A very high authority in hospital construction has said that people do not enough consider the difference between wards and dormitories in planning their buildings. But I go farther, and say, that healthy people never remember the difference between bed-rooms and sick-rooms, in making arrangements for the sick. To a sleeper in health it does not signify what the view is from his bed. He ought never to be in it excepting when asleep, and at night. Aspect does not very much signify either (provided the sun reach his bed-room some time in every day, to purify the air), because he ought never to be in his bed-room except during the hours when there is no sun. But the case is exactly reversed with the sick, even should they be as many hours out of their beds as you are in yours, which probably they are not. Therefore, that they should be able, without raising themselves or turning in bed, to see out of window from their beds, to see sky and sun-light at least, if you can show them nothing else, I assert to be, if not of the very first importance for recovery, at least something very near it. And you should therefore look to the position of the beds of your sick one of the very first things. If they can see out of two windows instead of one, so much the better. Again, the morning sun and the mid-day sun—the hours when they are quite certain not to be up, are of more importance to them, if a choice must be made, than the afternoon sun. Perhaps you can take them out of bed in the afternoon and set them by the window, where they can see the sun. But the best rule is, if possible, to give them direct sun-light from the moment he rises till the moment he sets.
Another great difference between the bed-room and the sick-room is, that the sleeper has a very large balance of fresh air to begin with, when he begins the night, if his room has been open all day as it ought to be; the sick man has not, because all day he has been breathing the air in the same room, and dirtying it by the emanations from himself. Far more care is therefore necessary to keep up a constant change of air in the sick room.
It is hardly necessary to add that there are acute cases, (particularly a few ophthalmic cases, and diseases where the eye is morbidly sensitive), where a subdued light is necessary. But a dark north room is inadmissible even for these. You can always moderate the light by blinds and curtains.
Heavy, thick, dark window or bed curtains should, however, hardly ever be used for any kind of sick in this country. A light white curtain at the head of the bed is, in general, all that is necessary, and a green blind to the window, to be drawn down only when necessary.
One of the greatest observers of human things (not physiological), says, in another language, "Where there is sun there is thought." All physiology goes to confirm this. Where is the shady side of deep valleys, there is cretinism. Where are cellars and the unsunned sides of narrow streets, there is the degeneracy and weakliness of the human race—mind and body equally degenerating. Put the pale withering plant and human being into the sun, and, if not too far gone, each will recover health and spirit.
It is a curious thing to observe how almost all patients lie with their faces turned to the light, exactly as plants always make their faces turned to the light; a patient will even complain that it gives him pain "lying on that side." "Then why do you lie on that side?" He does not know,—but we do. It is because it is the side towards the window. A fashionable physician has recently published in a government report that he always turns his patients' faces from the light. Yes, but nature is stronger than fashionable physicians, and depend upon it she turns the faces back and towards such light as she can get. Walk through the wards of a hospital, remember the bed sides of private patients you have seen, and count how many sick you ever saw lying with their faces towards the wall.
It cannot be necessary to tell a nurse that she should be clean, or that she should keep her patient clean,—seeing that the greater part of nursing consists in preserving cleanliness. No ventilation can freshen a room or ward where the most scrupulous cleanliness is not observed. Unless the wind be blowing through the windows at the rate of twenty miles an hour, dusty carpets, dirty wainscots, musty curtains and furniture, will infallibly produce a close smell. I have lived in a large and expensively furnished London house, where the only constant inmate in two very lofty rooms, with opposite windows, was myself, and yet, owing to the abovementioned dirty circumstances, no opening of windows could ever keep those rooms free from closeness; but the carpet and curtains having been turned out of the rooms altogether, they became instantly as fresh as could be wished. It is pure nonsense to say that in London a room cannot be kept clean. Many of our hospitals show the exact reverse.
