LONDON: HARRISON, Bookseller to the Queen, 59, PALL MALL. SIR BERNARD BURKE'S (Ulster King of Arms) PEERAGE AND BARONETAGE for i860. In 1 Vol., royal 8vo., Price 38s., 22iid Edition. CONTENTS. Introduction — f Short History of the Peer- age and Baronetage — rights and privileges — and origin; engravings and heraklic des- criptions of tlie Royal Crown and the Coronets of the Nobility) Royal Family. Kings of Scotland. House of Guelph. Peers entitled to quarter the Plantagenet Arms. DiCTioNAKT — Including the Peerage and Baronetage of England, Ireland, and Scot- land, and tlie United Kingdom. Scale of Precedence. Spiritual Lords. Toreigu titles of Nobility borne by British Bri- tish Subjects. Peerages recently extinct. Peerages claimed. Surnames of Peers and Peeresses, with Heirs Appi'.rent and Presumptive. Courtesy Titles of Eldest Sons. Peerages of the Three Kingdoms, collectively, in order of Precedence. Baronets in order of Precedence. Privy Councils of England and Ireland. 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ANTHEMS FOR PARISH CHOIRS, Bi/ Eminent Composers of the Encjlish Church. Collentert anil Edited liy the Rev. SIR WILLIAlfl H. COPE, Bart., ]*Iinor Canon of St. Peter's, ^Vestminster. No. I. (Price 8d.) Contains : Sing we merrily Adrian Batten Let my complaint Ditto I will not leavt! yon comfortless Dr. William Byrde No. II. (Price lOd.) Contains O (lap your hinds Dr, William Child When tlie Lord turned again . . Adrian Batten O Pray for the Peace of. leru.salem Dr. Benj. Rogers How long wilt Thou forget me.. Ditto No. III. (Price Is.) Contains : Unto Thee O Lord, will I lift "P The Lord is King In the beginning, () Lord Oil ! that the saL.ition .. ., I'raisf the f.ord, () my soul ., O Give thanks unto the Lord., Save me, O Goil if Man shall come Lord, we b.M-ech Tiiee .. .. No. IX. (Price 8d.) Contains O Lord, I have loved the habi- tation Great and marvellous He that hath pity upon the poor Thoma.s Tomkins Ditto Ditto No. X. (Price lOd.) Contains: O Lord God of our salvation Lord, who shall dwell O Praise the Lord : laud ye Rev. Dr. H. Aldrich Adrian Batten Dr. William Child NOTES ON NUESING: WHAT IT IS, AND WHAT IT IS NOT. BY nOEEKCE NIGHTINGALE. LONDON: HAHBISON, 59, PALL MALL, BOOKSELLER TO THE QUEEN. [7'Ae rifjiu of Translation u resarcd.] PREFACE. The following notes are by no means intcmlcd as a rule of thought by which nurses can teacli themselves to nurse, still less as a manual to teach nm'ses to nurse. They are meant simply to give hints for thought to women who have personal charge of the health of others. Every woman, or at least almost every woman, in England has, at one time or another of her life, charge of the personal health of somebody, whether child or invalid,— in other words, every woman is a nurse. Every day sanitary knowledge, or the knowledge of nursing, or in other words, of how to put the constitution in such a state as that it will have no disease, or that it can recover from disease, takes a higher place. It is recognized as the knowledge which every one ought to have—distinct from medical knowledge, which only a profession can have. If, then, every woman must, at some time or other of her life, become a nurse, i.e., have charge of somebody's hcaltli, how immense and how valuable would be the produce of her united experience if every woman would think how to nurse. I do not pretend to teach her how, I ask her to teach her- self, and for this purpose I venture to give her some hints. TABLE OF CONTENTS. Ventilation and Warming .... .... .... 8 Health of Houses .... .... .... .... 14 Petty Managesient .... .... .... .... 20 Noise ; .... .... .... .... .... ...= 25 Variety .... .... .... .... .... 33 Taking Food .... .... .... .... .... 36 What Food ?.... .... ; .... .... .... 39 . Bed and Bedding .... .... .... .... 45 Light .... .... .... .... ..- 47 Cleanliness of Rooms and Walls .... .... .... 49 Personal Cleanliness .... .... .... .... 62 Chattering Hopes and Advices .... .... .... 54 Observation of the Sick .... .... .... 59 Conclusion .... .... »... .... ... 71 Appendix .... ..-. — •••• •••• ^7 NOTES ON NURSING : WHAT IT IS, AND WHAT IT IS NOT. Shall we begin by taking it as a general principle — that all Disease a disease, at some period or other of its course, is more or less a reparative reparative process, not necessarily accompanied with suffering : an process, eftbrt of nature to remedy a process of poisoning or of decay, which has taken place weeks, months, sometimes years beforehand, unnoticed, the termination of the disease being then, while the antecedent process was going on, determined ? If we accept this as a general principle we sliall be immediately met with anecdotes and instances to prove the contrary. Just so if we were to take, as a principle — all the climates of the eartii are meant to be made habitable for man, by the efforts of man — the objection would be immediately raised, — 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 IMont Blanc in making the earth healthy. Wait till we have reached the bottom before we discuss the top. In watching disease, both in private houses and in public hos- of the sufTor- pitals, the thing which strikes the experienced observer most forcibly ings of disease, is this, that the symptoms or the sufferings generally considered to disease not be inevitable and incident to the disease are very often not symptoms «'^'^^ay.s the of the disease at all, but of something quite different — of the want ^^^^^' of fresh air, or of light, or of warmth, or of quiet, or of cleanliness, or of punctuality and care in the administration of diet, of each or of all of these. And this quite as much in private as in hospital nursing. The reparative process which Nature has instituted and which we call disease has been hindered by some want of knowledge or atten- tion, in one or in all of these things, and pain, suffering, or interrup- tion of the whole process seta in. 0 XOTES ON NUESING. If a patient is cold, if a patient is feverisli, if a patient is faint, if lie is sick after taking food, if he has a bed-sore, it is generally the fault not of the disease, but of the nursing. What nursing I use the word nursing for want of a better. It has been limited to ought to do. signify little more than the administration of medicines and the application of poultices. It ought to signify the proper use of fresh air, light, warmth, cleanliness, quiet, and the proper selection and administration of diet — all at the least expense of vital power to the patient. Kursing the It has been said and written scores of times, that every woman Bick little makes a good nurse. I believe, on the contrary, that the very understood, elements of nursing are all but unknown. By this I do not mean that the nurse is always to blame. Bad sanitary, bad architectural, and bad administrative arrangements often make it impossible to nurse. But the art of nursing ought to include such arrangements as alone make what I understand by nursing, possible. The art of nursing, as now practised, seems to be expressly constituted to unmake what Grod had made disease to be, viz., a reparative process. ZSTursing ought To recur to the first objection. If we are asked. Is such or to assist the such a disease a reparative process ? Can such an illness be unac- reparative companied with sutferino^ ? Will any care prevent such a patient ^ ■ from suffering this or that ? — I humbly say, I do not know. But when you have done away with all that pain and suffering, which in patients are the symptoms not of their disease, but of the absence of one or all of the above-mentioned essentials to the success of Nature's reparative processes, we shall then know what are the symptoms of and the sufferings inseparable from the disease. Another and the commonest exclamation which will be instantly made is — Would you do nothing, then, in cholera, fever, &c. ? — so deep-rooted and universal is the conviction that to give medicine is to be doing something, or rather everything; to give air, warmth, cleanliness, &c., is to do nothing. The reply is, that in these and many other similar diseases the exact value of particular remedies and modes of treatment is by no means ascertained, while there is universal experience as to the extreme importance of careful nursing in determining the issue of the disease. Nursing the II. The very elements of what constitutes good nursing are as ^®^^- little understood for the well as for the sick. The same laws of health or of nursing, for they are in reality the same, obtain among the well as among the sick. The breaking of them produces only a less violent consequence among the former than among the latter, — and this sometimes, not always. It is constantly objected, — "But how can I obtain this medical knowledge ? I am not a doctor. I must leave this to doctors." }f^^]^ ^^^^^" ^^j mothers of famihes ! 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 stood. 2fOTE3 ON NUBSIXO. 7 England, nearly one out of two?* "The life duration of tender babies" (as some Saturn, turned analytical chemist, says) "is the most delicate test" of sanitary conditions. Is all this premature suffering and death necessary ? Or did Nature intend mothers to be always accompanied by doctors ? Or is it better to learn the piano-forte than to learn the laws which subserve the preservation of offspring ? Macaulay somewhere says, that it is extraordinary that, whereas the laws of the motions of the heavenly bodies, far removed as they are from us, are perfectly well understood, the laws of the human mind, which are under our observation all day and every day, are no better understood than they were two thousand years ago. But how much more extraordinary is it that, whereas what we might call the coxcombries of education — e.g., the elements of astro- nomy— 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 Avords, the laws which make these bodies, into which He has put our minds, healthy or un- healthy organs of those minds, are all but unlearnt. Not but that these "laws— the laws of life — are in a certain measure understood, but not even mothers think it worth their while to study them— to study how to give their children healthy existences. They call it medical or physiological knowledge, fit only for doctors. Another objection. We are constantly told, — " But tlie circumstances which govern our children's healths are beyond our control. AVhat 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." ♦ Upon this fact the most wonderful deductions have been strung. For a Curious deduc- long time an announcement something like the following has been going the tions from an round of the papers:— " More than 25,000 children die ever)' year in London excessive under 10 years of age; therefore we Avant a Children's Hospital." This spring death rate, there was a prospectus issued, and divers other means taken to this effect:— *' There is a great want of sanitary knowledge in women ; therefore we want a Women's Hospital." Now, both the above facts are too sadly true. But what is the deduction ] The causes of the enormous child mortality are peifectly well known ; they are chiefly want of cleanliness, want of ventilation, want of white- washing; in one word, defective household hygiene. The remedies are just as well known: and among them is certainly not the establishment of a Child's Hospital. This may be a want ; just as there may be a want of hospital room for adults. But the Registrar-General would certainly never think of giving us aa 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. Again, women, and the best women, are wofully deficient in sanitary know- ledge; although it is to women that we must look, first and last, for its appli- cation, as far as honaihold hygiene is conc-erned. But who wouUl ever think of citini,' the institution of a Women's Hospital as the way to cure this want I We have it, indeed, upon very high authority that there is some fear lest hospitals, as they have been h{(herto,\n&y not have generally increased^ rather than diminiahed, the rate of mortality—especially of child mortality. 8" ]S"OTES OS 1!TURSI?TG. To this one can answer witli more certainty than to the former objections. Who is it who knows when the wind is in the east ? Not the Highland drover, certainly, exposed to the east wind, but the young lady who is worn out with the want of exposure to fresh air, to sunlight, &c. Put the latter under as good sanitary circum- stances as the former, and she too will not know when the wind is in the east. I. TEJS^TILATIOK AND WAEMIXa. First rule of Tlie very first canon of nursing, the first and the last thing upon ker^the^air ^^\^^ ^ nurse's attention must be fixed, the first essential to the within as pure P^^i^^^j without which all the rest you can do for him is as nothing, as the air ^i^^ which I had almost said you may leave all the rest alone, is this: without. To KEEP THE AIR HE EEEATHES AS PURE AS THE EXTERNAL AIR, WITHOUT CHiLLiNa HIM. Yet what is so little attended to ? Even where it is thought of at all, the most extraordinary misconceptions reign about it. Even in admitting air into the patient's room or ward, few people ever think, where that air comes from. It may come from a corridor into which other wards are ventilated, from a hall, always unaired, always full of the fumes of gas, dinner, of various kinds of mustiness ; from an underground kitchen, sink, washhouse, water-closet, or even, as I myself have had sorrowful experience, from open sewers loaded with filth ; and with this the patient's room or ward is aired, as it is called — poisoned, it should rather be said. Always air from the air without, and that, too, through those windows, through which the air comes freshest. Erom a closed court, especially if the wind do not blow that way, air may come as stagnant as any from a hall or corridor. Again, a thing I have often seen both in private houses and insti- tutions, 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.* Yet the nursery, ward, or sick room adjoining will positively be aired (?) by having the door opened into that room. Or children will be put into that room, without previous preparation, to sleep. A short time ago a man walked into a back-kitchen in Queen Why are unin- _ * The common idea as to uninhabited rooms is, that they may safely be left habited rooms 'with doors, windows, shutters, and chimney board, all closed— hermetically sealed shut up 1 i^ possible— to keep out the dust, it is said ; and that no harm will happen if the room is but opened a short hour before the inmates are put in. I have often been asked the question for uninhabited rooms. — But when ought the windows to be opened ] The answer is— When ought they to be shut ? VENTILATIOK ASD WAEMIKQ. 