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diff --git a/.gitattributes b/.gitattributes new file mode 100644 index 0000000..6833f05 --- /dev/null +++ b/.gitattributes @@ -0,0 +1,3 @@ +* text=auto +*.txt text +*.md text diff --git a/37142-8.txt b/37142-8.txt new file mode 100644 index 0000000..8c699f4 --- /dev/null +++ b/37142-8.txt @@ -0,0 +1,3516 @@ +Project Gutenberg's How to Care for the Insane, by William D. Granger + +This eBook is for the use of anyone anywhere at no cost and with +almost no restrictions whatsoever. You may copy it, give it away or +re-use it under the terms of the Project Gutenberg License included +with this eBook or online at www.gutenberg.org + + +Title: How to Care for the Insane + A Manual for Nurses + +Author: William D. Granger + +Release Date: August 21, 2011 [EBook #37142] + +Language: English + +Character set encoding: ISO-8859-1 + +*** START OF THIS PROJECT GUTENBERG EBOOK HOW TO CARE FOR THE INSANE *** + + + + +Produced by The Online Distributed Proofreading Team at +https://www.pgdp.net (This file was produced from images +generously made available by The Internet Archive.) + + + + + + + + + + HOW TO CARE FOR THE INSANE + + A MANUAL FOR NURSES + + + BY WILLIAM D. GRANGER, M.D. + PROPRIETOR-PHYSICIAN, VERNON HOUSE, MT. VERNON, N. Y. + + FORMERLY FIRST ASSISTANT PHYSICIAN BUFFALO STATE + HOSPITAL, BUFFALO, N. Y. MEMBER AMERICAN ASSOCIATION + OF SUPERINTENDENTS OF HOSPITALS FOR THE INSANE. MEMBER + NEW YORK NEUROLOGICAL SOCIETY. + + + _SECOND EDITION. REVISED._ + + + G. P. PUTNAM'S SONS + + NEW YORK + 27 WEST TWENTY-THIRD ST. + + LONDON + 27 KING WILLIAM ST., STRAND + + The Knickerbocker Press + 1891 + + + + + COPYRIGHT + G. P. PUTNAM'S SONS + 1886 + + + Press of + G. P. PUTNAM'S SONS + New York + + + + +NOTE TO SECOND EDITION. + + +At the time of starting a training school, in 1883, the author was unaware +that like work was commencing at the McLean Asylum, Somerville, Mass., by +Dr. Campbell Clark and others in Scotland, and in New South Wales. + +Each was independent, and each worked out the problem independently. Thus, +far separated efforts showed the time had come when attendants must be +evolved into trained nurses. + +The most gratifying feature has been the unanimous approval by American +superintendents and the establishment of training schools in almost every +asylum in the land, often under the most difficult conditions and at a +great sacrifice of the precious time and strength of the medical staff. + +The increasing number of these schools and pupils demands a second edition +of this little manual. + + VERNON HOUSE, MT. VERNON, N. Y., + March 21, 1891. + + + + +INTRODUCTION. + + +The writer began in October, 1883, at the Buffalo State Asylum for the +Insane, a course of instruction to the women attendants upon their duties +and how best to care for their patients. This has been regularly continued +till it has become a fixed part of the asylum life, and has developed into +a system of training, and now a class of attendants has nearly completed +its studies. Since July, 1885, instruction has been given to men +attendants. + +In April, 1885, the Superintendent, Dr. J. B. Andrews, who had encouraged +the school from its conception, asked the Board of Managers to officially +recognize it. They adopted the recommendation and fixed the qualifications +for admission, the pay and privileges of its members, and provided for a +certificate as a trained nurse and an attendant upon the insane, to be +given to all, who at the end of two years successfully finished the full +course of instruction. + +The writer believes that all attendants should be regularly instructed in +their duties, and the highest standard of care can be reached only when +this is done. He also believes that every person who is allowed to care +for the insane will be greatly benefited by such instruction, and will be +able to learn every thing taught, if the teacher uses simple methods and +is patient to instruct. + +As a rule they enter upon the study with interest, and soon a skilled +corps is formed, who are competent to fill the responsible positions, and +control the unstable class that drift in and out of an asylum. Even the +dullest are awakened to new zeal, and are advanced to positions of trust +they could not otherwise have filled. + +A brief outline of the course of instruction of the school may be of +interest. + +The first year is spent in learning the routine of ward work and filling +minor positions. The attendants are changed from ward to ward, and have +the care of all classes of the insane. + +They first receive instruction in the printed rules of the asylum. Every +rule relating to the duties of attendants is read and explained, and +special attention is called to the performance of the following duties: + + _a._ Duties to officers. + + _b._ Duties to each other. + + _c._ Duties to patients. + + _d._ Duties to the institution. + +Thus the new attendants early get an outline of their duties in the +special care of the insane. + +After this comes instruction in elementary anatomy and physiology. They +are taught of the bones, joints, muscles, and organs of the body, food and +digestion, the circulation and respiration, waste and repair, animal heat, +and the nervous system. + +In order to be ready for advanced instruction the elements of physiology +must be thoroughly learned. The teaching must be adapted to the ability +and wants of those instructed. Having fixed the limit of duties required +of an attendant, it is easy to fix the limit of instruction. It is an +error to teach too much medicine, for then we begin to make physicians. +All that is needed is attendants who are able to do their work +intelligently, and, keeping this object in mind, lectures by a physician, +devoid of too much detail, but simple, direct, and plain, are better than +instruction from any of the text-books. With notes of the lectures +furnished, and with repeated recitations, any lesson is readily learned. +This way of instructing, by lectures, notes, and recitations, is continued +throughout the entire two years. + +A course in hygiene follows the lectures in physiology. + +Instruction in these three studies occupies the first year. An attendant +who, at the end of this time, successfully passes an examination in them, +and who has been faithful in his duties, is ready to receive the advanced +instruction of the second year. This includes the nursing of the sick, the +management of emergencies, and finally the special work of caring for the +insane. The wits of an attendant upon the insane have to be sharpened in +many directions not required of a general nurse. The text-books on nursing +may properly be followed by another, which shall aid one skilled as a +nurse to perform the varied and difficult duties incident to the care of +the insane and the wards of an asylum. To furnish this is the object of +this manual. + +A brief review of the physiology of the nervous system is introduced for +the aid of students, in reading the chapters on the mind and insanity. + +To teach any thing metaphysical or pathological may seem questionable. The +class, however, has not only been interested in the simple study of the +phenomena of the mind, but has been able to comprehend and profit by the +lectures on this subject. + +The lectures on the care of the insane were given to the class almost as +they appear in these pages. The suggestion was made that if they were +printed they would find a place in the hands of attendants in other +asylums. This is the reason of their publication. + +To my colleague, Dr. A. W. Hurd, I wish to tender my thanks for the +valuable assistance he has given me in the preparation of this manual. I +am greatly indebted to Dr. Andrews for his ever kind but critical advice. +But for his encouragement and help neither the work of instruction nor the +preparation of these pages would have been begun, nor success, if success +be gained, achieved. + + + + +CONTENTS. + + + PAGE + + INTRODUCTION v + + + CHAPTER I. + + THE NERVOUS SYSTEM AND SOME OF ITS MORE IMPORTANT FUNCTIONS 1 + + Nerve Centres.--Brain and Spinal Cord.--The Nerves.--Nerve + Cells and Fibres.--Motor and Sensory Nerves.--The Five + Organs of Special Sense.--Nerve Impulses.--The Brain and + Nervous System Always Busy.--Need of Rest. + + + CHAPTER II. + + THE MIND AND SOME OF ITS FACULTIES 7 + + Mind and Matter.--Life.--Relation of Mind and Brain.-- + Faculties of the Mind.--Intellectual Faculties.--Will.-- + Emotions.--Instincts.--Moral Faculties. + + + CHAPTER III. + + INSANITY; OR, DISEASE OF THE MIND 13 + + Insanity a Change.--Involves Disease of the Brain.-- + Delusions.--Hallucinations.--Illusions.--Incoherence.-- + Mental States.--Mania.--Melancholia.--Dementia.-- + Monomania.--Emotional Insanity.--Dipsomania.--Moral + Insanity. + + + CHAPTER IV. + + THE DUTIES OF AN ATTENDANT 22 + + What an Attendant Should First Learn.--The Relation of + Attendants to Patients.--The Character of an Attendant.-- + Relation to the Institution.--How and What to Observe.-- + Systematized Plan of Observation.--Control and Influence + of Attendants over Patients.--Care and Study of the + Individual.--Liberty to be Allowed Patients.--Self-Control + of Patients to be Encouraged. + + + CHAPTER V. + + GENERAL CARE OF THE INSANE 33 + + Reception of New Patients.--Work and Employment.--Patients' + Care of Themselves.--Walking.--Clothing.--Bathing.--Serving + of Food.--Bed and Rising Time.--Night Care. + + + CHAPTER VI. + + CARE OF THE VIOLENT INSANE 45 + + Need of Studying Each Case.--Constant Attention and + Oversight.--Value of Employment and Out-Door Exercise.-- + Restriction and Idleness.--Paroxysms of Violence; How Cared + For.--How to Hold or Carry a Patient.--Danger of Injury.-- + Struggles to be Avoided.--Care of Destructive Patients.-- + Use of Restraint, Seclusion, and Covered Bed. + + + CHAPTER VII. + + CARE OF THE HOMICIDAL AND SUICIDAL INSANE, AND OF THOSE + INCLINED TO ACTS OF VIOLENCE 53 + + Delusions of Suspicion.--Homicidal Patients.--Suicidal + Patients.--Self-Mutilation.--Incendiary Patients. + + + CHAPTER VIII. + + CARE OF SOME OF THE COMMON MENTAL STATES AND THE ACCOMPANYING + BODILY CONDITIONS 60 + + Care in the Earlier Stages.--Insanity with Exhaustion.-- + Symptoms of Danger.--Care of Dementia, Early Dementia, + Chronic or Terminal Dementia.--Convalescence.--Relapse.-- + Epilepsy.--Paresis.--Care of Paralytics, the Helpless, the + Bed-ridden.--Bed-Sores. + + + CHAPTER IX. + + SOME OF THE COMMON ACCIDENTS AMONG THE INSANE, AND THE + TREATMENT OF EMERGENCIES 71 + + Certain Classes of Insane Liable to Injury.--Fractures.-- + Wounds.--Bites.--Blows on the Head--Cut Throat.--Wounds of + the Extremities with Hemorrhage.--Sprains.--Choking.-- + Artificial Respiration.--Burns.--Frost-bites.--States of + Unconsciousness.--Apoplexy.--Sunstroke.--Poisoning.--Eating + Glass.--Injury with Needles. + + + CHAPTER X. + + SOME SERVICES FREQUENTLY DEMANDED OF ATTENDANTS AND HOW TO + DO THEM 85 + + Administration and Effects of Medicine.--Opium, Chloral, + Hyoscine, and Hyoscyamine; Doses, Effects, Poisoning, + Treatment.--Stimulants.--Applications of Heat and Cold.-- + Baths and Wet Packing.--Hypodermic Injections.--Forcible + Feeding with Stomach-Tube.--Nutritive Enemata. + + + + +HOW TO CARE FOR THE INSANE. + + + + +CHAPTER I. + +THE NERVOUS SYSTEM AND SOME OF ITS MORE IMPORTANT FUNCTIONS. + + +The nervous system is made up of a nerve centre and nerves. + +The great nerve centre is the _Brain_ and _Spinal Cord_. + +The brain is a body weighing about forty ounces, and fills a cavity in the +upper part of the skull. The spinal cord, commonly called spinal marrow, +is directly connected with the brain. The skull rests upon the spinal +column, or backbone, and there is a cavity inside the whole length of this +column, which contains the cord. There is an opening through the base of +the skull where it rests upon the spinal column, and it is through this +opening that the fibres of the cord go, to pass into and become a part of +the brain. These most important parts are carefully protected by a strong +bony covering. + +Many nerves are given off from the brain and cord and go practically +everywhere, so that every part of the body is supplied with them. These +nerves are white cords of different sizes; the largest nerve of the body, +the one that goes to the leg, called the sciatic, is as large as the +little finger. + +There are really two brains and two cords, as along the central line of +the body there is a division of the brain and cord, making two halves +exactly alike. These halves are connected together, the division not being +complete. + +Nerves are given off in pairs; for example, from either side of the brain +arises a nerve that goes to each eye. So two nerves exactly alike spring +from the two sides of the spinal cord, going to each arm. + +A nerve is composed of a bundle of fibres, microscopic in size. As a nerve +passes to the extremities it divides by branching much as does an artery, +and thus a bundle of fibres is distributed to a muscle, or a part of the +skin, or to an organ, and every part of the body has a direct nerve +supply, much as you saw in the microscope it was supplied with blood by +means of the capillaries. We cannot prick our finger with the finest +needle but nerve, fibres are irritated, and we feel it, and capillaries +are injured and we get a drop of blood. + +Most of the nerves that go to the arms, legs, and organs of the chest and +abdomen, arise in and proceed from the spinal cord, but some of the fibres +begin in the brain and are continued down the cord, where, joining with +fibres that originate in the cord itself, both go to make up the nerve, +thus connecting all parts of the body with the great centre. + +The brain and cord are made up of blood-vessels, nerve cells, nerve +fibres, and, holding them all together, connective tissue. The cells are +very small, being microscopic in size; there are an immense number of +them, and they make up most of the gray matter or outside of the brain, +but in the spinal cord the gray matter is in the centre. The fibres that +go to make up the nerves begin and spring from the cells, and they also +unite them together. + +The cells are gathered into groups, which have each a separate function to +perform. There is a group from which the nerve of the eye proceeds; +another for the nerve that goes to the ear; another for the nerve that +goes to the arm; and another for the nerve of the heart. There is a group +that presides over speech, and other groups that preside over mental +action, while all of these are connected together by fibres. Thus it +appears that the brain is a true "centre," and the nerves but the means of +connection between different parts of the body and the brain, and also +between different parts of the brain. + +Nerves have two special functions: one to carry impressions made upon the +fibres, that end in the different parts and organs of the body, to the +brain; another to carry from the nerve cells so-called "nerve impulses," +to the different parts and organs of the body. Some nerves have in +themselves these two functions, as the nerves that go to the arm or leg; +others have but one, as the optic or eye nerve, which can only carry