But no particle of dust is ever or can ever be removed or really got rid of by the present system of dusting. Dusting in these days means nothing but flapping the dust from one part of a room on to another with doors and windows closed. What you do it for I cannot think. You had much better leave the dust alone, if you are not going to take it away altogether. For from the time a room begins to be a room up to the time when it ceases to be one, no one atom of dust ever actually leaves its precincts. Tidying a room means nothing now but removing a thing from one place, which it has kept clean for itself, on to another and a dirtier one.[28] Flapping by way of cleaning is only admissible in the case of pictures, or anything made of paper. The only way I know to remove dust, the plague of all lovers of fresh air, is to wipe everything with a damp cloth. And all furniture ought to be so made as that it may be wiped with a damp cloth without injury to itself, and so polished as that it may be damped without injury to others. To dust, as it is now practised, truly means to distribute dust more equally over a room.
As to floors, the only really clean floor I know is the Berlin lackered floor, which is wet rubbed and dry rubbed every morning to remove the dust. The French parquet is always more or less dusty, although infinitely superior in point of cleanliness and healthiness to our absorbent floor.
For a sick room, a carpet is perhaps the worst expedient which could by any possibility have been invented. If you must have a carpet, the only safety is to take it up two or three times a year, instead of once. A dirty carpet literally infects the room. And if you consider the enormous quantity of organic matter from the feet of people coming in, which must saturate it, this is by no means surprising.
As for walls, the worst is the papered wall; the next worst is plaster. But the plaster can be redeemed by frequent lime-washing; the paper requires frequent renewing. A glazed paper gets rid of a good deal of the danger. But the ordinary bed-room paper is all that it ought not to be.[29]
The close connection between ventilation and cleanliness is shown in this. An ordinary light paper will last clean much longer if there is an Arnott's ventilator in the chimney than it otherwise would.
The best wall now extant is oil paint. From this you can wash the animal exuviæ.[30]
These are what make a room musty.
The best wall for a sick-room or ward that could be made is pure white non-absorbent cement or glass, or glazed tiles, if they were made sightly enough.
Air can be soiled just like water. If you blow into water you will soil it with the animal matter from your breath. So it is with air. Air is always soiled in a room where walls and carpets are saturated with animal exhalations.
Want of cleanliness, then, in rooms and wards, which you have to guard against, may arise in three ways.
1. Dirty air coming in from without, soiled by sewer emanations, the evaporation from dirty streets, smoke, bits of unburnt fuel, bits of straw, bits of horse dung.
If people would but cover the outside walls of their houses with plain or encaustic tiles, what an incalculable improvement would there be in light, cleanliness, dryness, warmth, and consequently economy. The play of a fire-engine would then effectually wash the outside of a house. This kind of walling would stand next to paving in improving the health of towns.
2. Dirty air coming from within, from dust, which you often displace, but never remove. And this recalls what ought to be a sine quâ non. Have as few ledges in your room or ward as possible. And under no pretence have any ledge whatever out of sight. Dust accumulates there, and will never be wiped off. This is a certain way to soil the air. Besides this, the animal exhalations from your inmates saturate your furniture. And if you never clean your furniture properly, how can your rooms or wards be anything but musty? Ventilate as you please, the rooms will never be sweet. Besides this, there is a constant degradation, as it is called, taking place from everything except polished or glazed articles—E.g., in colouring certain green papers arsenic is used. Now in the very dust even, which is lying about in rooms hung with this kind of green paper, arsenic has been distinctly detected. You see your dust is anything but harmless; yet you will let such dust lie about your ledges for months, your rooms for ever.
Again, the fire fills the room with coal-dust.
3. Dirty air coming from the carpet. Above all, take care of the carpets, that the animal dirt left there by the feet of visitors does not stay there. Floors, unless the grain is filled up and polished, are just as bad. The smell from the floor of a school-room or ward, when any moisture brings out the organic matter by which it is saturated, might alone be enough to warn us of the mischief that is going on.
The outer air, then, can only be kept clean by sanitary improvements, and by consuming smoke. The expense in soap, which this single improvement would save, is quite incalculable.
