Notes on Nursing
by
Florence Nightingale
Part 2 out of 3
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.
[Sidenote: Flowers.]
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, e.g. lilies, the smell of which is said to depress
the nervous system. These are easily known by the smell, and can be
avoided.
[Sidenote: Effect of body on mind.]
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 able every day to walk up Regent-street, or out
in the country, to take your meals with others in other rooms, &c., &c.,
you little know how much your anxieties are thereby lightened; you
little know how intensified they become to those who can have no
change;[1] 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.
[Sidenote: Help the sick to vary their thoughts.]
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 to be always left in the darkest, dullest,
remotest, part of the room.[2]
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 thoughts" which "aggravate their disease," &c. 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 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.
[Sidenote: Supply to the sick the defect of manual labour.]
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,[3] 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,
excepting 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 needle-work, a little writing, a little cleaning, 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, though
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 needle-work, in
writing, in any other continuous employment, will produce the same
irritability that defect in manual employment (as one cause) produces in
the sick.
FOOTNOTES:
[1]
[Sidenote: Sick suffer to excess from mental as well as bodily pain.]
It is a matter of painful wonder to the sick themselves, how much
painful ideas predominate over pleasurable ones in their impressions;
they reason with themselves; they think themselves ungrateful; it is all
of no use. The fact is, that these painful impressions are far better
dismissed by a real laugh, if you can excite one by books or
conversation, than by any direct reasoning; or if the patient is too
weak to laugh, some impression from nature is what he wants. I have
mentioned the cruelty of letting him stare at a dead wall. In many
diseases, especially in convalescence from fever, that wall will appear
to make all sorts of faces at him; now flowers never do this. Form,
colour, will free your patient from his painful ideas better than any
argument.
[2]
[Sidenote: Desperate desire in the sick to "see out of window."]
I remember a case in point. A man received an injury to the spine, from
an accident, which after a long confinement ended in death. He was a
workman--had not in his composition a single grain of what is called
"enthusiasm for nature"--but he was desperate to "see once more out of
window." His nurse actually got him on her back, and managed to perch
him up at the window for an instant, "to see out." The consequence to
the poor nurse was a serious illness, which nearly proved fatal. The man
never knew it; but a great many other people did. Yet the consequence in
none of their minds, so far as I know, was the conviction that the
craving for variety in the starving eye, is just as desperate as that of
food in the starving stomach, and tempts the famishing creature in
either case to steal for its satisfaction. No other word will express it
but "desperation." And it sets the seal of ignorance and stupidity just
as much on the governors and attendants of the sick if they do not
provide the sick-bed with a "view" of some kind, as if they did not
provide the hospital with a kitchen.
[3]
[Sidenote: Physical effect of colour.]
No one who has watched the sick can doubt the fact, that some feel
stimulus from looking at scarlet flowers, exhaustion from looking at
deep blue, &c.
VI. TAKING FOOD.
[Sidenote: Want of attention to hours of 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 11 A.M., 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 from
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 tea-cup full of some
article of food every three hours. The patient's stomach rejects it. If
so, try a table-spoon full every hour; if this will not do, a tea-spoon
full 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 cordiale_ 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.
[Sidenote: Life often hangs upon minutes in taking food.]
If we did but know the consequences which may ensue, in very weak
patients, from ten minutes' fasting or repletion (I call it repletion
when they are obliged to let too small an interval elapse between taking
food and some other exertion, owing to the nurse's unpunctuality), we
should be more careful 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 fall in with no other minute's occupation, they can take
nothing till 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, where 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.
[Sidenote: Patients often starved to death in chronic cases.]
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 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 wot of.
[Sidenote: Food never to be left by the patient's side.]
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 disgust 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 ---- o'clock and ---- o'clock." The
thing was tried and succeeded. Patients very seldom, however, can tell
this; it is for you to watch and find it out.
[Sidenote: Patient had better not see more food than his own.]
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 punctuality 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 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 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.
[Sidenote: You cannot be too careful as to quality in sick diet.]
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 I have seen these things brought in to the sick in a state
perfectly perceptible to every nose or eye except the nurse's. 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 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 extemporize 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 am 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.
[Sidenote: Nurse must have some rule of thought about her patient's
diet.]
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 to-day. 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.[1] If it is used to having its stimulus at one hour to-day,
and to-morrow 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."
[Sidenote: Keep your patient's cup dry underneath.]
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
shall 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 bed-gown, 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.
FOOTNOTE:
[1]
[Sidenote: Nurse must have some rule of time about the patient's diet.]
