td align='center'>147</td><td align='center'>16</td></tr>
</table></div>



<h3><span class="smcap">Table B.</span></h3>

<h4>AGED 20 YEARS OF AGE, AND UPWARDS.</h4>


<div class='center'>
<table border="0" cellpadding="4" cellspacing="0" summary="">
<tr><td align='right'></td><td align='center'>Nurse</td><td align='center'>Nurse</td></tr>
<tr><td align='right'></td><td align='center'>(not Domestic Servant)</td><td align='center'>(Domestic Servant)</td></tr>
<tr><td align='left'>Great Britain and Islands in the British Seas.</td><td align='right'>25,466</td><td align='right'>21,017</td></tr>
<tr><td align='left'>England and Wales.</td><td align='right'>23,751</td><td align='right'>18,945</td></tr>
<tr><td align='left'>Scotland.</td><td align='right'>1,543</td><td align='right'>1,922</td></tr>
<tr><td align='left'>Islands in the British Seas.</td><td align='right'>172</td><td align='right'>150</td></tr>
<tr><td align='left'>1st Division. London.</td><td align='right'>7,807</td><td align='right'>5,061</td></tr>
<tr><td align='left'>2nd Division. South Eastern.</td><td align='right'>2,878</td><td align='right'>2,514</td></tr>
<tr><td align='left'>3rd Division. South Midland.</td><td align='right'>2,286</td><td align='right'>1,252</td></tr>
<tr><td align='left'>4th Division. Eastern Counties.</td><td align='right'>2,408</td><td align='right'>959</td></tr>
<tr><td align='left'>5th Division. South Western Counties.</td><td align='right'>3,055</td><td align='right'>1,737</td></tr>
<tr><td align='left'>6th Division. West Midland Counties.</td><td align='right'>1,225</td><td align='right'>2,383</td></tr>
<tr><td align='left'>7th Division. North Midland Counties.</td><td align='right'>1,003</td><td align='right'>957</td></tr>
<tr><td align='left'>8th Division. North Western Counties.</td><td align='right'>970</td><td align='right'>2,135</td></tr>
<tr><td align='left'>9th Division. Yorkshire.</td><td align='right'>1,074</td><td align='right'>1,023</td></tr>
<tr><td align='left'>10th Division. Northern Counties.</td><td align='right'>402</td><td align='right'>410</td></tr>
<tr><td align='left'>11th Division. Monmouth and Wales.</td><td align='right'>343</td><td align='right'>614</td></tr>
</table></div>


<p><a name="Page_79" id="Page_79"></a><span class='pagenum'>[Pg 79]</span></p>


<h3><span class="smcap">Note as to the Number of Women employed as
Nurses in Great Britain.</span></h3>


<p>25,466 were returned, at the census of 1851, as nurses by profession,
39,139 nurses in domestic service,<a name="FNanchor_40_40" id="FNanchor_40_40"></a><a href="#Footnote_40_40" class="fnanchor">[40]</a> and 2,822 midwives.
The numbers of different ages are shown in table A, and in table B
their distribution over Great Britain.</p>

<p>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.</p>

<p>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.</p>

<p>Now a nurse means any person in charge of the personal health
of another. And, in the preceding notes, the term <i>nurse</i> 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.</p>

<p>Then there are the school-mistresses 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, &amp;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&mdash;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?</p>
<p><a name="Page_80" id="Page_80"></a><span class='pagenum'>[Pg 80]</span></p>

<hr style="width: 65%;" />

<h4>FOOTNOTES</h4>

<div class="footnote"><p><a name="Footnote_1_1" id="Footnote_1_1"></a><a href="#FNanchor_1_1"><span class="label">[1]</span></a>
</p><p>
<span class="sidenote">Curious deductions
from an
excessive
death rate.</span></p><p>
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:&mdash;"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:&mdash;"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 white-washing;
in one word, defective <i>household</i> 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 a hospital for them.
</p><p>
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 <i>household</i> hygiene is concerned. But who would ever think of
citing the institution of a Women's Hospital as the way to cure this want?
</p><p>
We have it, indeed, upon very high authority that there is some fear lest
hospitals, as they have been <i>hitherto</i>, may not have generally increased, rather
than diminished, the rate of mortality&mdash;especially of child mortality.</p></div>

<div class="footnote"><p><a name="Footnote_2_2" id="Footnote_2_2"></a><a href="#FNanchor_2_2"><span class="label">[2]</span></a>
</p>
<div class="sidenote">Why are uninhabited
rooms
shut up?</div><p>
The common idea as to uninhabited rooms is, that they may safely be left
with doors, windows, shutters, and chimney board, all closed&mdash;hermetically sealed
if possible&mdash;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&mdash;But when ought the windows to be
opened? The answer is&mdash;When ought they to be shut?</p></div>

<div class="footnote"><p><a name="Footnote_3_3" id="Footnote_3_3"></a><a href="#FNanchor_3_3"><span class="label">[3]</span></a> It is very desirable that the windows in a sick room should be such as
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&mdash;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 [Transcriber's Note: Word, possibly "it" missing in original.] is true.</p></div>

<div class="footnote"><p><a name="Footnote_4_4" id="Footnote_4_4"></a><a href="#FNanchor_4_4"><span class="label">[4]</span></a>
</p><div class="sidenote">An air-test of
essential consequence.</div><p>
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 misdemeanour.
</p><p>
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."
</p><p>
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.</p></div>

<div class="footnote"><p><a name="Footnote_5_5" id="Footnote_5_5"></a><a href="#FNanchor_5_5"><span class="label">[5]</span></a> 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.
</p><p>
But it is often observed that 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 <i>must</i> 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.</p></div>

<div class="footnote"><p><a name="Footnote_6_6" id="Footnote_6_6"></a><a href="#FNanchor_6_6"><span class="label">[6]</span></a>
</p><div class="sidenote">Don't make
your sick-room
into a sewer.</div><p>
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>i.e.</i>, 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 diarrh&#339;a
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 the 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 <i>lid</i>, as well as your
utensil, be always thoroughly rinsed.
</p><p>
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&mdash;the good of their sick first, and second only the consideration
what it was their "place" to do&mdash;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 <i>making</i> of a nurse in them.</p></div>

