Classic Audiobook Collection - Notes on Nursing by Florence Nightingale ~ Full Audiobook [history]

Episode Date: June 14, 2023

Notes on Nursing by Florence Nightingale audiobook. Genre: history First published in 1859, Florence Nightingale's Notes on Nursing is a foundational guide to the everyday work of caring for the sick - written not as a medical textbook, but as a practical manual for anyone responsible for a patient's comfort and recovery. With crisp, unsentimental clarity, Nightingale argues that nursing is an art of observing: noticing small changes in a person's condition, habits, mood, and environment, and responding with thoughtful, disciplined care. She examines the overlooked forces that shape health - clean air, light, warmth, quiet, nutrition, cleanliness, and the careful management of a sickroom - and shows how well-meaning mistakes can do real harm. Along the way, she challenges conventional assumptions about illness, household management, and women's work, insisting on accountability, hygiene, and patient dignity. Whether addressing a mother caring for a child, a family member tending to a loved one, or a nurse in training, Nightingale's voice remains direct and urgent. Notes on Nursing is both a portrait of nineteenth-century life and a timeless call to combine compassion with competence, replacing guesswork with evidence, and turning daily care into a deliberate practice that can save lives. For ad-free listening try our premium subscription Chapters (Approximate) (00:00:00) Chapter 00 (00:10:48) Chapter 01 (00:30:05) Chapter 02 (00:48:33) Chapter 03 (01:01:28) Chapter 04 (01:27:11) Chapter 05 (01:36:19) Chapter 06 (01:48:09) Chapter 07 (02:05:09) Chapter 08 (02:15:31) Chapter 09 (02:22:15) Chapter 10 (02:32:25) Chapter 11 (02:37:59) Chapter 12 (02:55:45) Chapter 13 (03:30:02) Chapter 14 Learn more about your ad choices. Visit megaphone.fm/adchoices

Notes on Nursing, What It Is and What It Is Not, by Florence Nightingale. Preface The following notes are, by no means intended, as a rule of thought, by which nurses can teach themselves to nurse, still less as a manual to teach nurses to nurse. They are meant simply to give hints for thought to women who have personal charge of the health of others. Every woman, or at least almost every woman in England, has at one time or another of her life, charge of the personal health of somebody, with a child or invalid.

In other words, every woman is a nurse. Every day, sanitary knowledge or the knowledge of nursing, or in other words, 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 recognised as the knowledge which everyone 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. Notes on nursing. What it is and what it is not. Shall we begin by taking it as a general principle

that all disease, at some period or another 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 immediately be 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.

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. I use the word nursing for want of a better. It has been limited to signify little more than the administration of medicines and the application of poultices. It ought to signify the proper use of fresh air, light, warmth, cleanliness,

quiet, and the proper selection and administration of diet, all at the least expense of vital power to the patient. 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 a loan 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, that is a reparative process. To recur to the first objection, if we are asked, is such and 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 impatience 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 instantly be made, is, would you do nothing then in cholera, fever, etc. 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, etc., 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.

Two. 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. 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. 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 pianoforte than to learn the laws which subserve the preservation of offspring? McCauley somewhere says that it is extraordinary that, whereas the 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 Coxcomaries of education, e.g., the elements of astronomy, are now taught to every schoolgirl, neither mother-mother. of families of any class, nor schoolmistresses of any class, nor nurses of children, nor nurses of hospital, 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 unlearned. Not but those 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, etc. Put the latter under as good sanitary circumstances as the former, and she too will not know when the wind is. in the east. End of preface and start. Section 1 of Notes on Nursing by Florence Nightingale. This Librevox recording is in the public domain. Recording by Corey Samuel. Section 1. Ventilation and Warming.

The very first canon of nursing, the first and the last thing upon which a nurse's attention must be fixed, the first essential to a patient. without which all the rest you can do for him is as nothing, with which I had almost said you may leave all the rest alone, is this, to keep the air he breathes as pure as the external air without chilling him. Yet what is so little attended to? Even where it is thought of at all, the most extraordinary misconceptions reign about it. Even in admitting air into the patient's room or ward, few people ever think where that air comes from. It may come from a corridor,

into which other wards are ventilated, from a hall, always unaired, always full of the fumes of gas, dinner, of various kinds of mustiness, from an underground kitchen, sink, washhouse, water closet, or even, as I myself have had sorrowful experience, from open sewers loaded with filth. And with this, the patient's room or ward is aired, as it is called, poisoned it should rather be said. Always air from the air without, and that too, through those windows through which the air comes freshest. From a closed court, especially if the wind do not blow that way, air may come as stagnant as any from a hall or corridor. Again, a thing I have often seen both in private houses and institutions, A room remains uninhabited.

The fireplace is carefully fastened up with a board. The windows are never opened. Probably the shutters are kept always shut. Perhaps some kind of stores are kept in the room. No breath of fresh air can by possibility enter into that room, nor any ray of sun. The air is as stagnant, musty and corrupt as it can by possibility be made. It is quite ripe to breed smallpox, scarlet fever. diphtheria, or anything else you please.

Yet the nursery, ward or sick room adjoining will be positively 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's 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, though he knows the murderers, in the musty, unaired, unsunded room, the scarlet fever which is behind the door, or the fever and hospital gangrene which are stalking among the crowded beds of a hospital ward,

we say, it's all right. With a proper supply of windows and a proper supply of fuel in open fireplaces, 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 bedclothes 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 reaction. 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 reaction. 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 depressive as he found it cold in the morning, yet the nurse will be terrified if a window is opened. I know an intelligent, humane house surgeon who makes practice of keeping the ward windows open. The physicians and surgeons invariably closed 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. 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 lower, 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, putressing atmosphere, is a certain way to delay recovery or to destroy life. Do you ever go into the bedrooms of any persons of any class, whether they hold one, two or twenty people, whether they hold sick or well, at night, or before the winter.

windows 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 is it that it should not be so? During sleep, the human body, even when in health, is far more injured by the influence of foul air than when awake. Why can't you keep the air all night, then, as pure as the air without, in the rooms you sleep in? But for this, you must have sufficient outlet for the impure air you make yourselves to go out, sufficient inlet for the pure air from without to come in. You must have open chimneys, open windows or ventilators, no close curtains round your beds, no shutters or curtains to your windows, none of the contrivances by which you undermine your

own health or destroy the chances of recovery of your sick. A 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 he 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 24 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. morning. But nurses are very fond of heating the foot-warmer at night, and of neglecting it in the morning when they are busy. I should reverse the matter. All these things require common sense and care.

Yet perhaps in no one single thing is so little common sense shown, in all ranks, as in nursing. 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 necessary 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 drafts, of course, requires more care than to ventilate a large one. 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 anyone. 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 24 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 tends to making night the best time for airing the patients. one of our highest medical authorities on consumption and climate

has told me that the air in London is never so good as after ten o'clock at night 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 gas lights, 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 a fluvia, including a current of sewer air from an ill-placed sink, ascending in a continual stream by a well staircase, and just charging 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. 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. In laying down the principle that the first object of the nurse must be to keep the air breathed by her patient, as pure as the air without, it must not be forgotten that everything in the room which can give off effluvia, besides the patient, evaporates itself into his air. And it follows that there ought to be nothing in the room, excepting him, which can give off effluvia or moisture. Out of all damp towels, etc. 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 bedclothes 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 bedclothes and towels are not dried and aired,

or the air and dry 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 you to determine, for I cannot. Even in health, people cannot repeatedly breathe air in which they live with impunity, on account of it 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 excretia, it would seem unnecessary to speak, were they not so constantly neglected? Concealing the utensils behind the valence 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 underside of the mattress with the warm evaporations,

you would be startled and frightened too? The use of any chamber utensil without a lid 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 underside 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 patient's utensils. The very lid of the old abominable clothes stall 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. A slop pail should never be bought 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, 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 footpan and put back un-rinsed 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 should be carried direct to be emptied and rinsed at the proper place. I would it were so in the private house. Let no one ever depend on fumigations, disinfectants and the like for purifying the air. The offensive thing, not its smell, must be removed. A celebration. medical lecturer began one day. Fumigation's 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 emit fresh air. That would be a useful invention. End of Section 1. Section 2 of Notes on Nursing by Florence Nightingale. The Sliberovx recording is in the public domain.

Section 2. Health of Houses 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. 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 doctor's bills to the tenants. But if tenants should ever become so wise as to refuse to occupy unhealthy constructed houses, houses, and if insurance companies should ever come to understand their interests 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 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 ensure that the air in a house is stagnant and sickness is certain to follow. Two, pure water is more generally introduced into houses than it used to be, thanks to the exertions of the sanitary reformers. Within the last few years, a large part of London was in the daily habit of using water polluted by the drainage of its sewers and water closets. This has happily been remedied.

