Florence Nightingale.

Notes on Nursing What It Is, and What It Is Not online

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requires to repair his waste, what he can take and what he can't. You
cannot diet a patient from a book, you cannot make up the human body as
you would make up a prescription, - 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 when he was ill who disliked them when he
was well, I have known many fond of them when in health, who in sickness
would leave off anything sweet, even to sugar in tea, - 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.

[Sidenote: Jelly.]

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 1/8 oz. of gelatine and make it
into a certain bulk by dissolving it in water and then to give it to the
sick, as if the mere bulk represented nourishment. It is now known that
jelly does not nourish, that it has a tendency to produce 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 100
spoonfuls of jelly were given in the course of the day, you would have
given one spoonful of gelatine, which spoonful has no nutritive power

And, nevertheless, gelatine contains a large quantity of nitrogen, which
is one of the most powerful elements in nutrition; on the other hand,
beef tea may be chosen as an illustration of great nutrient power in
sickness, co-existing with a very small amount of solid nitrogenous

[Sidenote: Beef tea]

Dr. Christison says that "every one will be struck with the readiness
with which" certain classes of "patients will often take diluted meat
juice or beef tea repeatedly, when they refuse all other kinds of food."
This is particularly remarkable in "cases of gastric fever, in which,"
he says, "little or nothing else besides beef tea or diluted meat juice"
has been taken for weeks or even months, "and yet a pint of beef tea
contains scarcely 1/4 oz. of anything but water," - the result is so
striking that he asks what is its mode of action? "Not simply nutrient -
1/4 oz. of the most nutritive material cannot nearly replace the daily
wear and tear of the tissues in any circumstances. Possibly," he says,
"it belongs to a new denomination of remedies."

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 innutritious and beef tea nutritious to
the sick, is a secret yet undiscovered, but it clearly shows that
careful observation of the sick is the only clue to the best dietary.

[Sidenote: Observation, not chemistry, must decide sick diet.]

Chemistry has as yet afforded little insight into the dieting of sick.
All that chemistry can tell us is the amount of "carboniferous" or
"nitrogenous" elements discoverable in different dietetic articles. It
has given us lists of dietetic substances, arranged in the order of
their richness in one or other of these principles; but that is all. In
the great majority of cases, the stomach of the patient is guided by
other principles of selection than merely the amount of carbon or
nitrogen in the diet. No doubt, in this as in other things, nature has
very definite rules for her guidance, but these rules can only be
ascertained by the most careful observation at the 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 a quarter of a lb. of meat. But this is not
the whole question or nearly the whole. The main question is what the
patient's stomach can assimilate or derive nourishment from, and of this
the patient's stomach is the sole judge. Chemistry cannot tell this. The
patient's stomach must be its own chemist. The diet which will keep the
healthy man healthy, will kill the sick one. The same beef which is the
most nutritive of all meat and which nourishes the healthy man, is the
least nourishing of all food to the sick man, whose half-dead stomach
can _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

[Sidenote: Home-made bread.]

I have known patients live for many months without touching bread,
because they could not eat baker's bread. These were mostly country
patients, but not all. Home-made bread or brown bread is a most
important article of diet for many patients. The use of aperients may be
entirely superseded by it. Oat cake is another.

[Sidenote: Sound observation has scarcely yet been brought to bear on
sick diet.]

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 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.

[Sidenote: Tea and coffee.]

A great deal too much against tea[2] is said by wise people, and a great
deal too much of tea is given to the sick by foolish people. When you
see the natural and almost universal craving in English sick for their
"tea," you cannot but feel that nature knows what she is about. But a
little tea or coffee restores them quite as much as a great deal, and a
great deal of tea and especially of coffee impairs the little power of
digestion they have. Yet a nurse, because she sees how one or two cups
of tea or coffee restores her patient, thinks that three or four cups
will do twice as much. This is not the case at all; it is however
certain that there is nothing yet discovered which is a substitute to
the English patient for his cup of tea; he can take it when he can take
nothing else, and he often can't take anything else if he has it not. I
should be very glad if any of the abusers of tea would point out what to
give to an English patient after a sleepless night, instead of tea. If
you give it at 5 or 6 o'clock in the morning, he may even sometimes fall
asleep after it, and get perhaps his only two or three hours' sleep
during the twenty-four. At the same time you never should give tea or
coffee to the sick, as a rule, after 5 o'clock in the afternoon.
Sleeplessness in the early night is from excitement generally and is
increased by tea or coffee; sleeplessness which continues to the early
morning is from exhaustion often, and is relieved by tea. The only
English patients I have ever known refuse tea, have been typhus cases,
and the first sign of their getting better was their craving again for
tea. In general, the dry and dirty tongue always prefers tea to coffee,
and will quite decline milk, unless with tea. Coffee is a better
restorative than tea, but a greater impairer of the digestion. Let the
patient's taste decide. You will say that, in cases of great thirst, the
patient's craving decides that it will drink _a great deal_ of tea, and
that you cannot help it. But in these cases be sure that the patient
requires diluents for quite other purposes than quenching the thirst; he
wants a great deal of some drink, not only of tea, and the doctor will
order what he is to have, barley water or lemonade, or soda water and
milk, as the case may be.

