[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. 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:  [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.
[Sidenote: Common errors in diet.]
[Sidenote: Beef tea.]
[Sidenote: Meat without vegetables.]
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.
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.
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 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.
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.
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.
 [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.
 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.
 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.
[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. 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, 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.
 [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?"
 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.
[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.
[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. 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.
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.
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 exuvić.
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.
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.
 [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."
 [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.
 [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!
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