The inside air can only be kept clean by excessive care in the ways mentioned above—to rid the walls, carpets, furniture, ledges, &c., of the organic matter and dust—dust consisting greatly of this organic matter—with which they become saturated, and which is what really makes the room musty.
Without cleanliness, you cannot have all the effect of ventilation; without ventilation, you can have no thorough cleanliness.
Very few people, be they of what class they may, have any idea of the exquisite cleanliness required in the sick-room. For much of what I have said applies less to the hospital than to the private sick-room. The smoky chimney, the dusty furniture, the utensils emptied but once a day, often keep the air of the sick constantly dirty in the best private houses.
The well have a curious habit of forgetting that what is to them but a trifling inconvenience, to be patiently "put up" with, is to the sick a source of suffering, delaying recovery, if not actually hastening death. The well are scarcely ever more than eight hours, at most, in the same room. Some change they can always make, if only for a few minutes. Even during the supposed eight hours, they can change their posture or their position in the room. But the sick man, who never leaves his bed, who cannot change by any movement of his own his air, or his light, or his warmth; who cannot obtain quiet, or get out of the smoke, or the smell, or the dust; he is really poisoned or depressed by what is to you the merest trifle.
"What can't be cured must be endured," is the very worst and most dangerous maxim for a nurse which ever was made. Patience and resignation in her are but other words for carelessness or indifference—contemptible, if in regard to herself; culpable, if in regard to her sick.
In almost all diseases, the function of the skin is, more or less, disordered; and in many most important diseases nature relieves herself almost entirely by the skin. This is particularly the case with children. But the excretion, which comes from the skin, is left there, unless removed by washing or by the clothes. Every nurse should keep this fact constantly in mind,—for, if she allow her sick to remain unwashed, or their clothing to remain on them after being saturated with perspiration or other excretion, she is interfering injuriously with the natural processes of health just as effectually as if she were to give the patient a dose of slow poison by the mouth. Poisoning by the skin is no less certain than poisoning by the mouth—only it is slower in its operation.
The amount of relief and comfort experienced by sick after the skin has been carefully washed and dried, is one of the commonest observations made at a sick bed. But it must not be forgotten that the comfort and relief so obtained are not all. They are, in fact, nothing more than a sign that the vital powers have been relieved by removing something that was oppressing them. The nurse, therefore, must never put off attending to the personal cleanliness of her patient under the plea that all that is to be gained is a little relief, which can be quite as well given later.
In all well-regulated hospitals this ought to be, and generally is, attended to. But it is very generally neglected with private sick.
Just as it is necessary to renew the air round a sick person frequently, to carry off morbid effluvia from the lungs and skin, by maintaining free ventilation, so is it necessary to keep the pores of the skin free from all obstructing excretions. The object, both of ventilation and of skin-cleanliness, is pretty much the same, to wit, removing noxious matter from the system as rapidly as possible.
Care should be taken in all these operations of sponging, washing, and cleansing the skin, not to expose too great a surface at once, so as to check the perspiration, which would renew the evil in another form.
The various ways of washing the sick need not here be specified,—the less so as the doctors ought to say which is to be used.
In several forms of diarrhœa, dysentery, &c., where the skin is hard and harsh, the relief afforded by washing with a great deal of soft soap is incalculable. In other cases, sponging with tepid soap and water, then with tepid water and drying with a hot towel will be ordered.
Every nurse ought to be careful to wash her hands very frequently during the day. If her face too, so much the better.
One word as to cleanliness merely as cleanliness.
