Figure 1. A nurse bathing a leper (1 907).
Without knowledge of history as a base, the artistic side of any practice is neglected, ignored and lost sight of almost immediately, and the art of nursing is indeed sorely underdeveloped. Without knowing history one cannot approach knowing truth (Ashley, 1978, p. 30).
Who among us has not experienced the pure joy of a cooling shower, hair shampooed and rinsed until it "squeaks," the relief of a hot and aromatic tub bath at the end of a long hospital shift? Consider the bracing exhilaration of a dive into a cooling pool of water after a hot sauna, or the stimulation of a hot tub situated out in the cold night air. Were these experiences a function of cleanliness alone? Have we succeeded in wringing all aesthetic aspects of the experience out of "the bath" for our elderly patients? Has it been reduced to mere "task" in the service of bureaucracy in the modern nursing home setting, and a frequently unneeded or mindless task at that? And was it always like this?
To frame some answers to these questions, the history of the bath as a part of nursing practice has been examined from the time of Florence Nightingale onward through the 1920s. Reflections on present practice have also been incorporated. Primary and secondary sources have been utilized for analysis. Techniques of internal and external criticism were employed.
EARLY VIEWS ON BATHING
The bath has always been a part of nursing care. A glance through Dock and Stewart's (1907) A Short History of Nursing reveals a print of a nurse bathing a leper (Figure 1). Nightingale, in Notes on Nursing (1969/1859), noted that "...by simply washing or sponging with water you do not really clean your skin. Take a rough towel, dip one corner in very hot water - if a little spirit be added it will be more effectual - and then rub as if you were rubbing the towel into your skin with your fingers" (p. 95). She went on to say that washing, especially with "large quantities of water," had other effects than those of "mere cleanliness" (p. 95). Nightingale discussed how the skin absorbs the water and becomes softer, more "perspirable." The idea of the bath as therapeutic was already in evidence.
Current research related to bathing older persons corroborates Nightingale's discussion. Contrary to "conventional wisdom," Hardy (1996) found that skin dryness was improved in a sample of older persons who bathed more frequently. Findings from this study suggest that superhydration of the skin through frequent bathing may be a significant factor in decreasing skin dryness.
The practice context of nursing at the turn of the century was influenced by two major issues: 1) infectious diseases as a major health problem, and 2) the popular therapies of both massage and "hydrotherapy," or bathing (Ackernecht, 1982). A search of early nursing literature reveals that bathing the patient was a central component of nursing care. From the outset, scientific principles were espoused. Bathing, and its varieties, was a frequent topic in the American Journal of Nursing as well as early textbooks and procedure manuals. The themes of cleanliness and therapeutics consistently emerge as associated with bathing.
CLEANLINESS AS NEXT TO GODLINESS
Health and Healing, published in 1902, one of a series of "Little Masterpieces of Science," spelled out the scientific thinking of the day:
Connected with the cleanliness of clothing, as a means of health, is personal cleanliness. Perfected action of the skin, so essential to the perfect life, can only be obtained by thorough ablation of the whole body. The ablation ought, strictly, to be performed once in every twenty-four hours (Richardson, 1902, p. 153).
The concept of personal cleanliness was an important aspect of the 19th century public health movement. Nightingale was a prime spokesperson for the view of the need for fresh air, water, proper disposal of wastes, adequate food, exercise and rest for the health of the entire populace. These early views laid the foundation for continued scientific progress in the area of pubHe health.
The second phase of these efforts to promote the health of the populace and combat disease arose out of the achievements of Pasteur and Koch in the establishment of the "germ-theory" of disease causality. This led to an increased understanding of isolation, disinfection, and quarantine, the primary weapons in the fight against infectious organisms prior to the development of antimicrobials. This re-informed the healthful aspects of cleanliness.
Changing social structures also led to a heightened awareness of the need for cleanliness. This "cult of cleanliness" as it might be called, commenced with the dawning of the Industrial Age. A peasant's view of dirt had been quite different. In a previously agrarian society, people went around with visible traces of their work on their clothes and their bodies. Fishwives smelled of fish, and farmers smelled of cows. Dirt was even viewed as positive. Not washing too often meant that you did not feel the cold so easily; dirt and secretions afforded the body an additional layer of protection. The farmers knew that dirt gave life. A Swedish expression went, "A farmer's hand should be so dirty that if you put a seed in it, it will grow" (Eriksson, 1970, p. 10).
Cleanliness, self-control, and discipline went hand in hand as important tools in the historical process commonly referred to as the "domestication of the working class" (Frykman & Lofgren, 1987). The working class adopted middle class values via ideas of hygiene. They thereby became better workers in the industrial nation with its new norms. Dirty people were rebellious and hard to manage; clean and wholesome people represented orderliness. The battle against dirt, impurity, and disorder is the classic struggle against chaos.
