Yet all these are generally comprehended in the one sweeping assertion
that the patient has "no appetite."
Surely many lives might be saved by drawing a closer distinction; for
the remedies are as diverse as the causes. The remedy for the first is
to cook better; for the second, to choose other articles of diet; for
the third, to watch for the hours when the patient is in want of food;
for the fourth, to show him what he likes, and sometimes unexpectedly.
But no one of these remedies will do for any other of the defects not
corresponding with it.
I cannot too often repeat that patients are generally either too languid
to observe these things, or too shy to speak about them; nor is it well
that they should be made to observe them, it fixes their attention upon
themselves.
Again, I say, what _is_ the nurse or friend there for except to take
note of these things, instead of the patient doing so?[3]
[Sidenote: As to diarrhoea]
Again, the question is sometimes put, Is there diarrhoea? And the answer
will be the same, whether it is just merging into cholera, whether it is
a trifling degree brought on by some trifling indiscretion, which will
cease the moment the cause is removed, or whether there is no diarrhoea
at all, but simply relaxed bowels.
It is useless to multiply instances of this kind. As long as observation
is so little cultivated as it is now, I do believe that it is better for
the physician _not_ to see the friends of the patient at all. They will
oftener mislead him than not. And as often by making the patient out
worse as better than he really is.
In the case of infants, _everything_ must depend upon the accurate
observation of the nurse or mother who has to report. And how seldom is
this condition of accuracy fulfilled.
[Sidenote: Means of cultivating sound and ready observation.]
A celebrated man, though celebrated only for foolish things, has told us
that one of his main objects in the education of his son, was to give
him a ready habit of accurate observation, a certainty of perception,
and that for this purpose one of his means was a month's course as
follows:--he took the boy rapidly past a toy-shop; the father and son
then described to each other as many of the objects as they could, which
they had seen in passing the windows, noting them down with pencil and
paper, and returning afterwards to verify their own accuracy. The boy
always succeeded best, e.g., if the father described 30 objects, the boy
did 40, and scarcely ever made a mistake.
I have often thought how wise a piece of education this would be for
much higher objects; and in our calling of nurses the thing itself is
essential. For it may safely be said, not that the habit of ready and
correct observation will by itself make us useful nurses, but that
without it we shall be useless with all our devotion.
I have known a nurse in charge of a set of wards, who not only carried
in her head all the little varieties in the diets which each patient was
allowed to fix for himself, but also exactly what each patient had taken
during each day. I have known another nurse in charge of one single
patient, who took away his meals day after day all but untouched, and
never knew it.
If you find it helps you to note down such things on a bit of paper, in
pencil, by all means do so. I think it more often lames than strengthens
the memory and observation. But if you cannot get the habit of
observation one way or other, you had better give up the being a nurse,
for it is not your calling, however kind and anxious you may be.
Surely you can learn at least to judge with the eye how much an oz. of
solid food is, how much an oz. of liquid. You will find this helps your
observation and memory very much, you will then say to yourself, "A.
took about an oz. of his meat to day;" "B. took three times in 24 hours
about 1/4 pint of beef tea;" instead of saying "B. has taken nothing all
day," or "I gave A. his dinner as usual."
[Sidenote: Sound and ready observation essential in a nurse.]
I have known several of our real old-fashioned hospital "sisters," who
could, as accurately as a measuring glass, measure out all their
patients' wine and medicine by the eye, and never be wrong. I do not
recommend this, one must be very sure of one's self to do it. I only
mention it, because if a nurse can by practice measure medicine by the
eye, surely she is no nurse who cannot measure by the eye about how much
food (in oz.) her patient has taken.[4] In hospitals those who cut up
the diets give with sufficient accuracy, to each patient, his 12 oz. or
his 6 oz. of meat without weighing. Yet a nurse will often have patients
loathing all food and incapable of any will to get well, who just tumble
over the contents of the plate or dip the spoon in the cup to deceive
the nurse, and she will take it away without ever seeing that there is
just the same quantity of food as when she brought it, and she will tell
the doctor, too, that the patient has eaten all his diets as usual, when
all she ought to have meant is that she has taken away his diets as
usual.
Now what kind of a nurse is this?
[Sidenote: Difference of excitable and _accumulative_ temperaments.]