the +sensation of sight from the eye to the brain. + +The nerves that carry sensations to the brain are called _Sensory Nerves_. +The nerves that carry motor impulses from the brain are called _Motor +Nerves_. + +There are five special organs of sense, each receiving different +impressions, and sending by its sensory nerve or nerves a different +character of sensation to the brain, namely: + + The eye, giving sensations of light and color. + + The ear, giving sensations of sound. + + The nose, giving sensations of smell. + + The mouth, giving sensations of taste. + + The skin, giving sensations of touch, with ideas of roughness, + smoothness, hardness, softness, heat, and cold. + +There must be, in every case, a direct nerve connection from the organ of +special sense to the special group of cells in the brain to which the +nerve goes. If the connection is broken at any point, the impression made +upon the fibres in the organ of sense cannot reach the brain. Only after +the impression reaches the brain and the cells are affected, do we become +conscious of a sensation. We then say, as the case may be, I see, or hear, +or smell, or taste, or feel something. + +It thus appears that these organs of sense simply receive the impressions +made upon them to transmit to the brain, and it is really the brain that +sees, hears, smells, tastes, and feels. By the action of the organs and +nerves of special sense we get all our knowledge of the external world, +and, probably, if we had no organs of sense, we would have no +consciousness of our existence. + +Pain is due to abnormal action of sensory nerves, caused by disease, +injury, or pressure, and the irritation made, being carried to the brain +makes us conscious of the peculiar sensation we call pain. So the want of +food or water makes an impression upon nerves, which being carried to the +brain causes a peculiar sensation, and we say we feel hungry or thirsty. + +The _Motor Nerves_ arise in the cells of the brain and cord. Those which +go to the voluntary muscles cause them to contract, and are under the +control of the will. If the cells are diseased, if they do not get enough +arterial blood, or are poisoned by carbonic acid, or if the nerves are +diseased, injured, or cut, so that nerve impulses cannot be sent from the +brain to the muscles, we have paralysis of a muscle or a group of muscles, +according to the extent of the injury. Now we can appreciate the force of +this teaching in the physiology of the muscular system, that "paralysis is +a loss of power, either partial or complete, to contract muscles, due to +disease of the nerves." + +By the ready action of our mind, the quick working of our will, we direct +and control the action of our muscles, so as to perform with the utmost +skill and ease the varied and innumerable movements of our body. + +It seems very easy to do this, but watch a child learning to walk; it is +educating its mind and will to control the muscles, and it is a slow and +difficult education. + +But all motor impulses and bodily activities are not under the control of +the will. The heart is supplied with motor nerves, but we cannot by our +will stop its beating or control its action. The taking of food makes a +mental impression, and without the will being involved, impulses are sent +to the glands of the mouth, setting them actively at work, and saliva +flows. So the stomach begins to churn food when it is introduced, and the +liver is kept at work making bile and sugar, and we breathe when we are +asleep. + +All the organs of the body are supplied with motor nerves, that regulate +their action and give them the power to do their function or work, but +with the exception of the muscles, this power is sent without the action +of the will. + +Our brains are very busy. While we are awake we are constantly receiving +sensations, we are thinking, remembering, willing, and sending many +messages every minute, and directing power to all parts of the body. The +brain works and gets tired, just as the rest of the body gets tired, and, +if abused, injured, or overworked, may become diseased as may any part. +Its tissues wear out, are burned up, and require the same supply of +material to repair them that any other part of the body requires. It needs +then rest, good food, good blood, and plenty of oxygen. + +No wonder some brains give out, and fail to do their work properly, and so +cause insanity. + + + + +CHAPTER II. + +THE MIND AND SOME OF ITS FACULTIES. + + +We know there is something we call mind, because we know something of its +way of working, or its faculties. What mind is we do not know, but we know +it is not matter, because matter is something that occupies space, and has +qualities that do not belong to mind. We say of mind, it reasons, +remembers, or wills; of matter, that it is hard or soft, or cold or +elastic, or that it has color; speaking always of the faculties of mind or +what it does, and of the qualities of matter, or what it is. We do not +know what matter is, only how it appears to us; we know it is not mind +because mind is something spiritual, and possessed of faculties or powers +that do not belong to matter. + +_Mind and Matter_ are the only forms of existence of which we have any +knowledge. + +We speak of matter as inorganic--that is, without life, as iron, water, +oxygen; and as organic, or matter plus something we call life. Life +appears in two forms, namely, vegetable and animal. The lowest forms of +animal life have no nervous system, but as we ascend in the scale the +nervous system appears, and becomes more and more complete. + +Man possesses the most perfect nervous system, has the most perfect +brain, and also an intelligence far above that of any other animal, and is +endowed with some mental faculties that belong to him alone. The brain may +be said to be the organ of the mind, but we do not know what is the true +relation between them; that is, how the brain is acted upon by the mind, +or how the action of the mind affects the brain. Brain is matter, and very +solid matter as well, mind is immaterial, or spiritual, and the exact +connection between something material and something spiritual has never +been made out and never will be. + +Some say the brain makes mind a good deal as liver makes bile, or the +glands of the mouth make saliva, or the cells of the brain make motor +impulses, and if the brain does not act there is no mind made; so much +cell action, so much memory, reason, or will produced. But how, it is +immediately asked, is something material to make something immaterial? +Others say that mind is something, and has an existence of its own, and, +though spiritual, acts upon its organ, the brain, and by so doing, we are +conscious that we see, reason, remember, and will. But how, it is +immediately asked, does something immaterial act upon something material? +We do not know, and we probably never shall know. This intimate connection +between mind and matter exists during life only; it begins with life and +ends with life. + +We must then come back to the starting-point--there are two forms of +existence, mind and matter. We do not know what either really is, but only +the faculties or working of our minds, and the qualities or appearance of +matter. + +Mind thinks or remembers, reasons or wills, but these are faculties of the +mind; it is what the mind does, not mind itself. Gold is yellow, but +yellow is not gold; gold is hard, but hardness is not gold; these are +qualities of gold, and not gold itself. + +In the study of physiology you found the body divided into many parts, and +that these parts had each a separate function or duty to perform. In the +study of the mind, we find it has many different faculties or ways of +working. We did not study all the functions of the body, so we will not +study all the faculties of the mind. + +The mind is very complicated in its action, and difficult to understand. +Men study it all their lives and are not agreed about some of its simple +manifestations, and argue and even contend about their differences. There +are, however, some seemingly natural divisions of the faculties of the +mind, and a knowledge of these is sufficient for our purposes. + +We may say of the mind that it possesses: + + _a._ Intellectual faculties. + + _b._ Will. + + _c._ Emotions or feelings. + + _d._ Instincts. + + _e._ Moral faculties or conscience. + +The first three are commonly given as divisions of the mind; the last two +are included for convenience of teaching. + +_The Intellectual Faculties_ include those powers which in common language +are called "mind." A few only will be considered--namely, the perceptive +faculty, consciousness, memory, and reason. + +_The Perceptive Faculty_ is the power of the mind to perceive or know the +sensations brought to the brain by the sensory nerves, from the organs of +sense, and the action of this faculty gives us a knowledge of the +existence and qualities of matter. + +_Consciousness_ is that faculty by which we know we perceive, reason, +remember, will, or possess emotions. By its operation we know that we +exist, have a mind, and what that mind does. + +_Memory_ is that faculty by which we are able to recall to consciousness +the knowledge we possess of past events. + +_Reason_ is that faculty by which we are able to make use of what we know +and to acquire new knowledge. For instance, I know the distance between +two places is sixty miles, and I know that the cars, going between the +places, travel at the rate of twenty miles an hour, and that they leave at +four o'clock. Without reason, I could never of myself, know the two new +facts, that it would require three hours to make the journey, and that the +arrival will be at seven o'clock. The faculty of reason is one of the most +distinctive of the human mind. + +_The Will._--In consequence of our perceptions, our consciousness, our +memory, our reason, we are in a condition to know a good deal of what is +about us, and of ourselves, and we desire to bring ourselves into relation +with the outside world, and therefore we act. There is a faculty of mind +that allows us to choose how to act, and this is called the will, or that +faculty of the mind "by which we are capable of choosing." By the action +of the will, we direct and control the voluntary muscles and motions of +the body, while the action of the mind is also largely under its control. + +It may truly be said that unless we are under the compulsion of some +physical force, we always choose to do whatever we most wish to do. This +liberty of choosing is called "freedom of the will," and because we are +free to choose, we are responsible for the consequences of our choice. We +say, in common language, a person is responsible for what he does, and +both human and divine law holds each to a strict accountability for his +conduct, because all are free to choose how they will conduct themselves. + +_The Emotions or Feelings._--The emotions are joy, love, grief, hatred, +anger, jealousy, and other like conditions, and we speak of them as +"natural," because they appear without the operation of our intellect or +will, and the capacity for them seems to be a part of our existence. They +should, however, be under the control of reason and will, and a person who +gives way to his feelings, as of jealousy, and murders, is held +responsible by human and divine law. But though we control them, we cannot +prevent their action, and we must, as long as we live, feel love and joy, +be affected by grief, suffer from anger, or be jealous. + +_Instincts._--These belong largely to our animal nature; our appetites and +desires are instincts, and we speak of them as "natural." Children want +food and drink before they know what it is they want, and birds in the +nest, open their little mouths for the worm their mother brings them. + +Appetites indulged in become strong, and are often uncontrolled by the +reason and will; as the indulged appetite for liquor. A strong and healthy +mind should control the appetites, as we have learned it should control +the emotions, and we are justly held responsible for the consequences of +an indulged appetite. + +_Moral Faculties._--There exists in the mind of man a knowledge of right +and wrong, and a feeling of obligation to respect the rights of others. We +can hardly conceive of a man in his right mind who does not know it is +wrong to lie, or steal, or murder. The capacity to know right from wrong +is called conscience. + +Most people, perhaps all, have a feeling of relation and obligation to a +higher moral being than man. The feeling to do right because it is +pleasing to a God to whom we are directly responsible, is the foundation +of our religious convictions. + +The mind is a most complex affair, it is always active, nor is one faculty +at work and the rest idle, but many parts are at work at the same time, +and act and react upon each other. We may exercise our perceptive faculty, +or reason, memory, and will, and be affected by our feelings at the same +time. There is with it all a regulating power that coördinates or brings +these different actions into harmony, and we get the working of a healthy +mind. + + + + +CHAPTER III. + +INSANITY; OR, DISEASE OF THE MIND. + + +In common language we speak of the mind diseased. + +This is not strictly true, as it is the brain that is diseased and, in +consequence, we get disturbed mental action. + +Every person has individual characteristics. As no two faces are alike, so +the mind, character, and manner of no two are alike, and it is by the +manifestation of these, that each is known. + +When a person becomes insane there is always a change from his natural way +of thinking, feeling, and acting, due to disease of the brain. Sometimes +the change is slight, or concealed by the patient, and is apparent only to +near friends, or after a careful examination. Sometimes it is so great as +to attract immediate attention, when it may present the features of raving +madness, or of the most abject melancholy. + +To illustrate this change, we may suppose both a king and a pauper to +become insane: there is, of course, a vast difference between them, but +the king may be so changed by the disease as to believe that he is a +pauper, and himself and his family starving, and he may also wish and even +try to work and dig like a laborer to support them; or a pauper may think +himself a king, and try to act like one. Such conditions show a _marked_ +change in the manner of thinking, feeling, and acting, which involves +diseased action of the intellect, the emotions, and the will. + +Sometimes the appetites are also changed, or control over them is lost, +and sometimes the moral nature is affected as well, sometimes a single +faculty of the mind appears more disturbed than do others; it is, however, +doubtful, or at least denied, that one faculty can show such disturbed +mental action as to indicate insanity, and the rest of the mind appear +perfectly healthy and normal. With the changes that have been spoken of, +there is generally disturbances of the physical health, and often of a +marked character. It must be remembered that mere oddity of appearance or +eccentricity of conduct, however marked, if natural, do not of themselves +constitute signs of