But in many parts of the country, well water of a very impure kind is used for domestic purposes, and when epidemic disease shows itself, persons using such water are almost sure to suffer. 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 untapped drainpipe,

communicating immediately with a sewer, whether it be from water closet, sink or gully grate, can never be healthy. An untrapped sink may at times spread fever or pyemia among the inmates for palace. The ordinary oblong sink is an abomination. That great surface of stone, which is always left way,

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 unventilated by the closed windows in order that as much of the sewer air as possible might be conducted into and retained in the bedrooms. 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 smallpox 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 smallpox, 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. 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 bedrooms, 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, unclensed 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 health 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. Five. A dark house is always an unhealthy house, always an ill-aired house, always an ill-aired house, always a dirty house. Want of light stops growth and promotes scrofula,

rickets, etc., 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. Three, out of many, negligences and ignorances, in managing the health of houses generally, I will here mention as specimens.

One, 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 fireplace is always close? And if you have a fireplace, 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. 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 ensure that it is done when not done by yourself?

Can you ensure that it is not undone when you're back? is turned. This is what being in charge means, and a very important meaning it is too. The former only implies that just what you can do with your own hands is done. The latter, that what ought to be done, is always done. And now, you think these things trifles, or at least exaggerated. 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 paemia quite as severe in handsome private houses as in any of the worst hospitals, and from the same cause, that is, foul air.

Yet nobody learnt the lesson, nobody learned 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 a stifle all inquiry. In what sense is sickness being always there, a justification of its being there at all? I will tell you what It was the cause of this hospital paemia, 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 of the doors and closing all the passage windows. It was that the slops were emptied into the footpans. 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 area court, or they opened the room doors into the unaired halls and passages by way of airing the room. Now all of this is not fancy, but fact. In that handsome house I have known in one summer, three cases of hospital paemia, 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 preventable 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 course, 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 for the poor little feeble, people who are going to marry and 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. 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, unerred and dirty as usual,

the window of the sick room is kept a little open always and the door occasionally. Now, there are certainly 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, an unusually well-aired, in deference to the sick person? We must not forget what, in ordinary language, is called infection, a thing of which people are generally so afraid that they frequently follow the very practice in regard to it, which they ought to avoid.

Nothing used to be considered so infectious or contagious as smallpox, and people not very long ago used to cover up patients with heavy bedclothes while they kept up large fires and shut the windows. Smallpox, 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 smallpox 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, etc., than their forefathers did with smallpox? Does not the popular idea of infection involve that people should take greater care of themselves than of the patient? That, for instance, it is safer not to be too much with the patient, not to attend too much to his wants. Perhaps the best illustration of the utter absurdity of this view of duty in attending on infectious diseases is afforded by what was very recently the practice, if it is not so even now, in some of the European lazarets,

in which the plague patient used to be condemned to the horrors of filth, overcrowding and want of ventilation, while the medical attendant was ordered to examine the patient's tongue through an opera glass and to toss him a lancet to open his abscesses with. True nursing ignores infection, except to prevent it. Cleanliness and fresh air from open windows, with unremitting attention to the patient, are the only defence a true nurse either asks or needs. Wise and humane management of the patient is the best safeguard against infection.

There are not a few popular opinions in my mind. regards 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, etc. In other words, that they are born to have measles, whooping 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, whitewashing 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? End of Section 2. Section 3 of Notes on Nursing by Florence Nightingale. This Librevox recording is in the public. domain. Section 3. Petty Management. All the results of good nursing, as detailed in these notes, may be spoiled or utterly negative by one defect, that is, 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 always be there, nor is it desirable that she should, and she may give up her health or 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 be really 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'm 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 10pm, I'm 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 she'll be for her patient without the essentials of her nursing. A very few instances will be sufficient, not as precepts, but as illustrations. A strange washerwoman, coming late at night for the things, will burst in by mistake to the patient's sick room

after he has fallen into his first dose, giving him a shock, the effects of which are irremediable, though he himself laughs at the cause, and probably never even mentions it. The nurse, who is, and is quite right to be, at her supper, has not provided that the washerwoman shall not lose her way and go into the wrong room. The patient's room may always have the window open,

but the 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. An uninhabited room, a newly painted room, an uncleaned closet or cupboard, may often become a reservoir of foul air for the whole house, because the person in charge never thinks of arranging that these places she'll always be aired, always cleaned. She merely opens the window herself

when she goes in. 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 one whom it was of still more consequence not to see may be admitted, because the person in charge has never asked herself this question, what is done when I am not there? At all events, one may safely say, a nurse cannot be with a 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. to this, that the attempting this impossibility does more to increase the poor patient's hurry

and nervousness than anything else. It is never thought that the patient remembers these things if you do not. He has not only to think whether the visit or letter may arrive, but whether you will be in the way at the particular day and hour when it may arrive, so that your partial measures for being in the way yourself only increase the necessity for his thought, whereas if you could be arranged that the thing should always be done, whether you were there or not, you need never think at all about it. For the above reasons, whatever a patient can do for himself, it is better, that is, less anxiety, for him to do for himself, unless the person in charge has the spirit of management.

It is evidently much less exertion for a patient to answer a letter for himself by return of post than to have four conversations, wait five days, have six anxieties before, it is off his mind, before the person who is to answer it has done so. Apprehension, uncertainty, waiting, expectation, fear of surprise, do a patient more harm than any exertion. 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. 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 you're 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 will never feel secure again, that the things which depend upon you will be done when you are away, and in nine times 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 precond. as to the things which concern you both, or which you do for him. If you look into the reports of trials or accidents, and especially of suicides,

or into the medical history of fatal cases, it is almost incredible how often the whole thing turns upon something which 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 a sufficient reason, a justification. Why, the very fact of the thing having happened is the proof of it's 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. 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? 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 someone being 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 was ever built on her trial trip, destroyed several lives, and put several hundreds in general. 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 us a verdict accidental death. This is the meaning of the word on a large scale. On a much smaller scale, it happened a short time ago that an insane person burnt herself slowly and intentionally to death while in her doctor's charge and almost in his 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 everyone else does so too, to see that no one either willfully 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 weighted on by four with less precision, and is less really well cared for than ten who are waited on by one, or at least than 40 who were waited on by four, 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, that is, 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, etc., but themselves. It seems to me that the pride is rather in carrying on a system, in keeping stores, closets, books,

accounts, etc. so that anybody can understand and carry them on, so that, in case of absence or illness, one can deliver everything up to others and know that all will go on as usual, and that one shall never be missed. End of Section 3. Section 4 of Notes on Nursing by Florence Nightingale. This Liprovox recording is in the public domain. Section 4. 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, for example, 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, eye and lasting mischief, than any continuous noise, however loud. 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 both. will be terribly increased by want of sleep. This is the reason why sleep is so all-important. This is the reason why a patient waked in the early part of his sleep loses not only his sleep, but his power to sleep. A healthy person, who allows himself to sleep during the day,

will lose his sleep at night. But it is exactly the reverse with the sick generally. The more they sleep, the better will they be able to sleep. I have often been surprised at the thoughtlessness, resulting in cruelty quite unintentionally, of friends or of doctors, who will hold a long conversation just in the room or passage adjoining to the room of the patient, who is either every moment expecting them to come in, or who has just seen them, and knows they are talking about him. If he is an amiable patient, he will try to occupy his attention elsewhere and not to listen,

and this makes matters worse, for the strange. 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 tiptoe doing anything in the room very slowly are injurious for exactly the same reasons. A firm light quick step a steady quick hand at the deciderata, 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 entrance from the corridor, of the persons whose voices they are hearing there, these would never run the risk again of creating such unnecessary noise as 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 anyone 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 to be decided upon. I need hardly say that the other common cause, namely for a doctor or friend to leave the patient, and communicate his opinion on the result of his visit to the friends just outside the patient's door, or in the adjoining room after the visit, but within hearing or knowledge of the patient is, if possible, worst of all. It is, I think, alarming, peculiarly at this time, when the female ink bottles are perpetually impressing upon us,

women'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 women'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. All doctrines about mysterious finities 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'm 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 women, the noiseless drapery of women, a mere figures of speech in this day. As skirts, and well if they do not throw down some piece of furniture, will it at least least brush against every article in the room as she moves. Again, one nurse cannot open the door without making everything rattle, or she opens the door unnecessarily often, for want of remembering

all the articles that might be brought in at once. A good nurse will always make sure that no door or window in her patient's room shall rattle or creak, that no blind or curtain shall, by any change of wind 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. 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 fidgeting about, while a patient is, is talking business to him, or the friend who sits some pros is, 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. Always sit within the patient's view, so that when you speak to him, 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 were 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 a 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. 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 recomposition 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. If the invalid is forced by his avocations, to continue occupations requiring much thinking, the injury is doubly great. In feeding a patient suffering under delirium or stupor, you may suffocate him by giving him his food suddenly. But if you rub his lips gently with a spoon and thus attract his attention, he will swallow the food unconsciously, but with perfect safety.

