“Notes on Hospitals”

Chapter III.

“It may seem a strange principle to enunciate,” wrote Miss Nightingale in 1863, “as the very first requirement in a hospital that it should do the sick no harm. It is quite necessary, nevertheless, to lay down such a principle, because the actual mortality in hospitals, especially in those of large crowded cities is very much higher than any calculation founded on the mortality of the same class of diseases among patients out of hospitals would lead us to expect.”

At the time Miss Nightingale returned from the Crimea, the death rate in hospitals was lamentably high, and it was but natural that she should turn her attention to remedying such conditions, or at least to call attention to them. In 1858 her book, “Notes on Hospitals,” was issued. A noted man in acknowledging receipt of a copy stated that it appeared to him to be the most valuable contribution to sanitary science in application to medical institutions, that he had ever seen. In this book we find her calling attention to overcrowding, lack of drainage under hospitals, to ventilation, to the necessity of having non-absorbent floors and walls, to the desirability of iron beds, hair mattresses, and glass or earthen ware cups, instead of tin—also to needed improvements in hospital kitchens and laundries, to the curative effects of light—all of which ideas are today regarded as essentials in hospitals, but which were then years in advance of general practice. It is easy to point out defects—not always so easy to produce practical plans for correcting them, but Miss Nightingale not only called attention to the defects but at the same time showed how to remedy them. In the second edition of the book she enumerated “Sixteen Sanitary Defects in the Construction of Hospital Wards”—accompanying each statement with definite plans for correcting the defect. The publication of this little book on hospitals brought to her numerous requests for consultation regarding the construction of new hospitals which were being planned and more than a dozen hospitals constructed, soon after that time, had the benefit of her advice and detailed consideration of the architect’s plans. The questions as to the desirability of pavilion construction and whether a hospital should be built in the midst of a well-populated section, and among the class of people it is expected to serve—or in a more distant location, where better light and air are to be had—which are still debated among hospital people, were then as hotly debated as now. It was not unusual to find her making out the main specifications for an entire hospital building regarding which her advice had been sought, and architects and sanitary engineers were very glad to be able to quote her approval of their plans. Sir Edward Cook, her biographer, states that “in its day, Miss Nightingale’s Notes on Hospitals revolutionized many ideas, and gave a new direction to hospital construction.”

“NOTES ON NURSING.”

Between the return of Miss Nightingale from the Crimea, and the starting of the first real training school for nurses some three or four years elapsed, which were largely devoted to the securing of better sanitary conditions for the army—and in tedious and exhaustive work with military officials and legislators, in addition to her work in improving hospital buildings and methods.

During this time, her book, Notes on Nursing, was issued, in order to deepen the impression she was trying to make, that nursing skill was not something simply to be “picked up” by any woman, but that it required special gifts, special training—training by precept, as well as by example. The book furnished the precept teaching for that time, and was immensely popular. It is safe to say that no book on nursing which has appeared since, or which probably ever will appear, was received with the enthusiasm, that this book of hers aroused among all sorts of people, from the queen down to the laborer’s wife. It many ways, it was a remarkable book—remarkable in the underlying principles set forth, now, well understood and accepted, yet then a new story—and remarkable for its keen appreciation of the needs of the sick. Nurses of today, even graduates, might very profitably try to really learn and practice some of the lessons contained in that little book, written more than half a century ago. Her gospel of fresh air, and its application to health, was a new gospel at that time—yet after all these years it is still unheeded in many homes.

QUOTATIONS FROM HER “NOTES ON NURSING.”

“Do you ever go into the bedrooms of any persons of any class, whether they contain one, two or twenty people, whether they hold sick or well at night, or before the windows are opened in the morning and ever find the air anything but unwholesomely close and foul? And why should it be so? 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; and 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 the sick.”

“Let no one ever depend upon fumigations, ‘disinfectants,’ and the like for purifying the air. The offensive thing, not its smell, must be removed. A celebrated medical lecturer began one day, ‘Fumigations, gentlemen, are of essential importance. They make such an abominable smell that they compel you to open the windows.’”

“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 needs or asks.”

“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.”

“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.”

“Of all methods of keeping patients warm the very worst certainly is to depend for heat on the breath and bodies of the sick.”

“To be ‘in charge’ is certainly not only to carry out the proper measures yourself, but to see that every one else does so too; to see that no one either wilfully or ignorantly thwarts or prevents such measures. It is neither to do everything yourself nor to appoint a number of people to each duty, but to ensure that each does that duty to which he is appointed.”

“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.”

“‘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.”

“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.”

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

“The most important practical lesson that can be given to nurses is to teach them what to observe—how to observe—what symptoms indicate improvement—what the reverse—which are of importance—which are of none—which are the evidence of neglect—and of what kind of neglect. All this is what ought to make part, and an essential part, of the training of every nurse.”

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

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

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

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

“If you cannot get the habit of observation one way or other, you had better give up the being a nurse, for it is not your calling, however kind and anxious you may be.”

“It 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?”

“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.”

“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.”

“Unnecessary noise, then, is the most cruel absence of care which can be inflicted on the sick or well. Unnecessary (although slight) noise injures a sick person much more than necessary noise, of a much greater amount. 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. If you wait till your patients tell you of these things, where is the use of their having a nurse.”

“Always sit within the patient’s view, so that when you speak to him he has not painfully to turn his head round in order to look at you. Everybody involuntarily looks at the person speaking. If you make this act a wearisome one on the part of the patient, you are doing him harm.”

“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. * * * 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. * * * 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 bedridden 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 occurs to them, at least to move his bed so that he can look out of the window.”

“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.”

“A celebrated man has told us that one of the 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 afterward to verify their own accuracy. I have often thought how wise a piece of education this would be for 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.”

“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 sent to be schoolmaster because he ‘was past keeping the pigs’.”

“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.”

“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—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.”

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