Thus, the war against bacteria was not waged solely for medical motives. Qeanliness brought liberation from the old ways, from rigid distinctions between middle class and working class and between the peasantry and the bourgeoisie, as a new, more democratic, classless society emerged. Cleanliness became fashionable. A world without smells was an elegant, aristocratic world, far from the barnyard. There was a re-distribution of roles in the household. The master could distance himself from the physical toil of production, of agriculture, and take on the role of "squire," managing the work of others. Elementary school readers were filled with rules for good health stressing the need for clean, dry clothes, for clean, airy rooms, and for moderation in pleasure and rest.
Nursing texts of the same period spell out the need for the cleansing bath (Hampton, 1993/1893). In Practical Nursing: A Textbook for Nursing written by two nurses, Anna Maxwell and Amy Pope, originally published in 1911, the "Admission Bath" is discussed. It is noted that many patients admitted to the hospital are "exceedingly dirty," and it is suggested that after washing the face, some ammonia be added to the bath water. Hot alcohol is recommended for removing machine grease from the skin. It is noted that ether and benzene also remove grease, but that patiente do not like their smell. This source goes onto state:
If the feet cannot be made clean by one washing, after the bath is completed, put a rubber covered with a towel under them, envelop each foot in a compress of gauze or a towel saturated with a green soap solution, wrap the towel and rubber around them and let them remain thus for about an hour, then wash them again. The use of saplio and a nail brush may be necessary (Maxwell & Pope, 1911, pp. 130-131).
In addition, it is pointed out that "People who remain in bed may not look dirty but, nevertheless, they need baths as much as those who get up" (Hampton, 1993/1893, p. 119). The physiological rationale for this is spelled out. The skin is noted to be an excretory organ, secreting sebaceous matter and water in the form of perspiration that contains organic substances. If not removed from the skin through washing, it was thought that in addition to the unpleasant odor, these substances would be conducive to skin lesions, both annoying to the patient and "favoring chafing."
Tub baths are also discussed. It is stated that "Junior nurses should ask permission of the head nurse or senior before allowing a patient to have a tub bath" (p. 126). The bathroom, it said, should be warm, not lower than 78°F, and the tub water 960F. (See Figure 2 for a picture of the portable tub, and accompanying thermometer). Our elderly patients today could benefit from adherence to these temperature parameters for bathing to prevent the discomfort from being bathed in cold shower rooms or in bed without adequate covering.
THE THERAPEUTIC BATH RE-VISITED
Minnie Lee Crawford (1910), in an American Journal of Nursing article, "Why, when, and how to bathe a fever patient," summarized the purposes of the bath:
I have concluded that baths are given, first, for cleanliness or to remove dirt and dead epithelium; second, as an antipyretic or to reduce fever; third, to stimulate the function of the skin by reaction, to increase the activity of respiratory and circulatory organs; fourth, as a sedative (p. 314).
Figures 2A & B. Portable tub and accompanying thermometer. (Illustration or portable tub reprinted with permission from Hampton, I.A., Nursing: Its Principles and Practice for Hospital and Private Use, commemorative edition. Philadelphia, PA: W.B. Saunders, 1993.)
The therapeutic aspect of bathing was widely promoted in a time of limited pharmacotherapeutics. Infectious diseases, namely typhoid fever, polio, yellow fever, tuberculosis, scarlet fever, diphtheria, and pneumonia, were the major threats to health at the turn of the century. The treatment of the patient with an infectious disease was built around good and comprehensive nursing care, which always included bathing. Frequently, this would make the difference in the patient's survival.
Figure 3. The "spray bath."
Typhoid fever received particular attention and was described as "the great fever of the present time" (Lord, 1903, p. 276). Vandever, discussing typhoid fever in 1913, wrote that "...the systematic use of baths has greatly reduced the mortality" (Vandever, 1913, p. 842), and then noted that it was seldom necessary to give more than six per day! J.F. Botting in a 1912 article entitled "What is a Nurse?" wrote:
Some nurses enter hospitals with dreams of fevered brows soothed to rest under their gentle hands - they find they have to bathe mem in ice water till those gentle hands bleed at times...(p. 660).
THE "HYPROTHERAPEUnC CIRCUE"
Early nursing texts address a wide variety of baths. The term "hydrotherapy" was derived from two Greek words meaning "water treatment." According to Maxwell and Pope (1911), "...water is used merely as a convenient medium for surrounding the body or a part of it with the desired temperature" (p. 254). They refer to all treatments for the alleviation of diseased conditions in which water is the principal medium as hydrotherapy; these included baths, packs, sprays, douches, and irrigations in this category.