<div class="footnote"><p><a name="Footnote_7_7" id="Footnote_7_7"></a><a href="#FNanchor_7_7"><span class="label">[7]</span></a>
</p><div class="sidenote">Health of
carriages.</div><p>
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&mdash;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 <i>airing</i> 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.</p></div>

<div class="footnote"><p><a name="Footnote_8_8" id="Footnote_8_8"></a><a href="#FNanchor_8_8"><span class="label">[8]</span></a> 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&mdash;which would
be the case if the carrying out of His laws were <i>not</i> certain. Yet we seem to be
continually expecting that He will work a miracle&mdash;<i>i.e.</i> break His own laws
expressly to relieve us of responsibility.</p></div>

<div class="footnote"><p><a name="Footnote_9_9" id="Footnote_9_9"></a><a href="#FNanchor_9_9"><span class="label">[9]</span></a>
</p><div class="sidenote">Servants'
rooms.</div><p>
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 "<i>mansion</i>,"
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&mdash;but nearly every one of the
neglects enumerated above was there.</p></div>

<div class="footnote"><p><a name="Footnote_10_10" id="Footnote_10_10"></a><a href="#FNanchor_10_10"><span class="label">[10]</span></a>
</p><div class="sidenote">Diseases are
not individuals
arranged in
classes, like
cats and dogs,
but conditions
growing out of
one another.</div><p>
Is it not living in a continual mistake to look upon diseases, as we do now,
as separate entities, which <i>must</i> 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.
</p><p>
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.
</p><p>
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.
</p><p>
Nay, more, I have seen diseases begin, grow up, and pass into one another.
Now, dogs do not pass into cats.
</p><p>
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.
</p><p>
Would it not be far better, truer, and more practical, if we looked upon
disease in this light?
</p><p>
For diseases, as all experience shows, are adjectives, not noun substantives.</p></div>

<div class="footnote"><p><a name="Footnote_11_11" id="Footnote_11_11"></a><a href="#FNanchor_11_11"><span class="label">[11]</span></a>
</p><div class="sidenote">Lingering
smell of paint
a want of care.</div><p>
That excellent paper, the <i>Builder</i>, mentions the lingering of the smell of
paint for a month about a house as a proof of want of ventilation. Certainly&mdash;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?</p></div>

<div class="footnote"><p><a name="Footnote_12_12" id="Footnote_12_12"></a><a href="#FNanchor_12_12"><span class="label">[12]</span></a>
</p><div class="sidenote">Why let your
patient ever
be surprised?</div><p>
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?
</p><p>
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
<i>not</i> "let in," and such a parcel had been wrongly delivered or lost because A
and not B had opened the door!</p></div>

<div class="footnote"><p><a name="Footnote_13_13" id="Footnote_13_13"></a><a href="#FNanchor_13_13"><span class="label">[13]</span></a> There are many physical operations where <i>c&aelig;teris paribus</i> the danger is in
a direct ratio to the time the operation lasts; and <i>c&aelig;teris paribus</i> 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; <i>c&aelig;teris paribus</i>
their capability of bearing such operations depends directly on the quickness,
<i>without hurry</i>, with which they can be got through.</p></div>

<div class="footnote"><p><a name="Footnote_14_14" id="Footnote_14_14"></a><a href="#FNanchor_14_14"><span class="label">[14]</span></a>
</p><div class="sidenote">Petty management
better
understood in
institutions than
in private
houses.</div><p>
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.
</p><div class="sidenote">What institutions are the exception?</div><p>
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 know of fatal accidents, such as suicides
in <i>delirium tremens</i>, 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 <i>delirium
tremens</i>? The fault lies in there being no organized system of attendance.
Were a trustworthy <i>man</i> 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 <i>woman</i> 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.
</p><div class="sidenote">Nursing in Regimental Hospitals.</div><p>
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.
</p><p>
Now, have those who say this, considered that, in order to obey, you must
know <i>how</i> 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.</p></div>

<div class="footnote"><p><a name="Footnote_15_15" id="Footnote_15_15"></a><a href="#FNanchor_15_15"><span class="label">[15]</span></a>
</p><p><span class="sidenote">Burning of the
crinolines.</span>
Fortunate it is if her skirts do not catch fire&mdash;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&mdash;measures
which every chemist knows, such as putting alum into starch, which prevents
starched articles of dress from blazing up.
</p><div class="sidenote">Indecency of
the crinolines.</div><p>
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.</p></div>

<div class="footnote"><p><a name="Footnote_16_16" id="Footnote_16_16"></a><a href="#FNanchor_16_16"><span class="label">[16]</span></a>
</p><div class="sidenote">Never speak to
a patient in
the act of
moving.</div><p>
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, &amp;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.</p></div>

<div class="footnote"><p><a name="Footnote_17_17" id="Footnote_17_17"></a><a href="#FNanchor_17_17"><span class="label">[17]</span></a>
</p><div class="sidenote">Careless observation
of the
results of careless
visits.</div><p>
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."
</p><p>
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. <i>You</i> will have impunity&mdash;the poor patient will <i>not</i>. 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.</p></div>

<div class="footnote"><p><a name="Footnote_18_18" id="Footnote_18_18"></a><a href="#FNanchor_18_18"><span class="label">[18]</span></a>
</p><p>
<span class="sidenote">The sick would
rather be told a
thing than have
it read to them.</span></p><p>
Sick children, if not too shy to speak, will always express this wish. They
invariably prefer a story to be <i>told</i> to them, rather than read to them.</p></div>

<div class="footnote"><p><a name="Footnote_19_19" id="Footnote_19_19"></a><a href="#FNanchor_19_19"><span class="label">[19]</span></a>
</p><p>
<span class="sidenote">Sick suffer to
excess from
mental as well
as bodily pain.</span></p><p>
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.</p></div>