insanity. + +_Some Mental Symptoms of Insanity._--There are some important mental +symptoms which quite generally accompany insanity, and are found either +alone or combined in the individual case. These are: + + _a._ Delusions. + + _b._ Hallucinations. + + _c._ Illusions. + + _d._ Incoherence of speech. + +_Delusions_ are false beliefs. We think a belief in the religion of +Mahomet is a delusion, but not an insane one. Insane delusions arise from +disease of the brain, and are a part of those mental changes that appear +during its progress. The king, who, under the influence of disease, thinks +himself a pauper and that he and his family are starving, and the pauper, +who thinks himself a king, with all the wealth and power of one, have +each insane delusions. + +Some delusions are fleeting and changeable, lasting a few days, weeks, or +months, while others are fixed, lasting a lifetime; some are impossible +and beyond rational belief, as when a man thinks himself Queen Victoria, +or that his head is made of brass, or that he is dead, and yet sleeps and +eats and talks; other delusions are possible, as when a king thinks +himself a pauper, because such a thing may and even has happened, or when +a pauper thinks himself a king, because people of very low degree have +risen to such a station, but they are very improbable, and we do not +expect such things among Americans, much less among our patients. Other +delusions are not only possible, but relate to things that may or do +happen, or are within the bounds of a rational belief, as that of a person +who insists he has a cancer, or that he has committed the unpardonable +sin, or that poverty is impending and the poorhouse not far off; or that +of a woman that she has been violated, or that, when her child was sick +she so neglected it, that it died. Such beliefs as these are delusions, +when they have no other reason for their existence than that they are +caused by disease. + +Some delusions are called homicidal, suicidal, or dangerous, because they +cause a patient to do, or want to do, acts that are dangerous to himself +or others, or property. + +_Hallucinations._--When a patient has hallucinations, he thinks he sees, +hears, smells, tastes, or feels something, when there is really nothing to +cause the sensations or ideas except diseased action of the brain; nothing +being sent to the brain from any special organ of sense, he really sees, +hears, smells, tastes, or feels nothing, it is all imagination, though +seemingly very real. + +For instance, a person thinks he hears a voice, perhaps that of God, or of +some one who is dead, or of an absent friend, or thinks he sees these +persons, when there is nothing external to the brain to excite the +sensation or give the idea. + +_Illusions._--When illusions are present, the mind fails to perceive +correctly what the eye sees, or the ear hears, or the impressions that are +brought to the brain from any of the organs of sense. For instance, a +person looks at a row of trees, and they appear to him to be a row of +soldiers; or the whistle of a locomotive may be so changed as to seem to +be the voice of God; or the odor of a rose, burning sulphur; food may +taste like poison, or the hand of a friend feel like a piece of ice or a +red-hot iron, and is so believed to be. These are deceptions of the +senses. + +In insanity, the truth and existence of delusions, hallucinations, and +illusions are fully believed in, and the patient cannot be argued out of +the belief, however absurd or unreal it may be. + +_Incoherence of Speech._--When a person is incoherent, he rambles in talk; +there is little connection between different sentences, or the sentence +itself is meaningless, being a mere jumble of words; sometimes ideas come +too rapidly into the mind, and some new subject is begun and talked about +before the first is finished; sometimes the mind is slow, and memory +forgets what is being talked about. + +_General States of Insanity._--There are a few general mental states in +insanity, one of which being present gives the character and name to the +disease. These are: + + _a._ A state of exaltation of mind, or mania. + + _b._ A state of depression of mind, or melancholia. + + _c._ A state of enfeeblement of mind, or dementia. + +But one of these first two states of feeling can be present at the same +time, for a person cannot at any one moment be both exalted and depressed, +though he have mania to day, and afterward be so changed in his feeling as +to have melancholia to-morrow, or next week, or next month. + +In a general way all disease is divided into acute and chronic forms. An +acute disease is one of recent origin, and from which recovery is to be +hoped for; a chronic disease is prolonged and does not tend to recovery; +an acute disease may become chronic. + +Mania and melancholia are at first considered acute and curable, but, if +recovery does not take place, they pass into either chronic mania or +chronic melancholia, or, if the mind is much enfeebled, into a condition +of dementia. + +_Mania._--In mania the mind is generally very active, though lacking in +control, and is irregular and illogical in its action; the patient talks +rapidly, and upon many subjects, and is often incoherent, or he laughs, +sings, dances, or cries, perhaps in turn; he is often irritable and +unreasonable, and perhaps threatening, and becomes more violent if +interfered with. + +Accompanying this mental excitement there is frequently persistent loss of +sleep, constant restlessness, and great bodily activity, and indifference +to or refusal of food. Sometimes the brain excitement is so great that +all self-control is lost, and the patient becomes a raving maniac. + +The delusions of mania are largely of grandeur and self-exaltation; the +patient thinks himself in the best of health, and very strong, or of a +superior mind, or, that he is a great singer, poet, actor, or preacher; +perhaps, taking a higher flight, he thinks himself possessed of the wealth +of Vanderbilt, or that he is the Pope, or the President, or even God +himself. + +Sometimes the excitement comes on in paroxysms, lasting a few days or +weeks, with periods, more or less prolonged, of comparative mental quiet. + +_Melancholia._--In melancholia the expression of the face often tells the +character of the disease; the eyes are downcast, the lines of the face are +lengthened, and the whole appearance is that of unhappiness. + +In this form of insanity the patient may refuse to speak or interest +himself in any thing, or he may moan, groan and cry, and walk back and +forth wringing his hands; when he is quiet, the mind, however, may be very +active and full of delusions, which occupy it to the exclusion of every +thing, driving away sleep, and making him indifferent to the taking of +food or attending to his most necessary wants; sometimes the patient talks +a great deal, but always about his delusions, which are generally +connected with himself, his family, or his affairs. + +Melancholiacs are often tortured by fears, and, therefore, become frenzied +and as wild and violent as in mania; or they may be very suspicious, +thinking that some one is persecuting them, or poisoning their food, or +following to kill them. On account of their delusions they frequently +refuse food, they generally sleep poorly, and are often very suicidal. + +_Dementia._--This form of insanity is most frequently the result of acute +mania or melancholia, and comes after the force and intensity of the +disease has spent itself, leaving the mind crippled and weakened. The +perceptions are blunted and distorted, memory fails, the reasoning powers +are weakened, the will has ceased to control, the emotions and appetites +are dormant or changed, and the mind may become almost a blank, though in +the narrow circle of thought there is left remains of delusions, +illusions, and hallucinations. The patient is frequently careless of the +ordinary necessities and decencies of life, and requires constant care. + +There are degrees of dementia: it may be slight, partial, or nearly +complete. During the first few months or years dementia often ends in +recovery, but, as it continues, the case becomes more and more hopeless. + +_Monomania._--This is a term belonging to common speech, but there is not +an agreement of opinion as to the existence of such a special form of +insanity, nor among those who believe in it, as to what it is and what are +its symptoms. + +Monomania really means an insanity with but one, or, at most, a small +class of delusions of the same character, the rest of the mind showing no +disease. Hardly any one believes in the existence of such a narrow limit +to insanity, and, getting beyond this point, there is no agreement where +the limit should be set up to mark and bound it. + +Some think there is a special insanity of the emotions only, and call it +"emotional insanity." There is not an agreement of opinion as to what +emotional insanity is; the idea seems to be that the emotions, or one of +them, so overpower reason and will as to make the person irresponsible. +This condition is supposed to exist without disturbances of the +intellectual faculties, and to be unaccompanied by delusions, +hallucinations, or illusions. Others see in these cases no evidence of +insanity; nothing but over-indulgence of the emotions, or a want of +exercise of self-control, or an excuse for crime. + +Some persons believe that the appetites over-indulged become morbid and +produce disease of the nervous system, and as a consequence the reason and +will are weakened in relation to this indulged appetite, and the opinion +is reached that it is a form of insanity. An indulged appetite for drink +is called dipsomania. Others believe that unless there are present the +usual symptoms, associated as they generally appear in insanity, these +cases are nothing but unbridled appetites or vices. + +_Moral Insanity._--There are those who claim that the moral nature alone +may be diseased, and the persons in whom this occurs are said to lose the +appreciation of right and wrong, or have an uncontrollable propensity to +do some wrong act, and take a peculiar pleasure in so doing. Special names +are given to these acts, according to their character, as "kleptomania, an +impulse that prompts to steal"; or "pyromania, love of setting things on +fire"; or "homicidal mania, an intense desire to kill." Other persons +considering these cases and finding no delusions, or intellectual +disturbances, or change in feeling, thinking, or acting due to disease, +call the condition one of crime only. + +These are difficult matters to understand, and those who make a life-study +of insanity do not fully understand them, or agree together as to what +they know. They are, however, terms of common speech, and it is well to +have some idea of them, as it will add interest to the study of the +patients under care and charge. + + + + +CHAPTER IV. + +THE DUTIES OF AN ATTENDANT. + + +_What an Attendant Should First Learn._--The duties of an attendant upon +the insane are varied, arduous, and exacting; they are associated with +irritations, perplexities, and anxieties, bring grave responsibilities, +and call for the exercise of tact, judgment, and self-control. + +These many duties are not quickly nor easily learned, and the new +attendant must be willing to fill, at first, a minor position, to begin at +the beginning and learn gradually all the details of ward work; he must +acquire habits of caution and watchfulness, and learn in a general way the +care of the insane, before he can assume a position of authority over +other attendants, the control of a ward, and the responsibility of the +direct care of patients. + +This last duty is the most difficult of all, because it brings the +attendant into intimate relations with a class of persons, whose true +appreciation of themselves, of their conditions and surroundings, is +changed, whose thoughts and desires are unreasonable, whose conduct is +unnatural, and who are largely controlled by insane delusions, +hallucinations, and illusions. + +It requires an intimate association with the insane, and a careful study +of their manner of thought and conduct, to be able to successfully guide, +direct, and control them. + +_The Relation of Attendants to Patients._--The position of attendants is +often a trying one; they are liable to misrepresentation when they have +faithfully done their duty; they must learn to receive with calmness a +blow or an insult, or even so great an indignity as being spit upon; they +must bear with provocations that come day after day, and are seemingly as +malicious as they are ingenious and designing; they must watch over the +suicidal with tireless vigilance, control the violent, and keep the +unclean clean. + +To do all this requires the exercise of self-control and kindness; the +putting a curb upon the temper; the education of judgment and tact; +faithfulness in the performance of duty, and a knowledge of what to do and +what to avoid. + +These trials are, however, but a part of the experience of an attendant in +caring for the insane, for there is associated in this care much that is +satisfactory and pleasurable. It is a satisfaction to know that duty has +been well done; to be able to care for the sick; to do something to +alleviate suffering; to tenderly watch over and soothe the dying; it is a +pleasure to see a patient improving, going on to recovery, and finally +able to return home cured. + +Many delightful friendships are formed between attendants and patients, +some lasting for years within the asylum, and some for a lifetime, with +those who have recovered. Most of the insane appreciate the services +rendered them, and have a feeling of gratitude for those who care for +them. + +Attendants should always treat patients with politeness and respect; it +is something that is never thrown away, and exerts a good influence, +however rude and disrespectful a patient may behave. + +Patients should not be ridiculed, their mental weakness and peculiarities +made light of, nor should they be made a show to inquisitive visitors. + +It is useless for attendants to try to argue patients out of a belief in +their delusions, and to do so often results in fixing them more firmly in +the mind. We should not however pretend to believe them, nor humor their +belief, nor allow them to carry out their delusions in their dress, +conduct, and general behavior. + +_The Character of an Attendant._--The insane should always be treated with +kindness, and nowhere is the golden rule "thou shalt love thy neighbor as +thyself" more necessary of application than in caring for them; and it is +well for attendants, when tempted, to stop and think how, under like +circumstances, they would want their mother or sister or brother treated. + +Keeping this noble teaching and this high motive for right-doing ever in +mind, an attendant cannot go far astray. + +It is a development of character to care for the insane, and instead of +being brutalizing, as some ignorant people say, it is elevating and +humanizing. + +Attendants should never gossip, either among or about themselves, or of +their patients. It is a mean and degrading habit to indulge in; it will +undermine a good character, and