So true is this that I could mention two cases of women of very high position, both of whom died in the same way of the consequences of a surgical operation. And in both cases, I was told by the highest authority that the fatal result would not have happened in a London hospital.
[Sidenote: What institutions are the exception?]
But, as far as regards the art of petty management in hospitals, all the military hospitals I know must be excluded. Upon my own experience I stand, and I solemnly declare that I have seen or known of fatal accidents, such as suicides in delirium tremens, bleedings to death, dying patients dragged out of bed by drunken Medical Staff Corps men, and many other things less patent and striking, which would not have happened in London civil hospitals nursed by women. The medical officers should be absolved from all blame in these accidents. How can a medical officer mount guard all day and all night over a patient (say) in delirium tremens? The fault lies in there being no organized system of attendance. Were a trustworthy man in charge of each ward, or set of wards, not as office clerk, but as head nurse, (and head nurse the best hospital serjeant, or ward master, is not now and cannot be, from default of the proper regulations,) the thing would not, in all probability, have happened. But were a trustworthy woman in charge of the ward, or set of wards, the thing would not, in all certainty, have happened. In other words, it does not happen where a trustworthy woman is really in charge. And, in these remarks, I by no means refer only to exceptional times of great emergency in war hospitals, but also, and quite as much, to the ordinary run of military hospitals at home, in time of peace; or to a time in war when our army was actually more healthy than at home in peace, and the pressure on our hospitals consequently much less.
[Sidenote: Nursing in Regimental Hospitals.]
It is often said that, in regimental hospitals, patients ought to "nurse each other," because the number of sick altogether being, say, but thirty, and out of these one only perhaps being seriously ill, and the other twenty-nine having little the matter with them, and nothing to do, they should be set to nurse the one; also, that soldiers are so trained to obey, that they will be the most obedient, and therefore the best of nurses, add to which they are always kind to their comrades.
Now, have those who say this, considered that, in order to obey, you must know how to obey, and that these soldiers certainly do not know how to obey in nursing. I have seen these "kind" fellows (and how kind they are no one knows so well as myself) move a comrade so that, in one case at least, the man died in the act. I have seen the comrades' "kindness" produce abundance of spirits, to be drunk in secret. Let no one understand by this that female nurses ought to, or could be introduced in regimental hospitals. It would be most undesirable, even were it not impossible. But the head nurseship of a hospital serjeant is the more essential, the more important, the more inexperienced the nurses. Undoubtedly, a London hospital "sister" does sometimes set relays of patients to watch a critical case; but, undoubtedly also, always under her own superintendence; and she is called to whenever there is something to be done, and she knows how to do it. The patients are not left to do it of their own unassisted genius, however "kind" and willing they may be.
IV. NOISE.
[Sidenote: Unnecessary noise.]
Unnecessary noise, or noise that creates an expectation in the mind, is that which hurts a patient. It is rarely the loudness of the noise, the effect upon the organ of the ear itself, which appears to affect the sick. How well a patient will generally bear, e. g., the putting up of a scaffolding close to the house, when he cannot bear the talking, still less the whispering, especially if it be of a familiar voice, outside his door.
There are certain patients, no doubt, especially where there is slight concussion or other disturbance of the brain, who are affected by mere noise. But intermittent noise, or sudden and sharp noise, in these as in all other cases, affects far more than continuous noise—noise with jar far more than noise without. Of one thing you may be certain, that anything which wakes a patient suddenly out of his sleep will invariably put him into a state of greater excitement, do him more serious, aye, and lasting mischief, than any continuous noise, however loud.
[Sidenote: Never let a patient be waked out of his first sleep.]
Never to allow a patient to be waked, intentionally or accidentally, is a sine qua non of all good nursing. If he is roused out of his first sleep, he is almost certain to have no more sleep. It is a curious but quite intelligible fact that, if a patient is waked after a few hours' instead of a few minutes' sleep, he is much more likely to sleep again. Because pain, like irritability of brain, perpetuates and intensifies itself. If you have gained a respite of either in sleep you have gained more than the mere respite. Both the probability of recurrence and of the same intensity will be diminished; whereas both will be terribly increased by want of sleep. This is the reason why sleep is so all-important. This is the reason why a patient waked in the early part of his sleep loses not only his sleep, but his power to sleep. A healthy person who allows himself to sleep during the day will lose his sleep at night. But it is exactly the reverse with the sick generally; the more they sleep, the better will they be able to sleep.
[Sidenote: Noise which excites expectation.]