Thus it is with the brain. If you offer it a thought, especially one requiring a decision abruptly, You do it a real, not fanciful injury. Never speak to a sick person suddenly, but at the same time, do not keep his expectation on the tiptoe. This rule indeed applies to the well quite as much as to the sick.

I have never known persons who expose 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. 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 nothing done by the kindest nurses and friends,

I should have thought this caution quite superfluous. Patients are often accused of being able to do much of, 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 downstairs, 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. 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.

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 problem. point by which to steady himself in his feet. But on a bed or sofa, he is entirely at your mercy, and he feels every jar you give him all through him. In all that we have said, both here and elsewhere, let it be distinctly understood that we are not speaking of hypochondriacs. To distinguish between real and fancied disease forms an important branch of the education of a nurse. To manage fancy patients forms an important branch of her duties.

But the nursing which real and that which fancied patients require is of different or rather of opposite character. And the latter will not be spoken of here. Indeed, many of the symptoms which are here mentioned are those which distinguish real from fancied disease. It is true that hypochondriacs very often do that behind a nurse's back which they would not do before her face. many such I have had as patients who scarcely ate anything at their regular meals but if you concealed food for them in a drawer they would take it at night or in secret but this is from quite a different motive they do it from the wish to conceal whereas the real patient will often boast to his nurse or doctor if these do not shake

their heads at him of how much he has done or eaten or walked to return to real disease 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 homers,

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. 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 rewriting 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. Consiceness and decision in your movement, 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. 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. 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 when 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. One, 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. Houdine, the conjurer, 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. 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 so. suffering. Very few people know how to read to the sick. Very few people 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 singly, song, rather loud but not noisy, and above all, not too long. Be very sure of what your patient can bear. Two, 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 thus being read to, the self-absorption and want of observation of the person who does it is equally difficult to understand, although very often the is too amiable to say how much it hurts him. 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 worthwhile because no air however good no attendance however careful will do anything for such cases without quiet end of section four section five of notes on nursing by Florence Nightingale the slippery rocks recording is in the public domain section

five variety 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 stability has often been remarked upon, and attributed to the enjoyment of the former of their intervals of respite. I inclined to think that the majority of cheerful cases is to be found among those patients who are not confined to one room, whatever they're suffering, and that the majority of depressed cases will be seen among those subjected to a long monotony of objects about them.

The nervous frame really suffers as much from this as the digestive organs from long monotony of diet, as, for example, the soldier from his 21 years boiled beef. The effect in sickness of beautiful objects, a 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, for example, when they desire two contradictions. But much more often their so-called fancies are the most valuable indications. of what is necessary for their recovery, and it would be well if nurses would watch these so-called fancies closely.

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

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.

That is, if you show a patient ten or twelve engravings successively, ten to one that he does not become cold and faint, or feverish, or even sick, but hang one up opposite him, one on each successive day, or week, or month. and he will revel in the variety. The folly and ignorance which reign too often supreme over the sick room cannot be better exemplified than by this. While the nurse will leave the patient stewing in a corrupting atmosphere, the best ingredient of which is carbonic acid,

she will deny him, on the plea of unhealthiness, a glass of cut flowers, or a growing plant. Now, no one ever saw overcrowding by plants, in a room or ward. And the carbonic acid they give off at nights would not poison a fly. Nay, in overcrowded rooms, they actually absorb carbonic acid and give off oxygen. Cut flowers also decompose water and produce oxygen gas. It is true there are certain flowers, for example lilies,

the smell of which is said to depress the nervous system. These are easily known by the smell and can be of all. Volumes are now written and spoken upon the effect of the mind upon the body. Much of it is true. But I wish a little more was thought of the effect of the body on the mind. You who believe yourselves overwhelmed with anxieties, but are every day able to walk up Regent Street or out in the country, to take your meals with others in other rooms, etc., etc. You little know how much your anxieties are thereby lightened.

You little know how intensified they become to those who can have no change. How the very walls of their sick rooms seem hung with their cares. How the ghosts of their troubles haunt their beds. How impossible it is for them to escape from a pursuing thought without some help from variety. A patient can just as much move his leg when it is fractured. as change his thoughts when no external help from variety is given him. This is indeed one of the main sufferings of sickness,

just as the fixed posture is one of the main sufferings of the broken limb. It is an ever-recurring wonder to see educated people who call themselves nurses, acting thus. They vary their own objects, their own employments, many times a day, and while nursing, some bed-ridden sufferer, They let him lie there, staring at a dead wall, without any change of object to enable him to vary his thoughts, and it never even occurs to them, at least to move his bed so that he can look out of window. No, the bed is always to be left in the darkest, dullest, remotest part of the room. I think it is a very common error among the well to think that, with a little more self-control, the sick might if they choose, dismiss painful things.

thoughts which aggravate their disease, etc. Believe me, almost any sick person who behaves decently well, exercises more self-control every moment of his day than you will ever know till you are sick yourself. Almost every step that crosses his room is painful to him. Almost every thought that crosses his brain is painful to him, and if he can speak without being savage and look without being unpleasant, he, he is. is exercising self-control. Suppose you have been up all night, and instead of being allowed

to have your cup of tea, you were to be told that you ought to exercise self-control. What should you say? Now the nerves of the sick are always in the state that yours are in, after you have been up all night. We will suppose the diet of the sick to be cared for. Then, this state of nerves is most frequently to be relieved by care in affording them a pleasant view, a judicious variety as to flowers and pretty things. Light, by itself, will often relieve it. The craving for the return of day which the sick so constantly evince is generally nothing but the desire for light, the remembrance of the relief which a variety of objects before the eye affords to the harassed sick mind. Again, every man.

and every woman has some amount of manual employment, accepting a few fine ladies who do not even dress themselves, and who are virtually in the same category as to nerves as the sick. Now you can have no idea of the relief which manual labour is to you, of the degree to which the deprivation of manual employment increases the peculiar irritability from which many sick suffer. A little needlework, a little writing, a little cleaner. would be the greatest relief the sick could have if they could do it. These are the greatest relief to you, though you do not know it. Reading, although it is often the only thing the sick can do, is not this relief.

Bearing this in mind, bearing in mind that you have all these varieties of employment which the sick cannot have, bear also in mind to obtain for them all the varieties which they can enjoy. I need hardly say that I am well aware that excess in needlework, in writing, in any other continuous employment, will produce the same irritability that defect in manual employment, as one cause, produces in the sick. End of Section 5. Section 6 of Notes on Nursing by Florence Nightingale. This Liprofoch's recording is in the public domain. Section 6. Taking Food Every careful observer of the sick will agree in this, that thousands of patients are annually

starved in the midst of plenty from want of attention to the ways which alone make it possible for them to take food. This want of attention is as remarkable in those who urge upon the sick to do what is quite impossible to them, as in the sick themselves, who will not make the effort to do what is perfectly possible to them. For instance, to the large majority of very weak patients, it is quite impossible to take any solid food before 11am, nor then, if their strength is still further exhausted by fasting till that hour.

For weak patients have generally feverish nights, and in the morning, dry mouths, and if they could eat with those dry mouths, it would be the worse for them. A spoonful of beef tea, of arrowroot and wine, of egg flip, every hour will give them the requisite nourishment and prevent them being too much exhausted to take at a later hour the solid food which is necessary for their recovery. And every patient who can swallow at all can swallow these liquid things if he chooses. But how often do we hear a mutton chop, an egg, a bit of bacon, ordered to a patient for breakfast, to whom, as a moment's consideration would show us, it must be quite impossible to

masticate such things at that hour. Again, a nurse is ordered to give a patient a teacupful of some article of food every three hours. The patient's stomach rejects it. If so, try a tablespoon full every hour. If this will not do, a teaspoonful every quarter of an hour. I am bound to say that I think more patients are lost by want of care and ingenuity in these momentous minutiae in private nursing than in public hospitals. And I think there is more of the Entente Cordial to assist one another's hands between the doctor and his head nurse in the latter institutions

than between the doctor and the patient's friends in the private house. If we did but know the consequences which may ensue in very weak patients, from ten minutes' first, or repletion. I call it repletion, when they are obliged to let two small an interval elapse, between taking food and some other exertion, owing to the nurse's unpunctuality. We should be more careful than never to let this occur. In very weak patients there is often a nervous difficulty of swallowing,

which is so much increased by any other call upon their strength, that, unless they have their food punctually at the minute, which minute again must be arranged, so as to form. in with no other minutes occupation, they can take nothing until the next respite occurs, so that an unpunctuality or delay of ten minutes may very well turn out to be one of two or three hours. And why is it not as easy to be punctual to a minute? Life often literally hangs upon these minutes.