<div class="footnote"><p><a name="Footnote_20_20" id="Footnote_20_20"></a><a href="#FNanchor_20_20"><span class="label">[20]</span></a>
</p><div class="sidenote">Desperate desire
in the
sick to "see
out of window."</div><p>
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&mdash;had
not in his composition a single grain of what is called "enthusiasm for
nature,"&mdash;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 for 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.</p></div>

<div class="footnote"><p><a name="Footnote_21_21" id="Footnote_21_21"></a><a href="#FNanchor_21_21"><span class="label">[21]</span></a>
</p><div class="sidenote">Physical effect
of colour.</div><p>
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, &amp;c.</p></div>

<div class="footnote"><p><a name="Footnote_22_22" id="Footnote_22_22"></a><a href="#FNanchor_22_22"><span class="label">[22]</span></a>
</p><div class="sidenote">Nurse must
have some rule
of time about
the patient's
diet.</div><p>
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 <i>has</i> 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&mdash;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.</p></div>

<div class="footnote"><p><a name="Footnote_23_23" id="Footnote_23_23"></a><a href="#FNanchor_23_23"><span class="label">[23]</span></a>
</p><div class="sidenote">Intelligent
cravings of
particular sick
for particular
articles of
diet.</div><p>
In the diseases produced by bad food, such as scorbutic dysentery and
diarrh&#339;a, 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 of 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.
</p><p>
There is often a marked difference between men and women in this matter
of sick feeding. Women's digestion is generally slower.</p></div>

<div class="footnote"><p><a name="Footnote_24_24" id="Footnote_24_24"></a><a href="#FNanchor_24_24"><span class="label">[24]</span></a> 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 <i>with</i> the hot cup of tea, so
much the better, but not <i>instead</i> 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.
</p><p>
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&mdash;and nothing else.
</p><p>
Let experience, not theory, decide upon this as upon all other things.</p></div>

<div class="footnote"><p><a name="Footnote_25_25" id="Footnote_25_25"></a><a href="#FNanchor_25_25"><span class="label">[25]</span></a> 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, <i>at least</i>. 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.
</p><p>
Again, all laundresses, mistresses of dairy-farms, head nurses (I speak of the
good old sort only&mdash;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.
</p><p>
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.</p></div>

<div class="footnote"><p><a name="Footnote_26_26" id="Footnote_26_26"></a><a href="#FNanchor_26_26"><span class="label">[26]</span></a>
</p><div class="sidenote">Nurses often
do not think
the sick room
any business of
theirs, but
only the sick.</div><p>
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&mdash;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?"</p></div>

<div class="footnote"><p><a name="Footnote_27_27" id="Footnote_27_27"></a><a href="#FNanchor_27_27"><span class="label">[27]</span></a> 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.</p></div>

<div class="footnote"><p><a name="Footnote_28_28" id="Footnote_28_28"></a><a href="#FNanchor_28_28"><span class="label">[28]</span></a>
</p><div class="sidenote">How a room is
<i>dusted</i>.</div><p>
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 "<i>things</i>" 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 <i>other</i> side of the
"things" is therefore now evenly dirtied or dusted. The housemaid then flaps
every thing, or some things, not out of her reach, with a thing called a duster&mdash;the
dust flies up, then re-settles more equally than it lay before the operation.
The room has now been "put to rights."</p></div>

<div class="footnote"><p><a name="Footnote_29_29" id="Footnote_29_29"></a><a href="#FNanchor_29_29"><span class="label">[29]</span></a>
</p><div class="sidenote">Atmosphere in
painted and
papered rooms
quite distinguishable.</div><p>
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, <i>c&aelig;teris paribus</i>.
The latter will always be musty, even with all the windows open.</p></div>

<div class="footnote"><p><a name="Footnote_30_30" id="Footnote_30_30"></a><a href="#FNanchor_30_30"><span class="label">[30]</span></a>
</p><div class="sidenote">How to keep
your wall clean
at the expense
of your clothes.</div><p>
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!</p></div>

<div class="footnote"><p><a name="Footnote_31_31" id="Footnote_31_31"></a><a href="#FNanchor_31_31"><span class="label">[31]</span></a>
</p><div class="sidenote">Absurd statistical
comparisons
made in
common conversation
by
the most sensible
people
for the benefit
of the sick.</div><p>
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 <i>you</i> think <i>I</i> shall recover from consumption,
because somebody knows somebody somewhere who has recovered from
fever.
</p><p>
I have heard a doctor condemned whose patient did not, alas! recover, because
another doctor's patient of a <i>different</i> sex, of a <i>different</i> age, recovered
from a <i>different</i> disease, in a <i>different</i> 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&mdash;in fact, <i>all</i> the conditions essential to the question. It is the
merest <i>gossip</i>.</p></div>

<div class="footnote"><p><a name="Footnote_32_32" id="Footnote_32_32"></a><a href="#FNanchor_32_32"><span class="label">[32]</span></a> 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.</p></div>

<div class="footnote"><p><a name="Footnote_33_33" id="Footnote_33_33"></a><a href="#FNanchor_33_33"><span class="label">[33]</span></a> It is a much more difficult thing to speak the truth than people commonly
imagine. There is the want of observation <i>simple</i>, and the want of observation
<i>compound</i>, 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.
</p><p>
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 <i>not</i> observed nor remember
that they have forgotten.
</p><p>
Courts of justice seem to think that any body 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."
</p><p>
"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.
</p><p>
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.
</p><p>
I have heard thirteen persons "concur" in declaring that a fourteenth, who
had never left his bed, went to a distant chapel every morning at seven o'clock.
</p><p>
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 <i>ad infinitum</i> if necessary.</p></div>

<div class="footnote"><p><a name="Footnote_34_34" id="Footnote_34_34"></a><a href="#FNanchor_34_34"><span class="label">[34]</span></a> 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?</p></div>