often become overpowering and malicious. + +On the other hand, never be afraid to speak the truth, and never let a +lie, or the semblance of a lie, pass your lips, or remain for a moment in +your heart. Of all things be truthful. + +Attendants must acquire a spirit of willing obedience, of cheerful +execution of all commands and directions, and of faithful performance of +every duty that devolves upon them. Unless they have this spirit, they +will be unable to successfully assume positions where obedience is to be +exacted from others. + +They should preserve their own self-respect; in all things set a good +example; be neat and tidy in their dress, gentlemanly or ladylike in their +conduct; considerate of the wants and feelings of other attendants; they +should "cherish a high sense of moral obligation; cultivate an humble, +self-denying spirit; seek to be useful; and maintain at all hazards their +purity, truthfulness, economy, faithfulness, and honesty" (Utica Asylum +Rules and Regulations). + +In their relation to the institution, attendants should fulfil all their +engagements with the same sense of right, that they expect will be +observed towards them by those who employ them. It is a business contract +that is assumed, and brings with it mutual legal responsibilities, rights, +and obligations. Attendants should strive to so conduct themselves, that +when they leave their employment they can go away with the respect of +every one, and bear with them the reputation of a good character and of +work well done. + +_How and What to Observe in the Care of Patients._--It is important that +attendants should early learn habits of close observation. The exercise of +the habit increases the ability to observe, and one soon comes to see and +know things he never saw, or thought of before. It is necessary to learn +first the physical condition, mental symptoms, and habits of a patient, +before we are able to observe and appreciate any change. + +Observation, to be of value, should be systematically made, and only one +thing at a time can be noticed, which must be understood before passing to +another, otherwise every thing is confused. + +The condition and appearance of a single part should be looked at to see +what is natural, and what is evidence of disease. + +In practice, written notes taken at the time, are extremely valuable in +teaching close and accurate observation, and cultivating an ability to +clearly express to others the result. + +For the purpose of suggestion and guidance, the following system for +observation is given: + +Observe the effect of medicine. + +The face.--Observe if it is pale, and if the pallor is sudden, temporary +or permanent; if flushed, if congested, if blue with venous blood, if +there are any eruptions, bruises, or scars. Observe the expression of the +face. + +The tongue.--Observe if it is coated, and if so, if white, brown, red, +black, glazed, dry, or cracked; if it is tremulous, or drawn to one side, +or protruded with difficulty. + +The lips.--Observe if pale, blue, dry and cracked, if there is +tremulousness about the corners of the mouth; the teeth, if covered with +sordes; the gums, if bleeding. + +The breath.--Observe if sweet, sour, foul, or offensive. + +The respiration.--Observe if slow or fast, quiet and natural, or loud, +labored, and difficult, if puffing, wheezing, shallow, or irregular. + +The eyes.--Observe if congested, the color, if any blindness; the pupils, +if contracted, dilated, irregular, unequal, or if they respond readily to +light. + +If there is cough, observe if moist or dry, if croupy, if with pain, or if +prolonged. + +If any expectoration, observe if it is bloody or streaked with blood, if +thin and frothy, thick and purulent, or if it sticks to the cup. + +The pulse.--Observe if it is slow or rapid, full, weak and thin, if +irregular or intermitting. Count it. + +The temperature.--Observe by the hand or thermometer. + +The body.--Observe for eruptions of the skin, for sores, bruises, or +deformities, or if there is any paralysis. + +The appetite.--Observe if it is poor, changeable, if food is relished or +disliked; if refused, if it is constantly or occasionally, and if from +delusions or indifference; if there is overeating and gluttony, if food is +bolted, or chewed, or if the patient has teeth to eat with. + +The digestion.--Observe if natural, or painful, and if so, whether upon +taking food, or if the pain is delayed; if gas is discharged from the +mouth, if the stomach is sour, if the food is heavy and distressing; also +observe what kinds of food give dyspepsia, and what seem to be well borne. + +Of vomiting.--Observe if occasional or constant, if immediately after +food, or delayed, if sour or bitter, if preceded by pain or nausea, if it +contains any undigested food. + +Of diarrhoea.--Observe how frequent the discharges, if with pain, and +where it is situated, the color, the consistency, if there is any blood +or mucus, if it alternates with constipation. + +Of constipation.--Observe if alternating with diarrhoea, if habitual, +the effect of medicine and food; if there are any piles. + +The menses.--The quantity, if there is any pain, its cessation and +reappearance, if any effect upon the mental condition. + +Of pain.--Observe the character and severity, its location, and any +evidence of a cause. + +Of dropsy.--Observe if it is general or local, if in the chest, face, +abdomen, arms, or legs; if there are any varicose veins. + +Of sleep.--Observe the length of time, if quiet and natural, if restless, +if deep or light, if there is great drowsiness or continued wakefulness, +and the effects of medicine. + +Of unconsciousness.--Observe if it comes on slowly or suddenly, if partial +or complete, if the patient can be aroused. + +Of convulsions.--Observe if slight or severe, if of short or long +duration, if continued or interrupted, if general or of one side, or of an +arm or a leg, or the face, or of a few muscles only. + +Of the mental condition.--Observe if fixed or changeable, the nature of +delusions, illusions, or hallucinations; dangerous attempts or threats +toward himself or others; any change in the mental state. + +Of habits.--Observe if fixed or changeable, how formed or how corrected. + +Of the general conduct.--Observe the dress, if neat and tidy, or +otherwise, private habits, care of personal wants, improvement in conduct, +the influence of attendants and other patients, or the influence the +patient himself exerts on others. + +This by no means includes all that it is necessary to observe, but it +contains much that is important, and the system, if studied and used +practically, will suggest to the observer whatever may require attention. + +_The Control and Influence of Attendants over Patients._--By a "smart +attendant" is meant one who sees little to do beyond having a control of +the ward by a rule that is close and exacting, who maintains a strict +discipline, and who has a love for cleanliness, order, work, and +scrubbing. But a "useful attendant" is one who tempers these mentioned +traits, by striving to gain the confidence of his patients, by exerting +over them a beneficial influence, who is able to bring the individual +patient into accord with his surroundings in the asylum, so as to help his +improvement or recovery, meet his wants, and increase his comfort and +enjoyment. In order to do this it is necessary that the attendant should +give careful study and attention to each patient. Such a study will soon +demonstrate to, and teach the attendant the fact, that the insane are very +individual in their habits, and while no two are alike, there are +resemblances that in an asylum are made the basis of classification by +wards: there is the convalescent, the suicidal, the demented, the sick and +feeble, and the noisy or violent wards. + +Attendants must first learn that patients are not to be treated merely as +a ward full of people to be kept in order, to be clothed, fed, and put to +bed, but that the peculiarities of each patient are to be studied, and +that it is their duty to know thoroughly the wants, and condition of each +case, and how best to care for and control it. The better knowledge an +attendant has of the individual, the better he can care for a ward full of +individuals. + +The persons who are under our care are always to be considered as +patients, and it must be remembered that these sick people are sent away +from their homes and given over to us, though strangers, because it is +supposed that we can do better by them than their friends are able to do. + +Their position is one of helplessness and dependence upon those who are +placed in charge, and we are properly held responsible by the friends and +the public, for a judicious exercise of the power and influence we possess +over them. + +Patients are not rightly influenced by the mere exercise of authority or +by dictation or command; these they fear and obey, or resent and resist; +but we should always appeal to the highest motives for obedience and +correct conduct, and we should lead our patients to trust and not to fear +us. In our dealings with them we should be truthful, straightforward, and +strictly upright, and exercise over ourselves patience and self-control. + +We can generally control our patients by the exercise of sympathy, +kindness, and tact, joined with a reason for what is required, and where +more is needed, a firm, kind authority and command will suffice. + +The use of authority, restriction, and restraint is to be avoided, while +on the other hand patients are to be allowed all the liberty and freedom +they can safely enjoy, and taught to exercise all the self-control they +are capable of. + +The granting of more freedom and liberty of action than was formerly +accorded the insane, does not imply a change in the character of the +disease, but improved methods of care, and places more responsibility upon +the attendants. The degree of liberty to be allowed must, in each case, be +decided by the physician, and the attendants should closely observe the +patient, and report any symptoms which makes the enlarged freedom +dangerous to the patient or to others. + +Patients being sick, are sent to the asylum that they may be kindly and +judiciously cared for, and, if possible, cured. As many patients who may +never fully recover may so improve as to be able to return to their homes, +and, as it is impossible to say that any given patient will not recover, +each case deserves and should receive our best care and efforts to this +end. + +Because our patients are sick they must be nursed, and nursing means +tender care. And it is a nurse's duty to do all in his power to alleviate +pain and promote bodily comfort. The insane are subject to all the ills +that flesh is heir to, and there is always among our patients much +sickness and bodily suffering. Many patients cannot tell when they are +sick, nor when they suffer pain, but they show sickness and pain, and +often appeal by their manner for that care and sympathy, we all feel in +need of at such times. + +These silent symptoms should be observed by the attendants, who should +always see and know when their patients are sick. Some of these symptoms +are, crying, moaning, weakness, going to bed, or lying down, cough, +changes in respiration, signs of fever, a flushed face, quick pulse, or +chills, a pale face, vomiting, or diarrhoea, and loss of appetite. + +Much insanity is associated with great physical disturbances which require +careful nursing. The old and feeble, the paralytic and bedridden also +require special attention and care. + +From this it appears that the care of the insane calls for the exercise of +self-control, habits of close observation, the using of good judgment, the +putting forth of ennobling influences, and the tender care of the nurse. + + + + +CHAPTER V. + +THE GENERAL CARE OF THE INSANE. + + +_The Reception of New Patients._--Attendants must at once study the +peculiarities, the physical condition, and the mental symptoms of a new +patient, so as to know the case thoroughly. + +New patients should receive special attention; their fears quieted; they +should, if in a proper condition, be introduced to the other patients; the +effect of being in so large and strange a place, where the doors are +locked and the windows guarded should be noticed, and unpleasant +impressions overcome; they must be told they have come among friends and +will be kindly treated. + +The necessary rules of the ward should be explained; they should be +invited to their meals, shown to their rooms and told at bedtime the night +watch will visit them, and they must be assured that no harm will come to +them. + +The first impressions a new patient receives may be the lasting ones, and +influence their whole conduct in the asylum. If they resist what is +necessary to do for them, do not struggle and contend with them, and force +them to bed, or to the bath, but first seek advice from the supervisor, or +the physician. + +Always search new patients, unless otherwise ordered, for money, jewelry, +weapons, medicine, and other like articles, or if in doubt what to do ask +for directions. The head, body, and clothing should be examined for +vermin, and the body for injuries and bruises. If what is wished to be +done in this particular is explained, patients will generally quietly +allow it. + +_Work, Employment, and Occupation._--By this is meant whatever occupies +the patient's time and mind, in useful and pleasant ways. + +Of all things idleness and loafing are the worst; even games, such as +billiards and cards, if indulged in to the exclusion of useful employment, +will degenerate a patient. + +Some willing patients are kept in a tread-mill of daily work, their +monotonous life never broken by a diversion, an enjoyment, or a hope. It +is very questionable if it is beneficial to make a patient drudge through +such a daily routine. + +Asylum life should be made as home-like, pleasant, and natural as +possible; as a rule every patient who is able should do some useful work +every day, and to this should be added the diversion, that comes from +amusements and the enjoyment of innocent pleasures. + +Occupation then means a great deal more than work; it is the way a patient +spends his time. Unless encouraged and directed, patients may occupy +themselves in thinking of their delusions, in noise, violence, or +destructiveness, in idly walking up and down the wards, in the indulgence +of secret vices, in gossip, in spreading discontent, in prayer, or in +constant Bible reading. Some patients really work hard trying to do +nothing, and have no more ambition than to sit around on the ward, and +chew tobacco, and indulge in idleness. + +Patients should be encouraged to do something for themselves, the women to +make and mend their own clothes, to keep their rooms in good order, and +assist about the ward. They should be made to feel that they can add to +their own comfortable surroundings by their own efforts. + +For the men, ward work is not so natural or tasteful, but they will do +with interest much of this kind of work; to this may be added employment +in decorating their own rooms or the ward, and in caring for plants and +flowers. + +The women can add to ward