9 square, and cut the throat of a poor consumptive creature, sitting by the fire. The murderer did not deny the act, but simply said, " It's all right." Of course he was mad. But in our case, the extraordinary thing is that the victim says, " It's all right," and that we are not mad. Yet, although we " nose" the murderers, in the musty unaired unsunned room, the scarlet fever which is behind tlie door, or the fever and hospital gangrene which are stalking among the crowded beds of a hospital ward, we say, "It's all right." AVith a' proper supply of windows, and a proper supply of fuel Without chill, in open fire places, fresh air is comparatively easy to secure when your patient or patients are in bed. Never be afraid of open windows then. People don't catch cold in bed. This is a popular fallacy. With proper bed-clothes and hot bottles, if necessary, you can always keep a patient warm in bed, and well ventilate him at the same time. But a careless nurse, be her rank and education what it may, will stop up every cranny and keep a hot-house heat when her patient is in bed,— and, if he is able to get up, leave him compara- tively 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 there- by rendered more incapable of re-action. Then the same tempera- ture which refreshes the patient in bed may destroy the patient just risen. And common sense will point out that, while purity of air is essential, a temperature must be secured which shall not chill the patient. Otherwise the best that can be expected will be a feverish re-action. To have the air within as pure as the air without, it is not necessary, as often appears to be thought, to make it as cold. In the afternoon again, without care, the patient whose vital powers have then risen often finds the room as close and oppressive as he found it cold in the morning. Tet the nurse will be terrified, if a window is opened*. I know an intelligent humane house surgeon who makes a Open windows, practice of keeping the ward windows open. The physicians and surgeons invariably close them while going their rounds ; and the house surgeon very properly as invariably opens them whenever the doctors have turned their backs. In a little book on nursing, published a short time ago, we are told, that "with proper care it is very seldom that the windows cannot be opened for a few minutes twice in tlie day to admit frcsli * It is very desirable that the windows in a sick room should be such aa that the patient sliall, if he can move about, be able to open and shut them easily himself. In fact the 8ick. room is very seldom kei)t aired if iliis is not the ease— 80 very few people have any perception of what is a healthy atmosphere for the sick. The sick man often says, "This room where 1 spend '22 houi-s out of the 24 is fresher than the other where I only spend 2. Because here I can manage the windows myself." And it is true. 10 NOTES ON' KTTESINa. What kind of warmth desirable. Bedrooms almost univer- sally foul. air from without." I should think not ; nor twice in the hour either; It only shows how little the subject has been considered. Of all methods of keeping patients warm the very worst certainly is to depend for heat on the breath and bodies of the sick. I have known a medical officer keep his ward windows hermetically closed, thus exposing the sick to all the dangers of an infected atmosphere, because he was afraid that, by admitting fresh air, the temperature of the ward would be too much lowered. This is a destructive fallacy. To attempt to keep a ward warm at the expense of making the sick repeatedly breathe their own hot, humid, putrescing atmosphere is a certain way to delay recovery or to destroy life. 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 ? Eut 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.* An air-test of * Dr. Angus Smith's air test, if it could be made of simpler api>lication, would essential l^e invaluable to use in every sleeping and sick room. Just as without the use of consequence, ^ 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, nurser}^, or sleeping-room. If the main function of a nurse is to maintain the air within the room as fresh as the air without, vrithout lowering the temperature, then she should always be provided with a thermometer which indicates the temperature, with an air test Avhich 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 moi-ning, 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. And oh ; the crowded national school ! where so many children's epidemics have their origin, what a tale its air-test would tell ! We should have parents saying, and saying rightly, " I will not send my child to that school, the air-test stands at ' Horrid.'" And the dormitories of our great boarding schools ! Scarlet fever would be no more ascribed to contagion, but to its right cause, the air-test standing at "Foul." We should hear no longer of "Mysterious Dispensations," and of " Plague and Pestilence," being " in God's hands," when, so far as we know, He has put them into our own. The little air-test would both betray the cause of these "mysterious pestilences," and call upon us to remedy it. VENTILATION AND WAEMING. 11 A careful nurse will keep a constant watcli over her sick, When warmth especially weak, protracted, and collapsed cases, to guard against the ^^^^ ^^ "^ost effects of the loss of vital heat by the patient himself In certain f^^u^"J^f 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 tim.es, 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 eflect of the preceding day's diets is exhausted. Generally speaking, you may expect that weak patients will suffer cold much more in the morning than in the evening. The vital powers are much lower. If they are feverish at night, with burning hands and feet, they are almost sure to be chilly and shi- vering 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 bus3\ I should reverse the matter. AH these things require common sense and care. Tet perhaps in no one single thing is so little common sense shewn, in all ranks, as in nursing.* The extraordinary confusion between cold and ventilation, in Cold air not the minds of even well educated people, illustrates this. To ventilation, • make a room cold is by no means necessarily to ventilate it. Kor ^^^^ f''^^,^'' i^'^ '^ is it at all necessary, in order to ventilate a room, to chill it. ^^^^'^odof 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. * "With private sick, I think, but certainly with hospital t^iek, the nui-se should never be satisfied as to the frcblmess of their atmo.sphere, unlests she can feel the air gently moving over her face, when still. But it is often observed that nurses who make the greatest outcrj' against open windows arc those who take the least pains to prevent dangerous draught."*. The door of the patients' room or ward mv.d sometimes s^tand 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 profusse 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. chill. 12 IfOTES ON NTJESING, The safest atmospliere 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 with- out draughts of course requires more care than to ventilate a large one. Night air. Another extraordinary fallacy is the dread of night air. "What air can we breathe at night but night air ? The choice is between pure night air from without and foul night air from within. Most people prefer the latter. An unaccountable choice. AVhat will they say if it is proved to be true that fully one-half of all the disease we sufter 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. Air from the Always air your room, then, from the outside air, if possible, outside. "Windows are made to open ; doors are made to shut — a truth which Open your seems extremely difficult of apprehension. I have seen a careful windoATs, shut j^^^gg 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, includ- ing a current of sewer air from an ill-placed sink, ascending in a con- tinual stream by a well-staircase, and discharging themselves con- stantly into the patient's room. The window of the said room, if opened, was all that was desirable to air it. Every room must be aired from without — every passage from without. But the fewer passages there are in a hospital the better. Smoke. If we are to preserve the air within as pure as the air without, it is needless to say that the chimne}^ must not smoke. Almost all smoky chimneys can be cured — from the bottom, not from the top. Often it is only necessary to have an inlet for air to supply the fire, which is feeding itself, for want of this, from its own chimney. On the other hand, almost all chimneys can be made to smoke by a careless nurse, who lets the fire get low and then overwhelms it with coal; not, as we verily believe, in order to spare herself trouble, (for very rare is unkindness to the sick), but from not thinking what she is about. Airing damp In laying down the principle that the first object of the nurse things in a must be to keep the air breathed by her patient as pure as the air patient'sroom, -vvithout, it must not be forgotten that everything in the room which can give ofi" 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 oft' effluvia or moisture. Out of all damp towels, &c., which become dry in the room, the damp, of VENTILATION A>'J> WAHMING. 13 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 wlio acluiowledges by her practice that nothing at all ought to be aired in the patient's room, that nothing at all ought to be cooked at the patient's fire ! Indeed the arrangements often make this rule impossible to observe. If the nurse be a very careful one, she will, when the patient leaves his bed, but not his room, open the sheets wide, and throw the bed clothes back, in order to air his bed. And she will spread the wet towels or flannels carefully out upon a horse, in order to dry them. Isow 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. Even in health people cannot repeatedly breathe air in which Effluvia from they live with impunity, on account of its l3ecoming charged with excreta, unwholesome matter from the lungs and skin. In disease where everything given oft' from the body is highly noxious and dangerous, not only must there be plenty of ventilation to carry oft' the effluvia, but everything which the patient passes must be instantly removed away, as being more noxious than even the emanations from the sick. Of the fatal eftects of the effluvia from the excreta it would seem unnecessary to speak, were they not so constantly neglected. Con- cealing 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 ! The use of any chamber utensil ivithout a lid/^ should be utterly Chamber uten- abolished, whether among sick or well. Ton can easily convince sils without yourself of the necessity of this absolute rule, by taking one with a ^^^'^• • But never, never should the possession of this indispensable lid confirm you Don't make in the abominable practice of letting the chamber utensil remain in a patient's your sick-room room uncmptied, except once in the 24 hours, i.e., when the bed is made. Yes, into a scwcr. impossible as it may appear, I have known the best and most attentive nurses guilty of this; aye, and have known, too, a patient afflicted with severe diarrhoea for ten days, and the nurse (a very good one)'not know of it, because the chamber utensil (one with a lid) was emptied only once in 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 lid, as well as your utensil, be always thoroughly rinsed. If a nurse declines to do these kinds of things for her patient, " because it is not her business," I should say that nursing was not her calling. I have seen surgical " sisters," women whose hands were worth to them two or three guineas a-week, down upon their knees scouring a room or hut, because they thought it otherwise not tit 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 tlie true nurse-calling— the good of their sick first, and second only the consideratioa what it was iheir "place" to do— and that women who wait tor the housemaid to do this, or for the charwoman to do that, when their patients are sutlcring, have not the iiuikluQ of a nurse in them. [it T^OTIIM ON NIIU!mN(f. lid, and r^nniitiini^ IIk^ iiiidtw nlilo oi' l.lwil. lid. 11 will Ixi ioniid nJwnyM covonxl, vvliom^vrr l.li(< uUwiHd in nol- oinpl-v, Ny condofiNcd ull(MiMiv(> moiMl.iin'. VVIuM'o docm l.lial- f^jo, wIkmi Ihofd iH no lid P l'lnrUiniiWMn\ or il' lJi(^ro i.M Jiiiy wood, hif^ldy poliMliod and viiriHMlKMl w'ood,nn» Iho only luMh^riniM III. lor pntionlM* nl.cnHilM. 'I'ho vvvy li iinporinidi in tlio privato liouMo Minn (dMovvlHM'«\ ilinl. Mio idtMmil Hli()nld bo carried dircM^.ly io lilio vvnit^r (•loMi^l-, iMnpliod Hump, linMod Mioroj nnd bron^jbt back. Tiioro ulioidd ab.vavM IxMvnIor nnd a coidc in i^M^vy watiM* (d(»Nol, lor rinMinf,^ itnl. ovcmi if Mkm'o in not, yoti nuiNl- (Nirry wal-or l.horo l.o rioMo uilli. I bavo arlnaily W(mmi, in tlio privali^ nick room, Ibo nionHilM ompliod iido tbo fool.-pan, nnd p\d' back nnrinHcd nndor l.lio bed. I (•an bardly Hay vvbicb im moHJ. aboniinnblo, wbclluT to do thin or lo rinso l\\v nliMinil in M»o wick J'oom. In Ibo bt>Ml. boHj)II-MlH il- \h now a ndo Mud. no nlop piiil Mball iwiM' b(> bron^^ld^ into l-bo wardu, bnt Ihal; Ibo nlt>nMilpi nball bo (MirriiMl diroet io bo ompUiMl ami rioKod al. Mio prop(M' pliUMV I wonld il. wvvv mo in I b«> privalo bonwc. l''mniKnli«Mir!. Lcl no oiKM^vcr dc^pciid npon rnnujjjnl.ionM, " diHinl'ccliitdM," and Mil' hkc. 1(11- pniifyioii^ I b(> air. 'rbtM)ironNivt> Ibifi^, not itM Hmoll, MuiMt bo removed. A ctdobratiMl n>edieal lecitm'or be^jan ono day 'VFumif^ntionM, g(M>tiemen, ariM)!' (^MMt>nti;il importaniM). Tlmy mako Nncb an abonunal>l(> Hinoll tbnt tboy con)p(d yon to op(>n ibo window," I winb all t lu> diMinleidinff llnidn invcmtod mado Miiob an '*ubominablo unudl " (bat tbt>y forccMl yon to admit IVtv-^b air. 'I'bnt wotdd bo ii nctornl invention. II. iii:\i;ni ov' iiousks*. llp„IH, ,,|- Tbert^ nro nv<^ (^^Hentinl poinl.'i in MiMMirin;;; Ibo bonltli of hoiwoH. Kivrt luMlftOS; — pninis oNHoa^ I . Vuw air. ''"'• U. Vnro waltM'. U. I'*nicit>nt drainage). 4. ( 'bvudinoHH. " 'V\\o \wn\iU of noTlfVgrrt, cMj'orliUl^' rlow oHrrinjjon, in not of MulHoIont uni« viMMiil nni>iM»niuM' lo uunttlou \nm\ ol\wr\\\»v Hum inirMprll^V. ChiMrru, wIm) uro hIwiivs M»o most olu^- »irk mul voi;v lucky lor Ihoiu tluit it U xo. A rIoRo oiir- vlnp'. witk tho luMKo liuir iMiwhlouw mul litiiurif* ulwuyw 8nluri»li'giuiio nmMor. it to H\i» l»o utMtnl tko witulowH up. i« «)Uo«»r Iko luoul uuhoullliy ofhuiuivu iour)>l»u'los. Tko hlni ol" IjikiuK ivu (oVi/*;/ ii» It Iw t*o»uoll»iufj jnopostorouN. |)r. At»mirt Siuilh kat* wkowt^ tkttt » oro\v«lo«l •alhvuy oanlivfjo, wkioli goos ivl. iho nvto of ;U) \»\iloK an ko»n', i» «.« ujovI»oIohou\o um tko Htiotifr muoll of a Mowor, or »h a, bttok yunl in ono ol" Uio uu»»t uiiluiHltk) rouit* oil" ouo «>f Iko luo^t ualioaltliy MtrooU l(v MatveUostor, ll.V'lllh ol iiiiAi/ni or iHHiNKM. ir» Willutiil, ilu'M(\ ii<» lioiiMr run Ijd IwiilUiy. A iid il. w ill lie nnln'iilllis jiml. ill |ir(i|ii)rt.ioii mm I lioy iii'<^ (h^licitMil.. I. To liuvo |)iiri< nil', ydiir lioiiNd niiihl.lm MoroiiHlrncUul m timl. Mm I'm o air. oilier Ml. iiiiiH|)lH«nM(liiill IIikI iU wiiy willM'iiHo (o (ucry (ionicr ol' il.. II(HIN(» Mrcliil-ociN iiMi'dly ovor «NiiiMifl('i' MiIm. TIk^ nhicrl, in iMiildiiiK m, I«(MIH«» \H 1,0 nliiniii llu' liirf^chl. iiilcrrHl, lor Mm nioiiny, mil, lo hiivo ,( i\\r IdiiiiK' on " cnrront « do lor tlio iii'MlMiy wlwit biidly conNtnirtpd lioH|iitMlM do lor IIk* nit'L <)ii(M< itiMiiro MimI, tlio nil- in (i Iioiimo iH MtM;.