I would call attention to something else, in which nurses frequently
fail in observation. There is a well-marked distinction between the
excitable and what I will call the _accumulative_ temperament in
patients. One will blaze up at once, under any shock or anxiety, and
sleep very comfortably after it; another will seem quite calm and even
torpid, under the same shock, and people say, "He hardly felt it at
all," yet you will find him some time after slowly sinking. The same
remark applies to the action of narcotics, of aperients, which, in the
one, take effect directly, in the other not perhaps for twenty-four
hours. A journey, a visit, an unwonted exertion, will affect the one
immediately, but he recovers after it; the other bears it very well at
the time, apparently, and dies or is prostrated for life by it. People
often say how difficult the excitable temperament is to manage. I say
how difficult is the _accumulative_ temperament. With the first you have
an out-break which you could anticipate, and it is all over. With the
second you never know where you are--you never know when the
consequences are over. And it requires your closest observation to know
what _are_ the consequences of what--for the consequent by no means
follows immediately upon the antecedent--and coarse observation is
utterly at fault.
[Sidenote: Superstition the fruit of bad observation.]
Almost all superstitions are owing to bad observation, to the _post hoc,
ergo propter hoc_; and bad observers are almost all superstitious.
Farmers used to attribute disease among cattle to witchcraft; weddings
have been attributed to seeing one magpie, deaths to seeing three; and I
have heard the most highly educated now-a-days draw consequences for the
sick closely resembling these.
[Sidenote: Physiognomy of disease little shewn by the face.]
Another remark: although there is unquestionably a physiognomy of
disease as well as of health; of all parts of the body, the face is
perhaps the one which tells the least to the common observer or the
casual visitor. Because, of all parts of the body, it is the one most
exposed to other influences, besides health. And people never, or
scarcely ever, observe enough to know how to distinguish between the
effect of exposure, of robust health, of a tender skin, of a tendency to
congestion, of suffusion, flushing, or many other things. Again, the
face is often the last to shew emaciation. I should say that the hand
was a much surer test than the face, both as to flesh, colour,
circulation, &c., &c. It is true that there are _some_ diseases which
are only betrayed at all by something in the face, _e.g._, the eye or
the tongue, as great irritability of brain by the appearance of the
pupil of the eye. But we are talking of casual, not minute, observation.
And few minute observers will hesitate to say that far more untruth than
truth is conveyed by the oft repeated words, He _looks_ well, or ill, or
better or worse.
Wonderful is the way in which people will go upon the slightest
observation, or often upon no observation at all, or upon some _saw_
which the world's experience, if it had any, would have pronounced
utterly false long ago.
I have known patients dying of sheer pain, exhaustion, and want of
sleep, from one of the most lingering and painful diseases known,
preserve, till within a few days of death, not only the healthy colour
of the cheek, but the mottled appearance of a robust child. And scores
of times have I heard these unfortunate creatures assailed with, "I am
glad to see you looking so well." "I see no reason why you should not
live till ninety years of age." "Why don't you take a little more
exercise and amusement," with all the other commonplaces with which we
are so familiar.
There is, unquestionably, a physiognomy of disease. Let the nurse learn
it.
The experienced nurse can always tell that a person has taken a narcotic
the night before by the patchiness of the colour about the face, when
the re-action of depression has set in; that very colour which the
inexperienced will point to as a proof of health.
There is, again, a faintness, which does not betray itself by the colour
at all, or in which the patient becomes brown instead of white. There is
a faintness of another kind which, it is true, can always be seen by the
paleness.
But the nurse seldom distinguishes. She will talk to the patient who is
too faint to move, without the least scruple, unless he is pale and
unless, luckily for him, the muscles of the throat are affected and he
loses his voice.
Yet these two faintnesses are perfectly distinguishable, by the mere
countenance of the patient.
[Sidenote: Peculiarities of patients.]
Again, the nurse must distinguish between the idiosyncracies of
patients. One likes to suffer out all his suffering alone, to be as
little looked after as possible. Another likes to be perpetually made
much of and pitied, and to have some one always by him. Both these
peculiarities might be observed and indulged much more than they are.
For quite as often does it happen that a busy attendance is forced upon
the first patient, who wishes for nothing but to be "let alone," as that
the second is left to think himself neglected.
[Sidenote: Nurse must observe for herself increase of patient's
weakness, patient will not tell her.]
