Part 5

How few men, or even women, understand, either in great or in little things, what it is the being "in charge"--I mean, know how to carry out a "charge." From the most colossal calamities, down to the most trifling accidents, results are often traced (or rather not traced) to such want of some one "in charge" or of his knowing how to be "in charge." A short time ago the bursting of a funnel-casing on board the finest and strongest ship that ever was built, on her trial trip, destroyed several lives and put several hundreds in jeopardy--not from any undetected flaw in her new and untried works--but from a tap being closed which ought not to have been closed--from what every child knows would make its mother's tea-kettle burst. And this simply because no one seemed to know what it is to be "in charge," or who was in charge. Nay more, the jury at the inquest actually altogether ignored the same, and apparently considered the tap "in charge," for they gave as a verdict "accidental death."

This is the meaning of the word, on a large scale. On a much smaller scale, it happened, a short time ago, that an insane person burnt herself slowly and intentionally to death, while in her doctor's charge and almost in her nurse's presence. Yet neither was considered "at all to blame." The very fact of the accident happening proves its own case. There is nothing more to be said. Either they did not know their business or they did not know how to perform it.

To be "in charge" is certainly not only to carry out the proper measures yourself but to see that every one else does so too; to see that no one either wilfully or ignorantly thwarts or prevents such measures. It is neither to do everything yourself nor to appoint a number of people to each duty, but to ensure that each does that duty to which he is appointed. This is the meaning which must be attached to the word by (above all) those "in charge" of sick, whether of numbers or of individuals, (and indeed I think it is with individual sick that it is least understood. One sick person is often waited on by four with less precision, and is really less cared for than ten who are waited on by one; or at least than 40 who are waited on by 4; and all for want of this one person "in charge.)"

It is often said that there are few good servants now: I say there are few good mistresses now. As the jury seems to have thought the tap was in charge of the ship's safety, so mistresses now seem to think the house is in charge of itself. They neither know how to give orders, nor how to teach their servants to obey orders--i.e. to obey intelligently, which is the real meaning of all discipline.

Again, people who are in charge often seem to have a pride in feeling that they will be "missed," that no one can understand or carry on their arrangements, their system, books, accounts, &c., but themselves. It seems to me that the pride is rather in carrying on a system, in keeping stores, closets, books, accounts, &c., so that any body can understand and carry them on--so that, in case of absence or illness, one can deliver every thing up to others and know that all will go on as usual, and that one shall never be missed.

NOTE.--It is often complained, that professional nurses, brought into private families, in case of sickness, make themselves intolerable by "ordering about" the other servants, under plea of not neglecting the patient. Both things are true; the patient is often neglected, and the servants are often unfairly "put upon." But the fault is generally in the want of management of the head in charge. It is surely for her to arrange both that the nurse's place is, when necessary, supplemented, and that the patient is never neglected--things with a little management quite compatible, and indeed only attainable together. It is certainly not for the nurse to "order about" the servants.

IV. 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.

Never to allow a patient to be waked, intentionally or accidentally, is a sine qua non of all good nursing. If he is roused out of his first sleep, he is almost certain to have no more sleep. It is a curious but quite intelligible fact that, if a patient is waked after a few hours' instead of a few minutes' sleep, he is much more likely to sleep again. Because pain, like irritability of brain, perpetuates and intensifies itself. If you have gained a respite of either in sleep you have gained more than the mere respite. Both the probability of recurrence and of the same intensity will be diminished; whereas both will be terribly increased by want of sleep. This is the reason why sleep is so all-important. This is the reason why a patient waked in the early part of his sleep loses not only his sleep, but his power to sleep. A healthy person who allows himself to sleep during the day will lose his sleep at night. But it is exactly the reverse with the sick generally; the more they sleep, the better will they be able to sleep.

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.

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.

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).

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.

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.

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.

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.

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.