In acute cases, while life or death is to be determined in a few hours, these matters are very generally attended to, especially in hospitals, and the number of cases is large where the patient is, as it were, brought back to life, by exceeding care on the part of the doctor or nurse, or both, in ordering and giving nourishment, with minute selection and punctuality. But in chronic cases, lasting over months and years, where the fatal issue is often determined at last by mere protracted starvation, I had rather not to be a lot of the rather not enumerate the instances which I have known, where a little ingenuity, and a great deal of perseverance, might, in all probability, have averted the result. The consulting the

hours when the patient can take food, the observation of the times, often varying when he is most faint, the altering seasons of taking food, in order to anticipate and prevent such times. All this, which requires observation, ingenuity and perseverance, and these really constitute the good nurse, might save more lives than we what of. To leave the patient's untasted food by his side from meal to meal, in hopes that he will eat it in the interval, is simply to prevent him from taking any food at all. I have known patients literally incapacitated from taking one article of food after another by this piece of ignorance. Let the food come at the right time and be taken away, eaten or uneaten, at the right time, but never let a patient have something always standing by him, if you don't wish to discuss him of everything. On the other hand, I have known a patient's life saved, he was sinking for want of food, by the simple question put to him by the doctor.

But is there no hour when you feel you could eat? "'Oh, yes,' he said, "'I could always take something at—a clock and—' "'O'clock.' The thing was tried and succeeded. Patients very seldom, however, can tell you this. It is for you to watch and find it out. A patient should, if possible, not see or smell either the food of others,

or a greater amount of food than he himself can consume at one time, or even hear food talked about or see it in the raw state. I know of no exception to the above rule. The breaking of it always induces a greater or less incapacity of taking food. In hospital wards it is of course impossible to observe all this, and in single wards where a patient must be continuously and closely watched, it is frequently impossible to relieve the attendant, so that his or her own meals can be taken out of the ward.

But it is not the less true that, in such cases, even where the patient is not himself aware of it, his possibility of taking food is limited by seeing the attendant eating meals under his observation. In some cases the sick are aware of it, and complain. A case where the patient was supposed to be insensible, but complained as soon as able to speak, is now present to my recollection. Remember, however, that the extreme punctual. in well-ordered hospitals. The rule that nothing shall be done in the ward while the patients are having their meals go far to counterbalance what unavoidable evil there is in having patients

together. I have often seen the private nurse go on dusting or fidgeting about in a sick room all the while the patient is eating or trying to eat. That the more alone an invalid can be when taking food the better is unquestionable. And even if he must be fed, the nurse should not allow him to talk or to talk to him especially about food while eating. When a person is compelled, by the pressure of occupation, to continue his business while sick, it ought to be a rule without any exception whatever that no one shall bring business to him or talk to him while he is taking food, nor go on talking to him on interesting subjects up to the last moment before his meals, nor make an engagement with him immediately

after, so that there can be any hurry of mind while taking them. Upon the observance of these rules, especially the first, often depends the patient's capability of taking food at all, or if he is amiable and forces himself to take food, of deriving any nourishment from it. A nurse should never put before a patient, milk that is sour, meat or soup that is turned, an egg that is bad, or vegetables underdone. Yet often, often, Often I have seen these things brought into the sick, in a state perfectly perceptible to every nose or eye, except the nurses. It is here that the clever nurse appears. She will not bring in the peccant article, but not to disappoint the patient, she will whip up something else in a few minutes.

Remember that sick cookery should half do the work of your poor patient's weak digestion. But if you further impair it with your bad articles, I know not what is to be able to be. become of him or of it. If the nurse is an intelligent being, and not a mere carrier of diets to and from the patient, let her exercise her intelligence in these things. How often we have known a patient eat nothing at all in the day, because one meal was left untasted, at that time he was incapable of eating, at another the milk was sour, the third was spoiled by some other accident, and it never occurred to the nurse to extemporise some expedient. It never occurred to her that as he had had no solid food that day,

he might eat a bit of toast, say, with his tea in the evening, or he might have some meal an hour earlier. A patient who cannot touch his dinner at two will often accept it gladly if brought to him at seven. But somehow nurses never think of these things. One would imagine they did not consider themselves bound to exercise their judgment. They leave it to the patient. Now, I'm quite.

sure that it is better for a patient rather to suffer these neglects than to try to teach his nurse to nurse him if she does not know how. It ruffles him, and if he is ill, he is in no condition to teach, especially upon himself. The above remarks apply much more to private nursing than to hospitals. I would say to the nurse, have a rule of thought about your patient's diet. consider, remember how much he has had and how much he ought to have today. Generally, the only rule of the private patient's diet is what the nurse has to give. It is true she cannot give him what she has not got, but his stomach does not wait for her convenience, or even her necessity. If it is used to having its stimulus at one hour today, and tomorrow it does not have it,

because she has failed in getting it, he will suffer. She must be always exercising her ingenuity to supply defects and to remedy accidents, which will happen among the best contrivers, but from which the patient does not suffer the less because they cannot be helped. One very minute caution. Take care not to spill into your patient's saucer. In other words, take care that the outside bottom rim of his cup should be quite dry and clean. If, every time he lifts his cup to his lips, he has to carry the saucer with it, or else to drop the liquid upon, and to soil his sheet, or his bedgown, or pillow, or if he is sitting up, his dress, you have no idea what a difference this minute want of care on your part makes to his comfort,

and even to his willingness for food. End of Section 6 Section 7 of Notes on Nursing by Florence Nightingale. This Libravox recording is in the public domain. Section 7. What food? I will mention one or two of the most common errors among women in charge of sick, respecting sick diet. One is the belief that beef tea is the most nutritive of all articles.

Now, just try and boil down a pound of beef into beef tea. Evaporate your beef tea and see what is left of your beef. You will find that. that there is barely a teaspoonful of solid nourishment to half a pint of water in beef tea. Nevertheless, there is a certain reparative quality in it. We do not know what, as there is in tea, but it may be safely given in almost any inflammatory disease, and is as little to be depended upon with the healthy or convalescent,

where much nourishment is required. Again, it is an ever-ready saw that an egg is equivalent to a pound of meat, whereas it is not so at all. Also, it is seldom noticed, with how many patients, particularly of nervous or bilious temperament, eggs disagree. All puddings made with eggs are distasteful to them in consequence. An egg whipped up with wine is often the only form in which they can take this kind of nourishment.

Again, if the patient has attained to eating meat, it is supposed that to give him meat is the only thing needful for his reclassions. recovery. Whereas scorbutic sores have been actually known to appear among sick persons living in the midst of plenty in England, which could be traced to no other source than this, that is, that the nurse, depending on meat alone, had allowed the patient to be without vegetables for a considerable time, these latter being so badly cooked that he always left them untouched. Arrowroot is another grand dependence of the nurse. As a vehicle for wine, and as a restorative quickly prepared, it is all very well, but it is nothing but starch and water.

Flower is both more nutritive and less liable to ferment, and is preferable wherever it can be used. Again, milk and the preparations from milk are a most important article of food for the sick. Butter is the lightest kind of animal fat, and though it wants the sugar and some of the other elements which there are in milk, yet it is most valuable both in itself and in enabling the patient to eat more bread. Flower, oats, groats, barley, and their kind are, as we have already said, preferable in all their preparations to all the preparations of arrowroot, sago, tapioca and their kind. Cream, in many long chronic diseases, is quite irreplaceable by any other article whatever. It seems to act in the same manner as beef tea, and to most it is much easier of digestion than milk.

In fact, it seldom disagrees. Cheese is not usually digestible by the sick, but it is pure nourishment for repairing waste, and I have seen sick, and not a few either, whose craving for cheese showed how much it was needed by them. But if fresh milk is so valuable a food for the sick, the least change or sour. in it makes it, of all articles perhaps, the most injurious. Diarrhea is a common result of fresh milk allowed to become a tall sour. The nurse, therefore, ought to exercise her utmost care in this. In large institutions for the sick, even the poorest, the utmost care is exercised.