<div class="footnote"><p><a name="Footnote_35_35" id="Footnote_35_35"></a><a href="#FNanchor_35_35"><span class="label">[35]</span></a>
</p><div class="sidenote">More important
to spare
the patient
thought than
physical exertion.</div><p>
It is commonly supposed that the nurse is there to spare the patient from
making physical exertion for himself&mdash;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 <i>not</i> 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.</p></div>

<div class="footnote"><p><a name="Footnote_36_36" id="Footnote_36_36"></a><a href="#FNanchor_36_36"><span class="label">[36]</span></a>
</p><div class="sidenote">English
women have
great capacity
of but little
practice in
close observation.</div><p>
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&mdash;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
Englishwomen) are employed, <i>e.g.</i>, 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.
</p><p>
Now certainly Englishwomen are peculiarly capable of attaining to this.
</p><p>
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."
</p><p>
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.
</p><p>
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.
</p><p>
There are two causes for these mistakes of inadvertence. 1. A want of ready
attention; only part of the request is heard at all. 2. A want of the habit of
observation.
</p><p>
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.</p></div>

<div class="footnote"><p><a name="Footnote_37_37" id="Footnote_37_37"></a><a href="#FNanchor_37_37"><span class="label">[37]</span></a>
</p><div class="sidenote">Approach of
death, paleness
by no means
an invariable
effect, as we
find in novels.</div><p>
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 <i>recognized</i> 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 recognized livery, as I have said&mdash;<i>de rigueur</i> in novels, but nowhere else.</p></div>

<div class="footnote"><p><a name="Footnote_38_38" id="Footnote_38_38"></a><a href="#FNanchor_38_38"><span class="label">[38]</span></a> 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.
</p><p>
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.
</p><p>
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 <span class="smcap">a.m.</span> the pulse becomes 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.
</p><p>
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.
</p><p>
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.</p></div>

<div class="footnote"><p><a name="Footnote_39_39" id="Footnote_39_39"></a><a href="#FNanchor_39_39"><span class="label">[39]</span></a>
</p><div class="sidenote">Danger of physicking
by
amateur
females.</div><p>
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&mdash;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."
</p><p>
If women will take or give physic, by far the safest plan is to send for "the
doctor" every time&mdash;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, <i>e.g.</i>, colocynth with colchicum. This <i>is</i> playing with sharp
edged tools "with a vengeance."
</p><p>
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.
</p><p>
Hom&#339;opathy has introduced one essential amelioration in the practice of
physic by amateur females; for its rules are excellent, its physicking comparatively
harmless&mdash;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 hom&#339;opathic medicine. It won't do any harm.
</p><p>
An almost universal error among women is the supposition that everybody
<i>must</i> have the bowels opened once in every twenty-four hours or must fly immediately
to aperients. The reverse is the conclusion of experience.
</p><p>
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.
</p><p>
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.</p></div>

<div class="footnote"><p><a name="Footnote_40_40" id="Footnote_40_40"></a><a href="#FNanchor_40_40"><span class="label">[40]</span></a> 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.</p></div>

<p style="text-align: center;">
PRINTED BY HARRISON AND SONS,<br />
ST. MARTIN'S LANE, W.C.<br />
</p><p><a name="Page_81" id="Page_81"></a><span class='pagenum'>[Pg 81]</span></p><p><a name="Page_82" id="Page_82"></a><span class='pagenum'>[Pg 82]</span></p>



<hr style="width: 65%;" />

<p style="text-align: center;">
<b>HARRISON, 59, PALL MALL, LONDON, S.W.,<br />
Bookseller to the Queen.</b><br />
</p>

<p>A SUMMER SEARCH FOR SIR JOHN FRANKLIN,
with a Peep into the Polar Basin, by Commander E.A. Inglefield, R.N. Demy
8vo., 14s.</p>

<p>FRENCH NAVAL TACTICS; Translated from the French
by Augustus Phillimore, Captain, R.N. Demy 8vo., 10s.</p>

<p>DESPATCHES AND PAPERS RELATIVE TO CAMPAIGN
in Turkey, Asia Minor, and the Crimea in 1854 5-6, by Captain Sayer.</p>

<p>DESPATCHES OF VISCOUNT HARDINGE, LORD
Gough, and Sir Harry Smith. Demy 8vo., 6s.</p>

<p>PRESENT STATE OF THE TURKISH EMPIRE, by
Marshal Marmont, translated by General Sir F. Smith, K.H., F.R.S. Second
Edition, post 8vo., 7s. 6d.</p>

<p>PASTORAL AND OTHER POEMS, by Mrs. George Halse,
Fcap. 8vo., 2s. 6d. cloth.</p>

<p>THE LAUREL AND THE PALM, by Mrs. Challice,
Cloth, 6s.</p>

<p>EDA MORTON AND HER COUSINS. Fcap. 8vo., 6s.</p>

<p>CAVENDISH, OR THE PATRICIAN AT SEA, by
W. Johnson Neale. Fcap. 8vo., cloth. 2s. 6d.</p>

<p>CHOLLERTON, A TALE OF OUR OWN TIMES,
Fcap. 8vo, 7s. 6d.</p>

<p>EVELINA, by Miss Burney. Fcap. 8vo., 3s.</p>

<p><a name="Page_83" id="Page_83"></a><span class='pagenum'>[Pg 83]</span></p>

<p>THE PARISH CHOIR, OR CHURCH MUSIC BOOK,
In 3 vols., 21s. cloth.</p>

<p>A PLAIN TRACT ON SINGING IN PUBLIC WORSHIP.
1d., or 7s. per 100.</p>

<p>CONVERSATIONS ON THE CHORAL SERVICE, being
an Examination of popular prejudices against Church Music. Fcap, 8vo., 1s.</p>

<p>BISHOP BLOMFIELD AND HIS TIMES, by the Rev.
G.E. Biber, LL.D. 1 vol., post 8vo., 7s. 6d.</p>