^nMnt, mid MicKiK'UM in rcrtiiin to iollovv . '2. I'iirMt«'r \h nmn* /MMM-ndly mjiindijccd mtn lioiiiirM lluiii il, I'loo wnl.rr. iiN(Mi to li«*, tlwinhH to tlio nxcrtioiiM td' tlio MMiiitiiry ri'loniiriM. Within tIm JMnl, low yrMirn, ti l/irj^ii pMit of London vmim in tIm diiily IimImI. (d' iiMin/j; WMtcr ludliitrd hy tIm drMiiiM^o (d* itw nowci'M lunl wutcr (doHid.H. TluM Iimm Inijipily Immhi rnimdicd. Ihit, in iiiiiny p/irtH of Mm <*oiintry, W(-il wMter of a vrry iiii|Miro Kind \h iiMcd lor d(MM(mti(; iiiirpoHf^M. And wlion rpidcMtiin dim'M^t«i hIiowm itiudf, pcrMonii iiNin({ HiK'h WM.tnr iwv iilinoHt Niiro to hiiirri'. •'{. It would ho (MU'ioiiM to iiM(;<iiliit(do—i, f. break IIIn own luwK 16 NOTES ON NUESING. Scutari ; and I have seen tlie rooms in that house all ventilated by the open doors, and the passages all ^^wventilated by the closed windows, in order that as much of the sewer air as possible might be conducted into and retained in the bed-rooms. It is wonderful. Another great evil in house construction is carrying drains underneath the house. Such drains are never safe. All house drains should begin and end outside the walls. Many people will readily admit, as a theory, the importance of these things. But how few are there who can intelligently trace disease in their households to such causes ! Is it not a fact, that when scarlet fever, measles, or small-pox appear among the children, the very first thought which occurs is, "where" the children can have "caught" the disease? And the parents immediately run over in theii' 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. Iso 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. Cleanliness. 4. "Without cleanliness, within and without your house, ventila- tion 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. Eich people like to have their stables and dunghill near their houses. But does it ever occur to them that with many arrangements of this kind it would be safer to keep the windows shut than open ? You cannot have the air of the house pure with dung heaps under the windows. These are common all over London. And yet people are surprised that their children, brought up in large " well-aired" nurseries and bed-rooms suffer from children's epidemics. If they studied Nature's laws in the matter of children's health, they would not be so surprised. There are other ways of having filth inside a house besides having dirt in heaps. Old papered walls of years' standing, dirty carpets, uncleansed furniture, are just as ready sources of impurity to the air as if there were a dung-heap in the basement. People are so unac- customed 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" w^hen 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. Light. 5. A dark house is always an unhealthy house, always an ill- aired house, always a dirty house. Want of light stops growth, and pro- motes scrofula, Ticket's, &c., among the children. People lose their health in a dark house,_ and if thev get ill they cannot get well again in it. More will be said about this farther on. Three common Three out of many " negligences and ignorances " in managing the errors in health of houses generally, 1 will here mention as specimens— 1. That S^h of ^^^ ^^® female head in charge of any building does not think it necessary to houses. HEALTH OF HOUSES. 17 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 liouse in a healtliy condition than she who is in charge of it ? — 2. That it is not considered essential to air, to sun, and to clean rooms while unin- habited; which is simply ignoring the first elementary notion of vsanitary things, and laying the ground ready for all kinds of diseases. — 3. That the window, and one window, is considered enough to air a room. Have you never observed that any room without a fire-place is always close? And, if you have a fire-place, would you cram it up not only with a chimney-board, but perhaps with a great wisp of brown paper, in the throat of the chimney — to prevent the soot from coming down, you say ? If your chimney is foul, sweep it ; but don't expect that you can ever air a room with only one aperture ; don't suppose that to sliut up a room is the way to keep it clean. It is the best way to foul the room and all that is in it. Don't imagine that if you, who are in charge, don't look to all these things yourself, those under you will be more careful than you are. It appears as if the part of a mistress now is to complain of her servants, and to accept their excuses — not to show tliem how there need be neither complaints made nor excuses. But again, to look to all these things yourself does not mean to Headinchargo do them yourself. " I always open the windows," the head in Yl^^\ ^^^ *^ charge often says. If you do it, it is by so much the better, cer- giene!iiordo tainly, than if it were not done at all. But can you not insure that it hereelf. 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. And now, you think these things trifles, or at least exaggerated. I->oe3 God But what you " think " or what I *' think " matters little. Let us t^ink of these see what God thinks of them. God always justifies His ways, ^'^'"^^f'i'^ AVhile we are thinking, He has been teaching. I have known ^^"^"^ ^ ' cases of hospital pyaemia quite as severe in handsome private houses as in any of the worst hospitals, and from the same cause, viz., foul air. Yet nobody learnt the lesson. Nobody learnt anything at all from it. They went on thinking — thinking that the sulferer had scratched his thumb, or that it was singular that "all the servants" had "whitlows," or that something was "much about this year; there is always sickness in our house." This is a favourite mode of thought — leading not to inquire what is the uniform cause of these general " whitlows," but to stille all inquiry. In wliat sense is " sickness" being " always there," a justification of its being " there" at all 1 I will tell you what was the cause of this hospital pyaemia being How docs He in that large private house. It was that the sewer air from an ill- carry out His placed sink was carefully conducted into all the rooms by sedulously l^i^^^^ opening all the doors, and closing all the passage windows. It wag that the slops were emptied into the foot pans ; — it was that the utensils were never properly rinsed ; — it was that the chamber c 18 NOTES OX ^'UESIXG. crockery was rinsed with dirty water ; — it was that the beds were never properly shaken, aired, picked to pieces, or changed. It was that the carpets and curtains were always musty ; — it was that the furniture was always dusty ; it was that the papered walls were satu- rated with dirt ; — it was that the floors were never cleaned ; — it was that the uninhabited rooms were never sunned, or cleaned, or aired ; — it was that the cupboards were always reservoirs of foul air ; — it was that the windows were always tight shut up at night ; — it was that no window was ever systematically opened, even in the day, or that the right window was not opened. A person gasping for air might open a window for himself But the servants were not taught to open the windows, to shut the doors ; or they opened the windows upon a dank well between high walls, not upon the airier court ; or they opened the room doors into the unaired halls and passages, by way of airing the rooms, ^ow all this is not fancy, but fact. How does He In that handsome house I have known in one summer three teach His cases of hospital pyaemia, one of phlebitis, two of consumptive lawsl cough : all the immediate products of foul air. "When, in temperate climates, a house is more unhealthy in summer than in winter, it is a certain sign of something wrong. Yet nobody learns the lesson. Yes, God always justifies His ways. He is teaching while you are not learning. This poor body loses his finger, that one loses his life. And all from the most easily preventible causes.* Physical dege- The houses of the grandmothers and great grandmothers of this neration in generation, at least the country houses, with front door and back famines. Its Joor always standing open, winter and summer, and a thorough causes. draught always blowing through — with all the scrubbing, and clean- ing, and polishing, and scouring which used to go on, the grand- mothers, 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 Servants' * I must say a word about servants' bed-rooms. From the way they are built, rooms. hut oftener from the way they are kept, and from no intelligent inspection what- ever being exei'cised over them, they are almost invariably dens of foul air, and the ''servants' health" suffers in an "unaccountable"' (1) v.ay, even in the country. For I am by no means speaking only of London houses, where too often servants are put to live under the ground and over the roof. But in a country ''mansion,'' which was really a " mansion," (not after the fashion of advertisements), I have known three maids who slept in the same room ill of scarlet fever. " How catching it is," was of course the remark. One look at the room, one smell of the room, Avas quite enough. It was no longer '' unaccountable." The room was not a small one ; it was up stairs, and it had two large windows— but nearly every one of the neglects enumerated above was there. HEALTH OF HOUSES. 19 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. AVith regard to the health of houses where there is a sick person, Don't make it often happens that the sick room is made a ventilating sliaft for the your sick- rest of the house. For while the house is kept as close, unaired, ^^^ora into a 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 tvhole house 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 ? We must not forget what, in ordinary language, is called Infection. " Infection;"* — a thing of which people are generally so afraid that they frequently follow the very practice in regard to it which they ought to avoid. Nothing used to be considered so infectious or contagious as small pox ; and people not very long ago used to cover up patients with heavy bed clothes, while they kept up large fires and shut the windows. Small pox, of course, under this regime, is very " infectious." People are somewhat wiser now in tlieir manage- ment of this disease. They have ventured to cover the patients lightly and to keep the windows open; and we hear much less of the "infection" of small pox than we used to do. But do people in our days act with more wisdom on the subject of " infection " in fevers — scarlet fever, measles, &c. — than their forefathers did with small pox ? Does not the popular idea of "infection" involve that people should take greater care of themselves than of the patient ? that, for instance, it is safer not to be too much with the patient, not to attend too much to his wants? Perhaps the best illustration of the utter absurdity of this view of duty in attending on " infectious" diseases is afforded by what was very recentlv the practice, if it is * Is it not living in a continual mistake to look upon diseases, as we do now, Diseases arc as separate entities, which must exist, like cats and dogs 1 instead of looking upon not individuals them as conditions, like a dirty and a clean condition, and just as much luidor arranged in our own control ; or rather as the reactions of kindly nature, against the condi- classes, like tions in which we have placed ourselves. cats and do"^, I was brought up, both by scientific men and ignorant women, distinctly to but conditions believe that small-pox, for instance, was a thing of which there was once a first growin:; out of specimen in the world, which went on propagating itself, in a peri)ctual chain of one another, descent, ju.st as much as that there was a first dog, (or a fii-st pair of dogs), and that suiall-pox would not begin itself any more than a new dog would begin without there having been a parent dog. Since then I have seen with my eyes and smelt with my nose small-pox grow- ing up in first specimens, either in close rooms or in overcrowded wards, where it coiild not by any possibility have been " caught," but must have begun. Nay, more, I have seen diseases begin, grow up, and pass into one another. Now, dogs do not pass into cats. I have seen, for instance, with a little overcrowding, continued fever grow up ; and with a little more, typhoid fever; and with a little more, typhus, and all in the same ward or hut. Would it not be far better, truer, and more practical, if we looked upon disease in this liyht] For diseases, as all experience shows, are adjectives, not noun substantives. c 2 20 KOTES 02f NUESING. Why must children have' measles, &.c. not so even now, m some plague-patient used to be of the European lazarets — in wHcli the condemned to tlie horrors of filth, over- crowding, and want of ventilation, while the medical attendant was ordered to examine the patient's tongue through an opera-glass and to toss him a lancet to open his abscesses with ! True nursing ignores infection, except to prevent it. Cleanliness and fresh air from open windows, with unremitting attention to the patient, are the only defence a true nurse either asks or needs. AVise and humane management of the patient is the best safe- guard against infection. 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 com- monly thought that children must have what are commonly called " children's epidemics," " current contagions," &c., in other words, that they are born to have measles, hooping-cough, perhaps even scarlet fever, just as they are born to cut their teeth, if they live. Now, do tell us, why must a child have measles ? Oh because, you say, we cannot keep it from infection — other children have measles — and it must take them — and it is safer that it should. But why must other children have measles ? And if they have, why must yours have them too ? If you believed in and observed the laws for preserving the health of houses which inculcate cleanliness, ventilation, white-washing, and other means, and which, by the way, are laws, as implicitly as you believe in the popular opinion, for it is nothing more than an opinion, that your child must have children's epidemics, don't you think that upon the whole your child would be more likely to escape altogether? III. PETTI MANAGEMENT. Petty management. All the results of good nursing, as detailed in these notes, may be spoiled or utterly negatived by one defect, viz. : in petty manage- ment, 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 tJie?^e. Nor is it desirable that she should. And she may give up her health, all her other duties, and yet, for want of a little management, be not one-half so efficient as another who is not one-half so devoted, but who has this art of multiplying herself — that is to say, the patient of the first will not really be so well cared for, as the patient of the second. It is as impossible in a book to teach a person in charge of sick how to manage, as it is to teach her how to nurse. Circumstances must vary with each different case. But it is possible to press upon her to think for herself : Now what does happen during my absence ? I am obliged to be away on Tuesday. But fresh air, or punctuality is not less important to my patient on Tuesday than it was on PETTY MANAGEMENT. 21 Monday. Or : At 10 p.