Wenham Lake Ice is used for this express purpose every summer, while the private patient, perhaps, never tastes a drop of milk that is not sour, all through the hot weather, so little does the private nurse understand the necessity of such care. Yet, if you consider that the only drop of real nourishment in your patient's tea is the drop of milk, and how much almost all English patients depend upon their tea, you will see the great importance of not depriving your patient of this drop of milk. Butter milk, a totally different thing, is often very useful. useful, especially in fevers. In laying down rules of diet, by the amounts of solid nutriment in different kinds of food, it is constantly lost sight of what the patient requires to repair his

waist, what he can take and what he cannot. You cannot diet a patient from a book. You cannot make up the human body as you would make up a prescription. So many parts carboniferous, so many parts nitrogenous will constitute a perfect diet for the patient. The nurse's observation here will materially assist the doctor. The patient's fancies will materially assist the nurse. For instance, sugar is one of the most nutritive of all articles, being pure carbon, and is particularly recommended in some books. But the vast majority of all patients in England, young and old, male and female, rich and poor, hospital and private, dislike sweet things. And while I have never known a person take to sweets while he was ill, who disliked them when he was well,

I have known many fond of them when in health, who in sickness would leave off anything sweet, even to sugar in tea. Sweet puddings, sweet drinks are their aversion. The furred tongue almost always likes what is sharp or pungent. Scorbutic patients are an exception. They often crave for sweetmeats and jams. Jelly is another article of diet in great favour with nurses and friends of the sick. Even if it could be eaten solid, it would not nourish. But it is simply the height of folly to take an eighth of an ounce of gelatin and make it

into a certain bulk by dissolving it in water, and then to give it to the sick, as if the mere bulk represented nourishment. It is now known that jelly does not nourish, that it has a tendency to produce diarrhoea, and to trust to it to repair the waste of a diseased constitution, is simply to starve the sick under the guise of feeding them. If a hundred spoonfuls of jelly were given in the course of the day, you would have given one spoonful of gelatin, which spoonful has no nutritive power whatever. And, nevertheless, gelatin can contains a large quantity of nitrogen, which is one of the most powerful elements in nutrition. On the other hand, beef tea may be chosen as an illustration of great nutrient power in sickness,

coexisting with a very small amount of solid nitrogenous matter. Dr. Christensen says that everyone will be struck with the readiness with which certain classes of patients will often take diluted meat juice or beef tea repeatedly when they refuse all other kinds of food. This is particularly remarkable in cases of gastric fever in which, he says, little or nothing else besides beef tea or diluted meat juice has been taken for weeks or even months, and yet a pint of beef tea contains scarcely a quarter of an ounce of anything but water. The result is so striking that he asks what is its mode of action. Not simply nutrient. A quarter ounce of

the most nutritive material cannot nearly replace the daily wear and tear of the tissues in any circumstances. Possibly, he says, it belongs to a new denomination of remedies. It has been observed that a small quantity of beef tea, added to other articles of nutrition, augments their power out of all proportion to the additional amount of solid matter. The reason why jelly should be in-nutricious and beef-tee nutritious to the sick is a secretive. yet undiscovered, but it clearly shows that careful observation of the sick is the only clue to the best dietary. Chemistry has yet afforded little insight into the dieting of the sick. All that chemistry can tell us is the amount of carboniferous or nitrogenous elements

discoverable in different dietic articles. It has given us lists of dietic substances, arranged in the order of their richness in one or other of these principles, but that is all In the great majority of cases, the stomach of the patient is guided by other principles of selection than merely the amount of carbon or nitrogen in the diet. No doubt, in this, as in other things, nature has very definite rules for her guidance, but these rules can only be ascertained by the most careful observation at the bedside. She there teaches us that living chemistry, the chemistry of reparation, is something different from the chemistry of the laboratory.

Organic chemistry is useful, as all knowledge is, when we come face to face with nature, but it by no means follows that we should learn in the laboratory any one of the reparative processes going on in disease. Again, the nutritive power of milk and of the preparations from milk is very much undervalued. There is nearly as much nourishment in half a pint of milk as there is in quarter a pound of meat. But this is not the whole question or nearly the whole. The main question is what the patient's stomach can assimilate or derive nourishment from, and of this the patient's stomach is the sole judge. Chemistry cannot tell us this.

The patient's stomach must be its own chemist. The diet which will keep the healthy man healthy will kill the sick one. The same beef, which is the most nutritive of all meat, and which nourishes the healthy man is the least nourishing of all food to the sick man whose half-dead stomach can assimilate no part of it, that is, make no food out of it. On a diet of beef tea, healthy men on the other hand speedily lose their strength. I have known patients live for many months without touching bread because they could not eat baker's bread.

These were mostly country patients, but not all. homemade bread or brown bread is a most important article of diet for many patients. The use of asperians may be entirely superseded by it. Oatcake is another. To watch for the opinions then, which the patient's stomach gives, rather than to read analyses of foods, is the business of all those who have to settle what the patient is to eat, perhaps the most important thing to be provided for him after the air he is to breathe. Now, the medical man who sees the patient only once a day or even only once or twice a week cannot possibly tell this without the assistance of the patient himself or of those who are in constant observation on the patient the utmost the medical man can tell is whether the patient is weaker or stronger at this visit than he was at the last visit i should therefore say that incomparably the most important office of the nurse after she has taken care of the patient's

air, is to take care to observe the effect of his food and to report it to the medical attendant. It is quite incalculable, the good that would certainly come from such sound and close observation in this almost neglected branch of nursing, or the help it would give to the medical man. A great deal too much against tea is said by wise people, and a great deal too much of tea is given to the sick by foolish people. When you see the natural and almost universal craving in English sick for their tea, you cannot but feel that nature knows what she is about. But a little tea or coffee restores them quite as much as a great deal, and a great deal of tea, and especially of coffee, impairs the little power of digestion they have. Yet a nurse,

because she sees how one or two cups of tea or coffee restores her patient, thinks the that three or four cups will do twice as much. It is however certain that there is nothing yet discovered, which is a substitute to the English patient for his cup of tea. He can take it when he can take nothing else, and he often can take anything else if he has it not. I should be very glad if any of the abusers of tea would point out what to give to an English patient after a sleepless night instead of tea.

If you give it at five or six o'clock in the morning, he may even sometimes fall asleep after it, and get perhaps his only two or three hours sleep during the twenty-four. At the same time, you should never give tea or coffee to the sick, as a rule, after five o'clock in the afternoon. Sleeplessness in the early night is from excitement generally, and is increased by tea or coffee. Sleeplessness which continues to the early morning is from exhaustion often. and is relieved by tea.

The only English patients I have ever known refuse tea have been typhus cases, and the first sign of their getting better was their craving again for tea. In general, the dry and dirty tongue always prefers tea to coffee, and will quite decline milk and less with tea. Coffee is a better restorative than tea,

but a greater imperer of the digestion. Let the patient's taste decide. You will say that, in cases of great thirst, the patient's craving decides that it will drink a great deal of tea, and that you cannot help it. But in these cases, be sure that the patient requires diluance for quite other purposes than quenching the thirst. He wants a great deal of some drink, not only of tea,

and the doctor will order what he is to have, barley water or lemonade, or soda water and milk, as the case may be. Lemon, quoted by Dr. Christensen, says that among the well and active, the infusion of one ounce of roasted coffee daily will diminish the waste going on in the body by one-fourth. And Dr. Christensen adds that tea has the same property. Now this is actual experiment. Lemon weighs the man and finds the fact from his.

weight. It is not deduced from any analysis of food. All experience among the sick shows the same thing. Coco is often recommended to the sick in lieu of tea or coffee. But independently of the fact that English sick very generally dislike cocoa, it has quite a different effect from tea or coffee. It is an oily, starchy nut, having no restorative power at all, but simply increasing fat. It is pure mockery of the sick, therefore, to call it a substitute for tea. For any renovating stimulus it has, you might just as well offer them chestnuts instead of tea. An almost universal error among nurses is in the bulk of the food, and especially the drinks they offer to their patients. Suppose a patient ordered four ounces of brandy during the day.

How is he to take this if you make it into four pints with diluting it? The same with tea and beef tea, with arrowroot, milk, etc. You have not increased the nourishment. You have not increased the renovating power of these articles by increasing their bulk. You have very likely diminished both by giving the patient's digestion more to do. And, most likely of all, the patient will leave half of what he has been ordered to take because he cannot swallow the bulk with which you have been pleased to invest it. It requires very nice observation and care, and meets with hardly any, to determine what will not be too thick or strong for the patient to take, while giving him no more than the bulk which he is able to swallow.

End of Section 7. Section 8 of Notes on Nursing by Florence Nightingale. This Librevox recording is in the public domain. Section 8. bed and bedding. A few words upon bedsteads and bedding, and principally as regards patients who are entirely, or almost entirely, confined to bed.

Feverishness is generally supposed to be a symptom of fever. In nine cases out of ten, it is a symptom of bedding. The patient has had reintroduced into the body the emanations from himself which, day after day and week after week saturate his unerred bedding. How can it be otherwise? Look at the ordinary bed in which a patient lies. If I were looking out for an example in order to show what not to do, I should take the specimen of an ordinary bed in a private house, a wooden bedstead, two or even three mattresses piled up to above the height of a table,

a valence attached to the frame, nothing but a miracle could ever thoroughly dry. or air such a bed and bedding. The patient must inevitably alternate between cold damp after his bed is made and warm damp before, both saturated with organic matter, and this from the time the mattresses are put under him till the time they are picked to pieces, if this is ever done. If you consider that an adult in health exhales by the lungs and skin in the twenty-four hours, three pints at least of moisture, loaded with organic matter, ready to be able to be able to to enter into putrefaction, that in sickness the quantity is often greatly increased, the quality

is always more noxious. Just ask yourself next, where does all this moisture go to? Chiefly into the bedding, because it cannot go anywhere else. And it stays there, because, except perhaps a weekly change of sheets, scarcely any other airing is attempted. A nurse will be careful to fidgetiness about airing the clean sheets from clean. damp, but airing the dirty sheets from Noxia stamp will never even occur to her. Besides this, the most dangerous effluvia we know of are from the excretia of the sick. These are placed, at least temporarily, where they must throw their effluvia into the underside of the bed, and the space under the bed is never aired.

