Chapter 10

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.

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 woman 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-fashioned "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.]

To revert to children. They are much more susceptible than grown people to all noxious influences. They are affected by the same things, but much more quickly and seriously, viz., by want of fresh air, of proper warmth, want of cleanliness in house, clothes, bedding, or body, by startling noises, improper food, or want of punctuality, by dulness and by want of light, by too much or too little covering in bed, or when up, by want of the spirit of management generally in those in charge of them. One can, therefore, only press the importance, as being yet greater in the case of children, greatest in the case of sick children, of attending to these things.

That which, however, above all, is known to injure children seriously is foul air, and most seriously at night. Keeping the rooms where they sleep tight shut up, is destruction to them. And, if the child's breathing be disordered by disease, a few hours only of such foul air may endanger its life, even where no inconvenience is felt by grown-up persons in the same room.

The following passages, taken out of an excellent "Lecture on Sudden Death in Infancy and Childhood," just published, show the vital importance of careful nursing of children. "In the great majority of instances, when death suddenly befalls the infant or young child, it is an _accident_; it is not a necessary result of any disease from which it is suffering."

It may be here added, that it would be very desirable to know how often death is, with adults, "not a necessary, inevitable result of any disease." Omit the word "sudden;" (for _sudden_ death is comparatively rare in middle age;) and the sentence is almost equally true for all ages.

The following causes of "accidental" death in sick children are enumerated:--"Sudden noises, which startle--a rapid change of temperature, which chills the surface, though only for a moment--a rude awakening from sleep--or even an over-hasty, or an overfull meal"--"any sudden impression on the nervous system--any hasty alteration of posture--in short, any cause whatever by which the respiratory process may be disturbed."

It may again be added, that, with very weak adult patients, these causes are also (not often "suddenly fatal," it is true, but) very much oftener than is at all generally known, irreparable in their consequences.

Both for children and for adults, both for sick and for well (although more certainly in the case of sick children than in any others), I would here again repeat, the most frequent and most fatal cause of all is sleeping, for even a few hours, much more for weeks and months, in foul air, a condition which, more than any other condition, disturbs the respiratory process, and tends to produce "accidental" death in disease.

I need hardly here repeat the warning against any confusion of ideas between cold and fresh air. You may chill a patient fatally without giving him fresh air at all. And you can quite well, nay, much better, give him fresh air without chilling him. This is the test of a good nurse.

In cases of long recurring faintnesses from disease, for instance, especially disease which affects the organs of breathing, fresh air to the lungs, warmth to the surface, and often (as soon as the patient can swallow) hot drink, these are the right remedies and the only ones.

Yet, oftener than not, you see the nurse or mother just reversing this; shutting up every cranny through which fresh air can enter, and leaving the body cold, or perhaps throwing a greater weight of clothes upon it, when already it is generating too little heat.

"Breathing carefully, anxiously, as though respiration were a function which required all the attention for its performance," is cited as a not unusual state in children, and as one calling for care in all the things enumerated above. That breathing becomes an almost voluntary act, even in grown up patients who are very weak, must often have been remarked.

"Disease having interfered with the perfect accomplishment of the respiratory function, some sudden demand for its complete exercise, issues in the sudden standstill of the whole machinery," is given as one process:--"life goes out for want of nervous power to keep the vital functions in activity," is given as another, by which "accidental" death is most often brought to pass in infancy.

Also in middle age, both these processes may be seen ending in death, although generally not suddenly. And I have seen, even in middle age, the "_sudden_ stand-still" here mentioned, and from the same causes.

[Sidenote: Summary.]

To sum up:--the answer to two of the commonest objections urged, one by women themselves, the other by men, against the desirableness of sanitary knowledge for women, _plus_ a caution, comprises the whole argument for the art of nursing.

[Sidenote: Reckless amateur physicking by women. Real knowledge of the laws of health alone can check this.]

(1.) It is often said by men, that it is unwise to teach women anything about these laws of health, because they will take to physicking,--that there is a great deal too much of amateur physicking as it is, which is indeed true. One eminent physician told me that he had known more calomel given, both at a pinch and for a continuance, by mothers, governesses, and nurses, to children than he had ever heard of a physician prescribing in all his experience. Another says, that women's only idea in medicine is calomel and aperients. This is undeniably too often the case. There is nothing ever seen in any professional practice like the reckless physicking by amateur females.[1] But this is just what the really experienced and observing nurse does _not_ do; she neither physics herself nor others. And to cultivate in things pertaining to health observation and experience in women who are mothers, governesses or nurses, is just the way to do away with amateur physicking, and if the doctors did but know it, to make the nurses obedient to them,--helps to them instead of hindrances. Such education in women would indeed diminish the doctor's work--but no one really believes that doctors wish that there should be more illness, in order to have more work.

[Sidenote: What pathology teaches. What observation alone teaches. What medicine does. What nature alone does.]

(2.) It is often said by women, that they cannot know anything of the laws of health, or what to do to preserve their children's health, because they can know nothing of "Pathology," or cannot "dissect,"--a confusion of ideas which it is hard to attempt to disentangle.