Why, because the nurse has not got some food to-day which the patient
takes, can the patient wait four hours for food to-day, who could not
wait two hours yesterday? Yet this is the only logic one generally
hears. On the other hand, the other logic, viz., of the nurse giving a
patient a thing because she _has_ got it, is equally fatal. If she
happens to have fresh jelly, or fresh fruit, she will frequently give it
to the patient half an hour after his dinner, or at his dinner, when he
cannot possibly eat that and the broth too--or worse still, leave it by
his bed-side till he is so sickened with the sight of it, that he cannot
eat it at all.
VII. WHAT FOOD?
[Sidenote: Common errors in diet.]
[Sidenote: Beef tea.]
[Sidenote: Eggs.]
[Sidenote: Meat without vegetables.]
[Sidenote: Arrowroot.]
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 lb. of
beef into beef tea, evaporate your beef tea, and see what is left of
your beef. You will find 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 safely be 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 lb. of meat,--whereas it is not at all so. 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 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, viz.: 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. Flour is both more
nutritive, and less liable to ferment, and is preferable wherever it can
be used.
[Sidenote: Milk, butter, cream, &c.]
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. Flour, 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 shewed how much it was needed by
them.[1]
But, if fresh milk is so valuable a food for the sick, the least change
or sourness in it, makes it of all articles, perhaps, the most
injurious; diarrhoea is a common result of fresh milk allowed to become
at all 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. Buttermilk, a totally different thing, is
often very useful, especially in fevers.
[Sidenote: Sweet things.]
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 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 must 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
whatever.
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
matter.
[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
strength.
[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.
FOOTNOTES:
[1]
[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.
[2]
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.
[3]
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.
VIII. BED AND BEDDING.
[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
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 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.
FOOTNOTES:
[1]
[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?"
[2]
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.
The night-gown he has worn must be, to a certain extent, damp. It has
now got cold from having been off him for a few minutes. The fire will
dry and at the same time air it. This is much more important than with
clean things.
IX. LIGHT.
[Sidenote: Light essential to both health and recovery.]
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 them most is a dark room. And that it is
not only light but direct sun-light they want. I had rather have the
power of carrying my patient about after the sun, according to the
aspect of the rooms, if circumstances permit, than 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 _i.e._ 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.
[Sidenote: Aspect, view, and sunlight matters of first importance to the
sick.]
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 _bed_-rooms 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 sun reach his bed-room some time in every day, to
purify the air), because he ought never to be in his bed-room 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 sun-light at least, if you can
show them nothing else, I assert to be, if not of the very 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 mid-day 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 _bed_-room 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.
[Sidenote: Without sunlight, we degenerate body and mind.]
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
vallies, there is cretinism. Where are cellars and the unsunned 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.
[Sidenote: Almost all patients lie with their faces to the light.]
It is a curious thing to observe how almost all patients lie with their
faces turned to 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 bed sides of private patients you have
seen, and count how many sick you ever saw lying with their faces
towards the wall.
X. CLEANLINESS OF ROOMS AND WALLS.
[Sidenote: Cleanliness of carpets and furniture.]
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 twenty
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 free 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.
[Sidenote: Dust never removed now.]
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 on to another with doors
and windows closed. What you do it for I cannot think. You had much
better leave the dust alone, if you are 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, on to another and a
dirtier one.[1] 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 practised, truly means to distribute dust more equally over a
room.
[Sidenote: Floors.]
As to floors, the only really clean floor I know is the Berlin
_lackered_ 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 by no means surprising.
[Sidenote: Papered, plastered, oil-painted walls.]
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 bed-room paper is all that it ought _not_
to be.[2]
The close connection between ventilation and cleanliness is shown in
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
exuviae.[3]
These are what make a room musty.
[Sidenote: Best kind of wall for a sick-room.]
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.
[Sidenote: Dirty air from without.]
1. Dirty air coming in from without, soiled by sewer emanations, the
evaporation from dirty streets, smoke, bits of unburnt fuel, bits of
straw, bits of horse dung.
[Sidenote: Best kind of wall for a house.]
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.
[Sidenote: Dirty air from within.]
2. 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
pretence 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? Ventilate as 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--_E.g._ in colouring certain green papers arsenic is used. Now
in the very dust even, which is lying about in 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 for ever.
Again, the fire fills the room with coal-dust.
[Sidenote: Dirty air from the carpet.]
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 school-room 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.
[Sidenote: Remedies.]
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, &c., 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 of forgetting that what is to them but a
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.
FOOTNOTES:
[1]
[Sidenote: How a room is _dusted_.]
If you like to clean your furniture by laying out your clean clothes
upon your dirty chairs or sofa, this is one way certainly of doing it.
Having witnessed the morning process called "tidying the room," for many
years, and with ever-increasing astonishment, I can describe what it is.