work, sewing, knitting, mending, embroidery, +artificial flower making, quilting, care of flowers in the ward, and it is +often a real enjoyment for patients to make some little present for their +outside friends. The laundry offers an inviting field for some patients, +but it is often too hard work, especially when they are sent twice a day +to the wash-tub, or kept in the hot ironing room. A half day is enough for +most patients, and many are not strong enough to go there. + +Out-of-door work is well suited for the men. The farm, garden, lawn, +barns, and machine-shops offer much that can be made useful for the +patients' employment; the different mechanics and artisans about the +asylum should have patients working with them. + +Thus it appears there are many directions for patients to work, and it is +also true that all patients are not suited to do the same work nor the +same amount of work. Whatever they do should be for their benefit alone, +otherwise we might take a contract for a given number of patients to work +a given number of hours every day, a good deal as has been done in prisons +and reformatories, but no one would believe such a course for the +interest, improvement, or recovery of the patients. + +The only rule to go by is, that the work and occupation shall be for their +own good, and, that they shall not be made or encouraged to work for any +other purpose. + +As a rule, patients should be allowed to employ themselves in ways that +most interest them, provided it is useful and seems to be beneficial. + +Over-work is as bad as idleness; too much sewing will often give a +sleepless night. + +Generally all patients may be allowed to engage in light work, without +special directions; new patients, however, should not be sent off the +ward, or given tools that may become weapons, unless by order of a +physician. + +It is a bad habit for attendants to sit idly by, or stand around with +their hands in their pockets, and have patients do all the work. It may be +so necessary to watch the patients that the attendant cannot work +steadily, but he should have the appearance of doing something, and if +possible join with them in work. + +A party of women sewing, should be laughing, talking, telling stories, +perhaps singing; they should be made to enjoy the time, and not to look +upon it as something irksome. + +Some patients are too feeble in mind, and some too feeble in body to work; +many need rest, quiet, and nursing, and directions for the care and +occupation of such patients should come from the physician. + +Many of these patients will do a little, others can be amused, or read to, +and their minds thus diverted from their troubles, and turned into +pleasant and cheerful directions of thought. + +It has been shown that work is not the only useful way that patients may +occupy their time, that nothing but work is as bad as no work, and that +they should have diversion, enjoyment, and entertainment. + +For the entertainment and occupation of patients, there are furnished, +dances, concerts, theatricals, billiards, cards, pianos, books and papers, +schools, chapel services, walks, rides, and excursions, and they also +receive visits from friends, and write and receive letters. + +Patients should be encouraged and sometimes made to take part in these +natural and pleasant amusements; of course every patient cannot play the +piano, or billiards, but among these many forms of recreation, all +patients can find ways of diversion and means of enjoyment. + +Thus early in the study of the care of the insane, it is learned that the +life of patients is to be stripped, as much as possible, of restriction +and restraint; that self-control is to be taught; that useful work is to +be encouraged; that amusements and innocent pleasures are to be enjoyed; +in a word, attendants are to learn, that the characteristics of +institutional life are to be lessened, and those of a home life made +prominent. + +_The Patients' Care of Themselves._--The general tendency of the insane is +to mental enfeeblement, to neglect of person, and to slovenly habits. +Patients should be encouraged as much as possible to care for themselves; +to be helpful towards others; to do such work as they are able; to seek +amusements, and to live as much as possible such a life as we ordinarily +are accustomed to outside the asylum. + +Patients should be encouraged to keep themselves tidy, and nicely dressed, +to have the care of their clothing; if possible, they should be given a +room of their own, which they should take a pride in keeping in order, and +ornamenting with pictures and flowers; and should be allowed to do +whatever will help maintain their self-respect, self-care, and a feeling +of individuality. + +There is great difference in patients as shown in their capacity for +self-help. Some seem to be able to do nothing, some everything. Nothing +can lighten the burdens of attendants so much as to make the helpless +self-helpful. Nothing benefits the patients more. Do not abandon effort +for any patient. Unexpected and gratifying results are the rewards of +earnest efforts. + +_Out of Door Exercise--Walking._--If possible, patients should be out of +doors every day. In the summer much time can be spent in the fields, on +the lawn, either walking or sitting under the trees; in the winter time +shorter walks only can be taken, but on pleasant days, often an hour may +be spent out of doors. Warm clothing and good shoes must never be +neglected, and the person must be thoroughly protected, because the insane +are frequently "cold-blooded," that is, the circulation is poor, the hands +and feet congested, blue, and cold, they make animal warmth slowly and +with difficulty, and easily suffer from the cold. + +Many patients go out to walk on parole. Those who are allowed this liberty +will be designated by the physicians; any change in the patient that +makes such liberty dangerous should at once be reported. Others go out in +large parties, with few attendants to care for them, while the old, sick, +and feeble, the homicidal and suicidal, the noisy and violent, require +special care and attention in their exercise and walks. + +_Clothing of Patients._--In many asylums each patient has his own +clothing. Every article should be plainly marked with his own name, and +should be used only by the patient to whom it belongs, and never given to +any one else to wear. All clothing should be kept clean and well mended, +and should be properly put on and kept on during the day. There should +always be enough to keep the patient warm, and changed with the changes in +the weather, or the temperature of the ward, or the needs of the patient. +The sick, feeble, and old always need extra clothing; that worn next the +skin should be changed at least once a week, and all clothing should be +changed as often as soiled. + +_Bathing of Patients._--Every patient should be bathed once a week and as +much oftener as is necessary. The tub should be cleaned and the water +changed for each patient; the temperature should be about ninety-five +degrees, or not hot to the hand, and the tub should be about two-thirds +full. The head, neck, and body should be washed with soap; each patient +should have a clean towel, be wiped dry, and given a change of clean +clothing. + +Some patients object to bathing; they fear the tub, but will wash with +water and a sponge, and they should be allowed to do so. Others want to +bathe first; let them, if possible. Others will not bathe the day the rest +do; it is sometimes best to humor them. + +Some patients have to be forcibly bathed. In such cases always wait, use +every art to induce them to bathe, and before acting send for advice. + +Attendants are too prone to think that every thing should be done by rule, +and that all must be forced to obey the rule. Most will observe it without +trouble, and the object sought can generally be gained by patience, tact, +and kindness. + +_Serving of Food._--The dining-tables should be neatly set and made +attractive; the food should be promptly served, and while hot; all +patients should be at meals, unless excused by the physicians. Economy +should be practised, and every thing should be used or saved. Each person +should have enough, but no one should be allowed to make a meal of a +delicacy, or take all of the best of a dish. Some patients would waste a +pound of butter or sugar at each meal; enough is sufficient for anybody. + +The old and feeble should be served by attendants; those without teeth +should have their food prepared, and the meat should be cut very fine. +Those who will not eat must be kept in the dining-room and fed; the +attendants may use force by holding the hands, and placing food in or to +the mouth; but it is dangerous to do more, and holding the nose is +something that is never allowable. If these efforts to get them to take +food do not succeed, report to the physician. Some patients from delusions +will eat certain kinds of food, and either not get enough or not a +sufficient variety. + +A mixed diet is the best, and patients should if possible be made to eat +bread, butter, meat, vegetables, and drink milk and plenty of water. No +patient should be allowed to lose in flesh and strength on account of +failure to take sufficient, or proper food; before these things happen it +should be reported to the physician. Some patients will only eat enough if +they are allowed to eat it in their own way; they will eat it perhaps +standing, or after the others have finished, or alone, or in their room, +or they may steal it, if given the opportunity. Such peculiarities often +have to be indulged. + +Some patients will take nothing but milk, then about three quarts a day +are needed; eggs may be added and are often readily taken, and some may be +got to eat bread and milk, which is a very nutritious diet. + +The food of the sick should be nicely and invitingly served, and efforts +should be made to meet their whims and fancies. + +Patients who are so profane, violent, or noisy, that they are not allowed +to come to the dining-room, must always be fed by, and in the presence of +an attendant, and meals should not be passed into a patient's room and +left there. + +Knives and forks should always be counted by an attendant before and after +each meal; care should be used that they are not lost, secreted, or +carried out of the dining-room by patients. No one but an attendant should +ever handle the carving knife and fork, or the bread knife. + +_Care of Patients when Going to Bed, or Rising._--The beds should be daily +aired, and always clean and nicely made up; for a filthy patient a straw +bed, that can be changed, alone is clean. + +All patients do not need to go to bed at the same time, and while some are +able to care for themselves, most need care, attention, and watching. The +helpless should be dressed and undressed, and put to bed first: the +violent and homicidal need to be watched, and should be put to bed early, +while the suicidal should be kept under supervision, and put to bed at the +most convenient time. After a patient is in bed, an attendant should go +into the room, with a lantern, so as to see that every thing is in order +and safe, and, with a cheerful "good-night" close the door. Patients who +need care should be visited during the evening, and left clean and in good +condition to be cared for by the night watch. + +In the morning patients need attention before any thing else is done. +First, the suicidal, sick and feeble, the violent, and those likely to be +filthy should be visited, and every patient should be washed and dressed +before breakfast; or, if for any reason they do not come to this meal, +their faces and hands should be washed, the bed put in order, and the room +made clean and aired. + +After these things have been attended to, the ward work should be done, +though generally the two can go on together. + +_Care of Patients during the Night._--After the patients have gone to bed +the ward should be quiet, doors should be quietly closed, voices lowered, +and loud calls and laughter not indulged in, squeaking boots should not be +worn, and heavy walking avoided. Many patients go to sleep early, but are +easily awakened, and may remain sleepless till morning, or at least a part +of the night. + +The night watchers have responsible, arduous, and trying duties. +Attendants should always, during the night, quickly respond whenever a +demand is made upon them for assistance, though an unnecessary call +should never be made. The night watchers should be informed of any changes +that have occurred during the day, that will require their attention +during the night; they should see new patients and be made acquainted with +their peculiarities; they should visit the wards during the evening before +they come to the medical office to receive instructions from the +physicians. + +It is the duty of a night watch to visit regularly all the wards under his +charge; to see and know the condition of the sick, the helpless, feeble, +the suicidal, and the epileptic; to attend to, by taking up, those who are +inclined to be filthy, and wash those who need it, and make them, their +beds, and rooms perfectly clean. He should observe the conduct of new +patients, be watchful of the violent, know how much wakeful patients +sleep, visit all associated dormitories, wait upon all those who need +attention, and guard against fire and accident. The night watch should +place each day on the medical office table, a detailed account of every +patient that needed care or attention, who was disturbed, or did not sleep +during the previous night. + +Patients should be left clean for the night watch, who should leave them +in as good condition in the morning, for the day attendants, and any +neglect in these directions should be reported by either party. Sick +patients frequently have to receive special night service, to be watched, +and given food and medicine. When this cannot be done by the night watch, +it devolves upon the day attendants, and is a duty that should be +cheerfully rendered. + +During the night, any accident, attempt at suicide or to escape, or +unusual violence, persistent sleeplessness, or being out of bed, a serious +sickness or change for the worse, or the approach of death, should be +reported to the physician. It is, in many institutions, the duty of the +night watch to report any neglect or misconduct on the part of an +attendant or employé, and it is something that should be faithfully and +impartially done. + +Having briefly sketched the general duties of an attendant, it seems best +to again remind them, that an asylum is built and maintained for no other +purpose than for caring for the insane; that each patient is entitled to +the best our means can afford; that while the attendants are not +responsible for the medical treatment, they are for that kind and +intelligent care it is within their province to give; and they are also +reminded that, so far as it can be done, such personal attention is to be +given to each patient as will assist in recovery or improvement, or +promote his well-being. + + + + +CHAPTER VI. + +THE CARE OF THE VIOLENT INSANE. + + +A careful study of each violent patient, of his habits, delusions, and +hallucinations, of