Again, I think that few things press so heavily on one suffering from
long and incurable illness, as the necessity of recording in words from
time to time, for the information of the nurse, who will not otherwise
see, that he cannot do this or that, which he could do a month or a year
ago. What is a nurse there for if she cannot observe these things for
herself? Yet I have known--and known too among those--and _chiefly_
among those--whom money and position put in possession of everything
which money and position could give--I have known, I say, more accidents
(fatal, slowly or rapidly) arising from this want of observation among
nurses than from almost anything else. Because a patient could get out
of a warm-bath alone a month ago--because a patient could walk as far as
his bell a week ago, the nurse concludes that he can do so now. She has
never observed the change; and the patient is lost from being left in a
helpless state of exhaustion, till some one accidentally comes in. And
this not from any unexpected apoplectic, paralytic, or fainting fit
(though even these could be expected far more, at least, than they are
now, if we did but _observe_). No, from the unexpected, or to be
expected, inevitable, visible, calculable, uninterrupted increase of
weakness, which none need fail to observe.
[Sidenote: Accidents arising from the nurse's want of observation.]
Again, a patient not usually confined to bed, is compelled by an attack
of diarrhoea, vomiting, or other accident, to keep his bed for a few
days; he gets up for the first time, and the nurse lets him go into
another room, without coming in, a few minutes afterwards, to look after
him. It never occurs to her that he is quite certain to be faint, or
cold, or to want something. She says, as her excuse, Oh, he does not
like to be fidgetted after. Yes, he said so some weeks ago; but he never
said he did not like to be "fidgetted after," when he is in the state he
is in now; and if he did, you ought to make some excuse to go in to him.
More patients have been lost in this way than is at all generally known,
viz., from relapses brought on by being left for an hour or two faint,
or cold, or hungry, after getting up for the first time.
[Sidenote: Is the faculty of observing on the decline?]
Yet it appears that scarcely any improvement in the faculty of observing
is being made. Vast has been the increase of knowledge in pathology--
that science which teaches us the final change produced by disease on
the human frame--scarce any in the art of observing the signs of the
change while in progress. Or, rather, is it not to be feared that
observation, as an essential part of medicine, has been declining?
Which of us has not heard fifty times, from one or another, a nurse, or
a friend of the sick, aye, and a medical friend too, the following
remark:--"So A is worse, or B is dead. I saw him the day before; I
thought him so much better; there certainly was no appearance from which
one could have expected so sudden (?) a change." I have never heard any
one say, though one would think it the more natural thing, "There _must_
have been _some_ appearance, which I should have seen if I had but
looked; let me try and remember what there was, that I may observe
another time." No, this is not what people say. They boldly assert that
there was nothing to observe, not that their observation was at fault.
Let people who have to observe sickness and death look back and try to
register in their observation the appearances which have preceded
relapse, attack, or death, and not assert that there were none, or that
there were not the _right_ ones.[5]
[Sidenote: Observation of general conditions.]
A want of the habit of observing conditions and an inveterate habit of
taking averages are each of them often equally misleading.
Men whose profession like that of medical men leads them to observe
only, or chiefly, palpable and permanent organic changes are often just
as wrong in their opinion of the result as those who do not observe at
all. For instance, there is a broken leg; the surgeon has only to look
at it once to know; it will not be different if he sees it in the
morning to what it would have been had he seen it in the evening. And in
whatever conditions the patient is, or is likely to be, there will still
be the broken leg, until it is set. The same with many organic diseases.
An experienced physician has but to feel the pulse once, and he knows
that there is aneurism which will kill some time or other.
But with the great majority of cases, there is nothing of the kind; and
the power of forming any correct opinion as to the result must entirely
depend upon an enquiry into all the conditions in which the patient
lives. In a complicated state of society in large towns, death, as every
one of great experience knows, is far less often produced by any one
organic disease than by some illness, after many other diseases,
producing just the sum of exhaustion necessary for death. There is
nothing so absurd, nothing so misleading as the verdict one so often
hears: So-and-so has no organic disease,--there is no reason why he
should not live to extreme old age; sometimes the clause is added,
sometimes not: Provided he has quiet, good food, good air, &c., &c.,
&c.: the verdict is repeated by ignorant people _without_ the latter
clause; or there is no possibility of the conditions of the latter
clause being obtained; and this, the _only_ essential part of the whole,
is made of no effect. I have heard a physician, deservedly eminent,
assure the friends of a patient of his recovery. Why? Because he had now
prescribed a course, every detail of which the patient had followed for
years. And because he had forbidden a course which the patient could not
by any possibility alter.[6]
Undoubtedly a person of no scientific knowledge whatever but of
observation and experience in these kinds of conditions, will be able to
arrive at a much truer guess as to the probable duration of life of
members of a family or inmates of a house, than the most scientific
physician to whom the same persons are brought to have their pulse felt;
no enquiry being made into their conditions.
