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Notes on Nursing by Florence Nightingale

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

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

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





* * * * *

[Sidenote: Disease a reparative process.]

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

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

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

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

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

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

[Sidenote: What nursing ought to do.]

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

[Sidenote: Nursing the sick little understood.]

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

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

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

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

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

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

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

[Sidenote: Nursing the well.]

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

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

[Sidenote: Little understood.]

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

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

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

Another objection.

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

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


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

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

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


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

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

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

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

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

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

[Sidenote: Without chill.]

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

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

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

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

[Sidenote: Open windows.]

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

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

[Sidenote: What kind of warmth desirable.]

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

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

[Sidenote: Bedrooms almost universally foul.]

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

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

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

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

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

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

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

[Sidenote: Night air.]

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

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

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

[Sidenote: Smoke.]

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

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

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

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

[Sidenote: Effluvia from excreta.]

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

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

[Sidenote: Chamber utensils without lids.]

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

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

[Sidenote: Abolish slop-pails.]

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

[Sidenote: Fumigations.]

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


[Sidenote: Why are uninhabited rooms shut up?]

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

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

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

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

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

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

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

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

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

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

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


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

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

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

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

[Sidenote: Pure air.]

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

[Sidenote: Pure water.]

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

[Sidenote: Drainage.]

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

[Sidenote: Sinks.]

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

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

[Sidenote: Cleanliness.]

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

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

[Sidenote: Light.]

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

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

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

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

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

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

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

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

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

[Sidenote: How does He teach His laws?]

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

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

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

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

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

[Sidenote: Infection.]

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

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

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

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

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

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

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

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

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


[Sidenote: Health of carriages.]

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

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

[Sidenote: Servants rooms.]

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

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

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

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

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

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

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

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


[Sidenote: Petty management.]

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

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

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

[Sidenote: Illustrations of the want of it.]

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

[Sidenote: Strangers coming into the sick room.]

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

[Sidenote: Sick room airing the whole house.]

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

[Sidenote: Uninhabited room fouling the whole house.]

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


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

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

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

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

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

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

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

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

[Sidenote: What institutions are the exception?]

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

[Sidenote: Nursing in Regimental Hospitals.]

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

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


[Sidenote: Unnecessary noise.]

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

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

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

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

[Sidenote: Noise which excites expectation.]

[Sidenote: Whispered conversation in the room.]

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

[Sidenote: Or just outside the door.]

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

[Sidenote: Noise of female dress.]

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

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

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

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

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

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

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

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

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

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

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

[Sidenote: Hurry peculiarly hurtful to sick.]

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

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

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

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

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

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

[Sidenote: These things not fancy.]

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

[Sidenote: Interruption damaging to sick.]

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

[Sidenote: And to well.]

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

[Sidenote: Keeping a patient standing.]

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

[Sidenote: Patients dread surprise.]

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

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

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

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

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

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

[Sidenote: Difference between real and fancy patients.]

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

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

[Sidenote: Conciseness necessary with sick.]

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

[Sidenote: Irresolution most painful to them.]

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

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

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

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

[Sidenote: Reading aloud.]

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

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

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

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

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

[Sidenote: People overhead.]

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

[Sidenote: Music.]

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


[Sidenote: Burning of the crinolines.]

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

[Sidenote: Indecency of the crinolines.]

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

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

It is absolutely essential that a nurse should lay this down as a1
positive rule to herself, never to speak to any patient who is standing
or moving, as long as she exercises so little observation as not to know
when a patient cannot bear it. I am satisfied that many of the accidents
which happen from feeble patients tumbling down stairs, fainting after
getting up, &c., happen solely from the nurse popping out of a door to
speak to the patient just at that moment; or from his fearing that she
will do so. And that if the patient were even left to himself, till he
can sit down, such accidents would much seldomer occur. If the nurse
accompanies the patient, let her not call upon him to speak. It is
incredible that nurses cannot picture to themselves the strain upon the
heart, the lungs, and the brain, which the act of moving is to any
feeble patient.

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

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

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

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

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


[Sidenote: Variety a means of recovery.]

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

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

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

[Sidenote: Colour and form means of recovery.]

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

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

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

[Sidenote: This is no fancy.]

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

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

But it must be _slow_ variety, e.g., if you shew a patient ten or twelve
engravings successively, ten-to-one that he does not become cold and

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