<p>A PLAIN TRACT ON CHURCH ORNAMENTS, 1d., or
7s. per 100.</p>

<p>HOW TO STOP AND WHEN TO STOP; Punctuation
reduced to a System. Fcap. 8vo., cloth, 1s.</p>

<p>ANTHEMS FOR PARISH CHOIRS, collected and edited by
the Rev. Sir W.H. Cope, Bart. 1 vol., 4to., 9s.</p>

<p>GERMAN, IN FIFTY LESSONS, by Herr C.A.A. Bran,
Fcap. 8vo., 5s. 6d.</p>

<p>THE TURKISH CAMPAIGNER'S VADE-MECUM OF THE
Ottoman Colloquial Language, by J.W. Redhouse, F.R.A.S. Pocket Edition, 4s.
cloth.</p>

<p>COMPARATIVE GRAMMAR OF THE DRAVIDIAN
or South-Indian Family of Languages, by the Rev. R. Caldwell, B.A. Demy 8vo.,
cloth. 21s.</p>

<hr style='width: 45%;' />

<p>[Transcriber's Note: The following advertisements originally appeared
at the front of the book.]</p>

<p style="text-align: center;">
<b>HARRISON, 59, PALL MALL, LONDON, S.W.,<br />
Bookseller to the Queen.</b><br />
</p>


<hr style='width: 45%;' />

<div class="figleft" style="width: 100px;">
<img src="images/illus_001.png" width="100" height="117" alt="" title="" />
</div>

<p style="font-size: x-large; text-align: center;">SIR BERNARD BURKE'S (Ulster
King of Arms) PEERAGE AND
BARONETAGE for 1860.</p>

<p style="font-size: large; text-align: center;">In 1 Vol., royal 8vo., Price 38s., 22nd Edition.</p>


<p><b>CONTENTS</b></p>

<ul><li><span class="smcap">Introduction</span>&mdash;(Short History of the Peerage
and Baronetage&mdash;rights and privileges&mdash;and
origin; engravings and heraldic descriptions
of the Royal Crown and the
Coronets of the Nobility)</li>

<li>Royal Family.</li>

<li>Kings of Scotland.</li>

<li>House of Guelph.</li>

<li>Peers entitled to quarter the Plantagenet</li>
<li>Arms</li>
<li><span class="smcap">Dictionary</span>&mdash;Including the Peerage and
Baronetage of England, Ireland, and Scotland,
and the United Kingdom.</li>

<li>Scale of Precedence.</li>

<li>Spiritual Lords.</li>

<li>Foreign titles of Nobility borne by British
Subjects.</li>

<li>Peerages recently extinct.</li>

<li>Peerages claimed.</li>

<li>Surnames of Peers and Peeresses, with Heirs
Apparent and Presumptive.</li>

<li>Courtesy Titles of Eldest Sons.</li>

<li>Peerage of the Three Kingdoms, collectively,
in order of Precedence.</li>

<li>Baronets in order of Precedence.</li>

<li>Privy Councils of England and Ireland.</li>

<li>Orders of Knighthood: Garter, Thistle, St.
Patrick, Bath, St. Michael and St. George,
and Guelphic.</li>

<li>Knights Bachelors.</li>

<li>Mottoes Translated, with Illustrations.</li>

<li>Seats and Mansions of Peers and Baronets,
alphabetically arranged.</li>

<li>Daughters of Peers married to Commoners.</li></ul>


<hr style='width: 10%;' />

<p>"The best genealogical and heraldic dictionary of the Peerage and Baronetage."&mdash;<i>Globe.</i></p>

<p>"For the amazing quantity of personal and family history, admirable arrangements of
details, and accuracy of information, this genealogical and heraldic dictionary is without a rival.
It is now the standard and acknowledged book of reference upon all questions touching pedigree."&mdash;<i>Morning
Post.</i></p>

<p>"Nowhere else is there to be found so full an account of the families of men newly admitted
in the Peerage or the Baronetage. * * * * The minutest change to the date of
Publication will be found recorded in this Volume, which is in fact a Peerage and Baronetage,
not only beyond comparison with any other book of the same class extent, but while it remains
as it now is, perfect of its kind above all risk from any future competition."&mdash;<i>Examiner.</i></p>

<p>"The book combines, in one volume, and at one view, what no other work of the kind has
ever done, the complete past genealogy, and now living condition, of the family of each Peer and
Baronet of Great Britain and Ireland. * * * Burke's Peerage and Baronetage may be fairly
looked on us the golden book of the hereditary rank and aristocracy of the British Empire."&mdash;<i>Morning
Post.</i></p>

<p>"Burke's Peerage and Baronetage is now quite a national annual."&mdash;<i>Illus. London News.</i></p>

<hr style="width: 25%;" />

<p style="text-align: center;"><b>Complete in 1 Volume, Price &pound;2 [Transcriber's Note: Price unclear in original]s. 6d.</b></p>

<p style="font-size: x-large; text-align: center;">SIR BERNARD BURKE'S (Ulster King of
Arms) LANDED GENTRY OF GREAT
BRITAIN AND IRELAND.</p>

<p>"A work of this kind is of a national value."&mdash;<i>Morning Post.</i></p>

<p>"A work in which every gentleman will find a domestic interest, as it contains the fullest
account of every known family in the United Kingdom."&mdash;<i>Bell's Messenger.</i></p>

<p>"A [Transcriber's Note: Word unclear in original] work, now for the first time complete in one very handsome and portly volume, has
just been published."&mdash;<i>Illustrated London News.</i></p>

<hr style="width: 25%;" />

<p style="text-align: center;"><b>Now ready, Price 2s. 6d.</b></p>

<p style="font-size: x-large; text-align: center;">THE FOREIGN OFFICE LIST for 1860,</p>

<p>Exhibiting the Rank, Standing, and Various Services of every Person
employed in the Foreign Office, the Diplomatic Corps, and the Consular
Body. And also Regulations respecting Examinations, Passports, Foreign
Orders, &amp;c. Compiled by Francis W.H. Cavendish and Edward
Hertslet.</p>