^r. I am never with my patient ; but quiet is of no less consequence to him at 10 than it was at 5 minutes to 10. Curious as it may seem, this very obvious consideration occurs comparatively to few, or, if it does occur, it is only to cause the devoted friend or nurse to be absent fewer hours or fewer minutes from her patient — not to arrange so as that no minute and no hour shall be for her patient without the essentials of her nursing. A very few instances will be sufficient, not as precepts, but as Illustrations of illustrations. the want of it. A strange washerwoman, coming late at night for the "things," Strangers will burst in by mistake to the patient's sick-room, after he has coming into 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. The patient's room may always have the window open. But the Sjck room passage outside the patient's room, though provided with several large ^^"ng the 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. An uninhabited room, a newly painted room,* an uncleaned Uninhabited closet or cupboard, may often become a reservoir of foul air for the ^°^°^ fouling whole house, because the person in charge never thinks of arranging , ^® ^hole that these places shall be always aired, always cleaned ; she merely opens the window herself "when she goes in." An agitating letter or message may be delivered, or an important l^clivcry and letter or message 7iot delivered ; a visitor whom it was of consequence ^f jg^f ^\^^^a to see, may be refused, or one whom it was of still more consequence messages. 7iot to see may be admitted — because the person in charge has never asked herself this question, AVhat is done when I am not there ? f At all events, one may safely say, a nurse cannot be with the * That excellent paper, the Builder, mentions the lingering of the smell of Lingering paint for a month about a house as a proof of want of ventilation. Certainly — smell of paint and, where there are ample windows to open, and these are never opened to get a want of care. 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 ] i Why should you let your patient ever be surprised, except by thieves? I do Why let vour not know. In England, people do not come down the chimney, or through the patient eVer window, unless they are thieves. They come in by the door, and somebody must ]^^, surprised open the door to them. The "somebody" charged with opening the door is one of two, three, or at most four persons. Why cannot these, at most, four persons be put in charge as to what is to be done when there is a ring at the door bell ! The sentry at a post is changed much oftener than any servant at a private house or institution can possibly be. But what should we think of such an excuse a? this : that the enemy had entered such a post because A and not li had been on guard ? Yet I have constantly heard such an excuse made in the private house or institution and accepted : viz., that such a person had been " let in " or not " let in," and such a parcel had been wrongly delivered or lost because A and not B had opened the door ! 2^ ^^OTES OX IS-URSIXG. Partial mea- sures such as " being always in tlie way" yourself, in- crease instead of saving th i patient's anxiety. Be- cause tiiey must be only partial. What is the cause of half the accidents which happen ? patient, open the door, eat her meals, take a message, all at one and the same time. Nevertheless the person in charge never seems to look the impossibility in the face. Add to this that the attempting this impossibility does more to increase the poor Patient's hurry and nervousness than anything else. It is never thought that the patient remembers these things if YOU do not. He has not only to think -whether the visit or letter may arrive, but whether you will be in the way at the particular day and hour when it may arrive. So that your partial measures for "being in the way" yourself, only increase the necessity for his thought. Whereas, if you could but arrange that the thing should always be done whether you are there or not, he need never think at all about it. For the above reasons, whatever a patient can do for himself, it is better, i.e. less anxiety, for him to do for himself, unless the person in charge has the spirit of management. It is evidently much less exertion for a patient to answer a letter for himself by return of post, than to have four conversations, wait five days, have six anxieties before it is off his mind, before the person who is to answer it has done so. Apprehension, uncertainty, waiting, expectation, fear of surprise, do a patient more harm than any exertion. Eemember, he is face to face with his enemy all the time, internally wrestling with him, having long imaginary conversations with him. Ton are thinking of something else. "Eid him of his adversary quickly," is a first rule with the sick.'-" Por the same reasons, always tell a patient and tell him before- hand when you are going out and when you will be back, whether it is for a day, an hour, or ten minutes. Tou 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. iso such thing. Tou onglit 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 Avhen 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 precaution? as to the things which concern you both, or which you do for him. 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 * There are many physical operations where ccBteris paribus the danger is in a direct ratio to the time the operation lasts; and cceteris paribus the operators success will be in direct ratio to his quickness. K'ow there are many mental ope- rations where exactly the same rule holds good with the sick ; cceteris jyaribus their capability of bearing such operations depends directly on the quickness, without hurry, with which they can be got through. PETTY MANAGEMENT. 23 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 o-" its not being a justification. The person in charge was quite right not to be " there,'' he was called away for quite sufficient reason, or he was away for a daily recurring and unavoidable cause : yet no provision was made to supply his absence. The fault was not in his " being away," but in there being no management to supplement his " being away." When the sun is under a total eclipse or during his nightly absence, vre light candles. But it would seem as if it did not occur to us that Ave must also supplement the person in charge of sick or of children, whether under an occasional eclipse or during a regular absence. In institutions where many lives would be lost and the effect of such want of management would be terrible and patent, there is less of it than in the private house.* Petty manage - * So true is this that I could mention two cases of women of very high posi- ment better tion, both of whom died in the same way of the consequences of a surgical understood in operation. And in both cases, I was told by the highest authority that the fatal institutions result would not have happened in a London hospital. than in private But, as far as regards the art of petty management in hospitals, all the mili- houses, tary hospitals I know must be excluded. Upon my own experience I stand, and ,y. . . 1 solemnly declare that I have seen or known of fatal accidents, such as suicides . ^ ^^^th"" in ^e//nu"m 'a. Noise wliicli excites expec tation. Whispered conversation in the room. you have gained more than the mere respite. Eotli the pi^obability 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. I have often been surprised at the thoughtlessness, (resulting in cruelty, quite unintentionally) of friends or of doctors who will hold a long conversation just in the room or passage adjoining to the room of the patient, who is either every moment expecting them to come in, or who has just seen them, and knows they are talking about him. If he is an amiable patient, he will try to occupy his attention elsewhere and not to listen — and this makes matters worse — for the strain upon his attention and the effort he makes are so great that it is well if he is not worse for hours after. If it is a whispered conversation in the same room, then it is absolutely cruel ; for it is impossible that the patient's attention sliould 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 ic is often mistaken for such ; quickness, lightness, and gentleness are quite compatible. Again, if friends and doctors did but watch, as nurses can and should watch, the features sharpening, the eyes growing almost wild, of fever patients who are listening for the entrance from the corridor of the persons whose voices they are hearing there, these would never run the risk again of creating such expectation, or irritation of mind. — Such unnecessary noise has undoubtedly induced or aggravated delirium in many cases. I have known sucb — in one case death ensued. It is but fair to say that this death was attri- buted 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 communi- cated to him, will hesitate to believe that it was mere fear which pro- duced, 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. 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 know- ledge of the patient is, if possible, worst of all. Noiseoffemale It is, I think, alarming, peculiarly at this time, when the female dress. ink-bottles are perpetually impressing upon us "woman's" " parti- Or just out- side the door ^■OISE. 27 cular TTorth and general niissionariness," 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 shufiles or waddles — only a man can cross the floor of a sick-room without shaking it ! Wliat is become of woman's light Btep ? — the firm, light, quick step we have been asking for ? Unnecessary noise, then, is the most cruel absence of care which can be inflicted either on sick or well. For, in all these remarks., the sick are only mentioned as suffering in a greater proportion than the well from precisely the same causes. Unnecessary (although sliglit) noise injures a sick person much more than necessary noise (of a much greater amount). All doctrines about mysterious affinities and aversions will be Patient's re- found to resolve themselves very much, if not entirely, into presence P^^s^o^i ^ •I ' c • J.^ ^1 ■ nurses who or absence or care in these things. ru-tle I ~-^ A nurse who rustles (£ am speaking of nurses professional and unprofessional) is the horror of a patient, thougli perhaps he does not know why. Tlie fidget of silk and of crinoline, the rattlins; of keys, the creaking of stays and of shoes, will do a patient more harm than all the medi- cines in the world will do him good. The noiseless step of woman, the noiseless drapery of woman, are mere figures of speech in this day. Her skirts (and well if they do not throw down some piece of furniture) will at least brush against every article in the room as she moves.* Again, one nurse cannot open the door without making everything rattle. Or she opens the door unnecessarily often, for want of remembering all the articles that might be brought in at once. A good nurse will always make sure that no door or window in her patient's room shall rattle or creak ; that no blind or curtain shall, by any change of wind througli the open window, be made to flap — especially will she be careful of all this before she leaves her patients for the night. If you wait till your patients tell you, or remind you of these things, where is the use of their having a nurse? There are more shy than exacting patients, in all classes ; and many * Fortunate it is if her skirts do not catch fire — and if the nurse does not give Burning of the herself up a sacrifice together with her patient, to be burnt in lier own petticoats, crinolines. I wi.'OTES ON KrESIXG. Iron spring bedstead the best. Comfort and cleanliness of tico beds. Bed not to be too "R-ide, Bed not to be too higb. in," and I can only hope it is not true. TThat ? is the bed already saturated Ts-itb 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 ? ISo, not one. " It has been slept in every night." The only way of really nursing a real patient is to have an vrGn 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| feet wide. If the patient be entirely confined to his bed, there should be iico such bedsteads ; each bed to be '* made" with mattress, sheets, blankets, &c., complete — the patient to pass twelve hours in each bed ; on no account to carry his sheets with him. The whole of the bedding to be hung up to air for each intermediate twelve hours. Of course there are many cases where this cannot be done at all — many more where only an approach to it can be made. I am indicating the ideal of nursing, and what I have actually had done. But about the kind of bedstead there can be no doubt, whether there be one or two provided, Ther-e is a prejudice in favour of a wide bed — I believe it to be a prejudice. All the refreshment of moving a patient from one side to the other of his bed is far more effectually secured by putting him into a fresh bed ; and a patient who is really very ill does not stray far in bed. But it is said there is no room to put a tray down on a narrow bed. Ko 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 — a thing impossible if the bed be either too wide or too high. "When I see a patient in a room nine or ten feet high upon a bed between four and five feet high, with his head, when he is sitting up in bed, actually within two or three feet of the ceiling. I ask myself, is this expressly planned to produce that peculiarly distressing feeling common to the sick, 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 per- versity any farther go, in unmaking the process of restoration which God has made r The fact is, that the heads of sleepers or of sick should never be higher than the throat of the chimney, which ensures their being in the current of best air. And we will not suppose it possible that you have closed your chimney with a chimney-board. If a bed is higher than a sofa, the difference of the fatigue of getting in and out of bed will just make the difference, very often, to LIGHT. 47 the patient (who can get in and out of bed at all) of being able to take a few minutes' exercise, either in the open air or in another room. It is so very odd that people never think of this, or of how many more times a patient who is in bed for the twenty-four hours is obliged to get in and out of bed than they are, who only, it is to be hoped, get into bed once and out of bed once during the twenty-four hours. A patient's bed should always be in the lightest spot in the room ; Nor in a dark and he should be able to see out of window. place. I need scarcely say that the old four-post bed with curtains is Xor a four utterly inadmissible, whether for sick or well. Hospital bedsteads poster with are in many respects very much less objectionable than private c'^^^^his. ones. There is reason to believe that not a few of the apparently unac- Scrofula often countable cases of scrofula among children proceed from the habit ^ result of dis- of sleeping with the head under the bed clothes, and so inhaling air F'^f!