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Florence Nightingale 1898 : Notes on Nursing What It Is, and What It Is Not
Florence Nightingale 1898.



Sanitary nursing as essential in surgical as in medical cases, but not to supersede surgical nursing.

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

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

 Children their greater susceptibility to the same things.

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

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

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

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

The following causes of "accidental" death in sick children are enumerated--"Sudden noises, which startle--a rapid change of temperature, which chills the surface, though only for a moment--a rude awakening from sleep--or even an over-hasty, or an overfull meal"--"any sudden impression on the nervous system--any hasty alteration of posture--in short, any cause whatever by which the respiratory process may be disturbed."  
It may again be added, that, with very weak adult patients, these causes are also (not often "suddenly fatal," it is true, but) very much oftener than is at all generally known, irreparable in their consequences.  

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

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

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

Yet, oftener than not, you see the nurse or mother just reversing this; shutting up every cranny through which fresh air can enter, and leaving the body cold, or perhaps throwing a greater weight of clothes upon it, when already it is generating too little heat.  
"Breathing carefully, anxiously, as though respiration were a function which required all the attention for its performance," is cited as a not unusual state in children, and as one calling for care in all the things enumerated above. That breathing becomes an almost voluntary act, even in grown up patients who are very weak, must often have been remarked.

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

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


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.

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

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

 What pathology teaches. What observation alone teaches. What medicine does. What nature alone does.  

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

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

Now for the caution

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

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

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

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

What cruel mistakes are sometimes made by benevolent men and women in matters of business about which they can know nothing and think they know a great deal.  
The everyday management of a large ward, let alone of a hospital--the knowing what are the laws of life and death for men, and what the laws of health for wards--(and wards are healthy or unhealthy, mainly according to the knowledge or ignorance of the nurse)--are not these matters of sufficient importance and difficulty to require learning by experience and careful inquiry, just as much as any other art? They do not come by inspiration to the lady disappointed in love, nor to the poor workhouse drudge hard up for a livelihood.  

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

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

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

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

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

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


 Danger of physicking by amateur females.  

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

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

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

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

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

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

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


The figures in the left hand column, Table B: Nurse (not Domestic Servant) do not add up. There is probably a typographical error in this column since it cannot be accounted for by errors in transcription.


NURSES. Nurse (not Domestic Nurse (Domestic
Servant) Servant)
All Ages. 25,466 39,139
Under 5 years ... ...
5- ... 508
10- ... 7,259
15- ... 10,355
20- 624 6,537
25- 817 4,174
30- 1,118 2,495
35- 1,359 1,681
40- 2,223 1,468
45- 2,748 1,206
50- 3,982 1,196
55- 3,456 833
60- 3,825 712
65- 2,542 369
70- 1,568 204
75- 746 101
80- 311 25
85 and upwards 147 16


NURSES. Nurse (not Domestic Nurse (Domestic
Servant) Servant)
Great Britain and 25,466 21,017
Islands in the
British Seas.
England and Wales. 23,751 18,945
Scotland. 1,543 1,922
Islands in the
British Seas. 172 150
1st Division.
London. 7,807 5,061
2nd Division.
South Eastern. 2,878 2,514
3rd Division.
South Midland. 2,286 1,252
4th Division.
Eastern Counties. 2,408 959
5th Division.
South Western
Counties. 3,055 1,737
6th Division.
West Midland
Counties. 1,225 2,283
7th Division.
North Midland
Counties. 1,003 957
8th Division.
North Western
Counties. 970 2,135
9th Division.
Yorkshire. 1,074 1,023
10th Division.
Counties. 462 410
11th Division.
and Wales. 343 614

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

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

For there the material exists, and will be used for nursing, whether the real "conclusion of the matter" be to nurse or to poison the sick. A man, who stands perhaps at the head of our medical profession, once said to me, I send a nurse into a private family to nurse the sick, but I know that it is only to do them harm. Now a nurse means any person in charge of the personal health of another. And, in the preceding notes, the term nurse is used indiscriminately for amateur and professional nurses. For, besides nurses of the sick and nurses of children, the numbers of whom are here given, there are friends or relations who take temporary charge of a sick person, there are mothers of families. It appears as if these unprofessional nurses were just as much in want of knowledge of the laws of health as professional ones.

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

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




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