[Sidenote: Whispered conversation in the room.]
I have often been surprised at the thoughtlessness, (resulting in cruelty, quite unintentionally) of friends or of doctors who will hold a long conversation just in the room or passage adjoining to the room of the patient, who is either every moment expecting them to come in, or who has just seen them, and knows they are talking about him. If he is an amiable patient, he will try to occupy his attention elsewhere and not to listen—and this makes matters worse—for the strain upon his attention and the effort he makes are so great that it is well if he is not worse for hours after. If it is a whispered conversation in the same room, then it is absolutely cruel; for it is impossible that the patient's attention should not be involuntarily strained to hear. Walking on tip-toe, doing any thing in the room very slowly, are injurious, for exactly the same reasons. A firm light quick step, a steady quick hand are the desiderata; not the slow, lingering, shuffling foot, the timid, uncertain touch. Slowness is not gentleness, though it is often mistaken for such: quickness, lightness, and gentleness are quite compatible. Again, if friends and doctors did but watch, as nurses can and should watch, the features sharpening, the eyes growing almost wild, of fever patients who are listening for the entrance from the corridor of the persons whose voices they are hearing there, these would never run the risk again of creating such expectation, or irritation of mind.—Such unnecessary noise has undoubtedly induced or aggravated delirium in many cases. I have known such—in one case death ensued. It is but fair to say that this death was attributed to fright. It was the result of a long whispered conversation, within sight of the patient, about an impending operation; but any one who has known the more than stoicism, the cheerful coolness, with which the certainty of an operation will be accepted by any patient, capable of bearing an operation at all, if it is properly communicated to him, will hesitate to believe that it was mere fear which produced, as was averred, the fatal result in this instance. It was rather the uncertainty, the strained expectation as to what was to be decided upon.
[Sidenote: Or just outside the door.]
I need hardly say that the other common cause, namely, for a doctor or friend to leave the patient and communicate his opinion on the result of his visit to the friends just outside the patient's door, or in the adjoining room, after the visit, but within hearing or knowledge of the patient is, if possible, worst of all.
[Sidenote: Noise of female dress.]
It is, I think, alarming, peculiarly at this time, when the female ink-bottles are perpetually impressing upon us "woman's" "particular worth and general missionariness," to see that the dress of women is daily more and more unfitting them for any "mission," or usefulness at all. It is equally unfitted for all poetic and all domestic purposes. A man is now a more handy and far less objectionable being in a sick room than a woman. Compelled by her dress, every woman now either shuffles or waddles—only a man can cross the floor of a sick-room without shaking it! What is become of woman's light step?—the firm, light, quick step we have been asking for?
Unnecessary noise, then, is the most cruel absence of care which can be inflicted either on sick or well. For, in all these remarks, the sick are only mentioned as suffering in a greater proportion than the well from precisely the same causes.
Unnecessary (although slight) noise injures a sick person much more than necessary noise (of a much greater amount).
[Sidenote: Patient's repulsion to nurses who rustle.]
All doctrines about mysterious affinities and aversions will be found to resolve themselves very much, if not entirely, into presence or absence of care in these things.
A nurse who rustles (I am speaking of nurses professional and unprofessional) is the horror of a patient, though perhaps he does not know why.
The fidget of silk and of crinoline, the rattling of keys, the creaking of stays and of shoes, will do a patient more harm than all the medicines in the world will do him good.
The noiseless step of woman, the noiseless drapery of woman, are mere figures of speech in this day. Her skirts (and well if they do not throw down some piece of furniture) will at least brush against every article in the room as she moves.[1]
Again, one nurse cannot open the door without making everything rattle. Or she opens the door unnecessarily often, for want of remembering all the articles that might be brought in at once.
A good nurse will always make sure that no door or window in her patient's room shall rattle or creak; that no blind or curtain shall, by any change of wind through the open window be made to flap—especially will she be careful of all this before she leaves her patients for the night. If you wait till your patients tell you, or remind you of these things, where is the use of their having a nurse? There are more shy than exacting patients, in all classes; and many a patient passes a bad night, time after time, rather than remind his nurse every night of all the things she has forgotten.
If there are blinds to your windows, always take care to have them well up, when they are not being used. A little piece slipping down, and flapping with every draught, will distract a patient.
[Sidenote: Hurry peculiarly hurtful to sick.]