/^/{,°5 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 exhala- tions from his skin. A good nurse will be careful to attend to this. It is an important part, so to speak, of ventilation. It may be worth while to remark, that where there is any danger Bed sores, of bed-sores a blanket should never be placed under the patient. It retains damp and acts like a poultice. Never use anything but light Witney blankets as bed covering Heavy and im- for the sick. The heavy cotton impervious counterpane is bad, for pervious bed- the very reason that it keeps in the emanations from the sick person, clothes, while tiie blanket allows them to pass through. AVeak patients are invariably distressed by a great weight of bed-clothes, which often prevents their getting any sound sleep whatever. XoTE. — One word about pillows. Every weak patient, be lii^s illness what it may, snflTers more or less from difficulty in breathing. To take the we ght of the body off the poor chest, which is hardly up to its work as it is, ousrht therefore to be the object of the nurse in arranging his pillows. Now what docs 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 fa?t, lean upon the patient, not the patient upon the ])illows. It is impossible to give a rule for this, because it must vary with the figure of the patient. And tall patients suffer mu'di more than short ones, because of the drag of the long limbs upon the waist. But the object is to support, with the pillows, the back below the breathing apparatus, to allow the shoulders room to fall back, and to support the head, without throwing it forward. The suffering of dying patients is im- mensely increased by ncL'-lect 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. IX. LIGHT. It is the unqualified result of all my experience with the sick. Light essential that second only to their need ef fresh air is their need of light : ^^ ^^^th health and recovery. 48 NOTES Olf IfUESING. that, after a close room, what hurts tliem 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. Ton admit that he does the photograph. Without going into any scientific exposition we must admit that light has quite as real and tangible effects npon 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 expe- rience. Gro into a room where the shutters are always shut, (in a sick room or a bedroom there should never be shutters shut), and though the room be uninhabited, though the air has never been polluted by the breathing of human beings, you will observe a close, musty smell of corrupt air, of air i. e. unpurified by the effect of the sun's rays. The mustiness of dark rooms and corners, indeed, is proverbial. The cheerfulness of a room, the usefulness of light in treatiuej disease is all-important. Aspect, view, j^ vgj.y ]-jigh authority in hospital construction has said that and sunlight pg^p^Q ^q j^qj^ enough consider the difference between wards and importance ^"^ dormitories in planning their buildings. But I go farther, and say, to ilie sick. that healthy people never remember the difference between heel- rooms and sick-rooms, in making arrangements for the sick. To a sleeper in health it does not signify what the view is from his bed. He ought never to be in it excepting when asleep, and at night. Aspect does not very much signify either (provided the sun reach his bed-room some time in every day, to purify the air), because he ought never to be in his bed-room except during the hours when there is no sun. But the case is exactly reversed with the sick, even should they be as many hours out of their beds as you are in yours, which probably they are not. Therefore, that they should be able^ without raising themselves or turning in bed, to see out of window from their beds, to see sky and sun-light at least, if you can show them nothing else, I assert to be, if not of the very first importance for recovery, at least something very near it. And you should there- fore 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 tlie mid-day sun — the hours when they are quite certain not to be up, are of more importance to them, if a choice must be made, than the afternoon sun. Perliaps 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. Another great difference between the hed-room and the sick-voom is, that the sleeper has a very large balance of fresh air to begin with, when he begins the night, if his room has been open all day as it ought to be ; the sick man has not, because all day he has been CLEANLINESS OF llOGMS AND WALLS. 49 breathing the air in the same room, and dirtying it by the emanations from himself. Far more care is therefore necessary to keep up a constant change of air in the sick room. It is hardly necessary to add that tliere are acute cases, (particu- larly 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. Tou can always moderate the light by blinds and curtains. Heavy, thick, dark window or bed curtains should, however, hardly ever be used for any kind of sick in this country. A light white curtain at tlie head of the bed is, in general, all that is neces- sary, and a green blind to the window, to be drawn down only when necessary. One of the greatest observers of human things (not physiological), Without suu- aays, in another language, " AVhere there is sun there is thought." liglit, we de- All physiology goes to confirm this. Where is the shady side of »*^'"^"^^.**^ '"^*'.^' deep valleys, "there is cretinism. Where are cellars and the un- ^ ni>"d- sunned sides of narrow streets, there is the degeneracy and weakli- ness of the human race — mind and body equally degenerating. Put the pale withering plant and human being into the sun, and, if not too far gone, each will recover health and spirit. It is a curious thing to observe how almost all patients lie with Almost all their faces turned to tlie light, exactly as plants always make their patients lie way towards the light ; a patient will even complain that it gives "^^'^'^^ ^^^^^^ him pain "lying on that side." "Then why do you lie on that {j.'if^^^ ^"^ ^''^ side?" He does not know, — but we do. It is because it is the side ° towards the window. A fashionable physician has recently published in a government report that he always turns his patients' faces from the light. Tes, but nature is stronger than fashionable physicians, and depend upon it she turns the faces back and towards such light as she can get. Walk through the wards of a hospital, remember the bed sides of private patients you have seen, and count how many sick 3'ou ever saw lying with their faces towards the wall. X. CLEANLINESS OF EOOMS AND WALLS. It cannot be necessary to tell a nurse that she should be clean. Cloanljp.oss of or that she should keep her patient clean, — seeing that the greater carpets and part of nursing consists in preserving cleanliness. No ventilation furniture, 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 abovemcntioned dirty circumstances, no opening of windows could ever keep those E 50 IfOTES ON NUESIKG. Dust never re- moved now. Floors. Papered, plastered, oil- painted walls. How a room is dudtecl. rooms free from closeness ; but the carpet and curtains Laving: been turned out of the rooms altogether, they became instantly as fresh as could be wished. It is pure nonsense to say that in London a room cannot be kept clean. Many of our hospitals show the exact reverse. But no particle of dust is ever or can ever be removed or really- got rid of by the present system of dusting. Dusting in these days means nothing but flapping the dust from one part of a room on to another with doors and windows closed. What you do it for I cannot think. Tou 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 precmcts. 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.* Flapping by way of cleaning is only admissible in the case of pictures, or anything made of paper. The only way I know to remove dust, the plague of all lovers of fresh air, is to wipe everything with a damp cloth. And all furniture ought to be so made as that it may be wiped with a damp cloth without injury to itself, and so polished as that it may be damped without injury to others. To dust, as it is now practised, truly means to distribute dust more equally over a room. As to floors, the only really clean floor I know is the Berlin lachered floor, which is wet rubbed and dry rubbed every morning to remove the dust. The French parquet is always more or less dusty, although infinitely superior in point of cleanliness and healthiness to our absorbent floor. For a sick room, a carpet is perhaps the worst expedient which could by any possibility have been invented. If you must have a carpet, the only safety is to take it up two or three times a year, instead of once. A dirty carpet literally infects the room. And if you consider the enormous quantity of organic matter from the feet of people coming in, which must saturate it, this is by no means surprising. As for walls, the worst is the papered wall ; the next worst is plaster. But the plaster can be redeemed by frequent lime-washing;, the paper requires frequent renewing. A glazed paper gets rid of a * 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 there- fore comparatively clean from dust or blacks, the poor " things' having " caught" it, they are removed to other chairs, tables, sofas, upon which you could write your name with your finger in the dust or blacks. The other side of the " things" is therefore now evenly dirtied or dusted. The housemaid then flaps every thing, or some things, not out of her reach, with a thing called a duster — the dust flies ap, then re-settles more equally than it lav before the operatiort. The room has now been " put to rights." CLEANLINESS OF EOOMS AND WALLS. 51 good deal of the danger. But the ordinary bed-room paper is all that it ought not to be.* The close connection between ventilation and cleanliness is shown in this. An ordinary light paper will last clean much longer if there is an Arnott's ventilator in the chimney than it otherwise would. The best wall now extant is oil paint. From this you can wash the animal exuvia.t These are what make a room musty. The best wall for a sick-room or ward that could be made is Best kind of pure white non-absorbent cement or glass, or glazed tiles, if they wall for a were made sightly enough. sick-room. Air can be soiled just like water. If you blow into water you will soil it witli the animal matter from your breath. So it is with air. Air is always soiled in a room where walls and carpets are saturated with animal exhalations. Want of cleanliness, then, in rooms and wards, which you have to guard against, may arise in three ways. 1. Dirty air coming in from without, soiled by sewer emanations, Dirty air from the evaporation from dirty streets, smoke, bits of unburnt fuel, bits without. of straw, bits of horse dung. If people would but cover the outside walls of their houses -with Best kind of plain or encaustic tiles, what an incalculable improvement would wall for a there be in light, cleanliness, dryness, warmth, and consequently house, economy. The play of a fire-engine would then effectually wash the outside of a house. This kind of loalling would stand next to paving in improving the health of towns. 2. Dirty air coming from within, from dust, which you often Dirty air from displace, but never remove. And this recalls what ought to be a within. sine qua non. Have as few ledges in your room or ward as possible. And under no pretence have any ledge whatever out of sight. Dust accumulates there, and will never be wiped off. This is a certain way to soil the air. Besides this, the animal exhalations from your inmates saturate your furniture. And if you never clean your furniture properly, how can your rooms or wards be anything but musty ? Ventilate as you please, the rooms will never be sweet. Besides this, there is a constant (hr/rodation, as it is called, taking place from everything except polished or glazed articles — E. g., in colouring certain green papers arsenic is used. Now in the verv dust even, which is lying about in rooms hung with this kind of green paper, arsenic has been distinctly detected. Ton see your dust is anything but harmless ; yet you will let such dust lie about your ledges for months, your rooms for ever. Atmosphere in * I am sure that a person who has accustomed her senses to compare atnios- painted and phercs proiter and improper, for tlic .sick and lor children, could toll, hlindfold, jKipcrcfl rooms the ditference of the air in ohl painted and in old papered rooms, cceterl^ paribiu: quite di.stiu- The latter will always be musty, even with all the windows open. guishahle. t If you like to wipe your dirty door, or some portion of your dirty wall, by How to keep hanguig up your clean gown or shawl against it on a peg, this is one way cer- your wall taiuly, and the most usual M'ay, and generally the only way of cleaning either door clean at the or wall ill a bedroom 1 expcnce of E 2 your clothes 52 yOTES ON KUESING. Again, the fire fills the room with coal-dust. Dirty air from 3. Dirty air coming from the carpet. Above all, take care of the the carpet, 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. Remedies. The outer air, then, can only be kept clean by sanitary improve- ments, and by consuming smoke. The expense in soap, which this single improvement would save, is quite incalculable. The inside air can only be kept clean by excessive care in the ways mentioned above — to rid the walls, carpets, furniture, ledges, &c., of the organic matter and dust — dust consisting greatly of this organic matter — with which they becom.e saturated, and which is what really makes the room musty. "Without cleanliness, you cannot have all the effect of ventilation ; without ventilation, you can have no thorough cleanliness. A^ery few people, be they of what class they may, have any idea of the exquisite cleanliness required in the sick-room. Eor much of what I have said applies less to the hospital than to the private sick- room. The smoky chimney, the dusty furniture, the utensils emptied but once a day, often keep the air of the sick constantly dirty in the best private houses. The well have a curious habit of forgetting that what is to them but a trifling inconvenience, to be patiently " put up " with, is to the sick a source of suff'ering, 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, thej^ can change their posture or their position in the room. But the sick man, who never leaves his bed, who cannot change by any movement of his own his air, or his light, or his warmth; who cannot obtain quiet, or get out of the smoke, or the smell, or the dust ; he is really poisoned or depressed by what is to you the merest trifle. " What can't be cured must be endured," is the very worst and most dangerous maxim for a nurse which ever was made. Patience .and resignation in her are but other words for carelessness or indiflfereuce — contemptible, if in regard to herself; culpable, if in regard to her sick. XI. PEESONAL CLEANLINESS. Poisoning by In almost all diseases, the function of the skin is, more or less, the skin. 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 PEESONAL CLEANLINESS. 