CHAPTER VI.

Observing and reporting symptoms-General physiognomy, attitude, and expression-The vital signs, and allied symptoms-The skin —The eye and ear-The digestive tract, etc.-Nervous phenomena -Sleep-Associated symptoms-Bed-side notes.

A GREAT point of distinction between the trained and the untrained nurse is, or should be, the ability of the former to observe accurately, and describe intelligibly, what comes under her notice. The nurse, who is with her patient constantly, has, if she knows how to make use of it, a much better opportunity of becoming acquainted with his real condition, than the physician, who only spends half an hour with him occasionally. The very excitement of his visit will often temporarily change the entire aspect of the patient, and make him appear better or worse than he really is. In order to form correct judgments, it is necessary for the physician to know what goes on in his absence, as well as in his presence, and for such information he is forced to rely almost wholly upon the nurse. It is thus of the greatest importance that she cultivate the habit of critical observation, and simple, direct, truthful statement. Even where there is no intent to deceive, very few people are capable of making a report of anything which shall be neither deficient, exaggerated, nor perverted. The doctor wants facts, not opinions; and a nurse who can tell him exactly what has happened, without obscur

ing it in a cloud of vague generalities, hasty inferences, or second-hand information, will be recognized as an invaluable assistant.

The phenomena which accompany disease are termed symptoms. Symptoms may be classified as subjective, those which are evident only to the patient; objective, which may be appreciated by outside observers; and simulated, feigned for purposes of deceit, either to excite sympathy, or from other motives. It requires both experience and judgment to enable one to distinguish between real and feigned symptoms. An expert malingerer will now and then deceive an entire hospital staff into the treatment of a malady that has no real existence; while, on the other hand, genuine suffering may chance to be mistaken for fraud, or hysteria, if the usual objective manifestations are absent. The difficulty of determining the false from the true is often very great, especially where, as is frequently the case, there is an undoubted basis of fact. Entirely subjective symptoms may always be regarded with some degree of suspicion, as disease unaccompanied by any outward sign is comparatively rare. It is better to be duped once in a while than to fail to give aid or sympathy where it is really needed; but, without letting the patient feel that he is being watched, let nothing pass unseen, note the most fleeting signs, and, if you have any quickness of perception, you will soon get an impression of his mental attitude, as well as his physical state, and can judge to some extent whether his statements are to be relied upon, and whether he has a tendency to exaggerate his ills, or to make light of them.

To decide as to the existence of disease, of course belongs solely to the doctor, but he will be largely guided by the observations of the attentive nurse, and

she herself will often be called upon to judge as to the urgency of special indications. Shall she send for the doctor in the middle of the night, or apply her own resources? shall she give or withhold the medicine left to be used only in emergency? shall she alter or let alone an arrangement which has proved unexpectedly uncomfortable? are questions constantly arising. The nurse needs to be able to discriminate between the important symptoms, and those which are merely incidental-to recognize those which call for immediate action, and to know what kind of action on her part is called for.

When you have acquired the habit of observation so necessary for you, you will, in the first glance at a new patient, get an idea of his general physiognomy, and any prominent peculiarities; closer investigation will reveal more minute particulars.

Try to learn all you can of the previous history of the case; you will sometimes get valuable points which the patient would hesitate, or not think of sufficient consequence, to mention to the doctor in person.

Note the patient's apparent age, with any indications of premature or disguised age, signs of weakness, size, whether well or ill nourished, emaciated, corpulent or bloated, and any deformities, swellings, or wounds.

Attitude and expression are sometimes very characteristic, giving valuable indications. A sufferer instinctively takes the position most calculated for ease. Thus, when one lung is affected, the patient lies on that side, that the healthy one, which has to do most of the work, may have the greatest freedom of motion. Lying on the back, with the knees drawn up so as to relax the abdominal muscles, suggests peritonitis. With colic, on the contrary, you may find the patient lying on the abdomen, as pressure relieves pain of such character. When a

patient who has lain persistently on his back, turns over to the side, it may be looked upon as a sign of improvement. There is no surer indication that the distress of dyspnoea is removed than for a patient, who has been forced to sit up, to lie down and compose for sleep. The inability to breathe lying down is termed orthopnœa. It occurs in affections both of the lungs and of the heart. Lying quietly is usually a favorable sign; but, in acute rheumatism, the patient is quiet because the least motion causes pain. Again, extreme weakness may render it too great an exertion to move. Restlessness is ominous in most organic diseases. Slipping to the foot of the bed is sometimes a very bad sign.

A pinched and anxious look is often the forerunner of serious mischief, while a tranquil expression is usually of favorable import. Sudden lack of expression, apathy, or immobility of features, is a bad symptom. In facial paralysis, expression will be totally absent from half the face, or it will be drawn and distorted-the healthy side being the one thus affected.

Some painful abdominal affections are accompanied by a sort of sardonic smile-risus sardonicus—from contraction of the muscles of the mouth. Any such contortion of feature is noteworthy, as also extreme thinness or swelling of the lips, and excessive action of the nares.

The most important indices of disease are the pulse, respiration, and temperature, sometimes called the three vital signs. They have already been discussed under their several heads. The three are intimately associated, and correspondingly affected. The frequency, rhythm, and force of the pulse are to be carefully observed, and its relations to other symptoms. Note the rate and any peculiarities of respiration, whether it is most abdomi

nal or thoracic, if regular or irregular, easy or labored, and whether or not accompanied by pain. There is no pain in disease of lung-substance alone; when the pleura is involved, there is sharp pain. In bronchitis or asthma there is difficulty in breathing, evident muscular effort; in pneumonia it is rapid, but perfectly easy and quiet. Dyspnoea is common from various causes. There is one very peculiar form of it, known as the CheyneStokes respiration, in which the inspirations, at first short and shallow, become by degrees deep and difficult up to a certain point, and then again more and more superficial until they entirely cease. After a pause of from a quarter to half a minute, the same series of phenomena are repeated in the same order. This is a curious, and generally a fatal, symptom.

Cautious respiration indicates lung trouble of some kind. Edema of the lungs, the presence of fluid in the air-passages, is evidenced by rattling and shortness of breath. The sounds produced by the passage of air through the fluid in the air-cells, bronchi, or cavities, are known as râles.

Most disorders of the respiratory organs are accompanied by cough. This is caused by irritation of the air-passages, and is often an effort at the expulsion of a foreign body. Matters coughed up are called sputa. Cough not accompanied by expectoration is said to be dry. The character of the expectoration varies with different diseases. In bronchitis it is at first simply mucous, later it may become purulent: in chronic cases it is thick and yellow. The sputa of phthisis are at first tenacious and ropy, sometimes frothy, at an advanced stage becoming purulent and streaked with blood. With pneumonia, the expectoration is for the most part scanty; after a certain stage, it has a char