In Life Insurance and such like societies, were they instead of having
the person examined by the medical man, to have the houses, conditions,
ways of life, of these persons examined, at how much truer results would
they arrive! W. Smith appears a fine hale man, but it might be known
that the next cholera epidemic he runs a bad chance. Mr. and Mrs. J. are
a strong healthy couple, but it might be known that they live in such a
house, in such a part of London, so near the river that they will kill
four-fifths of their children; which of the children will be the ones to
survive might also be known.
[Sidenote: "Average rate of mortality" tells us only that so many per
cent. will die. Observation must tell us _which_ in the hundred they
will be who will die.]
Averages again seduce us away from minute observation. "Average
mortalities" merely tell that so many per cent. die in this town and so
many in that, per annum. But whether A or B will be among these, the
"average rate" of course does not tell. We know, say, that from 22 to 24
per 1,000 will die in London next year. But minute enquiries into
conditions enable us to know that in such a district, nay, in such a
street,--or even on one side of that street, in such a particular house,
or even on one floor of that particular house, will be the excess of
mortality, that is, the person will die who ought not to have died
before old age.
Now, would it not very materially alter the opinion of whoever were
endeavouring to form one, if he knew that from that floor, of that
house, of that street the man came.
Much more precise might be our observations even than this, and much
more correct our conclusions.
It is well known that the same names may be seen constantly recurring on
workhouse books for generations. That is, the persons were born and
brought up, and will be born and brought up, generation after
generation, in the conditions which make paupers. Death and disease are
like the workhouse, they take from the same family, the same house, or
in other words, the same conditions. Why will we not observe what they
are?
The close observer may safely predict that such a family, whether its
members marry or not, will become extinct; that such another will
degenerate morally and physically. But who learns the lesson? On the
contrary, it may be well known that the children die in such a house at
the rate of 8 out of 10; one would think that nothing more need be said;
for how could Providence speak more distinctly? yet nobody listens, the
family goes on living there till it dies out, and then some other family
takes it. Neither would they listen "if one rose from the dead."
[Sidenote: What observation is for.]
In dwelling upon the vital importance of _sound_ observation, it must
never be lost sight of what observation is for. It is not for the sake
of piling up miscellaneous information or curious facts, but for the
sake of saving life and increasing health and comfort. The caution may
seem useless, but it is quite surprising how many men (some women do it
too), practically behave as if the scientific end were the only one in
view, or as if the sick body were but a reservoir for stowing medicines
into, and the surgical disease only a curious case the sufferer has made
for the attendant's special information. This is really no exaggeration.
You think, if you suspected your patient was being poisoned, say, by a
copper kettle, you would instantly, as you ought, cut off all possible
connection between him and the suspected source of injury, without
regard to the fact that a curious mine of observation is thereby lost.
But it is not everybody who does so, and it has actually been made a
question of medical ethics, what should the medical man do if he
suspected poisoning? The answer seems a very simple one,--insist on a
confidential nurse being placed with the patient, or give up the case.
[Sidenote: What a confidential nurse should be.]
And remember every nurse should be one who is to be depended upon, in
other words, capable of being, a "confidential" nurse. She does not know
how soon she may find herself placed in such a situation; she must be no
gossip, no vain talker; she should never answer questions about her sick
except to those who have a right to ask them; she must, I need not say,
be strictly sober and honest; but more than this, she must be a
religious and devoted woman; she must have a respect for her own
calling, because God's precious gift of life is often literally placed
in her hands; she must be a sound, and close, and quick observer; and
she must be a woman of delicate and decent feeling.
[Sidenote: Observation is for practical purposes.]
To return to the question of what observation is for:--It would really
seem as if some had considered it as its own end, as if detection, not
cure, was their business; nay more, in a recent celebrated trial, three
medical men, according to their own account, suspected poison,
prescribed for dysentery, and left the patient to the poisoner. This is
an extreme case. But in a small way, the same manner of acting falls
under the cognizance of us all. How often the attendants of a case have
stated that they knew perfectly well that the patient could not get well
in such an air, in such a room, or under such circumstances, yet have
gone on dosing him with medicine, and making no effort to remove the
poison from him, or him from the poison which they knew was killing him;
nay, more, have sometimes not so much as mentioned their conviction in
the right quarter--that is, to the only person who could act in the
matter.