his peculiar manner of showing violence, and a +knowledge of what is likely to provoke outbursts is necessary to properly +care for him. An attendant's ability to successfully manage a ward full of +patients will depend largely upon the study given to, and the thorough +understanding of, each case. Such study will soon teach him that every +violent patient has peculiar and pretty constant ways of showing and +exercising violence, and that the same rule of individuality holds good +among this, as it does among other classes of the insane. + +Having learned what will cause violence, it can often be avoided by +removing the cause; having learned the symptoms that precede a patient's +outbursts of violence, they can sometimes be averted, or preparations made +to control them; having learned in what direction violence is shown, how +sudden, blind, or furious it may be, or how slow, deliberate, and planned, +the attendant is better able to meet, manage, and control it. + +Few patients are so continuously and furiously violent as to need constant +repression, and the directions how to care for such patients can always be +given by the physician. Most violent patients are subject to the firm, +kind control of attendants, and can be kept sufficiently quiet and +orderly; they should never be left alone, and mops, pails, brooms, +chambers, and all other articles, that may become weapons should not be +left within reach. Strong comfortable clothing can generally be kept on +the most violent and destructive, with care and attention from attendants, +but not without. + +Many violent patients will employ themselves and be the quieter for so +doing. Light out-of-door work is the best employment for this class, and +out-of-door walking and exercise should never be neglected. On the woman's +ward knitting, sewing, mending, and ward work are suitable for many, while +some will work at the laundry, and others will go quietly to church and +entertainment; books and illustrated papers should be furnished and will +be much read and enjoyed. + +As a rule the more violent patients are restricted, kept continuously on +the ward, or in a small room, and given no work, amusements, walks, and +exercise, the more noisy and violent do they become. + +Attendants must learn that mere noise, and much of maniacal activity, such +as running about, jumping, or pounding, is not in itself harmful, and that +unless such patients are doing themselves injury, or so disturbing the +ward and other patients as to require interference, it is better to +control than to repress and restrict them. + +Many violent patients are subject to such paroxysms of great violence as +to require immediate care and often temporary control at the hands of +attendants. Generally these paroxysms spend themselves after a short +time, but if they do not, advice and help can be called for. + +By careful watching, the approach of these paroxysms can be known and +often avoided. This may be done by removing the cause, which is often the +irritation of another patient or an attendant, by a word, a joke, by +simply letting the patient alone, or by a firm show of authority, or by +any other means experience has taught to be useful in the particular case. + +If necessary to hold a patient, three persons should be able to care for +the most violent. This can be done by grasping each arm at the wrist and +elbow, and holding it out straight, the attendants standing behind while +another passes the arm about the neck and holds the chin, to prevent +biting and spitting; the patient may then be walked backward and seated in +a chair. + +After the violence has subsided, though the patient should continue to +scold, swear, threaten, or cry, he should, as soon as possible, be left +alone, the attendants walking away, but remaining watchful. Do not, unless +it is necessary, interfere to stop the noise, for it is often a substitute +for the violence, and the attack wears itself out in this way. + +If necessary to carry a violent patient, it can be done by four or six +attendants. The face should be turned downward, thereby lessening the +power to resist, and, to prevent dislocating the arms, the patient should +be carried by the shoulders and chest; the bands about the neck should be +loosened. + +In using force in the care of violent patients, it should always be done +as gently as possible, and struggling should be avoided; he should never +be choked or kicked, receive a blow, or be knocked down; the arms should +never be twisted, nor a towel held over the mouth, but if the patient +persists in spitting it may be held in front of the face. + +Care must always be used not to injure a patient while exercising +necessary control. In the violence of a patient innocent injuries are +sometimes received. The attendant is excusable if he can show that he used +necessary force only, without malice. + +A violent patient should never be struggled with alone, and on a +well-managed ward help will always be within call. It may be necessary, +however, to break this rule in order to prevent homicide or suicide, or +serious injury to another patient, or setting the house on fire. + +It is better not to visit the room of a violent patient alone, and if an +attack is feared, especially with a weapon, the door should be slowly +opened, and held so it can be quickly closed. The patient usually makes an +immediate attack, and, before he has recovered for a second, can generally +be disarmed and controlled. + +Violence usually consists of noise, tearing the clothing, breaking glass +or furniture, biting, scratching, striking, hair pulling, kicking, or +attacking others with weapons. It is sometimes secretly and deliberately +planned and skilfully executed, though generally without reasoning or +direction, but blind and fierce. + +The care of the violent insane involves the careful study of each case, +with constant watchfulness, and the exercise of a control that is kind, +but firm and unyielding, that does not repress except when necessary, nor +restrict without reason, that indulges whenever possible, that never +drives, scolds, or threatens, but influences, guides, and directs. The +greatest liberty possible should be allowed, and self-control encouraged, +and work, occupation, and amusement should be furnished. An attendant must +always remember that fear is the lowest motive to govern by, and that +kindness will often be appreciated and returned. + +_Care of the Destructive Patients._--Besides the violently destructive +patients, there are some who are maliciously destructive, and who exercise +all their ingenuity to escape the watchfulness of the attendants; who +glory in their wrong-doing; who openly say they cannot be punished, and +exultantly tell the physician how they have outwitted the attendant, or +proclaim before him his shortcomings and neglect. Such patients will +destroy their own or others clothing, they will steal and hide, or throw +it out the window or down the water-closet, or erase the name by which it +is marked. They will destroy bedding, windows, crockery, pictures, or +furniture. With a pin, a nail, or a bit of glass or wood, they will mar +and deface their room or the ward, and often do damage that cannot be +repaired. The only way to meet such cases is by watchfulness. They should +be kept, if possible, at work, or at least with a company of workers, and +therefore under constant observation. When put to bed their clothing, +mouth, hair, and person should be thoroughly searched. Kindness often has +but little effect, but a threat is apt to make them more determined to +destroy. + +_The Care of Patients by Mechanical Restraint and Seclusion._--All the +restriction of an asylum is restraint. The locking of bedroom doors at +night is very restricted restraint. Most patients in an asylum have a +feeling that they are under great compulsion and restraint, in being +deprived of their liberty. It has already been taught that patients are to +be given all the liberty possible, that restraint over their freedom is to +be exercised no more than is absolutely necessary, and that the greatest +good of the patients alone is to be thought of. + +These teachings are equally true of special forms of restraint. If used at +all they are to be used for the good of the patient alone, and an +attendant should be able to care for any case without restraint. + +Restraining apparatus should never be kept on the ward. An attendant +should never ask that it be used, nor say he cannot get along without it. + +If ordered by the physician it is the attendant's duty to see that it is +so applied as to do no injury, that it does not bind or tie the patient +down, that it does not irritate and make the skin sore, nor restrict the +free movement of the limbs. + +Patients who are restrained are not to be further confined to a chair +without specific order. Restraint used during the day is not, unless so +ordered, to be continued at night nor reapplied the next day. Patients are +to be taken frequently to the closet. Restraint should be taken off +several times a day, and kept off long enough to give relief to any +feeling of discomfort, and free movement should be allowed. When patients +are restrained they need unusual care and watching, and should never be +left alone. + +The attendant should be informed why restraint is used, and what is hoped +to be gained by its use. He should closely observe the effect upon the +patient and compare his condition with what it is when not restrained. The +result of these observations should be reported. + +Thus used, an attendant will soon learn that it is not the easiest way to +care for a patient, that its use involves increased watchfulness and care, +and greater discretion, and that it is strictly a form of medical +treatment. It is a harsh remedy at its best, and needs to be used with +kindness, intelligence, and judgment, and it is to be applied but for one +purpose, namely, that the patient may be benefited. + +_The Use of the Covered Bed._--Like restraint it is never to be used +except by the orders of a physician, nor is its use to be repeated without +special orders; it is always to be considered a method of treatment and +something the attendant has no interest in, except to know how best to use +it when ordered to do so. + +When in a covered bed the patient should be frequently visited; he should +be taken up at least once in three hours, unless asleep; the bed and the +patient should be kept perfectly clean. If used in the daytime an +attendant should sit beside the patient for some hours and try to keep him +quietly in bed, and the same should be done in the evening when the +patient is put to bed. An attendant should be able to report how much the +patient sleeps, how much quiet and rest is obtained, the effect of the +treatment, and compare the condition of the patient when in the bed with +what it is when not used. + +_The Use of Seclusion._--Seclusion is shutting a patient alone in a room +in the daytime. If allowed to be done without orders from the physician +it should be immediately reported. If ordered to be continued the patient +should be seen at least once in fifteen minutes, while many need to be +seen once in five minutes, and an attendant should never be far from the +door. The patient should be frequently taken to the closet. The effect and +result of seclusion should be observed and reported. + +Many physicians never use any form of restraint, while others make +considerable use of it as a means of treatment. An attendant should be +able to successfully care for any case, so as to meet the wishes and +directions of the physician, and only as he is able to do this can he give +the patient the highest standard of attention, care, and nursing. + + + + +CHAPTER VII. + +THE CARE OF THE HOMICIDAL, SUICIDAL, AND THOSE INCLINED TO ACTS OF +VIOLENCE. + + +Patients with Delusions of Suspicion demand special care, and are properly +classed with those inclined to commit acts of violence, because they are +frequently fully under the control of delusions, which make them dangerous +and difficult to manage. + +Many patients have ideas that make them suspicious of those about them; +these may relate to the patients, but more frequently to the attendants +and physicians, and they may arise from delusions, hallucinations or +illusions. This class of patients is apt to be morose, cross, and +irritable; they sit brooding over their fancied wrongs; repulse advances +and friendly intercourse; they refuse to employ themselves, and do not +respond willingly to the requirements of the attendants. + +Our most trifling and unmeaning acts may give rise to the most intense +suspicions and hatred. A look, a shrug of the shoulder, the manner of +shaking the head, a cough, the squeaking of our boots, are frequently +enough to arouse, these feelings. + +Suspicious patients often think they are the subjects of ridicule; that +their thoughts are read and proclaimed to the ward; that their virtue, +truth, or honor is called in question, and the accusations openly told to +others, or that they are called vile and insulting names. They often have +delusions of conspiracy to do them or their families harm, and connect the +attendants and physicians with them, thinking, as they keep them locked in +the asylum, they are associated in the conspiracy. Sometimes these +patients think themselves some great persons, perhaps that they are a +member of the Deity, or a ruler, or prophet, or that they have some great +mission to perform, and that they are deprived of their rights, or their +work interfered with, by being kept in the asylum, and that those in +authority are imprisoning and persecuting them. Such persons may be, on +account of their fancied wrongs, very suspicious, and even violent towards +those who care for them. + +Other patients have suspicions and fears of bodily harm. They may think +they are to be tortured, that they are to be burned alive, or that some +one is trying to kill them. To-day, as I wrote these lines, a patient told +me she did not sleep last night for fear the night-watch would kill +her--saying that God told her the watch was armed with a knife for that +purpose, and she threatened homicidal violence in defending herself. + +Many patients mistake ordinary sensations of pain and bodily discomfort, +and have delusions that they are being injured. The feelings of dyspepsia +may make patients think they have been poisoned; ordinary pains or aches, +that they have been shot, stabbed, or pounded; women may, for some such +causes, think they have been violated or are pregnant. Peculiar sensations +of various kinds may make patients think some one is affecting them by +electricity or mesmerizing them. + +It is very easy to trace from such ideas of persecution and suspicion, the +origin of homicidal, suicidal, incendiary and other violent tendencies and +acts. + +_Homicidal Patients._--Patients are sometimes both homicidal and suicidal, +and sometimes they are inclined to only one of these forms of violence. +Homicides are not of frequent occurrence in an asylum. The better the care +the less is the liability to homicide. But there are always a great many +homicidal patients, and many more who have delusions and ideas that may +cause such tendencies to