Lehman, quoted by Dr. Christison, says that, among the well and active
"the infusion of 1 oz. of roasted coffee daily will diminish the waste"
going on in the body" "by one-fourth," [Transcriber's note: Quotes as in
the original] and Dr. Christison adds that tea has the same property.
Now this is actual experiment. Lehman 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.[3]

[Sidenote: Cocoa.]

Cocoa is often recommended to the sick in lieu of tea or coffee. But
independently of the fact that English sick very generally dislike
cocoa, it has quite a different effect from tea or coffee. It is an oily
starchy nut having no restorative power at all, but simply increasing
fat. It is pure mockery of the sick, therefore, to call it a substitute
for tea. For any renovating stimulus it has, you might just as well
offer them chestnuts instead of tea.

[Sidenote: Bulk.]

An almost universal error among nurses is in the bulk of the food and
especially the drinks they offer to their patients. Suppose a patient
ordered 4 oz. brandy during the day, how is he to take this if you make
it into four pints with diluting it? The same with tea and beef tea,
with arrowroot, milk, &c. 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.


[Sidenote: Intelligent cravings of particular sick for particular
articles of diet.]

In the diseases produced by bad food, such as scorbutic dysentery and
diarrhoea, the patient's stomach often craves for and digests things,
some of which certainly would be laid down in no dietary that ever was
invented for sick, and especially not for such sick. These are fruit,
pickles, jams, gingerbread, fat of ham or bacon, suet, cheese, butter,
milk. These cases I have seen not by ones, nor by tens, but by hundreds.
And the patient's stomach was right and the book was wrong. The articles
craved for, in these cases, might have been principally arranged under
the two heads of fat and vegetable acids.

There is often a marked difference between men and women in this matter
of sick feeding. Women's digestion is generally slower.

It is made a frequent recommendation to persons about to incur great
exhaustion, either from the nature of the service, or from their being
not in a state fit for it, to eat a piece of bread before they go. I
wish the recommenders would themselves try the experiment of
substituting a piece of bread for a cup of tea or coffee, or beef-tea,
as a refresher. They would find it a very poor comfort. When soldiers
have to set out fasting on fatiguing duty, when nurses have to go
fasting in to their patients, it is a hot restorative they want, and
ought to have, before they go, not a cold bit of bread. And dreadful
have been the consequences of neglecting this. If they can take a bit of
bread _with_ the hot cup of tea, so much the better, but not _instead_
of it. The fact that there is more nourishment in bread than in almost
anything else, has probably induced the mistake. That it is a fatal
mistake, there is no doubt. It seems, though very little is known on the
subject, that what "assimilates" itself directly, and with the least
trouble of digestion with the human body, is the best for the above
circumstances. Bread requires two or three processes of assimilation,
before it becomes like the human body.

The almost universal testimony of English men and women who have
undergone great fatigue, such as riding long journeys without stopping,
or sitting up for several nights in succession, is that they could do it
best upon an occasional cup of tea - and nothing else.

Let experience, not theory, decide upon this as upon all other things.

In making coffee, it is absolutely necessary to buy it in the berry and
grind it at home. Otherwise you may reckon upon its containing a certain
amount of chicory, _at least_. This is not a question of the taste, or
of the wholesomeness of chicory. It is that chicory has nothing at all
of the properties for which you give coffee. And therefore you may as
well not give it.

Again, all laundresses, mistresses of dairy-farms, head nurses, (I speak
of the good old sort only - women who unite a good deal of hard manual
labour with the head-work necessary for arranging the day's business, so
that none of it shall tread upon the heels of something else,) set great
value, I have observed, upon having a high-priced tea. This is called
extravagant. But these women are "extravagant" in nothing else. And they
are right in this. Real tea-leaf tea alone contains the restorative they
want; which is not to be found in sloe-leaf tea.

The mistresses of houses, who cannot even go over their own house once a
day, are incapable of judging for these women. For they are incapable
themselves, to all appearance, of the spirit of arrangement (no small
task) necessary for managing a large ward or dairy.


[Sidenote: Feverishness a symptom of 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.[1] The patient has had
re-introduced into the body the emanations from himself which day after
day and week after week saturate his unaired bedding. How can it be
otherwise? Look at the ordinary bed in which a patient lies.

[Sidenote: Uncleanliness of ordinary bedding.]

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 vallance 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[2], and
this from the time the mattresses are put under him till the time they
are picked to pieces, if this is ever done.

[Sidenote: Air your dirty sheets, not only your clean ones.]