53 should keep tliis fact constantly in mind, — for, if she allow her sick to remain unwashed, or their clothing ^o remain on them after being saturated with perspiration or other excretion, she is interfering injuriously with the natural processes of health just as effectually as if she were to give the patient a dose of slow poison by the mouth. Poisoning by the skin is no less certain than poisoning by the mouth — only it is slower in its operation. The amount of relief and comfort experienced by sick after the Ventilation skin has been carefully washed and dried, is one of the commonest and skin-cleau' observations made at a sick bed. But it must not be forgotten that liness equally the comfort and relief so obtained are not all. They are, in fact, cfisential. nothing more than a sign that the vital powers have been relieved by removing something that was oppressing them. The nurse, there- fore, must never put oft* attending to the personal cleanliness of her patient under the plea that all that is to be gained is a little relief, which can be quite as well given later. In all well-regulated hospitals this ouglit to be, and generally is, attended to. But it is very generally neglected with private sick. Just as it is necessary to renew the air round a sick person frequently, to carry oft' morbid eftluvia from the lungs and skin, by maintaining free ventilation, so is it necessary to keep the pores of the skin free from all obstructing excretions. The object, both of ventilation and of skin-cleanliness, is pretty much the same, — to wit, removing noxious matter from the system as rapidly as possible. Care should be taken in all these operations of sponging, washing, and cleansing the skin, not to expose too great a surface at once, bo as to check the perspiration, which would renew the evil in another form. The various ways of washing the sick need not here be specified, — the less so as the doctors ought to say which is to be used. In several forms of diarrhoea, dysentery, &c., where the skin is hard and harsh, the relief aftbrded by washing with a great deal of soft soap is incalculable. In other cases, sponging with tepid soap and water, then with tepid water and drying with a hot towel will be ordered. Every nurse ought to be careful to wash her liands very fre- quently during the day. If her face too, so much the better. One word as to cleanliness merely as cleanliness. Compare the dirtiness of the water in t\hich you have washed Sfoamin? nnd when it is cold without soap, cold with soap, hot with soap. You ruKbiug the 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 otf fiakes of dirt or dirty skin. Alter a vapour bath you may peel your whole self clean in this way. What I mean is, that by simply washing or sponging with water you do not really clean your skin. Take a rough towel, dip one corner in very hot water, — if a little spirit be added to it it will be more elfectual, — and then rub as if you were rubbing the towel into your skin with your fingers. The black fiakes which will come off* will convince 54 NOTES OX NUESING. 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 aiforded, and when they could not be moved out of their berths, as if all the appurtenances of home had been at hand. Washing, however, with a large quantity of water has quite other effects than those of mere cleanliness. The skin absorbs the water and becomes softer and more perspirable. To wash with soap and soft water is, therefore, desirable from other points of view than that of cleanliness. XII. CHATTEEIXG HOPES AND ADVICES. Advising the The sick man to his advisers. sit;k. " ^ly ad\ isers ! Their name is legion. * * # Somehow or other, it seems a provision of the universal destinies, that every man, woman, and child should consider him, her, or itself privileged especially to advise me. Why ? That is precisely what I want to know." And this is what I have to say to them. I have been advised to go to every place extant in and out of England — to take every kind of exercise by every kind of cart, carriage — yes, and even swing (!) and dumb-bell (!) in existence ; to imbibe every different kind of [stimulus that ever has been invented. And this when those hist 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 pntieiit must perforce say, in sheer self-defence, like Kosalind, *• I could not do with all." Chattering " Chattering Hopes" may seem an odd heading. But I really hopes the bane 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 expe- rience, wide and long, of its effects during sickness observed both upon others and upon myself. I would ajipeal 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. Ear more now than lormerly does the medical attendant tell the truth to the sick who are really desirous to hear it about their own state. of the sick. CHATTEEIXG HOPES AND ADVICES. DO How intense is the folly, tlicn, to say the least of it, of the friend, be he even a medical man, who thinks that his opinion, given after a cursory observation, will weigh with the patient, against the opinion of the medical attendant, given, perhaps, after years of observation, after using every help to diagnosis afforded by the stethoscope, the examination of pulse, tongue, &c. ; and certainly after much more observation than the friend can possibly have had. Supposing the patient to be possessed of common sense, — how can the '"favourable" opinion, if it is to be called an opinion at all, of the casual visitor " cheer " him, — when different from that of the experienced attendant ? Unquestionably the latter may, and often does, turn out to be wrong. But which is most likely to be wrong ? The fact is, that the patient* is not "cheered" at all by these Patient does well-meaning, most tiresome friends. On the contrary, he is de- not want to pressed and wearied. If, on the one hand, he exerts himself to tell talk of himself, each successive member of this too numerous conspiracy, whose name is legion, why he does not think as they do, — in what respect he is worse, — what symptoms exist that they know nothing of, — he is fatigued instead of " cheered," and his attention is fixed upon himself. In general, patients who are really ill, do not want to talk about themselves. Hypochondriacs do, but again I say we are not on the subject of hypochondriacs. If, on the other hand, and which is much more frequently the case. Absurd conso- the patient says nothing, but the Shakespearian "Oh !" "Ah!" "Go lations put to!" and " In good sooth 1" in order to escape from the conversation forth for the about himself the sooner, he is depressed by want of sympathy. He ^.^-'^^fit of the 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 pulliiig the string upon himself of this * There are, of course cases, as in first confinements, when an assurance from Absurd statis- the doctor or experienced nurse to the frightened sufiering woman thdt there is tical compari- nothing unusual in her case, that she has nothing to fear Init a few hours" pain, sons made in may cheer her most eflectually. This is advice of quite another order. It is the common con- advice of experience to utter inexperience. But the advice we have been refer- versation by ring to is the advice of inexperience to bitter experience; and, in general, the most sen- amounts to nothing more than this, that you think / shall recover from consump- sible people tion, because somebody knows somebody somewhere who has recovered from for the benefit fever. ' of the sick. I have heard a doctor condemned whose patient did not, alas ! recover, be- cause another doctor's patieut of a tliffi rfut sex, of a tiijercut age, recovered from a different disease, in a (I'lffmnif phice. Yes, this is really true. If jieople who make these compari.^ons did but know (only they do not care to know), the care and preciseness with which such compari.sons 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 compari.son between old men with dropsies and young women with consumptions. Yet, the cleverest men and the cleverest wumcn are often heard making .^^uch comparison!, ignoring entirely sex, age,di.scasc, place — in fact, all the conditions essential to the question. It is the merest gotssip. 50 >^OTES ON NUESING. 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, " unex- pectedly 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 1 feel entitled to believe, both from the internal evidence in such stories, and from watching similar cases: there was every reason to expect that A. would die, and he knew it ; but he found it useless to insist upon his own knowledge to his friends. In these remarks I am alluding neither to acute cases which terminate rapidly nor to "nervous " cases. By the first much interest in their own danger is very rarely felt. In writino:s 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 stale. The "nervous case," on the other hand, delights in fguring to himself and others a fictitious danger. But the long chronic case, who knows too well himself, and who has been told by his physician that he will never enter active life again, who feels that every month he has to give up something he could do the month before — oh ! spare such sufferers your chattering hopes. You do not know how you worry and weary them. Such real sufferers cannot bear to talk of themselves, still less to hope for what they cannot at all expect. So also as to all the advice showered so profusely upon such sick^ to leave off some occupation, to try some other doctor, some other house, climate, pill, powder, or specific ; I say nothing of the incon- sistency— for these advisers are sure to be the same persons who exhorted the sick man not to believe his own doctor's prog- nostics, 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 occupa- tion, while exhorting him to leave his own. Womlerfulpre- Wonderful is the face with Vvhich friends, lay and medical^ sumptiou oV will come in and worry the patient with recommendations to do the advisers of something or other, having just as little knowledge as to its being the sick. feasible, or even safe for him, as if they were to recommend a- man to take exercise, not knowing he had broken his leg. AVhat would the friend say, if he were the medical attendant, and if the patient, because some other friend had come in, because some- body, anybody, nobody, had recommended something, anything, nothing, were to disregard his orders, and take that other body's- recommendation ? But people never think of this. CHATTEEING HOPES A^B ADYICES. 57 A celebrated historical personage has related the commou- Advijscr-; the ;es which, when on the eve of executing a remarkable reso- f^°^^ ^^^ ^-"^ iution, were showered in nearly the same words by every one around successively for a period of six months. To these the - = • personage states that it was found least trouble always to reply the same thing, viz., that it could not be supposed that such a resolution had been taken without sufficient previous consideration. To patients enduring every day for years from every friend or acquaintance, either by letter or viva voce, some torment of this kind, I would suggest the same answer. It would indeed be spared, if such friends and acquaintances would but consider for one moment, that it is probable tlie patient has heard such advice at least fifty times before, and that, had it been practicable, it would have been practised long ago. But of such consideration there appears to be no chance. Strange, though true, that people should be just the same in these things as they were a few hundred years ago ! To me these commonplaces, leaving their smear upon the cheerful, single-hearted, constant devotion to duty, which is so often seen in the decline of such sufferers, recall the slimy trail left by the snail on the sunny southern garden-wall loaded with fruit. No mockery in the world is so hollow as the advice showered ^^o<-"k'-r}' of upon the sick. It is of no use for the sick to say anything, for what o-iv^n t'o^^t-k the adviser wants is, not to know the truth about the state of the " patient, but to turn whatever the sick may say to the support of his own argument, set forth, it must be repeated, without any inquiry whatever into the patient's real condition. "But it would be im- pertinent or indecent in me to make such an inquiry," says the adviser. True ; and how much more impertinent is it to give your advice when you can know nothing about the truth, and admit you could not inquire into it. To nurses I say — these are the visitors who do your patient harm. When you hear him told: — 1. That he has nothing the matter with him, and that he wants cheering. 2. That he is com- mitting suicide, and that he ^Yants preventing. 3. That he is the tool of somebody who makes use of him for a purpose, i. 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 ; — then know that your patient is receiving all the injury that he can receive from a visitor. How little the real sufferings of illness are known or understood. How little does any one in good health fancy him or even Jicrsclt into the life of a sick person. Do, you who are about the sick or who visit the sick, try and give Means of them pleasure, remember to tell them what will do so. How often in .2:»^"^»- P^j^'i- such visits the sick person has to do the whole conversation, exerting ^j'J"j^' ^^ ^ '^' his own imagination and memory, while you would take the visitor, " absorbed in his own anxieties, making no cffol-t of memory or imagination, for the sick person. " Oh ! my dear, I have so much to think of, I really quite forgot to tell liim that; besides, I thought he 58 ]S'OTES o:n' nuesing. would kuoTT 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." Tl]ere are many burthened with business who always manage to keep a pigeon-hole in their minds, full of things to tell the " invalid." I do not say, don't tell him your anxieties — T believe it is good for him and good for you too; but if you tell him what is anxious, surely you can remember to tell him what is pleasant too. A sick person does so enjoy hearing good news: — for instance, of a love and courtship, while in progress to a good ending. If you tell him only when the marriage takes place, he loses half the pleasure, which God knows he has little enough of ; and ten to one but you have told him of some love-making with a bad ending. A sick person also intensely enjoys hearing of any material good, any positive or practical success of the right. He has so much of books and fiction, of principles, and precept?, and theories ; do, in- stead of advising him with advice he has heard at least fifty times before, tell him of one benevolent act which has really succeeded practically, — it is like a day"s health to him.