arise. + +Many patients are homicidal merely from violence and frenzy, and without +any settled plan, any fixed delusion, or intense suspicion. They may +attack others suddenly and furiously; they may commit the act while trying +to escape, or it may be the result of the violence of acute mania. Other +patients become homicidal under the desire to protect themselves from +supposed assaults. They may think a person who is approaching them is +coming to kill or torture them. Others are homicidal from any of the ideas +of persecution and suspicion that have just been spoken of. Sometimes +patients hear voices telling them to commit the act, perhaps it is God's +voice commanding a father to offer up his only son as a sacrifice, or a +mother to kill her little children to save their souls, or keep them from +some misery or crime that awaits them. Patients may think themselves God, +or a king, or ruler, and therefore have a right to take life. Homicidal +patients are often among the quietest, and are found in the quiet wards. +They frequently lay careful plans, are secretive, and only try to commit +the act when they feel sure it will succeed. + +Patients who are homicidal should be especially watched. They should, if +possible, be kept employed, but never given tools that may become weapons. +They should sleep in a room by themselves. All persons against whom they +have delusions should be warned. Patients against whom they harbor +suspicious or homicidal ideas should be separated from them. + +Attendants should remember that a mop, a pail, or a chair, may become a +dangerous weapon, or that a knife, scissors, or a sharpened piece of iron +or tin, may make a fatal wound. + +_Suicidal Patients._--Patients with this tendency will generally talk +freely of their suicidal ideas, tell why they wish to commit it, what +provokes the idea, and how they would do the act. They are frequently +grateful for the care bestowed to help them resist the impulse, and will +sometimes tell the attendants when they feel the suicidal ideas coming on, +that they may be the more surely watched. + +Melancholic patients are most inclined to suicide, but any insane person, +whatever the mental state, may commit the act. Delusions of depression +generally cause the suicidal ideas, but hallucinations sometimes play an +important part. Some persons are simply tired of life, and see no hope in +living; some think they are a burden to their friends, and that they are +taking food away from their children; others wish to die to escape from +their misery, which is generally a mental, and not a physical suffering; +others that by so doing they may get forgiveness of their sins; others +because they think they will save their children from a fate like theirs; +sometimes it is the result of hallucination, as a direct command from God, +telling them to commit the act. + +But few patients are constantly determined to commit suicide. The +opportunity offered, as a bath-room door left open, a rope, a knife, often +prompts the desire and allows the accomplishment of the deed. + +Attendants must remember that it takes but a few minutes to commit +suicide, by drowning or hanging--but a moment to cut the throat; that +persons can drown themselves in a pail of water, hang themselves by the +hem of the sheets, cut their throat with a piece of glass or tin. +Sometimes patients slyly save their medicine until they get enough to +poison themselves. + +About dusk in the evening, or at early morning, is the time when patients +are most inclined to commit suicide. When patients are rising, going to +bed, or to their meals, when going to chapel, amusements, or to walk, when +all is busy and astir on the ward, are the times that offer the most +favorable opportunities for the act. + +Often patients have a certain way by which they will commit suicide, and +they will do it in no other; one wishes to drown himself, another to hang, +and another to take poison. Sometimes patients will appear cheerful to +avoid suspicion and so find their opportunity, while others may suddenly +and while convalescent commit the act. + +The only way to care for patients who are suicidal, is by constant +watchfulness day and night. During the day they should be employed and +kept with other patients, they should be especially looked after at those +times when opportunities for suicide are increased. At night it is better +to have them sleep in an associated dormitory with some one to watch them. +If a patient is found hanging he should at once be cut down, all +restriction about the neck removed and artificial respiration set up, or +if drowning, the mouth and lungs should be first emptied of water; if +there is hemorrhage compression should be made upon the artery, or if this +is not possible, then directly upon the wound. How to control hemorrhage +and do artificial respiration will be described in the chapter on +emergencies. + +_Patients Who Have Tendencies to Self-Mutilation._--Some patients horribly +mutilate themselves. They may gouge out an eye, cut off a hand, pull out +their tongue, or even disembowel or dreadfully burn themselves. Some +patients persistently beat their heads against the wall or floor, others +scratch the skin, making large sores. Such patients frequently think +certain passages from the Scriptures apply to them, and they must obey the +application and command. They quote in justification of the acts, "An eye +for an eye," "And if thy right eye offend thee, pluck it out," "And if thy +right hand offend thee, cut it off." Talk of this kind should make an +attendant very careful and watchful of the patient. + +The origin of the ideas that lead to the attempts at self-mutilation is to +be found in delusions, and arise in the same way as do ideas of suicide +and homicide. These patients are all of the same class and need the same +character of care, attention, and watching. + +_Patients with Tendencies to Setting Things on Fire._--Patients with these +tendencies generally desire to commit incendiary acts under the influence +of delusions or hallucinations; added to these there are frequently +suspicions and feelings of wrong treatment, and the patient takes this way +of showing revenge, or, as he may say, of repaying the wrong. Sometimes +patients are so feeble in mind that they light a fire because they think +it is a pretty sight to see it burn. There are some conditions +accompanying epilepsy where patients are liable to commit any of the class +of violent acts described in this chapter. The special care demanded by +these patients will be fully spoken of hereafter. + +There are some patients whose minds are so distorted by disease that they +seem to take a pleasure in wrong-doing, and are much inclined to do great +mischief, and sometimes to commit acts against life or property. + +The care demanded by patients who are inclined to acts of violence is +practically the same for all. The attendant should thoroughly know the +habits, peculiarities, and delusions of each person under his care; he +should exercise constant watchfulness, and remember that a moment of +thoughtless inattention may give the opportunity for a patient to commit +some violent act, that will cause him lasting regret. The mind of a +faithful attendant will, when upon duty, always be full of anxiety, and +there should be in the care of very troublesome patients of this class +frequent relief. + + + + +CHAPTER VIII. + +THE CARE OF SOME COMMON MENTAL STATES, AND ACCOMPANYING BODILY DISORDERS. + + +_Care of Patients in the Earlier Stages of Insanity._--Patients in the +earlier stages of insanity act differently, one from the other, when first +brought to the asylum and placed under care and restriction. Sometimes +patients accept the situation and fit into asylum life without any +friction. They may even come willingly, knowing they need care and +treatment, or from confidence in their friends or their physician's +advice. + +To some patients the restrictions of an asylum are irksome and +misunderstood; the quiet, regularity, and routine of the life on the ward +does not at first affect them; they may, and often do, become fretful, are +irritated by their confinement, sleep poorly, eat little, and may make +violent efforts to escape. + +These conditions, if nothing is done to occupy the patient's time and +mind, and so relieve them, will often be sufficient to provoke violence. +These patients should be carefully watched and their condition studied; +they should be brought under the kind control and influence of attendants, +induced to take part in the regular order of the ward, and, if strong +enough, should be furnished with proper work and occupation. + +Patients, when first brought to the asylum, frequently have much anxiety +about their homes, their families, or their business affairs. This is +particularly true in recent cases of insanity, because such patients often +have cares and responsibilities, or they have tried to continue to assume +them, up to the time of coming to the asylum. Special care should be taken +to quiet fears in these directions; they should be assured that they are +groundless, told they will be allowed to communicate with their friends, +that they will be visited by their family, and that all their interests +will be cared for. + +It is impossible to speak of the varied causes of insanity, or of the +equally varied manifestations of the disease and conduct of the patient at +its onset, but there are a few conditions which, being present, give a +character to a particular case, and suggest the care required. + +Sometimes, as has been said, the patient partly realizes his condition, +and is willing to come to the asylum, and in every way to conduct himself +in accordance with the rules and requirements. + +Sometimes the onset is slow and the symptoms so obscure as to attract +little attention. Following this, more decided symptoms may appear; the +patient may become violent, noisy, destructive, or sleepless, or he may +try to commit suicide or homicide, or do some other act of violence; or +the great restlessness, moaning, crying, and sleeplessness of melancholia +may come on, or the patient may refuse, for several days, all food. The +reason for bringing such patients to the asylum is that they can no longer +be kept at home. + +Following the treatment that has been described, these patients will +frequently in a short time become more quiet, self-controlled, and more +easily influenced and cared for. + +The earlier stages of insanity are frequently accompanied by considerable +disturbance of bodily health. The appetite is poor, the digestion +disordered, the bowels constipated, the breath foul, the secretions of the +skin changed and often offensive, the temperature a little elevated, the +pulse rapid, and the heart weak. Sometimes, on the other hand, the +temperature is normal, or a little below, while the hands are cold and +clammy. In addition, nutrition is frequently impaired, so that the food +taken by patients does not seem to properly nourish and strengthen. All of +these symptoms are not present in a given case; sometimes most of them may +be, and again but few are to be noticed. + +The important lesson to learn in the care of these cases is that such +patients may rapidly pass into a more serious condition, in which there is +great exhaustion, which is always alarming, and may even result fatally. + +Recent cases, such as have been spoken of, need our best care, closest +attention, and kindest nursing. The patient should daily take sufficient +food, which, if necessary, should be enforced, and the opportunity for +sleep promoted. A few days, or a day, without food and sleep may bring on +alarming symptoms. + +For these patients, milk is the best article of diet; it is most easily +given and readily taken; it should be given by the glassful, or if not +able to do this by the spoonful. Some patients, for reasons not always +known, will refuse food one hour and take it freely the next; it should, +therefore, be frequently offered. With milk as a basis, we may add to it, +as we are able. Raw egg, gruel, boiled rice, oatmeal, custard, and bread +are adjuncts that are nutritious and easily given. + +It makes but little difference why patients refuse food, except that a +knowledge of the reasons may enable us to overcome their disinclinations. +The thing to remember is that they must in some way be made to get enough. + +_Care of Patients with Insanity, Accompanied by Exhaustion._--There is a +condition associated with acute mania or melancholia--though it is +sometimes seen in connection with the more chronic forms of insanity,--of +exhaustion so overpowering, that it may be rightly compared with the +exhaustion of typhoid fever. It may last a few days or a month, or more, +if it does not sooner terminate fatally. Instead of the quiet delirium of +typhoid fever there is generally violent mania or frenzy. Neither mind nor +body is quiet; sleep seems to have fled. The patient may be destructive, +constantly out of bed, fighting care, refusing food, and wetting and +dirtying himself. With these unfortunate conditions there generally is +fever, often to a considerable degree, the heart is feeble, the pulse +rapid, the tongue and lips dry and cracked, the teeth covered with sordes, +and the body emaciated. Every case does not present all these symptoms, +nor show such alarming exhaustion. There are many degrees of severity in +this sickness. + +Such patients must never be left alone and need constant nursing day and +night. They must have food, even if it is given forcibly. They must, if +possible, be kept in bed, and covered with clothing, and they must be +kept clean. If wakeful, food must be administered during the night, and +especially towards morning, which is the time of greatest weakness and +physical depression. + +Hot baths may be ordered for these patients, and stimulants and medicine +to produce sleep left in the care of attendants. How to give the baths and +medicine, what results are to be expected, and what dangers are to be +feared, will be described later, in the chapter on the administration of +medicine. + +There are certain symptoms which should warn the attendant of danger, and +which often precede death. When any of these are present they should be +reported to the physician. They are: partial or complete unconsciousness, +slow and labored, rapid, shallow, or irregular breathing, increased +weakness and rapidity of heart or pulse, cold hands and feet. Picking at +the bedclothes, or at imaginary objects in the air, or vacant staring, are +bad symptoms. + +_The Care of Patients in a Condition of Dementia._--It is to be remembered +that dementia may be either, a condition of chronic insanity without +recovery, or a less permanent state of mental enfeeblement following the +acute attack, and from which recovery may be hoped. In the first of these +conditions there is little to be done except to care for the patient. Many +are able to do some work, and should be allowed, encouraged, and taught to +do it. Others do not know enough to dress, feed, or care for themselves. +These must be kept neatly dressed, taken to the table and their food +prepared, taken to the bath and closet, taken to walk, and put to bed. If +not so attended to, they will