Minnie Lee Crawford (1910) stated:
I learned to give the full bath, the half bath, the sponge bath, the sitz bath, the Turkish bath, the Russian bath, the sheet bath, the salt bath, the mustard bath, the hot vapor bath, the cold douche, the hot pack, the wet pack, the cold pack - those with various modifications - and the carbonated bath; until 1 began to think, as one of the attending physicians jocularly remarked one day, in a "hydrotherapeutic circle!" (p. 314).
THE COLD BATH
Tepid and cold baths were used to reduce inflammation and fever. Early texts were filled with various "demonstrations" which are what we have come to call procedures. Step-by-step, specific processes of bathing are described. Demonstration 40 in Maxwell and Pope (1911), for example, is "The Brandt Bath," or the use of the cold tub bath in the treatment of fever. Introduced in Germany by Dr. Brandt in 1861, it was brought to this country in 1890 and was especially popular for lowering the high fevers of typhoid. It was noted that when a patient has typhoid, the abdomen should not be rubbed, although other parts of the body are to be rubbed during this bathing procedure. "The nurse giving friction to the upper part of the body must rub the back particularly well" (Maxwell & Pope, 1911, p. 261).
In addition to being anti-pyretic, cold baths were used "...as nerve and circulatory stimulants in neurasthenia and general disability" (Maxwell & Pope, 1911, p. 263). The "Spray Bath," often used instead of the sponge bath because of the percussion effect of the spray upon the skin was thought to help induce a speedy reaction (Figure 3).
A variation on this technique was the Sheet-bath, or Drip-sheet, which was frequently "...applied in nervous diseases" (Stoney, 1910, pp. 9596). A sheet wrung out of tepid water is thrown over the patient from behind, covering the entire body. The patient is then rubbed (over the sheet) to produce friction (Figure 4). This was theorized to have a soothing and sedative effect.
Alcohol baths were used widely to reduce the temperature, as were cold packs. This treatment was also thought to reduce nervousness and induce sleep. Note how the patient is completely covered during this treatment (Figure 5). Preparing the sheets was an art in itself. Patients were handled in a similar fashion for a hot pack; sipping lemonade through a straw, as well as keeping damp cloths on the client's forehead, was recommended (Maxwell & Pope, 1911, p. 277; Stoney, 1910).
THE HOT BATH
Hot baths, hot packs, and vapor baths were given to produce perspiration. It was thought that dilation of the superficial blood vessels would help the body dispose of waste materials when the kidneys were not functioning properly (Stoney, 1910). Additionally, heat is described as a stimulant necessary for life, and "...when the body's vital activities are depressed, to surround it with heat is one of the first and most important requisites" (Maxwell & Pope, 1911, p. 282).
Figure 4. The sheet-bath or drip-sheet was frequently "...applied in nervous diseases."
Hot foot baths were a popular prescription to relieve congestion, "...in distant organs as the throat in tonsillitis, the lungs in pneumonia, and the pelvic organs in dysmenorrhea" (Stoney, 1910, p. 95) and to relieve local congestion and stiffness (Figure 6). The addition of mustard to the foot bath was often prescribed for additive heat effect in, for instance, severe colds when "...the symptoms were confined to the head," and for headaches when "...there may be too much blood going to the head" (Hampton, 1893M993, p. 124).
Figure 5. Alcohol bafhs were used widely to reduce the temperature, as were cold packs. This treatment was also thought to reduce nervousness and induce sleep. Note how the patient is completely covered during this treatment.
Sitz baths were a popular remedy for pelvic congestion (Figure 7). "Vapor baths," or moist heat baths also called Turkish baths, were used to induce perspiration, and they were also thought to act as stimulants to the nervous system. The proper administration of the "vapor" bath was an elaborate nursing intervention. Oilcloths were used under the sheets and clothing to keep in the heat. At the foot of the bed, a spout from a kettle of boiling water was inserted (Figure 8). This kettle, it was suggested, should stand over on a gas or oil stove, the whole thing being covered with a blanket to keep in the heat. The nurse was to guard against fire. If the patient was able to sit up for this treatment, it was suggested that the kettle be placed on an oil stove under the chair (Figure 9).
In all hot bath treatments, the nurse was instructed to guard against burning the patient, thought most likely to occur with hot packs, vapor baths, and electric light baths; she was to monitor for fainting, due to withdrawal of blood from the brain into the relaxed skin vessels; collapse, caused as a rule by the reduced blood pressure; and chills and headaches, thought to occur from the effects of heated blood within the cerebrum. It was recommended that an ice cap be put on the head during the hot bath to avert headache (Hampton, 1 893X1993).
