In the years succeeding her return from the Crimea Miss Nightingale, in addition to the important labours recorded in the foregoing chapter, was actively engaged with her pen. Her writings dealt with the subjects so near her heart of hospital reform, sick nursing and household sanitation. If the soldier needed hygienic reforms in barracks and camps, so did the great mass of the people in their own homes. Miss Nightingale’s interest in army reform did not absorb her attention to the neglect of civil matters.

Her writings are distinguished not only by expert and technical knowledge, but by much homely practical wisdom. There is nothing of the blue-stocking about Florence Nightingale. She puts aside formulas, and with tender human feeling, enlivened by witty epigram and racy humour, goes right to the heart of her subject, particularly in regard to the needs and management of the sick.

Her first published work after her return home was a statistical account of her distribution of the “Voluntary Contributions,” placed at her disposal for the sick soldiers, which has already been dealt with. In the following year (1858) she issued her Notes on Matters affecting the Health, Efficiency, and Hospital Administration of the British Army, which was of great value to the Commission on the War, then sitting, and led to the institution of many reforms.

In 1859 Miss Nightingale published her Notes on Hospitals, the basis of which was a paper she prepared for the Social Science Association. “It may seem a strange principle,” she writes with grim humour, “to enunciate 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 treated out of hospital would lead us to expect.”

It was the knowledge of this unsatisfactory fact which led Miss Nightingale to thoroughly investigate the influence which hospital construction exercised on the death-rate of patients received into the wards. The result was her Notes on Hospitals, which in the enlarged edition, published in 1863, became a standard work on the subject. It is technical in character, and, in addition to recommendations on the conduct and arrangements of hospitals, gives plans for hospital construction. It covers the whole field from floors and walls to hospital furniture.

In the following year of 1860 came that ever popular book, Notes on Nursing: What it Is, and What it is Not, of which more than one hundred thousand copies have been sold. In it Miss Nightingale gives such homely advice as can be put into practice by every girl and woman in the land. The subject is always topical, and I cannot do better than cull some of the words of wisdom from the Queen of Nurses.

The Notes, she explains, are not intended as a manual for nurses but simply to give hints for thought to women who have personal charge of the health of others, and almost every woman in England has some time or other the charge of the health of another. “Every woman is a nurse.” Then she proceeds with piquant saying and homely illustration to give simple rules for the amateur nurse. “No need to discuss,” she says, “whether the top of Mont Blanc will ever be inhabited—it will be thousands of years before we have reached the bottom of Mont Blanc in making the earth healthy. Nursing 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, quiet, and proper selection and administration of diet.”

She goes on to refer to the “coxcombries” of education, by which the elements of astronomy are taught to every schoolgirl while the future wives and mothers are not instructed in those laws which God has assigned to the relations of our bodies with the world in which He has put them. It is no use to blame the climate, which we cannot control, for sickness. “What can we do with the east wind?” people ask.

“Who is it who knows when the wind is in the east?” returns Miss Nightingale. “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. Put the latter under as good sanitary condition as the former, and she too will not know when the wind is in the east.”

Miss Nightingale groups young ladies and soldiers together as the most frequent victims of consumption, owing to foul air and exposure to chills. “Young ladies, like soldiers, go out in all weathers, the one to parties, the other to sentry duty; both enter foul air, the one in ball-rooms, the other in guard-rooms; both go home in damp night air after skin and lungs are oppressed in their functions by overcrowding.” She implores young ladies to open their windows and bedcurtains at night, and not be afraid of spoiling their complexions. This was written, it must be remembered, more than forty years ago, when girls were more afraid of fresh air than they are to-day, now that cycling, hockey, and golf have inured them even to east winds.

After dealing with household hygiene in chapters on “Ventilating and Warming,” and “Health of Houses,” she proceeds to consider the bad results of “Petty Management,” under which heading the want of relays of nurses is dealt with both in institutions and in private homes. A tired, jaded nurse is almost worse than no nurse at all. The nurse must have needed rest; still, the patient should not be left alone. “I once heard a neglectful official rebuked,” says Miss Nightingale, “in the words, ‘Patients, sir, will not stop dying while we are in church.’”