All hurry or bustle is peculiarly painful to the sick. And when a patient has compulsory occupations to engage him, instead of having simply to amuse himself, it becomes doubly injurious. The friend who remains standing and fidgetting about while a patient is talking business to him, or the friend who sits and proses, the one from an idea of not letting the patient talk, the other from an idea of amusing him, —each is equally inconsiderate. Always sit down when a sick person is talking business to you, show no signs of hurry give complete attention and full consideration if your advice is wanted, and go away the moment the subject is ended.
[Sidenote: How to visit the sick and not hurt them.]
Always sit within the patient's view, so that when you speak to him he has not painfully to turn his head round in order to look at you. Everybody involuntarily looks at the person speaking. If you make this act a wearisome one on the part of the patient you are doing him harm. So also if by continuing to stand you make him continuously raise his eyes to see you. Be as motionless as possible, and never gesticulate in speaking to the sick.
Never make a patient repeat a message or request, especially if it be some time after. Occupied patients are often accused of doing too much of their own business. They are instinctively right. How often you hear the person, charged with the request of giving the message or writing the letter, say half an hour afterwards to the patient, "Did you appoint 12 o'clock?" or, "What did you say was the address?" or ask perhaps some much more agitating question—thus causing the patient the effort of memory, or worse still, of decision, all over again. It is really less exertion to him to write his letters himself. This is the almost universal experience of occupied invalids.
This brings us to another caution. Never speak to an invalid from behind, nor from the door, nor from any distance from him, nor when he is doing anything.
The official politeness of servants in these things is so grateful to invalids, that many prefer, without knowing why, having none but servants about them.
[Sidenote: These things not fancy.]
These things are not fancy. If we consider that, with sick as with well, every thought decomposes some nervous matter,—that decomposition as well as re-composition of nervous matter is always going on, and more quickly with the sick than with the well,—that, to obtrude abruptly another thought upon the brain while it is in the act of destroying nervous matter by thinking, is calling upon it to make a new exertion,— if we consider these things, which are facts, not fancies, we shall remember that we are doing positive injury by interrupting, by "startling a fanciful" person, as it is called. Alas! it is no fancy.
[Sidenote: Interruption damaging to sick.]
If the invalid is forced, by his avocations, to continue occupations requiring much thinking, the injury is doubly great. In feeding a patient suffering under delirium or stupor you may suffocate him, by giving him his food suddenly, but if you rub his lips gently with a spoon and thus attract his attention, he will swallow the food unconsciously, but with perfect safety. Thus it is with the brain. If you offer it a thought, especially one requiring a decision, abruptly, you do it a real not fanciful injury. Never speak to a sick person suddenly; but, at the same time, do not keep his expectation on the tiptoe.
[Sidenote: And to well.]
This rule, indeed, applies to the well quite as much as to the sick. I have never known persons who exposed themselves for years to constant interruption who did not muddle away their intellects by it at last. The process with them may be accomplished without pain. With the sick, pain gives warning of the injury.
[Sidenote: Keeping a patient standing.]
Do not meet or overtake a patient who is moving about in order to speak to him, or to give him any message or letter. You might just as well give him a box on the ear. I have seen a patient fall flat on the ground who was standing when his nurse came into the room. This was an accident which might have happened to the most careful nurse. But the other is done with intention. A patient in such a state is not going to the East Indies. If you would wait ten seconds, or walk ten yards further, any promenade he could make would be over. You do not know the effort it is to a patient to remain standing for even a quarter of a minute to listen to you. If I had not seen the thing done by the kindest nurses and friends, I should have thought this caution quite superfluous.[2]
[Sidenote: Patients dread surprise.]
Patients are often accused of being able to "do much more when nobody is by." It is quite true that they can. Unless nurses can be brought to attend to considerations of the kind of which we have given here but a few specimens, a very weak patient finds it really much less exertion to do things for himself than to ask for them. And he will, in order to do them, (very innocently and from instinct) calculate the time his nurse is likely to be absent, from a fear of her "coming in upon" him or speaking to him, just at the moment when he finds it quite as much as he can do to crawl from his bed to his chair, or from one room to another, or down stairs, or out of doors for a few minutes. Some extra call made upon his attention at that moment will quite upset him. In these cases you may be sure that a patient in the state we have described does not make such exertions more than once or twice a day, and probably much about the same hour every day. And it is hard, indeed, if nurse and friends cannot calculate so as to let him make them undisturbed. Remember, that many patients can walk who cannot stand or even sit up. Standing is, of all positions, the most trying to a weak patient.