Compare the dirtiness of the water in which you have washed when it is cold without soap, cold with soap, hot with soap. You will find the first has hardly removed any dirt at all, the second a little more, the third a great deal more. But hold your hand over a cup of hot water for a minute or two, and then, by merely rubbing with the finger, you will bring off flakes of dirt or dirty skin. After a vapour bath you may peel your whole self clean in this way. What I mean is, that by simply washing or sponging with water you do not really clean your skin. Take a rough towel, dip one corner in very hot water,—if a little spirit be added to it it will be more effectual,—and then rub as if you were rubbing the towel into your skin with your fingers. The black flakes which will come off will convince you that you were not clean before, however much soap and water you have used. These flakes are what require removing. And you can really keep yourself cleaner with a tumbler of hot water and a rough towel and rubbing, than with a whole apparatus of bath and soap and sponge, without rubbing. It is quite nonsense to say that anybody need be dirty. Patients have been kept as clean by these means on a long voyage, when a basin full of water could not be afforded, and when they could not be moved out of their berths, as if all the appurtenances of home had been at hand.
Washing, however, with a large quantity of water has quite other effects than those of mere cleanliness. The skin absorbs the water and becomes softer and more perspirable. To wash with soap and soft water is, therefore, desirable from other points of view than that of cleanliness.
The sick man to his advisers.
"My advisers! Their name is legion. * * * Somehow or other, it seems a provision of the universal destinies, that every man, woman, and child should consider him, her, or itself privileged especially to advise me. Why? That is precisely what I want to know." And this is what I have to say to them. I have been advised to go to every place extant in and out of England—to take every kind of exercise by every kind of cart, carriage—yes, and even swing (!) and dumb-bell (!) in existence; to imbibe every different kind of stimulus that ever has been invented. And this when those best fitted to know, viz., medical men, after long and close attendance, had declared any journey out of the question, had prohibited any kind of motion whatever, had closely laid down the diet and drink. What would my advisers say, were they the medical attendants, and I the patient left their advice, and took the casual adviser's? But the singularity in Legion's mind is this: it never occurs to him that everybody else is doing the same thing, and that I the patient must perforce say, in sheer self-defence, like Rosalind, "I could not do with all."
"Chattering Hopes" may seem an odd heading. But I really believe there is scarcely a greater worry which invalids have to endure than the incurable hopes of their friends. There is no one practice against which I can speak more strongly from actual personal experience, wide and long, of its effects during sickness observed both upon others and upon myself. I would appeal most seriously to all friends, visitors, and attendants of the sick to leave off this practice of attempting to "cheer" the sick by making light of their danger and by exaggerating their probabilities of recovery.
Far more now than formerly does the medical attendant tell the truth to the sick who are really desirous to hear it about their own state.
How intense is the folly, then, to say the least of it, of the friend, be he even a medical man, who thinks that his opinion, given after a cursory observation, will weigh with the patient, against the opinion of the medical attendant, given, perhaps, after years of observation, after using every help to diagnosis afforded by the stethoscope, the examination of pulse, tongue, &c.; and certainly after much more observation than the friend can possibly have had.
Supposing the patient to be possessed of common sense,—how can the "favourable" opinion, if it is to be called an opinion at all, of the casual visitor "cheer" him,—when different from that of the experienced attendant? Unquestionably the latter may, and often does, turn out to be wrong. But which is most likely to be wrong?
The fact is, that the patient[31] is not "cheered" at all by these well-meaning, most tiresome friends. On the contrary, he is depressed and wearied. If, on the one hand, he exerts himself to tell each successive member of this too numerous conspiracy, whose name is legion, why he does not think as they do,—in what respect he is worse,—what symptoms exist that they know nothing of,—he is fatigued instead of "cheered," and his attention is fixed upon himself. In general, patients who are really ill, do not want to talk about themselves. Hypochondriacs do, but again I say we are not on the subject of hypochondriacs.