The subject of “Noise” gives Miss Nightingale the occasion to speak plainly on the dress of the amateur nurse. She wrote in the days of crinolines, but her strictures would equally apply to the woman who in modern times gets her long skirts entangled in the furniture, and creates as much noise and upset in the sick chamber as did the nurse of the olden days with her crinoline. Miss Nightingale endorses Lord Melbourne’s sentiments when he said: “I would rather have men about me when I am ill. I think it requires very strong health to put up with women.” It was “the fidget of silk and crinoline, the crackling of starched petticoats, the creaking of stays and shoes,” which led Lord Melbourne to make this ungallant observation.

Miss Nightingale advises the private woman called upon to nurse in her own family to copy the neat, trim style of dressing adopted by the professional nurse. Her manner should be as motionless as possible. “Never gesticulate when speaking to the sick,” cultivate conciseness and calmness, and avoid an irresolute manner.

The chapter on “Variety” deals in a beautiful and sympathetic spirit with the effect of colour and variety of objects on the sick person. “The effect in sickness,” she writes, “of beautiful objects, of variety of objects, and especially of brilliancy of colour, is hardly at all appreciated. Such cravings are not fancies.... Variety of form and brilliancy of colour in the objects presented to patients are actual means of recovery,” and she recalls her own case, already quoted, when a nosegay of wild-flowers brought to her hut on the heights of Balaclava, where she lay with fever, seemed to put new life into her. “Form and colour,” she says, “will free your patient from his painful ideas better than any argument.” People say it is the effect on the patient’s mind. It is no such thing; the effect is on the body too. While variety in objects is necessary, “it must be a slow variety; don’t show a patient ten or twelve engravings successively.” One fresh picture a day hung on his wall or brought to his bedside will be more appreciated.

The Queen of Nurses combats the frequently accepted idea that cut flowers and growing plants are unhealthy in a sick-room, even at night. “The carbonic acid they give off at nights,” she writes, “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.” The nurse should observe what colours are most pleasing to her patient. “Some sick persons feel stimulus from looking at scarlet flowers, others exhaustion from looking at deep blue.”

This reminds me of an incident which occurred while the present writer was going over Netley Hospital when it was filled with wounded from the battlefields of South Africa. The convalescent soldiers were doing fancy woolwork, and a sister came into a ward bearing a parcel of wool sent by a benevolent lady. When opened, the wool was found to be all in khaki colour. The men turned their heads in disgust. “Didn’t we see enough of khaki in South Africa, sister?” they exclaimed. “Why don’t these kind ladies send us bright colours which will drive the thought of khaki out of our minds.” A moment’s intelligent reflection on the colours most likely to please the brave fellows at Netley would have prevented such a foolish mistake. Miss Nightingale’s words of wisdom, written forty years ago, are not obsolete yet.

The subject of “Taking Food” is next dealt with, and Miss Nightingale vigorously attacks the accepted traditions. It is a common error “that beef tea is the most nutritious 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—barely a tablespoonful of solid nourishment to half a pint of water in beef tea.” Still, Miss Nightingale admits that there is a certain reparative quality in beef tea, as in ordinary tea. She denounces that favourite article with the friends of the sick, jelly, which usually contains no nourishment at all.

Miss Nightingale is constantly called the “soldier’s friend” and one may add that she is above all the patient’s friend. “Attend,” she writes, “to the intelligent cravings of the sick. Patients crave for things laid down in no sick dietary. It often happens that the patient’s stomach is right and the book wrong. You can’t diet a patient from a book.”

How many weary invalids will thank the Queen of Nurses for granting them the too often condemned cup of tea. “A great deal too much against tea is said by wise people,” she writes. “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. 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. It is 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, 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.” Cocoa increases fat, but has no restorative power, and it is “pure mockery to offer it as a substitute for tea—you might,” adds Miss Nightingale, “as well offer patients chestnuts instead of tea.” She gives the warning, however, that too much tea is given to the sick by foolish people, and that as a rule neither tea nor coffee should be given to invalids after five o’clock.