It cannot be with our arrangements. Must not such a bed be always saturated, and be always the means of the means of of reintroducing into the system of the unfortunate patient who lies in it, that excrementitious matter, to eliminate which from the body, nature had expressly appointed the disease. My heart always sinks within me, when I hear the good housewife of every class, say, I assure you the bed has been well slept in, and I can only hope it is not true. What? Is the bed already saturated with somebody else's damp, before my patient comes to exhale into it his own damp. Has it not had a single chance to be aired? No, not one. It has been

slept in every night. The only way of really nursing a real patient is to have an iron bedstead with reoclined springs, which are permeable by the air up to the very mattress, no valence, of course, the mattress to be a thin hair one, the bed to be not above three and a half feet wide. If the patient be entirely confined to his bed, there should be two such bedsteads, each bed to be made with mattress, sheets, blankets, etc., complete, the patient to pass 12 hours in each bed, on no account to carry his sheets with him. The whole of the bedding to be hung up to air for each intermediate 12 hours. Of course, there are many cases where this cannot be done at all,

many more where only an approach to it can be made. I'm indicating the ideal of nursing and what I have actually had done, but about the kind of bedstead there can be no doubt, whether there be one or two provided. There is a prejudice in favour of a wide bed, I believe it to be a prejudice. All the refreshment of moving a patient from one side to the other of his bed is far more effectually secured by putting him into a fresh bed,

and a patient who is really very ill does not stray far in bed. But it is said there is no room to put down a tray on a narrow bed. No good nurse will ever put a tray on a bed at all. If the patient can turn on his side, he will eat more comfortably from a bedside table, and on no account whatever should a bed ever be higher than a sofa. Otherwise, the patient feels himself out of humanity's reach. He can get at nothing for himself.

He can move nothing for himself. If the patient cannot turn, a table over the bed is a better thing. I need hardly say that a patient's bed should never have its side against the wall. The nurse must be able to get easily to both sides of the bed and to reach easily every part of the patient without stretching. A thing impossible if the bed be either too wide or too high. When I see a patient in a room nine or ten feet high, upon a bed between four and five feet high, with his head, when he is sitting up in bed, actually within two or three feet of the ceiling,

I ask myself, is this expressly planned to produce that peculiarly distressing feeling common to the sick, that is, as if the walls and ceiling were closing in upon them, and they becoming sandwiches between floor and ceiling, which imagination is not indeed here so far from the truth. If, over and above this, the window stops short of the ceiling, then the patient's head may literally be raised above the stratum of fresh air, even when the window is open. Can human perversity any farther go in unmaking the process of restoration which God has made?

The fact is that the heads of sleepers, or of sick, should never be higher than the throat of the chimney. which ensures their being in the current of best air, and we will not suppose it possible that you have closed your chimney with a chimney board. If a bed is higher than a sofa, the difference of the fatigue of getting in and out of bed will just make the difference very often to the patient,

who can get in and out of bed at all, of being able to take a few minutes' exercise, either in the open air or in another room. It is so very odd that people never. think of this, or of how many more times a patient who is in bed for the 24 hours is obliged to get in and out of bed than they are, who only it is to be hoped, get into bed once and out of bed once during the 24 hours. A patient's bed should always be in the lightest spot in the room, and he should be able to see out of window. I need scarcely say that the old

four-post bed with curtains is utterly inadmissible, where the first of the first place. sick or well. Hospital bedsteads are in many respects very much less objectionable than private ones. There is reason to believe that not a few of the apparently unaccountable cases of scrofula among children proceed from the habit of sleeping with the head under the bedclothes, and so inhaling air already breathed, which is farther contaminated by exhalations from the skin. Patients are sometimes given to a similar habit, and it often happens to that the bedclothes are so disposed that the patient must necessarily breathe air more or less contaminated by exhalations from his skin. A good nurse will be careful to attend to this. It is an important part, so to speak, of ventilation.

It may be worthwhile to remark that where there is any danger of bed sores, a blanket should never be placed under the patient. It retains damp and acts like a poultice. Never use anything but light Whitney blankets as bed covering for the sick. The heavy cotton impervious counterpane is bad, for the very reason that it keeps in the emanations from the sick person, while the blanket allows them to pass through. Weak patients are invariably distressed by a great weight of bedclothes, which often prevents their getting any sound sleep whatever.

Note. One word about pillows. Every weak patient, be his illness what it may, suffers more or less from difficulty in breathing. To take the weight of the body off the poor chest, which is hardly up to its work as it is, ought therefore to be the object of the nurse in arranging his pillows. Now, what does she do and what are the consequences? She piles the pillows one atop the other, like a wall of bricks. The head is thrown upon the chest, and the shoulders are pushed forward, so as not to allow the lungs room to expand.

The pillows, in fact, lean upon the patient, not the patient upon the pillows. It is impossible to give a rule for this, because it must vary with the figure of the patient, and tall patients suffer much more than short ones because of the drag of the long limbs upon the waist. But the object is to support, with the pillows, the back below the breathing apparatus,

to allow the shoulders room to fall back, and to support the head without throwing it forward. The suffering of dying patience is immensely increased by neglect of these points, and many an invalid, too weak to drag about his pillows himself, slips his book or anything at hand behind the lower part of his back to support it. End of Section 8. Section 9 of Notes on Nursing by Florence Nightingale. This Libreux recording is in the public domain.

Section 9. Light It is the unqualified result of all my experience with the sick that second only to their need of fresh air is their need of light. That, after a close room, what hurts the most is a dark room. And that it is not only light, but direct sunlight they want. I had rather have the power of carrying my patient about after the sun, according to the aspect of the room. according to the aspect of the rooms, if circumstances permit, then let him linger in a room when the sun is off. People think the effect is upon the spirits only.

This is by no means the case. The sun is not only a painter, but a sculptor. You admit that he does the photograph. Without going into any scientific exposition, we must admit that light has quite as real and tangible effects upon the human body. But this is not all. Who has not observed the purifying effect of light, and especially of direct sunlight, upon the air of a room?

Here is an observation within everybody's experience. Go into a room where the shutters are always shut. In a sick room or a bedroom there should never be shutters shut. And though the room be uninhabited, though the air has never been polluted by the breathing of human beings, you will observe a close, musty smell of corrupt air, of air, that is, unpurified by the effect of the sun's rays. The mustiness of dark rooms and corners, indeed, is proverbial. The cheerfulness of a room, the usefulness of light in treating disease, is all important.

A very high authority in hospital construction has said that people do not enough consider the difference between wards and dormitories, in planning their buildings. But I go farther, and say that healthy people never remember the difference between bedrooms and sick rooms in making arrangements for the sick. To a sleeper in health, it does not signify what the view is from his bed. He ought never to be in it, excepting when asleep and at night. Aspect does not very much signify either, provided the son reach his bedroom at some time in every day to purify the air.

because he ought never to be in his bedroom except during the hours when there is no sun but the case is exactly reversed with the sick even should they be as many hours out of their beds as you are in yours which probably they are not therefore that they should be able without raising themselves or turning in bed to see out of window from their beds to see sky and sunlight at least if you can show them nothing else i assert to be if not of the very first first importance for recovery, at least something very near it. And you should, therefore, look to the position of the beds of your sick, one of the very first things. If they can see out of two windows instead of one, so much the better. Again, the morning sun and the midday sun, the hours when they are quite certain not to be up, are of more importance to them if a choice must be made than the afternoon sun.

Perhaps you can take them out of bed in the afternoon and set them by the window where they can see the sun. But the best rule is, if possible, to give them direct sunlight from the moment he rises till the moment he sets. Another great difference between the bedroom and the sick room is that the sleeper has a very large balance of fresh air to begin with when he begins the night,

if his room has been open all day as it ought to be, The sick man has not, because all day he has been breathing the air in the same room and dirtying it by the emanations from himself. Far more care is therefore necessary to keep up a constant change of air in the sick room. It is hardly necessary to add that there are acute cases, particularly a few ophthalmic cases and diseases where the eye is morbidly sensitive, where a subdued light is necessary. But a dark north room is inadmissible even for these. You can always moderate the light by blinds and curtains. Heavy, thick, dark window or bed curtains should, however, hardly ever be used for any kind of sick in this country. A light white curtain at the head of the bed is, in general, all that is necessary,

and a green blind to the window to be drawn down only when necessary. One of the greatest observers of human things, not physiological, says in another language, Where there is sun, there is thought. All physiology goes to confirm this. Where is the shady side of deep valleys, there is cratinism. Where are cellars, and the unsund sides of narrow streets, there is the degeneracy and weakliness of the human race, mind and body equally degenerating. Put the pale, withering plant and human being into the sun, and, if not too far gone, each will recover health and spirit.