If, on the other hand, and which is much more frequently the case, the patient says nothing, but the Shakespearian "Oh!" "Ah!" "Go to!" and "In good sooth!" in order to escape from the conversation about himself the sooner, he is depressed by want of sympathy. He feels isolated in the midst of friends. He feels what a convenience it would be, if there were any single person to whom he could speak simply and openly, without pulling the string upon himself of this shower-bath of silly hopes and encouragements; to whom he could express his wishes and directions without that person persisting in saying "I hope that it will please God yet to give you twenty years," or, "You have a long life of activity before you." How often we see at the end of biographies or of cases recorded in medical papers, "after a long illness A. died rather suddenly," or, "unexpectedly both to himself and to others." "Unexpectedly" to others, perhaps, who did not see, because they did not look; but by no means "unexpectedly to himself," as I feel entitled to believe, both from the internal evidence in such stories, and from watching similar cases: there was every reason to expect that A. would die, and he knew it; but he found it useless to insist upon his own knowledge to his friends.
In these remarks I am alluding neither to acute cases which terminate rapidly nor to "nervous" cases.
By the first much interest in their own danger is very rarely felt. In writings of fiction, whether novels or biographies, these death-beds are generally depicted as almost seraphic in lucidity of intelligence. Sadly large has been my experience in death-beds, and I can only say that I have seldom or never seen such. Indifference, excepting with regard to bodily suffering, or to some duty the dying man desires to perform, is the far more usual state.
The "nervous case," on the other hand, delights in figuring to himself and others a fictitious danger.
But the long chronic case, who knows too well himself, and who has been told by his physician that he will never enter active life again, who feels that every month he has to give up something he could do the month before—oh! spare such sufferers your chattering hopes. You do not know how you worry and weary them. Such real sufferers cannot bear to talk of themselves, still less to hope for what they cannot at all expect.
So also as to all the advice showered so profusely upon such sick, to leave off some occupation, to try some other doctor, some other house, climate, pill, powder, or specific; I say nothing of the inconsistency—for these advisers are sure to be the same persons who exhorted the sick man not to believe his own doctor's prognostics, because "doctors are always mistaken," but to believe some other doctor, because "this doctor is always right." Sure also are these advisers to be the persons to bring the sick man fresh occupation, while exhorting him to leave his own.
Wonderful is the face with which friends, lay and medical, will come in and worry the patient with recommendations to do something or other, having just as little knowledge as to its being feasible, or even safe for him, as if they were to recommend a man to take exercise, not knowing he had broken his leg. What would the friend say, if he were the medical attendant, and if the patient, because some other friend had come in, because somebody, anybody, nobody, had recommended something, anything, nothing, were to disregard his orders, and take that other body's recommendation? But people never think of this.
A celebrated historical personage has related the commonplaces which, when on the eve of executing a remarkable resolution, were showered in nearly the same words by every one around successively for a period of six months. To these the personage states that it was found least trouble always to reply the same thing, viz., that it could not be supposed that such a resolution had been taken without sufficient previous consideration. To patients enduring every day for years from every friend or acquaintance, either by letter or vivâ voce, some torment of this kind, I would suggest the same answer. It would indeed be spared, if such friends and acquaintances would but consider for one moment, that it is probable the patient has heard such advice at least fifty times before, and that, had it been practicable, it would have been practised long ago. But of such consideration there appears to be no chance. Strange, though true, that people should be just the same in these things as they were a few hundred years ago!
To me these commonplaces, leaving their smear upon the cheerful, single-hearted, constant devotion to duty, which is so often seen in the decline of such sufferers, recall the slimy trail left by the snail on the sunny southern garden-wall loaded with fruit.
No mockery in the world is so hollow as the advice showered upon the sick. It is of no use for the sick to say anything, for what the adviser wants is, not to know the truth about the state of the patient, but to turn whatever the sick may say to the support of his own argument, set forth, it must be repeated, without any inquiry whatever into the patient's real condition. "But it would be impertinent or indecent in me to make such an inquiry," says the adviser. True; and how much more impertinent is it to give your advice when you can know nothing about the truth, and admit you could not inquire into it.