From the chairs, tables, or sofa, upon which the "things" have lain
during the night, and which are therefore comparatively clean from dust
or blacks, the poor "_things_" having "caught" it, they are removed to
other chairs, tables, sofas, upon which you could write your name with
your finger in the dust or blacks. The _other_ side of the "things" is
therefore now evenly dirtied or dusted. The housemaid then flaps
everything, or some things, not out of her reach, with a thing called a
duster--the dust flies up, then re-settles more equally than it lay
before the operation. The room has now been "put to rights."
[2]
[Sidenote: Atmosphere in painted and papered rooms quite
distinguishable.]
I am sure that a person who has accustomed her senses to compare
atmospheres proper and improper, for the sick and for children, could
tell, blindfold, the difference of the air in old painted and in old
papered rooms, _coeteris paribus._ The latter will always be dusty, even
with all the windows open.
[3]
[Sidenote: How to keep your wall clean at the expense of your clothes.]
If you like to wipe your dirty door, or some portion of your dirty wall,
by hanging up your clean gown or shawl against it on a peg, this is one
way certainly, and the most usual way, and generally the only way of
cleaning either door or wall in a bed room!
XI. PERSONAL CLEANLINESS.
[Sidenote: Poisoning by the skin.]
In almost all diseases, the function 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.
[Sidenote: Ventilation and skin-cleanliness equally essential.]
The amount of relief and comfort experienced by sick after the skin has
been carefully washed and dried, 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 wit, 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 here be specified,--the
less so as the doctors ought to say which is to be used.
In several forms of diarrhoea, dysentery, &c., 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.
[Sidenote: Steaming and rubbing the skin.]
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 vapour 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 a 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 as 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.
XII. CHATTERING HOPES AND ADVICES.
[Sidenote: Advising the sick.]
The sick man to his advisers.
"My advisers! Their 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 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
dumb-bell (!) in existence; to imbibe every different kind of stimulus
that ever has been invented; And this when those _best_ fitted to know,
viz., 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 adviser's? 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_ perforce say, in sheer
self-defence, like Rosalind, "I could not do with all."
[Sidenote: Chattering hopes the bane of the sick.]
"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 a
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, &c.; 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?
[Sidenote: Patient does not want to talk of himself.]
The fact is, that the patient[1] 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. Hypochondriacs
do, but again I say we are not on the subject of hypochondriacs.
[Sidenote: Absurd consolations put forth for the benefit of the sick.]
If, on the other hand, and which is much more frequently the case, the
patient says nothing but the Shakespearian "Oh!" "Ah!" "Go to!" 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 a 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 twenty 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 am alluding 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 death-beds are
generally depicted as almost seraphic in lucidity of intelligence. Sadly
large has been my experience in death-beds, and I can only say that I
have seldom or never seen such. Indifference, excepting 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 weary 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 advisers are sure to be the same persons who exhorted the sick
man not to believe his own doctor's prognostics, because "doctors are
always mistaken," but to believe some other doctor, because "this doctor
is always right." Sure also are these advisers to be the persons to
bring the sick man fresh occupation, while exhorting him to leave his
own.
[Sidenote: Wonderful presumption of the advisers of the sick.]
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 recommendation? But people never think of this.
[Sidenote: Advisers the same now as two hundred years ago.]
A celebrated historical personage has related the commonplaces which,
when on the eve of executing a remarkable resolution, were showered in
nearly the same words by every one 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, viz., 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 _viva voce_, 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 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, that 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 the
decline of such sufferers, recall the slimy trail left by the snail on
the sunny southern garden-wall loaded with fruit.
[Sidenote: Mockery of the advice given to sick.]
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 adviser
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 adviser. 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:--1. That he has nothing the matter with him, and that
he wants cheering. 2. That he is committing suicide, and that he wants
preventing. 3. That he is the tool of somebody who makes use of him for
a purpose. 4. That he will listen to nobody, but is obstinately bent
upon his own way; and 5. That, he ought to be called to a sense of duty,
and is flying in the face of Providence;--then know that your 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 any one in good health fancy him or even _her_self into the
life of a sick person.
[Sidenote: Means of giving pleasure to the sick.]
Do, you who are about the sick or who visit the sick, try and give them
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 burthened with business who always manage to keep a
pigeon-hole 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 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 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.[2]
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 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 lachrymose 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 whom 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, you
will of course correct it for both. It freshens up a 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 sick bed will do the sick person, thus 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 if 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, &c., 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.
[Sidenote: Two new classes of patients peculiar to this generation.]
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 pre-eminently inapplicable. 1.
Those who make health an excuse for doing nothing, and at the same time
allege that the being able to do nothing is their only grief. 2. 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 than the admiration too often bestowed on the latter
class for "pluck."
FOOTNOTES:
[1]
[Sidenote: Absurd statistical comparisons made in common conversation by
the most sensible people for the benefit of the sick.]