It is a curious thing to observe how almost all patients lie, with their faces turned towards the light, exactly as plants always make their way towards the light. A patient will even complain that it gives him pain lying on that side. Then why do you lie on that side? He does not know, but we do. It is because it is the side towards the window. A fashionable physician has recently published in a government report that he always turns his patient's faces from the light.

Yes, but nature is stronger than fashionable physicians, and depend upon it, she turns the faces back and towards such light as she can get. walk through the wards of a hospital remember the bedsides of private patients you have seen and count how many sick you ever saw lying with their faces towards the wall end of section nine section ten of notes on nursing by florence nightingale this lip-robox recording is in the public domain section ten cleanliness of rooms and walls It cannot be necessary to tell a nurse that she should be clean or that she should keep her patient clean,

seeing that the greater part of nursing consists in preserving cleanliness. No ventilation can freshen a room or ward where the most scrupulous cleanliness is not observed. Unless the wind be blowing through the windows at the rate of 20 miles an hour, dusty carpets, dirty wainscots, musty curtains and furniture will infallibly produce a close smell. I have lived in a large and expensively furnished London house, where the only constant inmate in two very lofty rooms,

with opposite windows, was myself, and yet, owing to the above-mentioned dirty circumstances, no opening of windows could ever keep those rooms from closeness. But the carpet and curtains, having been turned out of the rooms altogether, they became instantly as fresh as could be. wished. It is pure nonsense to say that in London a room cannot be kept clean. Many of our hospitals show the exact reverse. But no particle of dust is ever, or can ever be removed or really got rid of by the present system of dusting. Dusting, in these days, means nothing but flapping the dust from one

part of a room onto another with doors and windows closed. What you do it for, I cannot think. You had much better leave the dust alone, if you were not going to take it away altogether. For, from the time a room begins to be a room, up to the time when it ceases to be one, no one atom of dust ever actually leaves its precincts. Tidying a room means nothing now, but removing a thing from one place, which it has kept clean for itself, onto another and a dirtier one. Flapping by way of cleaning is only admissible in the case of pictures or anything made of paper. The only way I know to remove dust, the plague of all lovers of fresh air, is to wipe everything with a damp cloth. And all furniture ought to be so made

as that it may be wiped with a damp cloth without injury to itself, and so polished as that it may be damped without injury to others. To dust, as it is now practiced, truly means to distribute dust more equally over a room. As to floors, the only really clean floor I know is the Berlin lacquered floor, which is wet rubbed and dry rubbed every morning to remove the dust. The French parquet is always more or less dusty, although infinitely superior in point of cleanliness and healthiness to our absorbent floor. For a sick room, a carpet is perhaps the worst expedient which could by any possibility have been invented.

If you must have a carpet, the only safety is to take it up two or three times a year instead of once. A dirty carpet literally infects the room. And if you consider the enormous quantity of organic matter from the feet of people coming in, which must saturate it, this is a bit of. is by no means surprising. As for walls, the worst is the papered wall, the next worst is plaster. But the plaster can be redeemed by frequent lime washing, the paper requires frequent renewing. A glazed paper gets rid of a good deal of the danger, but the ordinary bedroom paper is all that it

ought not to be. The close connection between ventilation and cleanliness is shown in the This, an ordinary light paper will last clean much longer if there is an Arnott's ventilator in the chimney than it otherwise would. The best wall now extant is oil paint. From this you can wash the animal exuviai. These are what make a room musty. The best wall for a sick room or ward that could be made is pure white, non-absorbent cement or glass or glazed tiles if they were made sightly enough.

Air can be soiled just like water. If you blow into water, you will soil it with the animal matter from your breath. So it is with air. Air is always soiled in a room where walls and carpets are saturated with animal exhalations. Want of cleanliness then, in rooms and wards, which you have to guard against, may arise in three ways. 1. Dirty air coming in from without, soiled by sewer emanations, the evaporation from dirty streets, smoke, bits of unburned fuel, bits of straw, bits of horse dung. If people would but cover the outside walls of their houses with plain or encaustic tiles,

what an incalculable improvement would there be in light, cleanliness, dryness, warmth, and consequently economy. The play of a fire engine would then effectually wash the outside of a house. This kind of walling would stand next to paving in improving the health of towns. Two, dirty air coming from within, from dust, which you often displace but never remove, and this recalls what ought to be a sine qua non. Have as few ledges in your room or ward as possible, and under no pretense have any ledge whatever out of sight.

Dust accumulates there and will never be wiped off. This is a certain way to soil the air. Besides this, the animal exhalations from your inmates saturate your furniture. And if you never clean your furniture properly, how can your rooms or wards be anything but musty? Ventilators you please, the rooms will never be sweet. Besides this, there is a constant degradation, as it is called, taking place from everything except polished or glazed articles.

For example, in colouring certain green papers arsenic is used. Now, in the very dust even, which is lying about rooms hung with this kind of green paper, arsenic has been distinctly detected. You see your dust is anything but harmless, yet you will let such dust. lie about your ledges for months, your rooms forever. Again the fire fills the room with coal dust. 3. Dirty air coming from the carpet. Above all, take care of the carpets, that the animal dirt left there by the feet of visitors does not stay there.

Floors, unless the grain is filled up and polished, are just as bad. The smell from the floor of a schoolroom or ward when any moisture brings out the organic matter by which it is saturated might alone be enough to warn us of the mischief that is going on. The outer air then can only be kept clean by sanitary improvements and by consuming smoke. The expense in soap, which this single improvement would save, is quite incalculable.

The inside air can only be kept clean by excessive care in the ways mentioned above, to rid the walls, carpets, furniture, ledges, etc., of the organic matter and dust, dust consisting greatly of this organic matter, with which they become saturated, and which is what really makes the room musty. Without cleanliness, you cannot have all the effect of ventilation, without ventilation, you can have no thorough cleanliness. Very few people, be they of what class they may, have any idea of the exquisite cleanliness required in the sick-room.

For much of what I have said applies less to the hospital than to the private sick-room. The smoky chimney, the dusty furniture, the utensils emptied but once a day, often keep the air of the sick constantly dirty in the best private houses. The well have a curious habit. bit of forgetting that what is to them but trifling inconvenience to be patiently put up with is to the sick a source of suffering delaying recovery if not actually hastening death the well are scarcely ever more than eight hours at most in the same room some change they can always make if only for a few minutes even during the supposed eight hours they can change their posture

or their position in the room but the sick man who never leaves his bed, who cannot change by any movement of his own, his air, or his light, or his warmth, who cannot obtain quiet, or get out of the smoke, or the smell, or the dust, he is really poisoned or depressed by what is to you the merest trifle. What can't be cured must be endured is the very worst and most dangerous maxim for a nurse which ever was made. Patience and resignation in her are but other words for carelessness or indifference, contemptible if in regard to herself, culpable if in regard to her sick.

End of Section 10. Section 11 of Notes on Nursing by Florence Nightingale. This Liprovox recording is in the public domain. Section 11. Personal Cleanliness. In almost all diseases, the function of the function of the body of course. 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. The amount of relief and comfort, experienced by sick, after the skin has been carefully washed and dried, is one of the skin 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 which, 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 hear. be specified, the less so, as the doctors ought to say which is to be used. In several forms of diarrhea, dysentery, etc., 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. 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 vapor 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 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 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. End of Section 11. Section 12 of Notes on Nursing by Florence Nightingale.

This Librevox recording is in the public domain. Section 12. Chattering hopes and advices. The sick man to his advisers. My advisors, the 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 we are 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 dumbbell in existence, to imbibe every different kind of stimulus that ever has been invented.

And this, when those best fitted to know, that is 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 advisors? 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 perform say, in sheer defence like Rosalind, I could not do with all. 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 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, etc., and certainly after much more observation than the friend can possibly have had. Supposing the patient to be possessed of common sense, how can the favourable opinion, if it is to be called an opinion at all, of the casual visitor cheer him, when different from

that of the experienced attendant? Unquestionably, the latter may, and often does, turn out to be wrong, but which is most likely to be wrong? The fact is that the patient is not cheered at all by these 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.

Hypercondriacs do, but again I say we are not on the subject of hypercondriacs. If, on the other hand, and which is much more frequently the case, the patient says nothing, but the Shakespearean, oh, ah, go too, 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 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 20 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'm eluding 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 deathbeds are generally depicted as almost seraphic in lucidity of intelligence.