To nurses I say—these are the visitors who do your patient harm. When you hear him told:—1. That he has nothing the matter with him, and that he wants cheering. 2. That he is committing suicide, and that he wants preventing. 3. That he is the tool of somebody who makes use of him for a purpose. 4. That he will listen to nobody, but is obstinately bent upon his own way; and 5. That he ought to be called to the sense of duty, and is flying in the face of Providence;—then know that your patient is receiving all the injury that he can receive from a visitor.
How little the real sufferings of illness are known or understood. How little does any one in good health fancy him or even herself into the life of a sick person.
Do, you who are about the sick or who visit the sick, try and give them pleasure, remember to tell them what will do so. How often in such visits the sick person has to do the whole conversation, exerting his own imagination and memory, while you would take the visitor, absorbed in his own anxieties, making no effort of memory or imagination, for the sick person. "Oh! my dear, I have so much to think of, I really quite forgot to tell him that; besides, I thought he would know it," says the visitor to another friend. How could "he know it"? Depend upon it, the people who say this are really those who have little "to think of." There are many burthened with business who always manage to keep a pigeon-hole in their minds, full of things to tell the "invalid."
I do not say, don't tell him your anxieties—I believe it is good for him and good for you too; but if you tell him what is anxious, surely you can remember to tell him what is pleasant too.
A sick person does so enjoy hearing good news:—for instance, of a love and courtship, while in progress to a good ending. If you tell him only when the marriage takes place, he loses half the pleasure, which God knows he has little enough of; and ten to one but you have told him of some love-making with a bad ending.
A sick person also intensely enjoys hearing of any material good, any positive or practical success of the right. He has so much of books and fiction, of principles, and precepts, and theories; do, instead of advising him with advice he has heard at least fifty times before, tell him of one benevolent act which has really succeeded practically,—it is like a day's health to him.[32]
You have no idea what the craving of sick with undiminished power of thinking, but little power of doing, is to hear of good practical action, when they can no longer partake in it.
Do observe these things with the sick. Do remember how their life is to them disappointed and incomplete. You see them lying there with miserable disappointments, from which they can have no escape but death, and you can't remember to tell them of what would give them so much pleasure, or at least an hour's variety.
They don't want you to be lachrymose and whining with them, they like you to be fresh and active and interested, but they cannot bear absence of mind, and they are so tired of the advice and preaching they receive from every body, no matter whom it is, they see.
There is no better society than babies and sick people for one another. Of course you must manage this so that neither shall suffer from it, which is perfectly possible. If you think the "air of the sick room" bad for the baby, why it is bad for the invalid too, and, therefore, you will of course correct it for both. It freshens up a sick person's whole mental atmosphere to see "the baby." And a very young child, if unspoiled, will generally adapt itself wonderfully to the ways of a sick person, if the time they spend together is not too long.
If you knew how unreasonably sick people suffer from reasonable causes of distress, you would take more pains about all these things. An infant laid upon the sick bed will do the sick person, thus suffering, more good than all your logic. A piece of good news will do the same. Perhaps you are afraid of "disturbing" him. You say there is no comfort for his present cause of affliction. It is perfectly reasonable. The distinction is this, if he is obliged to act, do not "disturb" him with another subject of thought just yet; help him to do what he wants to do: but, if he has done this, or if nothing can be done, then "disturb" him by all means. You will relieve, more effectually, unreasonable suffering from reasonable causes by telling him "the news," showing him "the baby," or giving him something new to think of or to look at than by all the logic in the world.
It has been very justly said that the sick are like children in this, that there is no proportion in events to them. Now it is your business as their visitor to restore this right proportion for them—to shew them what the rest of the world is doing. How can they find it out otherwise? You will find them far more open to conviction than children in this. And you will find that their unreasonable intensity of suffering from unkindness, from want of sympathy, &c., will disappear with their freshened interest in the big world's events. But then you must be able to give them real interests, not gossip.
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."
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 a 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?[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.
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:
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]
Again, the question is sometimes put, Is there diarrhœa? 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 diarrhœa 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.