[Sidenote: What is the use of the question, Is he better?]
There is no more silly or universal question scarcely asked than this,
"Is he better?" Ask it of the medical attendant, if you please. But of
whom else, if you wish for a real answer to your question, would you ask
it? Certainly not of the casual visitor; certainly not of the nurse,
while the nurse's observation is so little exercised as it is now. What
you want are facts, not opinions--for who can have any opinion of any
value as to whether the patient is better or worse, excepting the
constant medical attendant, or the really observing nurse?
The most important practical lesson that can be given to nurses is to
teach them what to observe--how to observe--what symptoms indicate
improvement--what the reverse--which are of importance--which are of
none--which are the evidence of neglect--and of what kind of neglect.
All this is what ought to make part, and an essential part, of the
training of every nurse. At present how few there are, either
professional or unprofessional, who really know at all whether any sick
person they may be with is better or worse.
The vagueness and looseness of the information one receives in answer to
that much abused question, "Is he better?" would be ludicrous, if it
were not painful. The only sensible answer (in the present state of
knowledge about sickness) would be "How can I know? I cannot tell how he
was when I was not with him."
I can record but a very few specimens of the answers[33] which I have
heard made by friends and nurses, and accepted by physicians and
surgeons at the very bed-side of the patient, who could have
contradicted every word, but did not--sometimes from amiability, often
from shyness, oftenest from languor!
"How often have the bowels acted, nurse?" "Once, sir." This generally
means that the utensil has been emptied once, it having been used
perhaps seven or eight times.
"Do you think the patient is much weaker than he was six weeks ago?" "Oh
no, sir; you know it is very long since he has been up and dressed, and
he can get across the room now." This means that the nurse has not
observed that whereas six weeks ago he sat up and occupied himself in
bed, he now lies still doing nothing; that, although he can "get across
the room," he cannot stand for five seconds.
Another patient who is eating well, recovering steadily, although
slowly, from fever, but cannot walk or stand, is represented to the
doctor as making no progress at all.
[Sidenote: Leading questions useless or misleading.]
Questions, too, as asked now (but too generally) of or about patients,
would obtain no information at all about them, even if the person asked
of had every information to give. The question is generally a leading
question; and it is singular that people never think what must be the
answer to this question before they ask it: for instance, "Has he had a
good night?" Now, one patient will think he has a bad night if he has
not slept ten hours without waking. Another does not think he has a bad
night if he has had intervals of dosing occasionally. The same answer
has actually been given as regarded two patients--one who had been
entirely sleepless for five times twenty-four hours, and died of it, and
another who had not slept the sleep of a regular night, without waking.
Why cannot the question be asked, How many hours' sleep has ---- had?
and at what hours of the night?[34] "I have never closed my eyes all
night," an answer as frequently made when the speaker has had several
hours' sleep as when he has had none, would then be less often said.
Lies, intentional and unintentional, are much seldomer told in answer to
precise than to leading questions. Another frequent error is to inquire
whether one cause remains, and not whether the effect which may be
produced by a great many different causes, _not_ inquired after,
remains. As when it is asked, whether there was noise in the street last
night; and if there were not, the patient is reported, without more ado,
to have had a good night. Patients are completely taken aback by these
kinds of leading questions, and give only the exact amount of
information asked for, even when they know it to be completely
misleading. The shyness of patients is seldom allowed for.
How few there are who, by five or six pointed questions, can elicit the
whole case and get accurately to know and to be able to report _where_
the patient is.
[Sidenote: Means of obtaining inaccurate information.]
I knew a very clever physician, of large dispensary and hospital
practice, who invariably began his examination of each patient with "Put
your finger where you be bad." That man would never waste his time with
collecting inaccurate information from nurse or patient. Leading
questions always collect inaccurate information.
At a recent celebrated trial, the following leading question was put
successively to nine distinguished medical men. "Can you attribute these
symptoms to anything else but poison?" And out of the nine, eight
answered "No!" without any qualification whatever. It appeared, upon
cross-examination:--1. That none of them had ever seen a case of the
kind of poisoning supposed. 2. That none of them had ever seen a case of
the kind of disease to which the death, if not to poison, was
attributable. 3. That none of them were even aware of the main fact of
the disease and condition to which the death was attributable.
Surely nothing stronger can be adduced to prove what use leading
questions are of, and what they lead to.
I had rather not say how many instances I have known, where, owing to
this system of leading questions, the patient has died, and the
attendants have been actually unaware of the principal feature of the
case.
[Sidenote: As to food patient takes or does not take.]
It is useless to go through all the particulars, besides sleep, in which
people have a peculiar talent for gleaning inaccurate information. As to
food, for instance, I often think that most common question, How is your
appetite? can only be put because the questioner believes the questioned
has really nothing the matter with him, which is very often the case.
But where there is, the remark holds good which has been made about
sleep. The _same_ answer will often be made as regards a patient who
cannot take two ounces of solid food per diem, and a patient who does
not enjoy five meals a day as much as usual.
Again, the question, How is your appetite? is often put when How is your
digestion? is the question meant. No doubt the two things depend on one
another. But they are quite different. Many a patient can eat, if you
can only "tempt his appetite." The fault lies in your not having got him
the thing that he fancies. But many another patient does not care
between grapes and turnips,--everything is equally distasteful to him.
He would try to eat anything which would do him good; but everything
"makes him worse." The fault here generally lies in the cooking. It is
not his "appetite" which requires "tempting," it is his digestion which
requires sparing. And good sick cookery will save the digestion half its
work.
There may be four different causes, any one of which will produce the
same result, viz., the patient slowly starving to death from want of
nutrition:
1. Defect in cooking;
2. Defect in choice of diet;
3. Defect in choice of hours for taking diet;
4. Defect of appetite in patient.
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?[35]
[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.[36] In hospitals those who cut up
the diets give with quite 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 shown 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 expected, 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.[37]
[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.[38]
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 persons examined by a 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.