THE ACID STEAM-BATH
The acid steam-bath was a popular remedy for "rheumatism." The patient is prepared in the "usual manner" (Stoney, 1910, p. 94). Very hot bricks wrapped in flannel which have been steeped in vinegar are "placed around" the patient and left in place for 15 minutes. After that, the body is wiped over with a towel "wrung out of cold water," and then thoroughly and briskly dried.
Figure 6. Hot foot baths were a popular prescription to relieve congestion, "...in distant organs as the throat in tonsillitis, the lungs in pneumonia, and the pelvic organs in dysmenorrhea" (Stoney, 1 91 0, p. 95) and to relieve local congestion and stiffness.
Figure 7. Sitz baths were a popular remedy for pelvic congestion.
Figure 8. The proper administration of the "vapor" bath was an elaborate nursing intervention. Oilcloths were used under the sheets and clothing to keep in the heat. At the foot of the bed, a spout from a kettle of boiling water was inserted.
THE WARM, OR SEDATIVE BATH
There is a long and relatively complex explanation of the physiology behind the therapeutic effects of "warm or sedative baths," another popular, early treatment for the excitement of mania, insomnia, nervous exhaustion, and as a preventative of "nerve fag during periods in which the individual is subjected to nervous strain from any cause" (Maxwell & Pope, 1911, p. 310). The duration of this bath would vary from one-half hour, to several hours, to practically continuously in some cases. Boric acid was mixed, sufficient to make a 1% solution, and added to the bath water; the patient's skin was smeared with vaseline or ointment in order to prevent maceration.
There were also "medicated baths." Those used for skin "affections" might be an antiseptic like boric acid, or a parasiticide such as mustard; they might be a bland substance to allay irritation, like bran; or a substance to alleviate itching, such as sodium bicarbonate. Additionally, mustard and various other salts such as "the imitation Nauheim and Carlsbad salts" were used to "...stimulate sensory nerve endings in the skin, thus promoting general stimulation of the nervous system, thereby improving the circulation" (Maxwell & Pope, 1911, p. 314). The treatment termed "effervescent bath" increased the amount of blood in the derma and muscles, relieving "congestion of the viscera" (Hampton, 1993/1893; Stoney, 1910). Specific instructions for each bath, including the variety of temperatures employed for various purposes, are clearly spelled out in these early texts. A "sea salt" bath, for example, is obtained by dissolving about 10 pounds of the salt in a tub half full of water. The sulphur bath was prepared by "...placing four ounces of potassium sulphide in a porcelain tub containing thirty gallons of water" (Stoney, 1910, p. 94). This was ordered for scabies and other skin diseases.
"Heliotherapy," also referred to as a "light bath," was another therapeutic modality used at the turn of the century. Several sources discussed this technique, which was used primarily to produce diaphoresis. Usually these baths were administered in a box-like cabinet which would surround the body, except the head, which was supplied with electric lights. Local electric-light baths were also used to treat indolent ulcers and infected wounds. When administering in bed, it was recommended that a cradle bed be put over the part to be treated, and to suspend a light or lights, covered with reflectors, so that the rays will be diverted directly onto the exposed wound. The cradle was lastly to be covered with sterile sheets.
THE SUN BATH
Lastly, but not to be forgotten, is the therapeutic "sun bath." Early nursing manuals and texts also spell out this procedure. The equipment was Usted as follows:
1. A comfortable cot or couch provided with sufficient pillows to make the patient comfortable.
2. Colored sunglasses or an eyeshade and, in hot weather, an umbrella.
3. A loin binder and safety pins.
4. A bath blanket.
5. A screen.
The procedure is described and one source concluded with the following:
It is said to get the greatest possible benefit from sunlight baths, they must be taken on high mountains, under a clear sky, because the vapor in the atmosphere, which is present in largest amounts near sea level, absorbs the short actinic (ultra-violet) rays and these, in many conditions, are the most important rays (Maxwell & Pope, 1911, p. 323).
THE BATH AS A THERAPEUTIC ART
In 1903, Gordon, in an article entitled "Some Observations on the Nursing of Typhoid Fever," wrote "...let the patient regard the process with pleasure and not with dread...Endeavor to be an artist in sponging. Know why you sponge...Let your touch be gentle, firm, and soothing" (p. 593). Ashton, writing in the Canadian Journal of Nursing in 1907 said, "Baths to reduce the temperature should be agreeable to the patient, so that he enjoys them" (p. 370). Dicks, circa 1900, wrote in one of the very first editions of the American Journal of Nursing, that "The sponge bath is an old and generally applied remedy. Its effect is stimulating, soothing to the nervous system, and tends to produce sleep" (p. 208).