The remarks on “Beds and Bedding” are not as relevant now as when they were written in the days of the much be-curtained four-post bedstead and luxurious feather beds. Most people now acknowledge the superiority of the iron bedstead with spring mattress. The bed coverings should be light as well as warm and “a true nurse,” says Miss Nightingale, “always makes her patient’s bed and does not leave it to the housemaid.” She recommends that the bed should always be in the lightest place in the room, and the patient able to see out of window. “A fashionable physician,” she writes, “has been saying that he turns his patients’ 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.” Observation of the sick shows that patients do not turn their faces to the wall.

Miss Nightingale, in illustration of the craving of the sick to see out of window, relates a beautiful story of a nurse’s self-sacrifice. A poor man in one of the hospitals was suffering from spinal accident and expressed an intense longing just to have one look out of the window. The nurse, moved with compassion for the poor fellow’s craving, raised him on her back so that he might take his coveted look at the outside world once again. His joy was great, but the effort cost the nurse a long and serious illness.

Under the heading of “Chattering Hopes and Advices,” Miss Nightingale evidently speaks out of the fulness of her own experience. “‘Chattering Hopes,’” she says, “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 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.... The fact is that the patient is not ‘cheered’ at all by these well-meaning, most tiresome friends.” The advice or opinion of the experienced does not of course come under the head of “Chattering Hopes,” but it is the advice of “inexperience to bitter experience” which Miss Nightingale condemns, and which amounts to nothing more than this, “that you think I shall recover from consumption, because somebody knows somebody, somewhere, who has recovered from fever.” Nurses should protect their patients from visitors of the class indicated.

The “Observation of the Sick” is a quality which needs cultivation. “The most important practical lesson that can be given to nurses is to teach them what to observe,” writes Miss Nightingale, also “how to observe,” and to accurately state the result of observation. It is a more difficult thing to speak the truth than people commonly imagine. “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 do that. She quotes a little incident to illustrate the point. “I know I fibs dreadful; but believe me, miss, I never finds out I have fibbed until they tells me so,” was a remark once made to her, which is, as she says, “one of more extended application than most people have the least idea of.”

Needless to say, unintentional “fibbing,” or in other words lack of observation, which leads a nurse to wrongly inform the doctor regarding the patient, often leads to disastrous results. “I knew,” says Miss Nightingale, “a very clever physician of large dispensary and hospital practice, who invariably began his examination of a patient with ‘Put your finger where you be bad.’ That man would never waste his time with collecting inaccurate information from nurse or patient.” Nothing leads to inaccurate information more than putting “leading questions” to sick people. “How do you sleep?” “How is your appetite?” A tactful and observant nurse will be better able to answer such questions than the patient himself.

Miss Nightingale thinks that Englishwomen are not naturally good observers, though capable of attaining to it by training. The French or Irish woman is much quicker. She records a homely little example of want of observation. “I remember when a child,” she writes, “hearing the story of an accident related by some one who sent two nieces to fetch a ‘bottle of sal-volatile from her room.’ ‘Mary could not stir,’ she said; ‘Fanny ran and fetched a bottle that was not sal-volatile, and that was not in my room.’ If Fanny had observed the bottle of sal-volatile in the aunt’s room every day she was there, she would have found it when it was suddenly wanted. This habit of inattention generally pursues a person through life, a woman is asked to fetch a large new-bound red book lying on the table by the window, and she fetches five small old boarded brown books lying on the shelf by the fire.”

In contrast to this type of careless person, Miss Nightingale instances the trained observations of a famous actress. “I was once taken,” she writes, “to see a great actress in Lady Macbeth. To me it appeared the mere transference upon the stage of a death-bed, such as I had often witnessed. So, just before death, have I seen a patient get out of bed and feebly re-enact some scene of long ago, exactly as if walking in sleep.” The actress played her part so well because she had actually observed life.

“The very alphabet of a nurse,” says Miss Nightingale, “is to observe so well that she is able to interpret every change which comes over a patient’s countenance, without causing him the exertion of saying what he feels.... A patient is not merely a piece of furniture, to be kept clean and arranged against the wall, and saved from injury or breakage—though to judge from what many a nurse does and does not do, you would say he was.” Then comes a caution that all sick people dislike being watched, and the nurse must observe without appearing to do so. Miss Nightingale relates that the best observer she ever knew was a distinguished doctor for lunacy. “He leans back in his chair, with half-shut eyes,” she relates, “and, meanwhile, he sees everything, observes everything, and you feel he knows you better than many who have lived with you twenty years. I believe it is this singular capacity of observation and of understanding what observed appearances imply which gives him his singular influence over lunatics.”