FOOTNOTES:
[1]
It is a much more difficult thing to speak the truth than people
commonly imagine. There is the want of observation _simple_, and the
want of observation _compound_, compounded, that is, with the
imaginative faculty. Both may equally intend to speak the truth. The
information of the first is simply defective. That of the second is much
more dangerous. The first gives, in answer to a question asked about a
thing that has been before his eyes perhaps for years, information
exceedingly imperfect, or says, he does not know. He has never observed.
And people simply think him stupid.
The second has observed just as little, but imagination immediately
steps in, and he describes the whole thing from imagination merely,
being perfectly convinced all the while that he has seen or heard it; or
he will repeat a whole conversation, as if it were information which had
been addressed to him; whereas it is merely what he has himself said to
somebody else. This is the commonest of all. These people do not even
observe that they have _not_ observed, nor remember that they have
forgotten.
Courts of justice seem to think that anybody can speak "the whole truth,
and nothing but the truth," if he does but intend it. It requires many
faculties combined of observation and memory to speak "the whole truth,"
and to say "nothing but the truth."
"I knows I fibs dreadful; but believe me, Miss, I never finds out I have
fibbed until they tells me so," was a remark actually made. It is also
one of much more extended application than most people have the least
idea of.
Concurrence of testimony, which is so often adduced as final proof, may
prove nothing more, as is well known to those accustomed to deal with
the unobservant imaginative, than that one person has told his story a
great many times.
I have heard thirteen persons "concur" in declaring that fourteenth, who
had never left his bed, went to a distant chapel every morning at seven
o'clock.
I have heard persons in perfect good faith declare, that a man came to
dine every day at the house where they lived, who had never dined there
once; that a person had never taken the sacrament, by whose side they
had twice at least knelt at Communion; that but one meal a day came out
of a hospital kitchen, which for six weeks they had seen provide from
three to five and six meals a day. Such instances might be multiplied
_ad infinitum_ if necessary.
[2]
This is important, because on this depends what the remedy will be. If a
patient sleeps two or three hours early in the night, and then does not
sleep again at all, ten to one it is not a narcotic he wants, but food
or stimulus, or perhaps only warmth. If, on the other hand, he is
restless and awake all night, and is drowsy in the morning, he probably
wants sedatives, either quiet, coolness, or medicine, a lighter diet, or
all four. Now the doctor should be told this, or how can he judge what
to give?
[3]
[Sidenote: More important to spare the patient thought than physical
exertion.]
It is commonly supposed that the nurse is there to spare the
patient from making physical exertion for himself--I would rather
say that she ought to be there to spare him from taking thought
for himself. And I am quite sure, that if the patient were spared
all thought for himself, and _not_ spared all physical exertion, he
would be infinitely the gainer. The reverse is generally the case
in the private house. In the hospital it is the relief from all
anxiety, afforded by the rules of a well-regulated institution,
which has often such a beneficial effect upon the patient.
[4]
[Sidenote: English women have great capacity of, but little practice in
close observation.]
It may be too broad an assertion, and it certainly sounds like a
paradox. But I think that in no country are women to be found so
deficient in ready and sound observation as in England, while peculiarly
capable of being trained to it. The French or Irish woman is too quick
of perception to be so sound an observer--the Teuton is too slow to be
so ready an observer as the English woman might be. Yet English women
lay themselves open to the charge so often made against them by men,
viz., that they are not to be trusted in handicrafts to which their
strength is quite equal, for want of a practised and steady observation.
In countries where women (with average intelligence certainly not
superior to that of English women) are employed, e.g., in dispensing,
men responsible for what these women do (not theorizing about man's and
woman's "missions,") have stated that they preferred the service of
women to that of men, as being more exact, more careful, and incurring
fewer mistakes of inadvertence.
Now certainly English women are peculiarly capable of attaining to this.
I remember when a child, hearing the story of an accident, related by
some one who sent two girls to fetch a "bottle of salvolatile from her
room;" "Mary could not stir," she said, "Fanny ran and fetched a bottle
that was not salvolatile, and that was not in my room."
Now this sort of thing pursues every one through life. A woman is asked
to fetch a large new bound red book, lying on the table by the window,
and she fetches five small old boarded brown books lying on the shelf by
the fire. And this, though she has "put that room to rights" every day
for a month perhaps, and must have observed the books every day, lying
in the same places, for a month, if she had any observation.
Habitual observation is the more necessary, when any sudden call arises.
If "Fanny" had observed "the bottle of salvolatile" in "the aunt's
room," every day she was there, she would more probably have found it
when it was suddenly wanted.