<hr style="width: 25%;" />

<p style="font-size: x-large; text-align: center;"><b>EASY ANTHEMS.</b></p>

<p><b>For Four Voices, with Organ or Piano Forte Accompaniments.</b></p>


<div class='center'>
<table border="0" cellpadding="4" cellspacing="0" summary="">
<tr><td align='left'>O love the Lord</td><td align='right'>Goldwin</td><td align='right'>2d.</td></tr>
<tr><td align='left'>Praise the Lord</td><td align='right'>Okeland</td><td align='right'>2d.</td></tr>
<tr><td align='left'>For unto us a Child is Born</td><td align='right'>Haselton</td><td align='right'>2d.</td></tr>
<tr><td align='left'>O Praise God in his Holiness</td><td align='right'>Weldon</td><td align='right'>2d.</td></tr>
<tr><td align='left'>Behold, now Praise the Lord</td><td align='right'>Rogers</td><td align='right'>2d.</td></tr>
<tr><td align='left'>Deliver us, O Lord our God</td><td align='right'>Batten }</td><td align='right'>4d</td></tr>
<tr><td align='left'>Teach me, O Lord</td><td align='right'>Rogers }</td></tr>
<tr><td align='left'>O Praise the Lord</td><td align='right'>Weldon</td><td align='right'>2d.</td></tr>
<tr><td align='left'>Veni, Creator Spiritus</td><td align='right'>Tallis</td><td align='right'>3d.</td></tr>
<tr><td align='left'>Out of the Deep</td><td align='right'>Aldrich</td><td align='right'>6d.</td></tr>
</table></div>

<p><b>The above ANTHEMS, forming PART I, may also be had in Wrapper, 2s.</b></p>


<div class='center'>
<table border="0" cellpadding="4" cellspacing="0" summary="">
<tr><td align='left'>O Praise the Lord</td><td align='right'>Batten</td><td align='right'>2d.</td></tr>
<tr><td align='left'>Plead Thou my Cause</td><td align='right'>Glareanus</td><td align='right'>2d.</td></tr>
<tr><td align='left'>Praise the Lord, O Jerusalem</td><td align='right'>Scott</td><td align='right'>4d.</td></tr>
<tr><td align='left'>My Soul Truly Waiteth</td><td align='right'>Batten</td><td align='right'>2d.</td></tr>
<tr><td align='left'>If Ye Love Me</td><td align='right'>Tallis</td><td align='right'>2d.</td></tr>
<tr><td align='left'>Thou Visitest the Earth</td><td align='right'>Greene</td><td align='right'>2d.</td></tr>
<tr><td align='left'>O How Amiable</td><td align='right'>Richardson }</td></tr>
<tr><td align='left'>Offertory Anthem</td><td align='right'>Whitbroke }</td><td align='right'>3d.</td></tr>
<tr><td align='left'>Not unto Us, O Lord</td><td align='right'>Aldrich</td><td align='right'>3d.</td></tr>
<tr><td align='left'>Hear my Prayer</td><td align='right'>Batten</td><td align='right'>4d.</td></tr>
<tr><td align='left'>Lord, Who shall dwell</td><td align='right'>Rogers</td><td align='right'>4d.</td></tr>
</table></div>

<p><b>The above ANTHEMS, forming PART II, may also be had in Wrapper, 2s.</b></p>


<div class='center'>
<table border="0" cellpadding="4" cellspacing="0" summary="">
<tr><td align='left'>Have mercy upon Me</td><td align='right'>Gibbs</td><td align='right'>2d.</td></tr>
<tr><td align='left'>Wherewithal shall a Young Man</td><td align='right'>Alcock</td><td align='right'>2d.</td></tr>
<tr><td align='left'>I give you a New Commandment</td><td align='right'>Shephard</td><td align='right'>3d.</td></tr>
<tr><td align='left'>Holy, Holy, Holy</td><td align='right'>Bishop</td><td align='right'>2d.</td></tr>
<tr><td align='left'>Call to Remembrance</td><td align='right'>Farrant</td><td align='right'>2d.</td></tr>
<tr><td align='left'>Teach Me Thy Way, O Lord</td><td align='right'>Fox }</td><td align='right'></td></tr>
<tr><td align='left'>Blessed art Thou, O Lord</td><td align='right'>Weldon }</td><td align='right'>2d.</td></tr>
<tr><td align='left'>O Israel, Trust in the Lord</td><td align='right'>Croft</td><td align='right'>2d.</td></tr>
<tr><td align='left'>Blessing and Glory</td><td align='right'>Boyce</td><td align='right'>2d.</td></tr>
<tr><td align='left'>Lilt Up Your Heads</td><td align='right'>Turner</td><td align='right'>2d.</td></tr>
<tr><td align='left'>Thou Knowest, Lord</td><td align='right'>Purcell }</td></tr>
<tr><td align='left'>Set up Thyself, O God</td><td align='right'>Wise }</td><td align='right'>2d.</td></tr>
<tr><td align='left'>Behold now, Praise the Lord</td><td align='right'>Creyghton</td><td align='right'>2d.</td></tr>
<tr><td align='left'>Gloria in Excelsis</td><td align='right'>S. Mark's use</td><td align='right'>2d.</td></tr>
</table></div>

<p><b>The above ANTHEMS, forming PART III, may also be had in Wrapper, 2s.</b></p>

<p><i>The Three Parts, forming Vol. I of EASY ANTHEMS, may be had, neatly bound
together in cloth, price 6s.</i></p>


