Notes on Nursing Part 6

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 patients 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.[22] 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.

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 s...o...b..tic 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, b.u.t.ter, cream, &c.]

Again, milk and the preparations from milk, are a most important article of food for the sick. b.u.t.ter 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 arrow root, 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.[23]

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 inst.i.tutions 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. b.u.t.termilk, 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 const.i.tute a perfect diet for the patient.

The nurse's observation here will materially a.s.sist the doctor--the patient's "fancies" will materially a.s.sist 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. s...o...b..tic 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 const.i.tution 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 quant.i.ty of nitrogen, which is one of the most powerful elements in nutrition; on the other hand, beef tea may be chosen as an ill.u.s.tration 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 cla.s.ses 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 circ.u.mstances. Possibly,"

he says, "it belongs to a new denomination of remedies."

It has been observed that a small quant.i.ty 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 bed-side. 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 a.s.similate 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 nouris.h.i.+ng of all food to the sick man, whose half-dead stomach can _a.s.similate_ 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 "a.n.a.lyses 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 a.s.sistance 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[24] 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 subst.i.tute 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.