There are two causes for these mistakes of inadvertence. 1. A want of
ready attention; only a part of the request is heard at all. 2. A want
of the habit of observation.
To a nurse I would add, take care that you always put the same things in
the same places; you don't know how suddenly you may be called on some
day to find something, and may not be able to remember in your haste
where you yourself had put it, if your memory is not in the habit of
seeing the thing there always.
[5]
[Sidenote: Approach of death, paleness by no means an invariable
effect, as we find in novels.]
It falls to few ever to have had the opportunity of observing the
different aspects which the human face puts on at the sudden approach of
certain forms of death by violence; and as it is a knowledge of little
use, I only mention it here as being the most startling example of what
I mean. In the nervous temperament the face becomes pale (this is the
only _recognised_ effect); in the sanguine temperament purple; in the
bilious yellow, or every manner of colour in patches. Now, it is
generally supposed that paleness is the one indication of almost any
violent change in the human being, whether from terror, disease, or
anything else. There can be no more false observation. Granted, it is
the one recognised livery, as I have said--_de rigueur_ in novels, but
nowhere else.
[6]
I have known two cases, the one of a man who intentionally and
repeatedly displaced a dislocation, and was kept and petted by all the
surgeons; the other of one who was pronounced to have nothing the matter
with him, there being no organic change perceptible, but who died within
the week. In both these cases, it was the nurse who, by accurately
pointing out what she had accurately observed, to the doctors, saved the
one case from persevering in a fraud, the other from being discharged
when actually in a dying state.
I will even go further and say, that in diseases which have their origin
in the feeble or irregular action of some function, and not in organic
change, it is quite an accident if the doctor who sees the case only
once a day, and generally at the same time, can form any but a negative
idea of its real condition. In the middle of the day, when such a
patient has been refreshed by light and air, by his tea, his beef-tea,
and his brandy, by hot bottles to his feet, by being washed and by clean
linen, you can scarcely believe that he is the same person as lay with a
rapid fluttering pulse, with puffed eye-lids, with short breath, cold
limbs, and unsteady hands, this morning. Now what is a nurse to do in
such a case? Not cry, "Lord, bless you, sir, why you'd have thought he
were a dying all night." This may be true, but it is not the way to
impress with the truth a doctor, more capable of forming a judgment from
the facts, if he did but know them, than you are. What he wants is not
your opinion, however respectfully given, but your facts. In all
diseases it is important, but in diseases which do not run a distinct
and fixed course, it is not only important, it is essential that the
facts the nurse alone can observe, should be accurately observed, and
accurately reported to the doctor.
I must direct the nurse's attention to the extreme variation there is
not unfrequently in the pulse of such patients during the day. A very
common case is this: Between 3 and 4 A.M., the pulse become quick,
perhaps 130, and so thready it is not like a pulse at all, but like a
string vibrating just underneath the skin. After this the patient gets
no more sleep. About mid-day the pulse has come down to 80; and though
feeble and compressible, is a very respectable pulse. At night, if the
patient has had a day of excitement, it is almost imperceptible. But, if
the patient has had a good day, it is stronger and steadier, and not
quicker than at mid-day. This is a common history of a common pulse; and
others, equally varying during the day, might be given. Now, in
inflammation, which may almost always be detected by the pulse, in
typhoid fever, which is accompanied by the low pulse that nothing will
raise, there is no such great variation. And doctors and nurses become
accustomed not to look for it. The doctor indeed cannot. But the
variation is in itself an important feature.
Cases like the above often "go off rather suddenly," as it is called,
from some trifling ailment of a few days, which just makes up the sum of
exhaustion necessary to produce death. And everybody cries, Who would
have thought it? except the observing nurse, if there is one, who had
always expected the exhaustion to come, from which there would be no
rally, because she knew the patient had no capital in strength on which
to draw, if he failed for a few days to make his barely daily income in
sleep and nutrition.
I have often seen really good nurses distressed, because they could not
impress the doctor with the real danger of their patient; and quite
provoked because the patient "would look" either "so much better" or "so
much worse" than he really is "when the doctor was there." The distress
is very legitimate, but it generally arises from the nurse not having
the power of laying clearly and shortly before the doctor the facts from
which she derives her opinion, or from the doctor being hasty and
inexperienced, and not capable of eliciting them. A man who really cares
for his patients, will soon learn to ask for and appreciate the
information of a nurse, who is at once a careful observer and a clear
reporter.