Everything you do in a patient's room, after he is "put up" for the night, increases tenfold the risk of his having a bad night. But, if you rouse him up after he has fallen asleep, you do not risk, you secure him a bad night.
One hint I would give to all who attend or visit the sick, to all who have to pronounce an opinion upon sickness or its progress. Come back and look at your patient after he has had an hour's animated conversation with you. It is the best test of his real state we know. But never pronounce upon him from merely seeing what he does, or how he looks, during such a conversation. Learn also carefully and exactly, if you can, how he passed the night after it.
[Sidenote: Effects of over-exertion on sick.]
People rarely, if ever, faint while making an exertion. It is after it is over. Indeed, almost every effect of over-exertion appears after, not during such exertion. It is the highest folly to judge of the sick, as is so often done, when you see them merely during a period of excitement. People have very often died of that which, it has been proclaimed at the time, has "done them no harm."[3]
Remember never to lean against, sit upon, or unnecessarily shake, or even touch the bed in which a patient lies. This is invariably a painful annoyance. If you shake the chair on which he sits, he has a point by which to steady himself, in his feet. But on a bed or sofa, he is entirely at your mercy, and he feels every jar you give him all through him.
[Sidenote: Difference between real and fancy patients.]
In all that we have said, both here and elsewhere, let it be distinctly understood that we are not speaking of hypochondriacs. To distinguish between real and fancied disease forms an important branch of the education of a nurse. To manage fancy patients forms an important branch of her duties. But the nursing which real and that which fancied patients require is of different, or rather of opposite, character. And the latter will not be spoken of here. Indeed, many of the symptoms which are here mentioned are those which distinguish real from fancied disease.
It is true that hypochondriacs very often do that behind a nurse's back which they would not do before her face. Many such I have had as patients who scarcely ate anything at their regular meals; but if you concealed food for them in a drawer, they would take it at night or in secret. But this is from quite a different motive. They do it from the wish to conceal. Whereas the real patient will often boast to his nurse or doctor, if these do not shake their heads at him, of how much he has done, or eaten or walked. To return to real disease.
[Sidenote: Conciseness necessary with sick.]
Conciseness and decision are, above all things, necessary with the sick. Let your thought expressed to them be concisely and decidedly expressed. What doubt and hesitation there may be in your own mind must never be communicated to theirs, not even (I would rather say especially not) in little things. Let your doubt be to yourself, your decision to them. People who think outside their heads, the whole process of whose thought appears, like Homer's, in the act of secretion, who tell everything that led them towards this conclusion and away from that, ought never to be with the sick.
[Sidenote: Irresolution most painful to them.]
Irresolution is what all patients most dread. Rather than meet this in others, they will collect all their data, and make up their minds for themselves. A change of mind in others, whether it is regarding an operation, or re-writing a letter, always injures the patient more than the being called upon to make up his mind to the most dreaded or difficult decision. Farther than this, in very many cases, the imagination in disease is far more active and vivid than it is in health. If you propose to the patient change of air to one place one hour, and to another the next, he has, in each case, immediately constituted himself in imagination the tenant of the place, gone over the whole premises in idea, and you have tired him as much by displacing his imagination, as if you had actually carried him over both places.
Above all, leave the sick room quickly and come into it quickly, not suddenly, not with a rush. But don't let the patient be wearily waiting for when you will be out of the room or when you will be in it. Conciseness and decision in your movements, as well as your words, are necessary in the sick room, as necessary as absence of hurry and bustle. To possess yourself entirely will ensure you from either failing—either loitering or hurrying.
[Sidenote: What a patient must not have to see to.]
If a patient has to see, not only to his own but also to his nurse's punctuality, or perseverance, or readiness, or calmness, to any or all of these things, he is far better without that nurse than with her— however valuable and handy her services may otherwise be to him, and however incapable he may be of rendering them to himself.
[Sidenote: Reading aloud.]
With regard to reading aloud in the sick room, my experience is, that when the sick are too ill to read to themselves, they can seldom bear to be read to. Children, eye-patients, and uneducated persons are exceptions, or where there is any mechanical difficulty in reading. People who like to be read to, have generally not much the matter with them; while in fevers, or where there is much irritability of brain, the effort of listening to reading aloud has often brought on delirium. I speak with great diffidence; because there is an almost universal impression that it is sparing the sick to read aloud to them. But two things are certain:—
[Sidenote: Read aloud slowly, distinctly, and steadily to the sick.]