<div class='center'>
<table border="0" cellpadding="4" cellspacing="0" summary="">
<tr><td align='left'>O Praise the Lord</td><td align='right'>Goldwin</td><td align='right'>2d.</td></tr>
<tr><td align='left'>O Give Thanks</td><td align='right'>Rogers }</td></tr>
<tr><td align='left'>Lord, We Beseech Thee</td><td align='right'>Batten }</td><td align='right'>4d.</td></tr>
<tr><td align='left'>Offertory Anthems</td><td align='right'>Monk</td><td align='right'>2d.</td></tr>
<tr><td align='left'>Glory be to God on High</td><td align='right'>Loosemore</td><td align='right'>4d.</td></tr>
<tr><td align='left'>Lord, for Thy Tender Mercies</td><td align='right'>Farrant</td><td align='right'>2d.</td></tr>
<tr><td align='left'>O Lord, Grant the King</td><td align='right'>Child</td></tr>
<tr><td align='left'>Behold How Good and Joyful</td><td align='right'>Rogers</td><td align='right'>2d.</td></tr>
<tr><td align='left'>The Lord is King</td><td align='right'>King</td><td align='right'>2d.</td></tr>
<tr><td align='left'>Sing We Merrily</td><td align='right'>Batten</td><td align='right'>4d.</td></tr>
<tr><td align='left'>O Pray for the Peace</td><td align='right'>Rogers</td><td align='right'>4d.</td></tr>
</table></div>

<div style="text-align: center;">
<p><b>The above ANTHEMS, forming PART IV, may also be had in Wrapper, 2s.</b></p>

<hr style='width: 45%;' />

<p style="text-align: center; font-size: x-large;"><b>ANTHEMS FOR PARISH CHOIRS,</b></p>

<p style="text-align: center;"><i>By Eminent Composers of the English Church.</i></p>

<p style="text-align: center;"><b>Collected and Edited by the Rev. SIR WILLIAM H. COPE, Bart., Minor Canon
of St. Peter's, Westminster.</b></p></div>


<p><b>No. I. (Price 8d.) Contains:</b></p>


<div class='center'>
<table border="0" cellpadding="4" cellspacing="0" summary="">
<tr><td align='left'>Sing we merrily</td><td align='left'>Adrian Batten</td></tr>
<tr><td align='left'>Let my complaint</td><td align='left'>Ditto</td></tr>
<tr><td align='left'>I will not leave you comfortless</td><td align='left'>Dr. William Byrde</td></tr>
</table></div>

<p><b>No. II. (Price 10 d.) Contains:</b></p>


<div class='center'>
<table border="0" cellpadding="4" cellspacing="0" summary="">
<tr><td align='left'>O Clap your hands</td><td align='left'>Dr. William Child</td></tr>
<tr><td align='left'>When the Lord turned again</td><td align='left'>Adrian Batten</td></tr>
<tr><td align='left'>O Pray for the Peace of Jerusalem</td><td align='left'>Dr. Benj. Rogers</td></tr>
<tr><td align='left'>How Long wilt Thou forget me</td><td align='left'>Ditto</td></tr>
</table></div>

<p><b>No. III. (Price 1s.) Contains:</b></p>


<div class='center'>
<table border="0" cellpadding="4" cellspacing="0" summary="">
<tr><td align='left'>Oh! that the salvation</td><td align='left'>Dr. Benj. Rogers</td></tr>
<tr><td align='left'>Praise the Lord, O my soul</td><td align='left'>Ditto</td></tr>
<tr><td align='left'>O Give thanks unto the Lord</td><td align='left'>Ditto</td></tr>
<tr><td align='left'>Save me, O God</td><td align='left'>Ditto</td></tr>
<tr><td align='left'>Behold how good and joyful</td><td align='left'>Ditto</td></tr>
</table></div>

<p><b>No. IV. (Price 8d.) Contains:</b></p>


<div class='center'>
<table border="0" cellpadding="4" cellspacing="0" summary="">
<tr><td align='left'>By the waters of Babylon</td><td align='left'>Rev. Dr. H. Aldrich</td></tr>
<tr><td align='left'>Not unto us, O Lord</td><td align='left'>Thomas Kelway</td></tr>
<tr><td align='left'>O praise the Lord all ye heathen</td><td align='left'>John Goldwin</td></tr>
</table></div>

<p><b>No. V. (Price 8d.) Contains:</b></p>


<div class='center'>
<table border="0" cellpadding="4" cellspacing="0" summary="">
<tr><td align='left'>Haste Thee, O God, to deliver me</td><td align='left'>Adrian Batten</td></tr>
<tr><td align='left'>Why art thou so heavy</td><td align='left'>Dr. Orlando Gibbons</td></tr>
<tr><td align='left'>Behold now praise the Lord</td><td align='left'>Rev. Dr. H. Aldrich</td></tr>
</table></div>

<p><b>No. VI. (Price 10d.) Contains:</b></p>


<div class='center'>
<table border="0" cellpadding="4" cellspacing="0" summary="">
<tr><td align='left'>Praise the Lord, O my soul</td><td align='left'>Dr. John Blow</td></tr>
<tr><td align='left'>In Thee, O Lord, have I put my trust</td><td align='left'>William Evans</td></tr>
</table></div>

<p><b>No. VII. (Price 8d.) Contains:</b></p>


<div class='center'>
<table border="0" cellpadding="4" cellspacing="0" summary="">
<tr><td align='left'>Unto Thee O Lord, will I lift up</td><td align='left'>Thomas Kelway</td></tr>
<tr><td align='left'>The Lord is King</td><td align='left'>William King</td></tr>
<tr><td align='left'>In the beginning, O Lord</td><td align='left'>Matthew Lock</td></tr>
</table></div>

<p><b>No. VIII (Price 1s.) Contains:</b></p>


<div class='center'>
<table border="0" cellpadding="4" cellspacing="0" summary="">
<tr><td align='left'>Let God arise</td><td align='left'>Matthew Lock</td></tr>
<tr><td align='left'>Sing unto the Lord a new song</td><td align='left'>Ditto</td></tr>
<tr><td align='left'>When the Son of Man shall come</td><td align='left'>Ditto</td></tr>
<tr><td align='left'>Lord, we beseech Thee</td><td align='left'>Adrian Batten</td></tr>
</table></div>

