[Sidenote: Poisoning by the skin.]

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

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

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

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

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

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

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

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

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

One word as to cleanliness merely as cleanliness.

[Sidenote: Steaming and rubbing the skin.]

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

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


[Sidenote: Advising the sick.]

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


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

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

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

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


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

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

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

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

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

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

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

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

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

[Sidenote: Leading questions useless or misleading.]

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

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

[Sidenote: Means of obtaining inaccurate information.]

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

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

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

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

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

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

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

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

1. Defect in cooking;

2. Defect in choice of diet;

3. Defect in choice of hours for taking diet;

4. Defect of appetite in patient.

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

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

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

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

[Sidenote: As to diarrhoea]

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

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

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

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

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

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

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

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

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

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

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

Now what kind of a nurse is this?

[Sidenote: Difference of excitable and accumulative temperaments.]

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

[Sidenote: Superstition the fruit of bad observation.]

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

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

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

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

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

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

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

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

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

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

[Sidenote: Peculiarities of patients.]

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

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

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

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

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

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

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

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

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

[Sidenote: Observation of general conditions.]

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

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

But with the great majority of cases, there is nothing of the kind; and the power of forming any correct opinion as to the result must entirely depend upon an enquiry into all the conditions in which the patient lives. In a complicated state of society in large towns, death, as every one of great experience knows, is far less often produced by any one organic disease than by some illness, after many other diseases, producing just the sum of exhaustion necessary for death. There is nothing so absurd, nothing so misleading as the verdict one so often hears: So-and-so has no organic disease,—there is no reason why he should not live to extreme old age; sometimes the clause is added, sometimes not: Provided he has quiet, good food, good air, &c., &c., &c.: the verdict is repeated by ignorant people without the latter clause; or there is no possibility of the conditions of the latter clause being obtained; and this, the only essential part of the whole, is made of no effect. I have heard a physician, deservedly eminent, assure the friends of a patient of his recovery. Why? Because he had now prescribed a course, every detail of which the patient had followed for years. And because he had forbidden a course which the patient could not by any possibility alter.[6]

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

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

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

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

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

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

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

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

[Sidenote: What observation is for.]

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

[Sidenote: What a confidential nurse should be.]

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

[Sidenote: Observation is for practical purposes.]

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

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

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

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

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

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

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

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

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

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

It is commonly supposed that the nurse is there to spare the patient from making physical exertion for himself—I would rather say that she ought to be there to spare him from taking thought for himself. And I am quite sure, that if the patient were spared all thought for himself, and not spared all physical exertion, he would be infinitely the gainer. The reverse is generally the case in the private house. In the hospital it is the relief from all anxiety, afforded by the rules of a well-regulated institution, which has often such a beneficial effect upon the patient.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

[Sidenote: Summary.]

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

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

(1.) It is often said by men, that it is unwise to teach women anything about these laws of health, because they will take to physicking,—that there is a great deal too much of amateur physicking as it is, which is indeed true. One eminent physician told me that he had known more calomel given, both at a pinch and for a continuance, by mothers, governesses, and nurses, to children than he had ever heard of a physician prescribing in all his experience. Another says, that women's only idea in medicine is calomel and aperients. This is undeniably too often the case. There is nothing ever seen in any professional practice like the reckless physicking by amateur females.[1] But this is just what the really experienced and observing nurse does not do; she neither physics herself nor others. And to cultivate in things pertaining to health observation and experience in women who are mothers, governesses or nurses, is just the way to do away with amateur physicking, and if the doctors did but know it, to make the nurses obedient to them,—helps to them instead of hindrances. Such education in women would indeed diminish the doctor's work—but no one really believes that doctors wish that there should be more illness, in order to have more work.

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

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

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

Now for the caution:—

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

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

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

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

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

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

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

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

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

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

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

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

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


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

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

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

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

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

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

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

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


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

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

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

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

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

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

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