Notes on Nursing Part 11

[Sidenote: Superst.i.tion the fruit of bad observation.]

Almost all superst.i.tions are owing to bad observation, to the _post hoc, ergo propter hoc_; and bad observers are almost all superst.i.tious.

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, flus.h.i.+ng, 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 p.r.o.nounced 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 a.s.sailed 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 amus.e.m.e.nt?" 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 a.s.sert 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 a.s.sert 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, a.s.sure 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 n.o.body 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 G.o.d'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 circ.u.mstances, 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.

CONCLUSION.

[Sidenote: Sanitary nursing as essential in surgical as in medical cases, but not to supersede surgical nursing.]

The whole of the preceding remarks apply even more to children and to puerperal women than to patients in general. They also apply to the nursing of surgical, quite as much as to that of medical cases. Indeed, if it be possible, cases of external injury require such care even more than sick. In surgical wards, one duty of every nurse certainly is _prevention_. Fever, or hospital gangrene, or pyaemia, or purulent discharge of some kind may else supervene. Has she a case of compound fracture, of amputation, or of erysipelas, it may depend very much on how she looks upon the things enumerated in these notes, whether one or other of these hospital diseases attacks her patient or not. If she allows her ward to become filled with the peculiar close foetid smell, so apt to be produced among surgical cases, especially where there is great suppuration and discharge, she may see a vigorous patient in the prime of life gradually sink and die where, according to all human probability, he ought to have recovered. The surgical nurse must be ever on the watch, ever on her guard, against want of cleanliness, foul air, want of light, and of warmth.

Nevertheless let no one think that because _sanitary_ nursing is the subject of these notes, therefore, what may be called the handicraft of nursing is to be undervalued. A patient may be left to bleed to death in a sanitary palace. Another who cannot move himself may die of bed-sores, because the nurse does not know how to change and clean him, while he has every requisite of air, light, and quiet. But nursing, as a handicraft, has not been treated of here for three reasons: 1. that these notes do not pretend to be a manual for nursing, any more than for cooking for the sick; 2. that the writer, who has herself seen more of what may be called surgical nursing, i.e., practical manual nursing, than, perhaps, any one in Europe, honestly believes that it is impossible to learn it from any book, and that it can only be thoroughly learnt in the wards of a hospital; and she also honestly believes that the perfection of surgical nursing may be seen practised by the old-fas.h.i.+oned "Sister" of a London hospital, as it can be seen nowhere else in Europe. 3. While thousands die of foul air, &c., who have this surgical nursing to perfection, the converse is comparatively rare.

[Sidenote: Children: their greater susceptibility to the same things.]