In a concluding chapter, Miss Nightingale refers to the dangers of “reckless physicking by amateur females,” and tells of the lady who, having procured a prescription for a blue pill which suited her during one indisposition, proceeded to dose not only herself but her family too, “for all complaints upon all occasions.” Then there are the women who have no ideas beyond calomel and aperients, and the Lady Bountifuls who dose their poorer neighbours with a favourite prescription when it would be doing more good if they persuaded the people 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 their cottages.”

She has some last words to say on nursing as a profession, and gives a humorous little thrust at “the 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 school-master because he was ‘past keeping the pigs.’”

Miss Nightingale sums up the matter with some condensed wisdom on the question as to whether women are fitted for the medical and other professions. She urges them to keep clear of “the jargon” which impels a woman on the one hand to do things simply to imitate men, and on the other to refrain from doing what she has the power to accomplish simply because it has hitherto been considered man’s work. “Surely woman,” she writes, “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, but listening to the ‘what people will say’ opinion, to the voices from without? No one has ever done anything great or useful by listening to the voices from without. You want to do the thing that is good, whether people call it ‘suitable for a woman’ or not. Oh, leave these jargons, and go your way straight to God’s work, in simplicity and singleness of heart.”

A year after the publication of Notes on Nursing, Miss Nightingale issued (1861) a modified edition of the work, under the title of Notes on Nursing for the Labouring Classes, adding a chapter on “Minding Baby,” which is specially addressed to young girls in working families, who have a great deal to do with minding mother’s baby. It is delightfully written and reveals how conversant the author was with the homes of the poor. It would do more good than many tracts if distributed by the district visitor, and would be a useful addition to the textbooks of our elementary schools. With her usual quick insight the Queen of Nurses recognises the importance of the working-girl nurse. “One-half of all the nurses in service,” she writes, “are girls of from five to twenty years old. You see you are very important little people. Then there are all the girls who are nursing mother’s baby at home; and in all these cases it seems pretty nearly to come to this, that baby’s health for its whole life depends upon you, girls, more than upon anything else.” Simple rules such as a girl of six could understand are given for the feeding, washing, dressing, nursing, and even amusement of that important person, “baby.”

“The healthiest, happiest, liveliest, most beautiful baby I ever saw was the only child of a busy laundress,” writes Miss Nightingale; “she washed all day in a room with the door open upon a larger room, where she put the child. It sat or crawled upon the floor all day with no other play-fellow than a kitten, which it used to hug. Its mother kept it beautifully clean, and fed it with perfect regularity. The child was never frightened at anything. The room where it sat was the house-place; and it always gave notice to its mother when anybody came in, not by a cry, but by a crow. I lived for many months within hearing of that child, and never heard it cry day or night. I think there is a great deal too much of amusing children now; and not enough of letting them amuse themselves.”

The versatility of Miss Nightingale’s pen is shown by her next publication, The Sanitary State of the Army in India, which came out in 1863. The hand which could write with such tender womanly concern about baby could deal vigorous blows at the insanitary condition of the soldiers in India. She had been keenly interested in Lord Herbert’s scheme for uniting the Indian with the Home army, and followed it up by a thorough investigation of the causes affecting the health of the army in India. An elaborate series of written evidence procured from all the principal stations of India by the Royal Commission appointed for the purpose, was laid before Miss Nightingale in 1861, and at the request of the Commission she wrote a valuable paper of comments on the reports. Lord Stanley succeeded Lord Herbert as President of the Commission, and to him Miss Nightingale addressed her observations, which form a book of some hundred pages. She points out in her usual concise style the evils arising from the defective sanitation of the camps, the bad water, lack of drainage, and the imperfections of the hospitals, and deals with the preventable causes which lead to drunkenness and a low tone of morality amongst the Indian troops.