* Ton have no idea what the craving of sick with undiminished power of thinking, but little power of doing, is to hear of good practical action, when they can no longer partake in it. Do observe these things with the sick. Do remember how their life is to them disappointed and incomplete. Tou see them lying there with miserable disappointments, from which they can have no escape but death, and you can't remember to tell them of what would give them so much pleasure, or at least an hour's variety. They don't want you to be lachrymose and whining with them, they like you to be fresh and active and interested, but they cannot bear absence of mind, and they are so tired of the advice and preach- ing they receive from every body, no matter whom it is, they see. There is no better society than babies and sick people for one another. Of course you must manage this so that neither shall suffer from it, which is perfectly possible. It you think the " air of the sick room" bad for the baby, wriy it is bad for the invalid too, and, therefore, you will of course correct it for both. It freshens up a sick person's whole mental atmosphere to see " the baby." And a very young child, if unspoiled, will generally adapt itself wonderfully to the ways of a sick person, if the time they spend together is not too long. If you knew how unreasonably sick people suffer from reasonable causes of distress, you would take more pains about all these things. An infant laid upon the sick bed will do the sick person, thus suffer- ing, more good than all your logic. A piece of good news will do the same. Perhaps you are afraid of "disturbing" him. Tou say there is no comfort for his present cause of afiiiction. It is perfectly * A small pet animal is often an excellent compan'on for the sick, for long chronic casecs especially. A pet bird in a cai^e 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. OBSEEVATION" OF THE SICK. 59 reasonable. The distinci-ion is this, if he is obliged to act, do not *' disturb" him with anotlier subject of thou^^ht just yet; help him to do what he wants to do : but, if he has done this, or if nothing can be done, then ''disturb" him by all means. You will relieve, more effectually, unreasonable suffering from reasonable causes by telling him "the news," showing him "the baby," or giving him something new to thiuk of or to look at than by all the logic in the world. It has been very justlv said that the sick are like children in this, that there is no proportion in events to them. Now it is your busi- ness as their visitor to restore this right proportion for them — 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 sufi"ering from unkindness, from want of sympathy, &c., will disappear with their freshened interest in the big world's events. But then you must be able to give them real interests, not gossip. Note. — There are two clai=scs of patients which arc unfortunately becoming ^^^ ^'^^ more common every day, especially among women of the richer orders, to whom ^ ^/!^^^^. ^ all these remarks are pre-eminently inapplicable. 1. Tho.se who make health an paticnts pecu- €xcuse for doing nothing, and at the same time allege that the bein- able to do ^^^ ° ^^ nothing is their only grief. 2. Those who have brought upon themselves ill- generaiion. health by over pursuit of amusement, which they and their friends have most unhappily called intellectual activity. I scarce'y know a greater injury that can be indicted than the advice too often given to the first class "to vegetate" — or than the admiration too often bestowed on the latter class for "pluck." XIII. OBSERYATIOX OF THE SICK. There is no more silly or universal question scarcely asked than What is the this, " Is he better ?" Ask it of the medical attendant, if you ])lea8e. use of the But of whom else, if you wish for a real answer to your question, g"^^^^^^'^"' ^^ ^^ would you ask it? Certainly not of the casual visitor; certainly not ot the nurse, while the nurse's observation is so little exercised as it is now. What you want are facts, not oi)inions— for who can have any opinion of" any value as to whether the patient is better or worse, excepting the constant medical attendant, or the really observing nurse ? The most important practical lesson that can be given to nurses is to teach them what to observe — how to observe— what symptoms indicate improvement — what' the reverse— which are of importance — which are of none— which are the evidence of neglect — and of what kind of neglect. All this is what ought to make part, and an essential part, of the training of every nurse. At present how few there are, either pro- fessional or unprolessional, who really know at all whether any sick person they may be with is better or worse. The vagueness and looseness of the information one receives in answer to that much abused question, "Is he better?" would be 60 l^OTES OJT NUESING. ludicrous, if it were not painful. The only sensible answer (in the present state of knowledge about sickness) would be " How can I know^ ? I cannot tell how he was when I was not with him." I can record but a very few specimens of the answers* which I have heard made by friends and nurses, and accepted by physicians and surgeons at the very bed-side of the patient, who could have contradicted every word, but did not — sometimes from amiability^ often from shyness, oftenest from languor ! "How often have the bowels acted, nurse?" "Once, sir." This generally means that the utensil has been emptied once, it having been used perhaps seven or eight times. " Do you think the patient is much weaker than he was six weeks ago 1" " Oh no, sir; you know it is very long since he has been up and dressed, and he can get across the room now." This means that the nurse has not observed that whereas six weeks ago he sat up and occupied himself in bed, he now lies still doing nothing; that, although he can "get across the room," he cannot stand for five seconds. Another patient who is eating well, recovering steadily, although slowl}^ from fever, but cannot walk or stand, is represented to the doctor as making no progress at all. * It is a much more difficult thing to speak the truth than people commonly imagine. There is the want of observation sinqjle, and the want of observation (-ompound, 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 stnpid. The second has observed just as little, but imagination immediately steps in, and he describes the whole thing from imagination merely, being perfectly convinced all the while that he has seen or heard it ; or he will repeat a whole conversation, as if it were information which had been addressed to him ; whereas it is merely what he has himself said to somebody else. This is the commonest of all. These people do not even observe that they have not observed nor re- member that they have forgotten. 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." " I knows I fibs dreadful : but believe me, ]Miss, I never finds out I have fibbed until they tells me so," was a remark actually made. It is also one of much more extended application than most people have the least idea of. Concurrence of testimony, which is so often adduced as final proof, may prove nothing more, as is well known to those accustomed to deal with the unobservant imaginative, than that one person has told his story a great many times I have heard thirteen persons "concur" in declaring that a fourteenth, who had never left his bed, went to a distant chapel every morning at seven o'clock. I have heard persons in perfect good faith declare, that a man came to dine every day at the house where they lived, who had never dined there once; that a person had never taken the sacrament, by whose side they had twice at least knelt at Communion ; that but one meal a day came out of a hospital kitchen, which for six weeks they had seen provide from three to five and six meals a day. Such instances might be multiplied ad infinitum if necessary. OBSERVATION OF THE SICK. Gl Questions, too, as asked now (but too generally) of or about licading ques- patients, would obtain no information at all about them, even if the t ions useless person asked of had every information to give. The question is ^^ nnslcading. generally a leading question; and it is singular that people never think what must be the answer to this question before they ask it: for instance, "Has he had a good night?" Now, one patient will think he has a bad night if he has not slept ten hours without waking. Another does not think he has a bad night if he has had intervals of dosing occasionally. The same answer has actually been given as regarded two patients — one who had been entirely sleepless for five times twenty-four hours, and died of it, and another who had not slept the sleep of a regular night, without waking. Why cannot the question be asked, How many hours' sleep has had ? and at what hours of the night?* "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 tlian to leading (piestions. Another frequent error is to inquire whether one cause remains, and not whether the effect which may be produced by a great many different causes, not inquired after, remains. As when it is asked, whether there was noise in the street last night ; and if there were not, the patient is reported, without more ado, to have liad a good night. Patients are completely taken aback by these kinds of leading ques- tions, and give only the exact amount of information asked for, even when they know it to be completely misleading. The shyness of patients is seldom allowed for. How few there are who, by five or six pointed questions, can elicit the whole case and get accurately to know and to be able to report ivhere the patient is. 1 knew a very clever physician, of large dispensary and hospital Mean:* of practice, who invariably began his examination of each patient with obtaining " Put your finger where you be bad." That man would never waste j^aceuratc his time with collecting inaccurate information from nurse or patient. ^^ oi'^^^^io"- Leading questions always collect inaccurate information. At a recent celebrated trial, the following leading question was put successively to nine distinguished medical men. " Can you attri- bute these symptoms to anything else but poison ?" And out of the nine, eight answered "No!" without any qualification whatever. It appeared, upon cross-examination : — 1. That none of them had ever 8een a case of the kind of poisoning supposed. 2. That none of them liad ever seen a case of the kind of disease to wliich the death, if not to poison, was attributable. 3. That none of them were even aware * This is important, because on tliis depends what the icmedy will be If a patient sleeps two or three hours early in the night, and then docs 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, ho 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 ? 62 NOTES ON NURSING. of the main fact of the disease and condition to which the death was attributable. Surely nothing stronger can be adduced to prove what use leading questions are of, and what they lead to. I had rather not say how many instances I have known, where, owing to this system of leading questions, the patient has died, and the attendants have been actually unaware of the principal feature of the case. As to food It is useless to go through all the particulars, besides sleep, in patient takes which people have a peculiar talent for gleaning inaccurate infor- or does not mation. As to food, for instance, I often think that most common ^^^' question, How is your appetite ? can only be put because the ques- tioner believes the questioned has really nothing the matter with him, which is very often the case. But where there is, the remark holds good which has been made about sleep. The same answer will often be made as regards a patient who cannot take two ounces of solid food per diem, and a patient who does not enjoy five meals a day as much as usual. Again, the question. How is your appetite ? is often put when How is your digestion ? is the question meant. No doubt the two things depend on one another. But they are quite different. Many a patient can eat, if you can only "tempt his appetite." The fault lies in your not having got him the thing that he fancies. But many another patient does not care between grapes and turnips, — everything is equally distasteful to him. He would try to eat any- thing which would do him good ; but everything " makes him worse." The iault here generally lies in the cooking. It is not his " appetite " which requires " tempting," it is his digestion which requires sparing. And good sick cookery will save the digestion half its work. There may be four different causes, any one of which will produce the same result, viz., the patient slowly starving to death from want of nutrition : 1. Defect in cooking ; 2. Defect in choice of diet ; 3. Defect in choice of hours for taking diet ; 4. Defect of appetite in patient. Yet all these are generally comprehended in the one sweeping assertion that the patient has " no appetite."^ ^ _ . Surely many lives might be saved by drawing a closer distinction; for the remedies are as diverse as the causes. The remedy for the first is, to cook better ; for the second, to choose other articles ot 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 some- times unexpectedly. But no one of these remedies will do for any other of the defects not corresponding with it. I cannot too often repeat that patients are generally either too languid to observe these things, or too shy to speak about them ; nor is it well that they should be made to observe them, it fixes their attention upon themselves. OBSEEVATIOX OF THE SICK. 6d Again, I say, what is the nurse or friend there for except to take note of these things, instead of tlie patient doing so ?"^ Again, the question is sometimes put, Is there diarrhoea ? And As to diar- the answer will be the same, whether it is just merging into cholera, ^"oea. whether it is a trifling degree bi-ought on by some trifling indiscre- tion, which will cease the moment the cause is removed, or whether there is no diarrhoea at all, but simply relaxed bowels. It is useless to multiply instances of this kind. As long as observation is so little cultivated as it is now, I do believe that it ia better for the physician not to see the friends of the patient at all. They will oftener mislead him tlian not. And as often by making the patient out worse as better than he really is. In the case of infants, everijtliuif] must depend upon the accurate observation of the nurse or mother who has to report. And how seldom is this condition of accuracy fultilled. A celebrated man, though celebrated only for foolish things, has Means of told us tliat one of his main objects in the education of his son, was cultivating to give him a ready habit of accurate observation, a certainty of per- sound and ception, and that for this purpose one of his means was a month's '"[^^^y obscrva- course as follows : — he took the boy rapidly past a toy-shop ; the father and son then described to each other as many of the objects as they could, which they had seen in passing the windows, noting them down with pencil and paper, and returning afterwards to verify their own accuracy. The boy always succeeded best, e.g., if the father described 30 objects, the boy did 40, and scarcely ever made a mistake. I have often thought how wise a piece of education this would be for much higher objects ; and in our calling of nurses the thing itself is essential. For it may safely be said, not that the habit of ready and correct observation will by itself make us useful nurses, but that without it we shall be useless with all our devotion. I have known a nurse in charge of a set of wards who not only carried in her head all the little varieties in the diets which each patient was allowed to fix for himself, but also exactly what each patient had taken during each day. I have known another nurse in charge of one single patient, who took away his meals day after day all but untouched, and never knew it. If you find it helps you to note down such things on a bit of paper, in pencil, by all means do so. 1 think it more often lames than strengthens the memory and observation. Eut 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. * It is commonly supposed that the nur?e is there to spare the patient from ^,[Q^Q impor- making physical exertion for himself— I wouUl rather say thatsheonglitto be there ^.