Figure 9. If the patient was able to sit up for a vapor bath, the kettle was placed on an oil stove under the chair. The nurse was to guard against fire.
Looking at the art of nursing as it was historically practiced helps us to rediscover the meaning of the skillful and artful therapeutic bath. Current nursing procedures and practices, as well as research on and about bathing, benefit from an approach directed by an historical appreciation and understanding of the comforting and therapeutic nature of the bath. To reiterate Wolf's words (1993):
"The bath represents part of the essential character of nursing and is rooted in the beliefs, art and scienee; it is a channel for many other nursing activities and responses, and as such, occupies a necessary part of nursing's repertoire and identity" (p. 146).
In today's nursing world, the bath is seen as "basic" nursing care and often delegated to non-professionals. The therapeutic and aesthetic effects of bathing are either taken for granted or not considered in designing and evaluating bathing interventions. "It is often assumed that a patient's comfort, relaxation and well-being are enhanced regardless of which bathing procedure is used or the condition of the patient. The choice of bathing procedure is rarely based on the therapeutic value to the patient. More often, the choice is determined by the nurse's available time and the patient's ability to care for himself" (Barsevick & Llewellyn, 1982, p. 27). The aesthetic aspects of the bath are rarely addressed. We would do well to take a lesson from nursing's history and reflect on our therapeutic "options" and the concept of aesthetic milieu.
There is a paucity of nursing research related to bathing despite findings that self-care deficit related to bathing is one of the most frequently cited nursing diagnoses in both acute and long-term care (Daly, Maas & Buckwalter, 1995; McKeighen, Mehmert, & Dickel, 1990). Wolf (1993) stated, "few seem interested in objective searches for knowledge on the effects of bathing patients" (p. 141). She goes on to caution against "discarding the bathing ritual by giving it to nonprofessional personnel-the bath is more than a standardized and repetitive series of activities...the bath can be viewed as a healing rite with greater healing power" (p. 145).
Have we not thrown out "the baby with the bath water" when we reduce bathing to a task to be accomplished, often without the expertise and involvement of the professional nurse? This question is particularly appropriate for gerontological nurses in the long-term care setting to consider. Rather than being a therapeutic and satisfying experience for older persons, bathing in institutions becomes routine, depersonalized, and often harmful. Rader, Lavelle, Hoeffer, and McKenzie (1996) ask us to look at the effects of the institutional method of bathing to determine if it is a pleasurable and comforting experience for our patients. They call on us to create individualized and aesthetic approaches to meet bathing needs by shifting to a person-focused rather than a taskcentered approach (p. 38).
Could we not be more creative in our approaches? Are there not other benefits to be derived from the activity of bathing than cleanliness? Where is the involvement of the professional nurse in the design and evaluation of therapeutic and comforting bathing interventions for older people? With the expertise of the gerontological nurse, the routine shower schedules so commonly seen in our nursing homes would be replaced by individualized bathing care plans as suggested by Rader and colleagues (1996). These individualized bathing care plans would be based on the gathering of a bathing history to determine past patterns and preferences; assessment of skin care needs; evaluation of self-care abilities and needs for self-care; assessment of the environment and equipment best suited to meet bathing needs; and an evaluation of the response of the person to the bathing experience. Using a framework such as this would encourage us to focus on the therapeutic and comforting outcomes of bathing, and the role of the professional nurse in the design and testing of interventions.
This examination of our earliest literature urges a return to nursing's historic roots in care, inspires aesthetic approaches and appreciations, and should generate new ideas and approaches. In closing, we ask you to reflect upon the words of another great nurse, Isabel M. Stewart, writing an editorial on the art and science of nursing for Nursing Education Bulletin of Teachers College, Columbia University, New York, 1929:
The real essence of nursing, as of any fine art, lies not in the mechanical details of execution, nor yet in the dexterity of the performer, but in the creative imagination, the sensitive spirit, and the intelligent understanding lying back of these techniques and skills.
Without these, nursing may become a highly skilled trade, but it cannot be a profession or a fine art. All the rituals and ceremonials which our modern worship of efficiency may devise, and all our elaborate scientific equipment will not save us if the intellectual and spiritual elements in our art are subordinated to the mechanical, and if the means come to be regarded as more important than ends (Stewart, 1929).
A true appreciation of the art and of the bath as a key nursing modality allows us to re-title this article, "The History of the Bath: Art to Task and Back Again."
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