The state of the army in India continued to be a matter of great concern to Miss Nightingale, and at the request of the National Social Science Congress she prepared a paper on the subject, to which she gave the arresting title “How People may Live and not Die in India.” This was read at the Edinburgh meeting in 1863, and published in pamphlet form the following year. In a prefatory note Miss Nightingale refers with pleasure to the improvement in the condition of the soldiers which had taken place in many respects. The introduction of soldiers’ gardens, trades, and workshops enabled the men to realise that it was better to work than to sleep and to drink, even during hot weather.

She gives an interesting instance of how these reforms had worked. “One regiment marching into a station,” she writes, “where cholera had been raging for two years, were ‘chaffed’ by the regiments marching out, and told they would never come out of it alive.

“The men of the entering battalion answered, They would see; we won’t have cholera. And they made gardens with such good effect that they had the pleasure not only of eating their own vegetables, but of being paid for them too by the commissariat. And this in a soil which no regiment had been able to cultivate before. And not a man had cholera. These good soldiers fought against disease, too, by workshops and gymnasia, and at a few hill stations the men have covered the whole hill-sides with their gardens.”

She goes on to tell of the good results taking place from the introduction of gymnastics for the men and cricket and other outdoor sports. “In short,” she adds in a pithy sentence, “work and all kinds of exercise cause sickly men to flourish.” Soldiers’ libraries were being established by Government, better cook-houses built, and the soldiers taught to cook. And so far she is glad to record that the soldiers’ habits had improved. “But the main causes of diseases in India—want of drainage, want of water supply for stations and towns—remain as before,” she ironically remarks, “in all their primitive perfection.” The death-rate of troops serving in India was the alarming one of sixty-nine per thousand per annum. “It takes something more than climate to account for this,” she writes. “All that the climate requires is that men shall adapt their social habits and customs to it, as, indeed, they must do to the requirements of every other climate under heaven. There is not a shadow of proof that India was created to be the grave of the British race.”

Miss Nightingale then enumerates the simple rules for dress, diet, and exercise to be observed by soldiers serving in India. But though a man can regulate his personal habits, “he cannot,” she adds, “drain and sewer his own city, nor lay a water supply on to his own station, nor build his own barracks,” and she proceeds to urge that sanitary reform in India is still one of the most pressing questions for the Government. By wise measures the enormous death-rate of sixty-nine per thousand might be reduced to ten per thousand. “What a work, what a noble task for a Government—no ‘inglorious period of our dominion’ that,” she writes, “but a most glorious one!”

Ten years later Miss Nightingale again returned to the “charge” and prepared a paper on “Life or Death in India,” which was read at the meeting of the National Association for the promotion of Social Science at Norwich in 1873, and afterwards published as a pamphlet with an appendix on “Life or Death by Irrigation.”

In this paper Miss Nightingale pointed out the cheering fact that during the past ten years in which sanitary reforms had been progressing the death-rate of the army in India had been reduced from sixty-nine per thousand to eighteen per thousand—that is, eighteen men died where sixty-nine had died before. Still, she considered that this only sufficed to show the work that yet remained to be done, especially with regard to the drainage, water supply, and the irrigation of the country for commercial purposes, on account not only of the soldier, but to promote the health of the teeming millions of our fellow-subjects in India and their general prosperity.

Miss Nightingale disposes of the “caste” difficulty with an amusing incident. When the Government’s new water supply “was first introduced into Calcutta, the high-caste Hindoos still desired their water-carriers to bring them their sacred water from the river; but these functionaries, finding it much easier to take the water from the new taps, just rubbed in a little (vulgar not sacred) mud, and presented it as Ganges water.

“When at last the filthy fraud was discovered, public opinion, founded on experience, had already gone too far to return to dirty water. And the new water supply was, at public meetings, adjudged to be theologically as well as physically safe.”

Miss Nightingale urges that irrigation schemes should be set on foot by the Government as a preventive against the ever-recurring famines which afflict our fellow Indian subjects so severely. “Is not the Government of India,” she asks, “too much like a dispensary, which does all that man can do to cure when too late to do anything to prevent?”

While Miss Nightingale’s pen was pleading so eloquently and practically during this period for the good of the great Empire in the East, she was not unmindful of the people at home. Her writings and work in connection with the sick poor must form the subject of a separate chapter.