Part 12

NOTE.--There are two classes of patients which are unfortunately becoming more common every day, especially among women of the richer orders, to whom all these remarks are pre-eminently inapplicable. 1. Those who make health an excuse for doing nothing, and at the same time allege that the being able to do nothing is their only grief. 2. Those who have brought upon themselves ill-health by over pursuit of amusement, which they and their friends have most unhappily called intellectual activity. I scarcely know a greater injury that can be inflicted than the advice too often given to the first class "to vegetate"--or than the admiration too often bestowed on the latter class for "pluck."

XIII. OBSERVATION OF THE SICK.

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 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.

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? "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.

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.

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?

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.

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.