There are, of course, cases, as in first confinements, when an assurance
from the doctor or experienced nurse to the frightened suffering woman
that there is nothing unusual in her case, that she has nothing to fear
but a few hours' pain, may cheer her most effectually. This is advice of
quite another order. It is the advice of experience to utter
inexperience. But the advice we have been referring to is the advice of
inexperience to bitter experience; and, in general, amounts to nothing
more than this, that _you_ think _I_ shall recover from consumption
because somebody knows somebody somewhere who has recovered from fever.
I have heard a doctor condemned whose patient did not, alas! recover,
because another doctor's patient of a _different_ sex, of a _different_
age, recovered from a _different_ disease, in a _different_ place. Yes,
this is really true. If people who make these comparisons did but know
(only they do not care to know), the care and preciseness with which
such comparisons require to be made, (and are made,) in order to be of
any value whatever, they would spare their tongues. In comparing the
deaths of one hospital with those of another, any statistics are justly
considered absolutely valueless which do not give the ages, the sexes,
and the diseases of all the cases. It does not seem necessary to mention
this. It does not seem necessary to say that there can be no comparison
between old men with dropsies and young women with consumptions. Yet the
cleverest men and the cleverest women are often heard making such
comparisons, ignoring entirely sex, age, disease, place--in fact, _all_
the conditions essential to the question. It is the merest _gossip_.
[2]
A small pet animal is often an excellent companion for the sick, for
long chronic cases especially. A pet bird in a cage is sometimes the
only pleasure of an invalid confined for years to the same room. If he
can feed and clean the animal himself, he ought always to be encouraged
to do so.
XIII. OBSERVATION OF THE SICK.
[Sidenote: What is the use of the question, Is he better?]
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? 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, excepting 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 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. 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 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 a very few specimens of the answers[1] which I have
heard made by friends and nurses, and accepted by physicians and
surgeons at the very bed-side of the patient, who could have
contradicted every word, but did not--sometimes from amiability, often
from shyness, oftenest from languor!
"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 progress at all.
[Sidenote: Leading questions useless or misleading.]
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 occasionally. The same answer
has, actually been given as regarded two patients--one who had been
entirely sleepless for five times twenty-four 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?[2] "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 seldomer told in answer to
precise than to 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.
[Sidenote: Means of obtaining inaccurate information.]
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:--1. That none of them had ever seen a case of the
kind of poisoning supposed. 2. That none of them had ever seen a case of
the kind of disease to which the death, if not to poison, was
attributable. 3. 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.
[Sidenote: As to food patient takes or does not take.]
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
has really nothing the matter with him, which is very often the case.
But where 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, viz., 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 one sweeping 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 other of the 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 there for except to take
note of these things, instead of the patient doing so?[3]
[Sidenote: As to diarrhoea]
Again, the question is sometimes put, Is there diarrhoea? 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 diarrhoea
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
oftener 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 upon the accurate
observation of the nurse or mother who has to report. And how seldom is
this condition of accuracy fulfilled.
[Sidenote: Means of cultivating sound and ready observation.]
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 bit 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 other, 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 oz. of
solid food is, how much an oz. of liquid. You will find this helps your
observation and memory very much, you will then say to yourself, "A.
took about an oz. of his meat to day;" "B. took three times in 24 hours
about 1/4 pint of beef tea;" instead of saying "B. has taken nothing all
day," or "I gave A. his dinner as usual."
[Sidenote: Sound and ready observation essential in a nurse.]
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 one's self 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 oz.) her patient has taken.[4] In hospitals those who cut up
the diets give with sufficient accuracy, to each patient, his 12 oz. or
his 6 oz. 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 a nurse is this?
[Sidenote: Difference of excitable and _accumulative_ temperaments.]
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 some time after slowly sinking. The same
remark applies to the action of narcotics, of aperients, which, in the
one, take effect directly, in the other not perhaps for twenty-four
hours. A journey, a visit, an unwonted 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 out-break 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 coarse observation is
utterly at fault.
[Sidenote: Superstition the fruit of bad observation.]
Almost all superstitions are owing to bad observation, to the _post hoc,
ergo propter 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 now-a-days draw consequences for the
sick closely resembling these.
[Sidenote: Physiognomy of disease little shewn by the face.]
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 shew emaciation. I should say that the hand
was a much surer test than the face, both as to flesh, colour,
circulation, &c., &c. It is true that there are _some_ diseases which
are only betrayed at all by something in the face, _e.g._, 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 _saw_
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 am
glad to see you looking so well." "I see no reason why you should not
live till ninety 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 re-action 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 the throat are affected and he
loses his voice.
Yet these two faintnesses are perfectly distinguishable, by the mere
countenance of the patient.
[Sidenote: Peculiarities of patients.]
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