(1.) If there is some matter which must be read to a sick person, do it slowly. People often think that the way to get it over with least fatigue to him is to get it over in least time. They gabble; they plunge and gallop through the reading. There never was a greater mistake. Houdin, the conjuror, says that the way to make a story seem short is to tell it slowly. So it is with reading to the sick. I have often heard a patient say to such a mistaken reader, "Don't read it to me; tell it me."[4] Unconsciously he is aware that this will regulate the plunging, the reading with unequal paces, slurring over one part, instead of leaving it out altogether, if it is unimportant, and mumbling another. If the reader lets his own attention wander, and then stops to read up to himself, or finds he has read the wrong bit, then it is all over with the poor patient's chance of not suffering. Very few people know how to read to the sick; very few read aloud as pleasantly even as they speak. In reading they sing, they hesitate, they stammer, they hurry, they mumble; when in speaking they do none of these things. Reading aloud to the sick ought always to be rather slow, and exceedingly distinct, but not mouthing—rather monotonous, but not sing song—rather loud but not noisy—and, above all, not too long. Be very sure of what your patient can bear.
[Sidenote: Never read aloud by fits and starts to the sick.]
(2.) The extraordinary habit of reading to oneself in a sick room, and reading aloud to the patient any bits which will amuse him or more often the reader, is unaccountably thoughtless. What do you think the patient is thinking of during your gaps of non-reading? Do you think that he amuses himself upon what you have read for precisely the time it pleases you to go on reading to yourself, and that his attention is ready for something else at precisely the time it pleases you to begin reading again? Whether the person thus read to be sick or well, whether he be doing nothing or doing something else while being thus read to, the self-absorption and want of observation of the person who does it, is equally difficult to understand—although very often the read_ee_ is too amiable to say how much it hurts him.
[Sidenote: People overhead.]
One thing more:—From, the flimsy manner in which most modern houses are built, where every step on the stairs, and along the floors, is felt all over the house; the higher the story, the greater the vibration. It is inconceivable how much the sick suffer by having anybody overhead. In the solidly built old houses, which, fortunately, most hospitals are, the noise and shaking is comparatively trifling. But it is a serious cause of suffering, in lightly built houses, and with the irritability peculiar to some diseases. Better far put such patients at the top of the house, even with the additional fatigue of stairs, if you cannot secure the room above them being untenanted; you may otherwise bring on a state of restlessness which no opium will subdue. Do not neglect the warning, when a patient tells you that he "Feels every step above him to cross his heart." Remember that every noise a patient cannot see partakes of the character of suddenness to him; and I am persuaded that patients with these peculiarly irritable nerves, are positively less injured by having persons in the same room with them than overhead, or separated by only a thin compartment. Any sacrifice to secure silence for these cases is worth while, because no air, however good, no attendance, however careful, will do anything for such cases without quiet.
[Sidenote: Music.]
NOTE.—The effect of music upon the sick has been scarcely at all noticed. In fact, its expensiveness, as it is now, makes any general application of it quite out of the question. I will only remark here, that wind instruments, including the human voice, and stringed instruments, capable of continuous sound, have generally a beneficent effect—while the piano-forte, with such instruments as have no continuity of sound, has just the reverse. The finest piano-forte playing will damage the sick, while an air, like "Home, sweet home," or "Assisa a piè d'un salice," on the most ordinary grinding organ, will sensibly soothe them—and this quite independent of association.
FOOTNOTES:
[1] [Sidenote: Burning of the crinolines.]
Fortunate it is if her skirts do not catch fire—and if the nurse does not give herself up a sacrifice together with her patient, to be burnt in her own petticoats. I wish the Registrar-General would tell us the exact number of deaths by burning occasioned by this absurd and hideous custom. But if people will be stupid, let them take measures to protect themselves from their own stupidity—measures which every chemist knows, such as putting alum into starch, which prevents starched articles of dress from blazing up.
[Sidenote: Indecency of the crinolines.]
I wish, too, that people who wear crinoline could see the indecency of their own dress as other people see it. A respectable elderly woman stooping forward, invested in crinoline, exposes quite as much of her own person to the patient lying in the room as any opera dancer does on the stage. But no one will ever tell her this unpleasant truth.
[2] [Sidenote: Never speak to a patient in the act of moving.]