<p><b>No. IX. (Price 8d.) Contains:</b></p>


<div class='center'>
<table border="0" cellpadding="4" cellspacing="0" summary="">
<tr><td align='left'>O Lord, I have loved the habitation</td><td align='left'>Thomas Tomkins</td></tr>
<tr><td align='left'>Great and marvellous</td><td align='left'>Ditto</td></tr>
<tr><td align='left'>He that hath pity upon the poor</td><td align='left'>Ditto</td></tr>
</table></div>

<p><b>No. X. (Price 10d.) Contains:</b></p>


<div class='center'>
<table border="0" cellpadding="4" cellspacing="0" summary="">
<tr><td align='left'>O Lord God of our salvation</td><td align='left'>Rev. Dr. H. Aldrich</td></tr>
<tr><td align='left'>Lord, who shall dwell</td><td align='left'>Adrian Batten</td></tr>
<tr><td align='left'>O Praise the Lord: laud ye</td><td align='left'>Dr. William Child</td></tr>
</table></div>








<pre>





End of Project Gutenberg's 

*** END OF THIS PROJECT GUTENBERG EBOOK NOTES ON NURSING ***

***** This file should be named 17366-h.htm or 17366-h.zip *****
This and all associated files of various formats will be found in:
        https://www.gutenberg.org/1/7/3/6/17366/

Produced by Jonathan Ingram, Susan Skinner and the Online
Distributed Proofreading Team at https://www.pgdp.net (This
file was produced from images generously made available
by The Internet Archive/Canadian Libraries)


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

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



*** START: FULL LICENSE ***

THE FULL PROJECT GUTENBERG LICENSE
PLEASE READ THIS BEFORE YOU DISTRIBUTE OR USE THIS WORK

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


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

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

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

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

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

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

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

This eBook is for the use of anyone anywhere 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

1.E.2.  If an individual Project Gutenberg-tm electronic work is derived
from the public domain (does not contain a notice indicating that it is
posted with permission of the copyright holder), the work can be copied
and distributed to anyone in the United States without paying any fees
or charges.  If you are redistributing or providing access to a work
with the phrase "Project Gutenberg" associated with or appearing on the
work, you must comply either with the requirements of paragraphs 1.E.1
through 1.E.7 or obtain permission for the use of the work and the
Project Gutenberg-tm trademark as set forth in paragraphs 1.E.8 or
1.E.9.

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

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

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

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

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

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

- You pay a royalty fee of 20% of the gross profits you derive from
     the use of Project Gutenberg-tm works calculated using the method
     you already use to calculate your applicable taxes.  The fee is
     owed to the owner of the Project Gutenberg-tm trademark, but he
     has agreed to donate royalties under this paragraph to the
     Project Gutenberg Literary Archive Foundation.  Royalty payments
     must be paid within 60 days following each date on which you
     prepare (or are legally required to prepare) your periodic tax
     returns.  Royalty payments should be clearly marked as such and
     sent to the Project Gutenberg Literary Archive Foundation at the
     address specified in Section 4, "Information about donations to
     the Project Gutenberg Literary Archive Foundation."

- You provide a full refund of any money paid by a user who notifies
     you in writing (or by e-mail) within 30 days of receipt that s/he
     does not agree to the terms of the full Project Gutenberg-tm
     License.  You must require such a user to return or
     destroy all copies of the works possessed in a physical medium
     and discontinue all use of and all access to other copies of
     Project Gutenberg-tm works.

- You provide, in accordance with paragraph 1.F.3, a full refund of any
     money paid for a work or a replacement copy, if a defect in the
     electronic work is discovered and reported to you within 90 days
     of receipt of the work.

- You comply with all other terms of this agreement for free
     distribution of Project Gutenberg-tm works.

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

1.F.

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

1.F.2.  LIMITED WARRANTY, DISCLAIMER OF DAMAGES - Except for the "Right
of Replacement or Refund" described in paragraph 1.F.3, the Project
Gutenberg Literary Archive Foundation, the owner of the Project
Gutenberg-tm trademark, and any other party distributing a Project
Gutenberg-tm electronic work under this agreement, disclaim all
liability to you for damages, costs and expenses, including legal
fees.  YOU AGREE THAT YOU HAVE NO REMEDIES FOR NEGLIGENCE, STRICT
LIABILITY, BREACH OF WARRANTY OR BREACH OF CONTRACT EXCEPT THOSE
PROVIDED IN PARAGRAPH F3.  YOU AGREE THAT THE FOUNDATION, THE
TRADEMARK OWNER, AND ANY DISTRIBUTOR UNDER THIS AGREEMENT WILL NOT BE
LIABLE TO YOU FOR ACTUAL, DIRECT, INDIRECT, CONSEQUENTIAL, PUNITIVE OR
INCIDENTAL DAMAGES EVEN IF YOU GIVE NOTICE OF THE POSSIBILITY OF SUCH
DAMAGE.

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

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

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

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


Section  2.  Information about the Mission of Project Gutenberg-tm

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

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


Section 3.  Information about the Project Gutenberg Literary Archive
Foundation

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

The Foundation's principal office is located at 4557 Melan Dr. S.
Fairbanks, AK, 99712., but its volunteers and employees are scattered
throughout numerous locations.  Its business office is located at
809 North 1500 West, Salt Lake City, UT 84116, (801) 596-1887, email
business@pglaf.org.  Email contact links and up to date contact
information can be found at the Foundation's web site and official
page at https://pglaf.org

For additional contact information:
     Dr. Gregory B. Newby
     Chief Executive and Director
     gbnewby@pglaf.org


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

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

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

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

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

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


Section 5.  General Information About Project Gutenberg-tm electronic
works.

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


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


Most people start at our Web site which has the main PG search facility:

     https://www.gutenberg.org

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


</pre>

</body>
</html>
generated by cgit v1.2.3 (git 2.25.1) at 2026-03-31 07:41:03 +0000