If you consider that an adult in health exhales by the lungs and skin in
the twenty-four hours three pints at least of moisture, loaded with
organic matter ready to enter into putrefaction; that in sickness the
quantity is often greatly increased, the quality is always more noxious
- just ask yourself next where does all this moisture go to? Chiefly
into the bedding, because it cannot go anywhere else. And it stays
there; because, except perhaps a weekly change of sheets, scarcely any
other airing is attempted. A nurse will be careful to fidgetiness about
airing the clean sheets from clean damp, but airing the dirty sheets
from noxious damp will never even occur to her. Besides this, the most
dangerous effluvia we know of are from the excreta of the sick - these
are placed, at least temporarily, where they must throw their effluvia
into the under side of the bed, and the space under the bed is never
aired; it cannot be, with our arrangements. Must not such a bed be
always saturated, and be always the means of re-introducing into the
system of the unfortunate patient who lies in it, that excrementitious
matter to eliminate which from the body nature had expressly appointed
the disease?

My heart always sinks within me when I hear the good house-wife, of
every class, say, "I assure you the bed has been well slept 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 in it his own
damp? Has it not had a single chance to be aired? No, not one. "It has
been slept in every night."

[Sidenote: Iron spring bedsteads the best.]

[Sidenote: Comfort and cleanliness of _two_ beds.]

The only way of really nursing a real patient is to have an _iron_
bedstead, with rheocline springs, which are permeable by the air up to
the very mattress (no vallance, of course), the mattress to be a thin
hair one; the bed to be not above 3-1/2 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, &c., complete - the
patient to pass twelve hours in each bed; on no account to carry his
sheets with him. The whole of the bedding to be hung up to air for each
intermediate twelve hours. Of course there are many cases where this
cannot be done at all - many more where only an approach to it can be
made. I am indicating the ideal of nursing, and what I have actually had
done. But about the kind of bedstead there can be no doubt, whether
there be one or two provided.

[Sidenote: Bed not to be too wide.]

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 a tray down on a narrow bed.
No good nurse will ever put a tray on a bed at all. If the patient can
turn on his side, he will eat more comfortably from a bed-side table;
and on no account whatever should a bed ever be higher than a sofa.
Otherwise the patient feels himself "out of humanity's reach;" he can
get at nothing for himself: he can move nothing for himself. If the
patient cannot turn, a table over the bed is a better thing. I need
hardly say that a patient's bed should never have its side against the
wall. The nurse must be able to get easily to both sides 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.

[Sidenote: Bed not to be too high.]

When I see a patient in a room nine or ten feet high upon a bed between
four and five feet high, with his head, when he is sitting up in bed,
actually within two or three feet of the ceiling, I ask myself, is this
expressly planned to produce that peculiarly distressing feeling common
to the sick, viz., as if the walls and ceiling were closing in upon
them, and they becoming sandwiches between floor and ceiling, which
imagination is not, indeed, here so far from the truth? If, over and
above this, the window stops short of the ceiling, then the patient's
head may literally be raised above the stratum of fresh air, even when
the window is open. Can human 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

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 twenty-four hours is obliged to get in and
out of bed than they are, who only, it is to be hoped, get into bed once
and out of bed once during the twenty-four hours.

[Sidenote: Nor in a dark place.]

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

[Sidenote: Nor a four poster with curtains.]

I need scarcely say that the old four-post bed with curtains is utterly
inadmissible, whether for sick or well. Hospital bedsteads are in many
respects very much less objectionable than private ones.

[Sidenote: Scrofula often a result of disposition of bed clothes.]

There is reason to believe that not a few of the apparently
unaccountable cases of scrofula among children proceed from the habit of
sleeping with the head under the bed clothes, and so inhaling air
already breathed, which is farther contaminated by exhalations from the
skin. Patients are sometimes given to a similar habit, and it often
happens that the bed clothes are so disposed that the patient must
necessarily breathe air more or less contaminated by exhalations from
his skin. A good nurse will be careful to attend to this. It is an
important part, so to speak, of ventilation.

[Sidenote: Bed sores.]

It may be worth while 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.

[Sidenote: Heavy and impervious bed clothes.]

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 bed clothes, 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 a-top of the other like a wall of bricks. The head is
thrown upon the chest. And the shoulders are pushed forward, so as not
to allow the lungs room to expand. The pillows, in fact, lean upon the
patient, not the patient upon the pillows. It is impossible to give a
rule for this, because it must vary with the figure of the patient. And
tall patients suffer much more than short ones, because of the _drag_ of
the long limbs upon the waist. But the object is to support, with the
pillows, the back _below_ the breathing apparatus, to allow the
shoulders room to fall back, and to support the head, without throwing
it forward. The suffering of dying patients is 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.


[Sidenote: Nurses often do not think the sick room any business of
theirs, but only, the sick.]

I once told a "very good nurse" that the way in which her patient's room
was kept was quite enough to account for his sleeplessness; and she
answered quite good-humouredly she was not at all surprised at it - as if
the state of the room were, like the state of the weather, entirely out
of her power. Now in what sense was this woman to be called a "nurse?"

For the same reason if, after washing a patient, you must put the same
night-dress on him again, always give it a preliminary warm at the fire.

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