It is absolutely essential that a nurse should lay this down as a positive rule to herself, never to speak to any patient who is standing or moving, as long as she exercises so little observation as not to know when a patient cannot bear it. I am satisfied that many of the accidents which happen from feeble patients tumbling down stairs, fainting after getting up, &c., happen solely from the nurse popping out of a door to speak to the patient just at that moment; or from his fearing that she will do so. And that if the patient were even left to himself, till he can sit down, such accidents would much seldomer occur. If the nurse accompanies the patient, let her not call upon him to speak. It is incredible that nurses cannot picture to themselves the strain upon the heart, the lungs, and the brain, which the act of moving is to any feeble patient.
[3] [Sidenote: Careless observation of the results of careless Visits.]
As an old experienced nurse, I do most earnestly deprecate all such careless words. I have known patients delirious all night, after seeing a visitor who called them "better," thought they "only wanted a little amusement," and who came again, saying, "I hope you were not the worse for my visit," neither waiting for an answer, nor even looking at the case. No real patient will ever say, "Yes, but I was a great deal the worse."
It is not, however, either death or delirium of which, in these cases, there is most danger to the patient. Unperceived consequences are far more likely to ensue. You will have impunity—the poor patient will not. That is, the patient will suffer, although neither he nor the inflictor of the injury will attribute it to its real cause. It will not be directly traceable, except by a very careful observant nurse. The patient will often not even mention what has done him most harm.
[4] [Sidenote: The sick would rather be told a thing than have it read to them.]
Sick children, if not too shy to speak, will always express this wish. They invariably prefer a story to be told to them, rather than read to them.
V. VARIETY.
[Sidenote: Variety a means of recovery.]
To any but an old nurse, or an old patient, the degree would be quite inconceivable to which the nerves of the sick suffer from seeing the same walls, the same ceiling, the same surroundings during a long confinement to one or two rooms.
The superior cheerfulness of persons suffering severe paroxysms of pain over that of persons suffering from nervous debility has often been remarked upon, and attributed to the enjoyment of the former of their intervals of respite. I incline to think that the majority of cheerful cases is to be found among those patients who are not confined to one room, whatever their suffering, and that the majority of depressed cases will be seen among those subjected to a long monotony of objects about them.
The nervous frame really suffers as much from this as the digestive organs from long monotony of diet, as e.g. the soldier from his twenty-one years' "boiled beef."
[Sidenote: Colour and form means of recovery.]
The effect in sickness of beautiful objects, of variety of objects, and especially of brilliancy of colour is hardly at all appreciated.
Such cravings are usually called the "fancies" of patients. And often doubtless patients have "fancies," as e.g. when they desire two contradictions. But much more often, their (so called) "fancies" are the most valuable indications of what is necessary for their recovery. And it would be well if nurses would watch these (so called) "fancies" closely.
I have seen, in fevers (and felt, when I was a fever patient myself), the most acute suffering produced from the patient (in a hut) not being able to see out of window, and the knots in the wood being the only view. I shall never forget the rapture of fever patients over a bunch of bright-coloured flowers. I remember (in my own case) a nosegay of wild flowers being sent me, and from that moment recovery becoming more rapid.
[Sidenote: This is no fancy.]
People say the effect is only on the mind. It is no such thing. The effect is on the body, too. Little as we know about the way in which we are affected by form, by colour, and light, we do know this, that they have an actual physical effect.
Variety of form and brilliancy of colour in the objects presented to patients are actual means of recovery.
But it must be slow variety, e.g., if you shew a patient ten or twelve engravings successively, ten-to-one that he does not become cold and 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 most nutritive of all articles, being pure carbon, and is particularly recommended in some books. But the vast majority of all patients in England, young and old, male and female, rich and poor, hospital and private, dislike sweet things,—and while I have never known a person take to sweets when he was ill who disliked them when he was well, I have known many fond of them when in health, who in sickness would leave off anything sweet, even to sugar in tea,—sweet puddings, sweet drinks, are their aversion; the furred tongue almost always likes what is sharp or pungent. Scorbutic patients are an exception, they often crave for sweetmeats and jams.
[Sidenote: Jelly.]
Jelly is another article of diet in great favour with nurses and friends of the sick; even if it could be eaten solid, it would not nourish, but it is simply the height of folly to take 1/8 oz. of gelatine and make it into a certain bulk by dissolving it in water and then to give it to the sick, as if the mere bulk represented nourishment. It is now known that jelly does not nourish, that it has a tendency to produce diarrhoea,— and to trust to it to repair the waste of a diseased constitution is simply to starve the sick under the guise of feeding them. If 100 spoonfuls of jelly were given in the course of the day, you would have given one spoonful of gelatine, which spoonful has no nutritive power 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.