^^^ ^^ spare to spare him from taking' thought for himself. And I am quite sure, that if the ^^^^ patient patient were spared all thoiinht for h.mself, and not spared all physical exertion, thought than he would he infinitely the gainer. The reverse is generally the ctise in the private physical oxer* house. In the ho.spital it is the relief from all an.xicty, afl'orded by the rules of a ^^^^^^ well-regulated institution, which has often such u beneficial cflect upon the patient. 61 irOTES ON Is'UESING. Sound and ready obscrva tion essential in a nurse. English ^vomt'ii have great capacity of, but little practice in close observa- tion. 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 ^ pint of beef tea;" instead of saying " B. has taken nothing all day," or " I gave A. his dinner as usual." I have known several of our real old-fashioned hospital " sisters," who could, as accurately as a measuring glass, measure out all their 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.* 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 * It may be too broad an assertion, and it certainly sounds like a paradox. But I think that in no country are women to be found so deficient in ready and sound observation as in England, while peculiarly capable of being trained to it. The French or Irish woman is too quick of perception to be so sound an observer — the Teuton is too slow to be so ready an observer as the English woman might be. Yet English women lay themselves open to the charge so often made against them by men, viz., that they are not to be trusted in handicrafts to which their strength is quite equal, for want of a practised and steady observation. In countries where women (with average intelligence certainly not superior to that of Englishwomen) are employed, e. g., in dispensing, men responsible for what these women do (not theorizing about man's and woman's "missions"), havestated that they preferred the service of women to that of men, as being more exact, more careful, and incurring fewer mistakes of inadvertence. Now certainly Englishwomen are peculiarly capable of attaining to this. I remember when a child, hearing the story of an accident, related by some one who sent two girls to fetch a " bottle of salvolatile from her room ;" *' Mary could not stir," she said, " Fanny ran and fetched a bottle that was not salvolatile, and that v.-ns not in my room." Now this sort of thing pursues every one through life. A woman is asked to fetch a large new bound red book, lying on the table by the window, and she fetches five small old boarded brown books lying on the shelf by the fire. And this, though she has " put that room to rights" every day for a month perhaps, and must have observed the books every day, lying in the same places, for a month, if she had any observation. Habitual observation is the more necessary, when any sudden call arises. If " Fanny " had observed " the bottle of salvolatile " in " the aunt's room," every day she was there, she would more probably have found it when it was suddenly wanted. Tiiere 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. 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 your- self had put it, if your memory is not in the habit of seeing the thing there always. OBSEETATIoy OF THE SICK. 65 has eaten all his diets as usual, when all she ought to have meant is that she has taken away his diets as usual. Now wliat kind of a nurse is this ? I would call attention to something else, in which nurses fre- DiflTerence of quently i'ail in observation. 'Jliere is a well-marked distinction ♦^•'^c^^ablc and between the excitable and what I will call the accumulative tempera- "c^'*"'*"/"^'^"^ ment in patients. One will blaze up at once, under any shock or ^'^™P^'"'^" 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 v.'ill find him some time after slowly sinking. The same remark applies to the action of narcotics, of ape- rients, which, in the one, take eftect directly, in the other not perhaps for twenty-four hours. A journey, a visit, an unwonted exertion, will aft'cct the one immediately, but he recovers after it ; the other bears it very well at the time, apparently, and dies or is pros- trated for life by it. People often say how diiiicult the excitable temperament is to manage. I say how difficult is the accumulative temperament. With the first you have an out-break which you could anticipate, and it is all over. With the second you never know where you are — you never know when the consequences are over. And it requires your closest observation to know what are the consequences of what — for the consequent by no means follows immediately upon the antecedent — and coarse observation is utterly at fault. Almost all superstitions are owing to bad observation, to the post Superstition Jioc, ergo propter hoc ; and bad observers are almost all superstitious, t-bc fruit of Farmers used to attribute disease among cattle to witchcraft ; ^ved- ^.^^ **^^*^^^^' dings 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. Another remark : although there is unquestionably a physi- phvsionomv ognomy of disease as well as of health ; of all parts of the body,"the of disease ' face is perhaps the one which tells the least to the common observer little shewn or the casual visitor. Because, of all parts of the body, it is ^*y ^^^ ^^'^' the one most exposed to other influences, besides health. And people never, or scarcely ever, observe enough to know how to dis- tinguish between the efiect of exposure, of robust health, of a tender skin, of a tendency to congestion, of suffusion, flushing, or many other things. Again, the face is often the last to shew emaciation. I should say that the hand was a much surer test than the face, both as to flesh, colour, circulation, &c., &c. It is true that there are some diseases which are only betrayed at all by something in the face, e.g., the eye or the tongue, as great irritability of brain by the appearance of the pupil of the eye. But we are talking of casual, not minute, observation. And few minute observers will hesitate to say that far more untruth than truth is conveyed by the olt repeated words, lie looks well, or ill, or better or worse. Wonderful is the way in which people will go uoon the slightest observation, or often upon no observation at all, or upon some saw which th.e world's experience, if it had any, would have pronounced utterly falac long ago. 1* 66 170TES ON NimSTNG. I have known patients dying of slieer 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 eiieek, but the mottled appearance uf a robust child. And scores of times have I heard these unfortunate creatures assailed with, " I am o-lad to see you looking so well." " 1 see no reason why you should not live till ninety years of age." " Why don't you take a little more exercise and amusement r" with all the other common- places with which we are so familiar. There is, unquestionably, a physiognomy of disease. Let tbe nurse learn it. The experienced nurse can always tell that a person kas 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 wiU point to as a proof of health. There is, again, a fiiintness, which does not betray itself by the colour at all, or in which the patient becomes brown instead of white. There is a taiiitness of another kind which, it is true, can always be seen by the paleness. But the nurse seldom distinguishes. She will talk to the patient who is too faint to move, without the least scruple, unless he is pale and unless, luckily for him, the muscles of the throat are affected and lie loses his voice. Yet these two faintnesses are perfectly distinguishable, by the mere countenance of the patient. Again, the nurse must distinguish between the idiosyncracies of patients. One likes to suffer out all bis suffering alone, to be as little looked after as possible. Another likes to be perpetually made muck 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. Again, I think that tew 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 patient's weak- ^ month or a vear ago. What is a nurse there for if she cannot S'lfofteU observe these 'things for herself? Yet I have known— and known too among those — and chiefly among those — whom money and position put in possession of everything which money and position could give — I have known, I say, more accidents, (fatal, slowly or rapidly,) arising from this want of observation among nurses than from almost anything else. Because a patient could get out of a warm-bath alone a month ago — because a patient could walk as far as his bell a week ago, the nurse concludes that he can do so now. She has never observed the change ; and the patient is lost from being left in a helpless state of exhaustion, till some one accidentally comes in. And this not from any unexpected apoplectic, paralytic, or fainting fit (though even these could be expected far more, at Peculiarities of patients. iSTursc must observe for herself in- crease of her. OBSERVATION OF THE SICK. 67 least, than they are now, if we did but observe). Xo, from tlie expected, or to be expected, inevitable, visible, calculable, uninter- rupted increase of weakness, which none need fail to observe. Again, a patient not usually confined to bed, is compelled by an Accidents attack of diarrhoea, vomiting, or other accident, to keep liis bed for a arisin.;,' from few days; he gets up for the first time, and the nurse lets him go ^^^ nurse's into another room, without cominor in, a few minutes afterwards, to ^^'^^^ of obser- 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 ouj^ht to make some excuse to go in to him. IMore 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. Yet it appears that scarcely any improvement in the faculty Is the faculty of observing is being made. A^'ast has been the increase of know- of obscrvini? ledge in pathology — that science which teaches us the final change ^"^ ^^^ decline, produced by disease on the human frame — scarce any in the art of observing the signs of the change while in progress. Or, rather, is it not to be feared that observation, as an essential part of medicine, has been declining ? Which of us has not heard fifty times, from one or another, a nurse, or a friend of the sick, aye, and a medical friend too, the following remark: — "So A is worse, or B is dead. I saw him the day before; I thought him so much better; there certainlv was no appearance from which one could have expected so sudden (?) a change." I have never heard any one say, though one would think it the more natural thing, " There must have been some appearance, which I should have seen if I had but looked; let me try and remember what there was, that I may observe another time." No, this is not what people say. They boldly assert that there was nothing to observe, not that their observation was at fault. Let people who have to observe sickness and death look back and try to register in their observation the appearances which have preceded relapse, attack, or death, and not assert that there were none, or tliat there were not the right ones.* A want of the habit of observing conditions and an inveterate Ohscn-ation habit of taking averages are each of them often equally misleading. ^^ ptncral • It falls to few ever to have had the opportunitj- of observinc: the difTcrent .\pproach of aspects which the human face puts on at the sudden approar-h of certain forms of death, palcnc.'^s death by violence; and as it is a knowledge of little use I only mention it here bv no means as bcitiu: the most startling example of what I mean. In the ntrvous tcm- an invariable peramcnt the face becomes pale (this is the only recognized effect), • in the effect, as we sanirn ne temperament purple; in the bilious yellow, or every manner of colour liud in novcU, 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 8aid~rf CO~ r-T i S 1 40- CO CO Si ^^ CI r-< 1 CO S So co_ {.iox J^ 8 •uoisiAid ins •S9I1U1103 uaais^Ai J^ ^ TILtOJi ■^ •noisiAitl '118 •S3nuno3 CO vmvm R o q'4J0,«^ -noisiAiQ qii, •S3nnn03 P'reiPfW ?) ?? l*3AV CI •noisiAKi i\%o •s9nTrao3 U.13JS3.V\. s ?i ijanos CO •aotsiAiQ ii;g •s9iiimo3 i OJ UJ3)Sir,[ o» •uoisiAjd mf •wv-mK s CI ipnos ^l ^i< •aoisiAi;! pjg •IU3'JSRJ[ 00 f;7 ^ i{}iios 0°, Ci •noisuiQ pu2 MlOpUO"[ ^ ZD •UOISIAICX IS I i>^ >r> •SB3S qsnua o> O 91H UI Sp.lHlSI Cl •pUBJpOS u. o> '" •S91RM iS pun •-■^ °\ ptit^I^ug: •SB3S qsiiua: ■9 t^ 3111 Ul o spinqs] puB l.O wy.v.ii] ;v.9.i9 S :3 u g o S3 "^ 1 i -s e p 5 12; >^. NOTE. 79 Note as to the Numbee of TVomett employed as NUESES IN GeEAT BeITAIN". 25,-166 were returned, at tlie census of 1S51, as nurses by pro- fession, 39,139 nurses in domestic service,* and 2,822 midwives. The numbers of different ages are shown in table A, and in table B their distribution over Great Britain. To increase the efficiency of this class, and to make as many of ihem as possible the disciples of the true doctrines of health, would be a great national work. For there the material exists, and will be used for nursing, whether the real " conclusion of the matter" be to nurse or to poison the sick. A man, who stands perhaps at the head of our medical profession, once said to me, I send a nurse into a private family to nurse the sick, but I know that it is only to do them harm. Now a nurse means any person in charge of the personal health of another. And, in the preceding notes, the term 7iurse is used indiscriminately for amateur and professional nurses. For, besides nurses of the sick and nurses of children, the numbers of whom are here given, there are friends or relations who take temporary charge of a sick person, there are mothers of families. It appears as if these unprofessional nurses were just as much in want of knowledge of the laws of health as professional ones. Then there are the 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 6i,600 nurses recorded above, or schoolmistresses in their turn. If the laws of health, as far as regards fresh air, cleanliness, light, &c., were taught to these, would this not prevent some children being killed, some evil being perpetuated ? On women we must depend, first and last, for personal and household hygiene — for preventing the race from degenerating in as far as these things are concerned. Would not the true way of infusing the art of preserving its own health into the human race be to teach the female part of it in schools and hospitals, both by practical teaching and by simple experiments, in as fur as these illus- trate what may be called the theory of it ? * A curious fact \yill be shown by Table A, vix., that 18,122 out of 30,139, or nearly one-half of all the nurses, in domestic service; are between 5 and 20 years of asre. A SUMMEE SEAECH EOE SIE JOHN EEANKLIN, with a Peep into the Polar Basin, by Commander E. A. Inglefield, R.N. Demy 8vo., 14s. EEENCH NAYAL TACTICS ; Translated from tbe Ereiicli by Augustus Phillimore, Captain, R.N". Demy Svo., 10s. DESPATCHES AND PAPEES EELATIYE TO CAM- paign in Turkey, Asia Minor, and the Crimea in 185i-5-6, by Captain Sayer. DESPATCHES OE VISCOUNT HAEDINaE, LOED Gough, and Sir Harry Smith. Demy Svo., 6s. PEESENT STATE OE THE TURKISH EMPIEE, by Marshal Marmont, translated- by General Sir P. Smith, K.H., F.R.S. 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