Part 13

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."

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. 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?

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.