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.