Sadly, large has been my experience in deathbeds, and I can only say that I have seldom or never seen such. Indifference, accepting 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 wearer. 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 advisors are sure to be the same persons who exhorted the sick person not to believe his own doctor's prognostal. because doctors are always mistaken,

but to believe some other doctor because this doctor is always right. Sure also are these advisors to be the persons to bring the sick man fresh occupation, while exhorting him to leave his own. 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 recommendations? But people never think of this. A celebrated historical personage has related to the commonplaces, which, when on the eve of executing a remarkable resolution, were showered in nearly the same words by everyone 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, that is, 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 vivivouche, 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 that 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, the 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 a degree. of such sufferers, recall the slimy trail left by the snail on the sunny southern garden wall loaded with fruit. No mockery in the world is so hollow as the advice showered upon the sick. It is of no use for the sick to say anything, for what the advisor 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 advisor 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, one, that he has nothing the matter with him and that he wants cheering, two, that he is committing suicide and that he wants preventing. Three, that he is the tool of somebody who makes use of him for a purpose. Four, that he will listen to nobody but is obstinately

bent upon his own way, and five, that he ought to be called to the sense of duty and is flying in the face of providence. Then know that your pay. The 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 anyone in good health fancy him or even herself into the life of a sick person? Do you who are about the sick or who visit the sick, try and give them some 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 burdened with business who always manage to keep a pigeonhole 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 of 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 Prince William. 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. 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 can 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 lacrimose 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 who 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 of course you will correct it for both.

It freshenes up our 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 sickbed will do the sick person, 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 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, etc., will disappear with their freshened interest in the big world's events. But then you must be able to give them real interests, not gossip. Note. There are two classes of patients which are, unfortunately, becoming more common every day, especially among women of the richer orders, to whom all these remarks are preeminently inapplicable.

One, those who make health an excuse for doing nothing, and, at the same time, alleged that the being able to do nothing is their only grief. Two, 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 the admiration too often bestowed on the latter class for pluck. End of Section 12.

Section 13 of Notes on Nursing by Florence Nightingale. This Libre Rock's recording is in the public domain. Section 13. Observation of the sick. There is no more silly or universal question scarcely asked than this. Is he better? Ask it of the medical attendant, if you please. But of whom else, if you wish for a real answer to your question, would you ask it? Certainly not of the casual visitor, certainly not of the nurse, while the nurse's observation is so little exercised as it is now. What you want are facts, not opinions, for who can have any opinion of any value as to whether the patient is better or worse, accepting 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 were 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 most of 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 of very few specimens of the answers which I have heard made by friends and nurses, and accepted by physicians and surgeons at the very bedside of the patient, who could have contradicted every word, but did not, sometimes from amiability, often from shyness, oftenest from Langer. 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 moment. progress at all. 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 regularly. The same answer has actually been given as regarded two patients, one who had been entirely sleepless for five times 24 hours and died of it, and another who had not slept the sleep of a regular night without waking. Why cannot the question be asked, how many hours sleep has had? And at what hours of the night? I have never closed my eyes all night. An answer as frequently

made when the speaker has had several hours sleep as when he has had none, would then be less often said. Lies, intentional and unintentional, are much seldom are told in answer to precise than 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. 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, one, that none of them had ever seen a case of the kind of poisoning supposed, two, that none of them had ever seen a case of the kind of disease to which the death, if not to poison, was attributable. Three, 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. 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 really has nothing the matter with him, which is very often the case. But when 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, that is, 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 ones sweeping us. 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 of the other 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 therefore, except to take notice of these things? instead of the patient doing so. Again, the question is sometimes put, is there diarrhea? 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 diarrhea 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 often a 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 on the accurate observation of the nurse or mother who has to report,

and how seldom is this condition of accuracy fulfilled. 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 piece 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 another,

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 ounce of solid food is, how much an ounce of liquid. You will find this helps your observation and memory very much. You will then say to yourself, A took about an ounce of his meat today, B took three times in 24 hours, about a quarter of a pint of beef tea,

instead of saying, B has taken nothing all day, or I gave A his dinner as usual. I have known several of our real old-fashioned hospital sisters, who could, as accurately as a measuring glass, measure out all their patients wine and medicine by the eye, and never be wrong. I do not recommend this, one must be very sure of oneself 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 ounces her patient has taken. In hospitals, those who cut up the diets give with quite sufficient accuracy to each patient, his 12 ounces or his 6 ounces 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 nurse is this? 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 sometime after slowly sinking. The same remark applies to the action of narcotics, of aperian's, which in the one take effect directly, in the other not perhaps for 24 hours.

A journey, a visit, an unwanted 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 outbreak, 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 course observation is utterly at fault. Almost all superstitions are owing to bad observation, to the post hoc ergo proctor 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 nowadays draw consequences for the sick, closely resembling these.

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 show amaciation.

I should say that the hand was a much surer test than the face, both as to flesh, colour, circulation, etc, etc. It is true that there are some diseases which are only betrayed at all by something in the face, for example 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 sore 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'm glad to see you looking so well. I see no reason why you should not live till 90 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 reaction 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 throat are affected and he loses his voice. Yet these two faintnesses are perfectly distinguishable by the mere countenance

of the patient. Again, the nurse must distinguish between the nurse. the idiosyncrasies 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 someone 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 a very patient. As a very often does it happen, that the second is left to think himself neglected. 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 to among those, and chiefly among those, who 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 someone 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 expected or what to be expected, inevitable, visible, calculable, uninterrupted increase of weakness, which none need fail to observe. Again, a patient not usually confined to bed is compelled by an attack

of diarrhea, 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 fidgeted after. Yes, he said so some weeks ago, but he never said he did not like to be fidgeted after, when he is in the state he is in now, and if he did, you ought to make some excuse to go into him. More patients have been lost in this way than is at all generally known, that is, from relapses brought on by being left for an hour or two,

faint or cold or hungry after getting up for the first time. Yet it appears that scarcely any improvement in the faculty 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, I and a medical friend too, the following remark. So A is worse, or B is dead, I saw him the

the day before, I thought him so much better. There certainly was no change from which one could have expected so sudden a change. I have never heard anyone 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. 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 just as often 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 you. 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 inquiry into all the conditions in which the patient lives. In a complicated state of society in large towns, death, as everyone 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 etc etc etc 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. 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 inquiry being made into their conditions. In life insurance, and such like societies, were they instead of having the persons examined by a medical man to have the houses, conditions,

ways of life of these persons examined, at how much truer results would they arrive? W. Smith appears a fine Hailman, but it might be known that the next cholera epidemic he runs a bad chance. Mr. and Mrs. Jay 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. Averages again seduce us away from minute observation. Average mortalities merely tell, that so many percent 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 thousand will die in London next year. But minute inquiries 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 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 was 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 eight out of ten, 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. 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 the injury, without regard to the fact that a curious mine of observation is therefore 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 upon a confidential nurse being placed with the

patient or give up the case 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. 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 attendance 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. End of Section 13. Section 14 of Notes on Nursing by Florence Nightingale. This Libre Fox recording is in the public domain. main. Section 14. Conclusion. The whole of the preceding remarks apply even more to children

and to puerperal women than to patients in general. They also apply to the nursing of surgical quite as much as to that of medical cases. Indeed, if it be possible, cases of external injury require such care even more than sick. In surgical wards, one duty of every nurse, CERC certainly is prevention. Fever or hospital gangrene or paemia or purulent discharge of some kind may else supervene. Has she a case of compound fracture, of amputation or of Chrysippilis, 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 a peculiar close fetid 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 ever be 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-saws, 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. One, that these notes do not pretend to be a manual for nursing any more than for cooking for the sick. Two, that the writer, who has herself seen more of what may be called surgical nursing, that is, practical manual nursing, than perhaps anyone in Europe, honestly believe, 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. Three, while thousands die of foul air, etc., who have this surgical

nursing to perfection, the converse is comparatively rare. To revert to children, 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, that is, 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 dullness 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 the moment. 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 inevitable 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. 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 over-full meal.

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 even for

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 was 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 standstill here mentioned, and from the same causes. 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. 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 Kalimel-Givisive. 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 calamil and a pariance. This is undeniably too often the case. There is nothing ever seen in any professional practice,

like the reckless physocking by amateur females. 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 fiscing. 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 illnesses in order to have more work. Two, 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 disson. entangle. 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 wound. 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 omit 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, a right, 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 Mayor Angelique of Port Royal? What would our own Mrs. Frye have said to this? Note. I would earnestly ask my sisters to keep clear of both the jargons now current everywhere, 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 a certain. 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 will people 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. End of Notes on Nursing, What it is and what it is not,

by Florence Nightingale