[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 quâ 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.[15]
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.[16]
[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."[17]
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."[18] 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 disturbs 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.