SECLUSION.
It is rare to find any of the class of patients I have described so free
from the influence of their habitual surroundings as to make it easy to
treat them in their own homes. It is needful to disentangle them from
the meshes of old habits and to remove them from contact with those who
have been the willing slaves of their caprices. I have often made the
effort to treat them where they have lived and to isolate them there,
but I have rarely done so without promising myself that I would not
again complicate my treatment by any such embarrassments. Once separate
the patient from the moral and physical surroundings which have become
part of her life of sickness, and you will have made a change which will
be in itself beneficial and will enormously aid in the treatment which
is to follow. Of course this step is not essential in such cases as are
merely anæmic, feeble, and thin, owing to distinct causes, like the
exhaustion of overwork, blood-losses, dyspepsia, low fevers, or nursing.
There are but too many women who have broken down under such causes and
failed to climb again to the level of health, despite all that could be
done for them; and when such persons are free from emotional excitement
or hysterical complications there is no reason why the seclusion needful
to secure them repose of mind should not be pleasantly modified in
accordance with the dictates of common sense. Very often a little
experimentation as to what they will profitably bear in the way of
visits and the like will inform us, as their treatment progresses, how
far such indulgence is of use or free from hurtful influences. Cases of
extreme neurasthenia in men accompanied with nutritive failures require
as to this matter cautious handling, because, for some reason, the ennui
of rest and seclusion is far better borne by women than by the other
sex.
Even in cases whose moral aspects do not at once suggest an imperative
need for seclusion it is well to remember, as regards neurasthenic
people, that the treatment involves for a time daily visits of some
length from the masseur, the doctor, and possibly an electrician, and
that to add to these even a single friendly visitor is often too much
to be readily borne; but I am now speaking chiefly of the large and
troublesome class of thin-blooded emotional women, for whom a state of
weak health has become a long and, almost I might say, a cherished
habit. For them there is often no success possible until we have broken
up the whole daily drama of the sick-room, with its little selfishness
and its craving for sympathy and indulgence. Nor should we hesitate to
insist upon this change, for not only shall we then act in the true
interests of the patient, but we shall also confer on those near to her
an inestimable benefit. An hysterical girl is, as Wendell Holmes has
said in his decisive phrase, a vampire who sucks the blood of the
healthy people about her; and I may add that pretty surely where there
is one hysterical girl there will be soon or late two sick women. If
circumstances oblige us to treat such a person in her own home, let us
at least change her room, and also have it well understood how far we
are to control her surroundings and to govern as to visitors and the
company of her own family. Do as we may, we shall always lessen thus our
chances of success, but we shall certainly not altogether destroy them.
I should add here a few words of caution as to the time of year best
fitted for treatment. In the summer seclusion is often undesirable when
the patient is well enough to gain help by change of air; moreover, at
this season massage is less agreeable than in winter, and, as a rule, I
find it harder to feed and to fatten persons at rest during our summer
heats. That this rule is not without exception has been shown by Drs.
Goodell and Sinkler, both of whom have attained some remarkable
successes in midsummer.
One of the questions of most importance in the carrying out of this
treatment is the choice of a nurse. Just as it is desirable to change
the home of the patient, her diet, her atmosphere, so also is it well,
for the mere alterative value of such change, to surround her with
strangers and to put aside any nurse with whom she may have grown
familiar. As I have sometimes succeeded in treating invalids in their
own homes, so have I occasionally been able to carry through cases
nursed by a mother, or sister, or friend of exceptional firmness; but to
attempt this is to be heavily handicapped, and the position should never
be accepted if it be possible to make other arrangements. Any firm,
intelligent woman of tact, a stranger to the patient, is better than
the old style of nurse, now, happily, disappearing. The nurse for these
cases ought to be a young, active, quick-witted woman, capable of firmly
but gently controlling her patient. She ought to be intelligent, able to
interest her patient, to read aloud, and to write letters. The more of
these cases she has seen and nursed, the easier becomes the task of the
doctor. Young, I have said she ought to be, but youthful would be a
better word. If, as she grows older, the nurse loses the strenuous
enthusiasm with which she made her first entrance into her work,
scarcely any amount of conscientious devotion or experience will ever
replace it; but there are fortunate people who seem never to grow old in
this sense. It is always to be borne in mind that most of these patients
are over-sensitive, refined, and educated women, for whom the
clumsiness, or want of neatness, or bad manners, or immodesty of a nurse
may be a sore and steadily-increasing trial. To be more or less isolated
for two months in a room, with one constant attendant, however good, is
hard enough for any one to endure; and certain quite small faults or
defects in a nurse may make her a serious impediment to the treatment,
because no mere technical training will dispense in the nurse any more
than in the physician with those finer natural qualifications which make
their training available. Over-harshness is in some ways worse than
over-easiness, because it makes less pleasant the relation between nurse
and patient, and the latter should regard the former as her "next
friend." Let the nurse, therefore, place upon the doctor the burden of
decision in disputed matters; his position will not be injured with the
patient by strict enforcement of the letter of the law, while the
nurse's may be. But one nurse will suit one patient and not another: so
that I never hesitate to change my nurse if she does not fit the case,
and to change if necessary more than once.
The degree of seclusion should be prescribed from the first, and it is
far better to find that the original rules may be profitably relaxed
than to be obliged to draw the lines more strictly when the patient has
at first been indulged. For instance, it is well to forbid the receipt
of any letters from home, unless anxious relatives insist that the
patient must have home news. In that case the letters should be mere
bulletins, should contain nothing, no matter how trifling, that might
annoy a too sensitive person, and, most important of all, should come to
the nurse and by her be read to the patient.