degenerate into a ragged, dirty, and even +filthy state, and the ward upon which they live will be offensive to the +smell. They should be frequently examined for body vermin, as these pests +are liable to breed and flourish among these patients. The condition of +the demented affords the best evidence of the care given to the patients +in an institution. Attendants will often be gratified to see some of these +apparently hopeless cases greatly improve and sometimes recover. + +If attendants will watch their patients as they come out of acute mania or +melancholia and become quiet, they will often notice that they gain in +flesh and become demented. The dementia may be but partial, or so very +complete that the patient knows nothing. From this they may gradually go +on to improvement, or even recovery. They need all the care demanded by +the confirmed dement, and, in addition, advantage must be taken of every +means to promote recovery. They must be well fed, regularly taken out for +exercise, and, as they are able, encouraged to employ themselves. Any +symptoms of a return of their more violent condition, any failure to +sleep, or change noticed in the health of the patient, should be at once +reported. + +_Care of the Convalescent Patients._--This is the period that precedes +recovery from disease. With the insane it is often a critical time, and if +not properly cared for they may fail to get well, and become chronic +lunatics. The patients, and frequently their friends, think they are well +and should be at home. It is the attendant's duty to encourage the +patient, and to promote his confidence in the physician. They should not +be told of their past conditions, or the disagreeable features of their +sickness called to mind, and their last, as well as their first +impressions of the asylum should be made pleasant. Sometimes there is a +slight return of depression or mania, and the patient may suddenly begin +to lose sleep. These conditions must be observed and reported, for it is +very easy for patients who are recovering to become as disturbed as when +they were first insane, and to suffer a relapse from which they may never +recover. It is hardly necessary to remind the attendant that employment, +amusement, and all the healthful means of occupation afforded by the +asylum, should be judiciously allowed these patients. + +Sometimes patients feel too well. They are too contented, happy, and +indifferent, and are very active in body and mind. They want to work all +day, from early in the morning until late at night. They sing as they +work, and talk rather loud and fast. These patients need restriction; they +should not be allowed to work too much, so as to overtax their strength. +So long, however, as they continue to gain, and sleep well, little is to +be feared, and they generally become quieter and recover. + +_The Care of the Epileptic Insane._--Not all epileptics are insane, but +they are all liable to insanity. Generally the most hopeless and difficult +to be cared for are brought to the asylum. Epileptics are liable to have +fits at any time, but some patients have them at night only. The attack is +generally sudden, though sometimes patients have feelings that warn them +of their approach. This may precede the fit for a very short time, or the +patient may know during the day that he will have a fit during the night. + +Epileptic fits are accompanied by convulsions and unconsciousness, and +are the type of all convulsions. The unconsciousness may be but momentary, +or last an hour or longer, and even prolonged several days; the +convulsions may be but the twitching of a few muscles, as of the face, or +may consist of the most terrible writhings, and last for several minutes, +and be often repeated. Sometimes the fits are ushered in by a scream. + +The fit itself is not dangerous to life, but patients may at night turn +their face downward and so smother; they may fall from high places, or +down stairs, or into the water, or into the fire, and so injure +themselves. There is little to do during an epileptic attack. Patients +should not be held to prevent the convulsions, but so that they shall not +injure themselves. A pillow should be placed under the head and the bands +about the neck loosened. The nurse is sometimes given remedies which, if +properly administered when the attack is felt to be coming on, may ward +off the fit. Nitrite of amyl in small glass pearls is a common remedy. It +is to be broken in a handkerchief and several strong breathfuls taken. + +At their best, epileptics are cross, irritable, quick-tempered, +unreasonable, and quarrelsome, and they will often give a blow at slight, +or even for no provocation. After a fit they are frequently dangerous and +always require guarded care and watching. As has been said, they may soon +recover their natural condition, or remain in a more or less prolonged +state of unconsciousness, or they may pass into a condition that appears +natural, but in which they have but little or no appreciation of their +situation or surroundings, or remember afterwards what they do. In these +states they may, without warning, make violent assaults, commit murder or +suicide, or set things on fire. Sometimes they do outrageous acts, such as +beating their own children to death against the wall, or mutilating them, +or roasting them to death on the stove. Many often suffer from +hallucinations or illusions of sight or hearing, and have delusions of +impending harm or assaults, and think they must defend themselves. + +_Care of Patients with Paresis._--This is a form of insanity characterized +by progressive dementia and increasing bodily enfeeblement and paralysis. +The paralysis is partial, not complete; the patient's walk is feeble, +unsteady, and shuffling; the hands are tremulous, lose their fineness of +touch and ability to do work and write; there is twitching in the muscles +of the tongue and about the mouth, and the speech is thick and indistinct. +As the disease progresses the patient becomes helpless, bedridden, wet, +and filthy. The result is always death. Convulsions like those of epilepsy +are liable to occur, from which the patients may rally, or in which they +may die or linger a few days. In the earlier stages the patients are often +strong, and controlled by delusions and hallucinations that make them +violent. Sometimes they are simply good-natured and easily managed. They +generally have very exalted and extravagant delusions, and are without +appreciation of their condition or surroundings, and are irritated at the +control of the asylum, and on account of their unreasonableness they can +rarely be allowed the liberty others enjoy. + +Paretics often eat ravenously and rapidly, they stuff their mouths full of +food and so choke themselves. Their condition of paralysis may render them +unconscious of danger and powerless to help themselves. The care needed +by bedridden, filthy paretics is practically the same demanded by helpless +paralytics, the old, feeble, or demented class, and all others who cannot +care for themselves. + +_Care of the Paralytic, Helpless, Bedridden, and Filthy Patients._--There +are many patients in an asylum who are indifferent to all the wants of +nature, who wet and dirty themselves. Some of these patients are +bedridden; some are about the ward, but demented; some are violent and +maniacal, and some from delusions make their persons and rooms as filthy +as possible. Much can be done with many of these patients by regularly +taking them to the closet, and their bad habits may in this way be broken +up. Patients of this class should be visited during the evening, attended +to frequently by the night watch, and seen the first thing in the morning. +Patients, when dirty, should be thoroughly washed and carefully dried. +Their beds should be cleaned and changed, and during the day clean +clothing should be given them as often as required. + +The greatest danger that comes from not keeping patients clean is the +formation of bed-sores. + +_Bed-Sores._--Bed-sores occur in patients long confined to bed, and who +suffer from exhaustive diseases. Paralytics and paretics are particularly +liable to them, the diseased condition of the nerves allowing the tissues +to break down easily. Sometimes the fingers or toes of a paretic become +gangrenous or large surfaces of the skin die, and sometimes deeper tissues +slough away rapidly. These conditions may come on in a day or a night. + +Patients who are wet and dirty are more liable to have bed-sores. They +will always appear in a bedridden paretic in a few days if not kept +perfectly clean. They most frequently occur over bony projections where +the weight comes in lying, as upon the hips, back, or shoulders. + +Such patients, should, if possible, be made to sit up several hours every +day, or placed first on one side, then on the back, and then on the other +side. If it can be done, they should, as they lie in bed, rest their hips +on an inflated rubber ring, and if the skin is red the part should be +bathed in diluted alcohol. After being bathed and dried the skin about the +hips should be dusted with some dry powder. Powdered oxide of zinc is +perhaps the best, but ordinary corn-starch flour is valuable and serves a +good purpose. Insane patients frequently will resist all care and every +effort to prevent bed-sores, tearing off the bandages and dressings and +picking and irritating the sores. + +Bed-sores should never be allowed to come because of want of attention or +cleanliness, but there are conditions in which they will appear in spite +of every preventive. + +Bed-sores once formed should be treated as ulcers and according to the +direction of the physician. + + + + +CHAPTER IX. + +SOME OF THE COMMON ACCIDENTS AMONG THE INSANE, AND THE TREATMENT OF +EMERGENCIES. + + +The insane, like others, may suffer from almost any accident. It is not +intended to treat of all accidents, nor how to care for every emergency. +This is so large a subject as to demand a separate text-book, and there +are several excellent ones, that attendants would do well to read. But +there are among the insane certain kinds of accidents that are likely to +occur, certain classes who are liable to receive accidents, and certain +emergencies that frequently have to be cared for by the attendant, and +these will be described. Every injury received by a patient should be +immediately reported to a physician. + +Attendants, in the care of the insane should always remember the liability +to accident and guard against it. The old, the feeble, the paralytic, and +paretic need special care. They are weak, easily pushed over, or stumble +and fall, and they cannot break the weight of their fall, or so defend +themselves; they are irritable, childish, and often provokingly +troublesome to the other patients, and their bones seem to be easily +fractured. Some injuries are self-inflicted, some come to the patient in +consequence of his own or others' violence, and some, as has been said, +from the very weakness of the patient. + +_Care of Fractured Bones._--Any of the bones may be fractured, and from +slight cause. The bones most frequently fractured are: the collar bones, +the ribs, the bones of the forearm just above the wrist, the bones of the +lower leg and of the thigh. This last bone, the femur, is among old people +most frequently broken at its neck, which is the constriction of the bone +just below the rounded end that fits into the joint at the hip. + +Fractures should, as much as possible, be let alone till the physician +comes. The parts should be kept quiet so as not to cause unnecessary pain, +and do further injury. By rough handling it is very easy to push a +fragment of bone through the skin, thus making a simple fracture a +compound one. When a rib is fractured a sharp end may pierce the skin or +the lung; either complication is serious. If the lung is injured the sputa +will be bloody, and the appearance of such a condition should be at once +reported. Sometimes patients are violent after the injury and need to be +firmly held, and sometimes they have to be carried to the ward from the +outside, or placed upon a bed. Always carry the fractured limb as well as +the patient. + +If temporary splints are put on do not make them too tight, and loosen +them from time to time as needed. The extremities sometimes swell rapidly +after a fracture, and the splints may so stop the circulation that, in a +few hours, gangrene may be caused by them. Besides, many patients cannot +tell us if the part is swollen or painful. + +_The Care of Wounds._--Bites. Insane patients often bite others and +penetrate the skin. They may be very angry, their mouths foul and running +with saliva, and this irritating substance introduced into the wound by +the teeth may set up an ugly inflammation. The wound should be immediately +and thoroughly washed. It should be well cleaned with a wet sponge or +cloth, and soaked in warm water. A good after-dressing is powdered +iodoform, sprinkled over the wound. + +_Wounds of the Head._--These wounds are quite common. They should be +thoroughly washed and cleaned from dirt and hair. Hemorrhage may be +controlled by continued pressure upon the bones of the skull, and if an +artery is cut, it can in this way be kept from bleeding till the physician +arrives. Most wounds of the head, even though large, generally heal +quickly, but the most trifling ones may assume serious proportions, and +even prove fatal. If within two or three days heat, pain, redness, and +swelling appear, pus is probably forming beneath the scalp, and this, +within a few hours, may spread under a large surface and do serious +injury, or erysipelas may be set up. + +_Injuries from Blows on the Head._--Persons are sometimes stunned by blows +on the head. They should be placed in bed with the head elevated, and kept +perfectly quiet till the doctor comes. Efforts should not be made to +arouse them, they should not be given liquor of any kind, but ice may be +applied to the head. The danger to be feared is from the skull being +fractured, or from bleeding vessels inside of the skull. Either of these +conditions may, by pressure upon the brain, cause unconsciousness, +paralysis, and death. + +_The Care of a Cut Throat._--Patients may cut their throats from ear to +ear and do really little injury, or they may make a small stabbing wound +and divide a large blood-vessel and die almost immediately, or they may +cut the windpipe and not cut the blood-vessels. The windpipe you can +notice upon yourselves as a large, stiff tube, prominently situated in the +middle and front of the neck; the blood-vessels are together on each side +of the windpipe, and situated quite deep down among the muscles, and the +carotid artery may be felt beating by the finger. Little can be done by +the attendants to stop the flow of blood, even if the great blood-vessels +are not cut. The head should be kept bent forward and the chin pressed +against the chest. + +After the physician has dressed the wound, constant watching day and night +may be required to prevent the patient tearing off the bandages and +reopening it. This same rule of watchfulness applies to the after-care +needed to be given to many cases of fracture, and other serious injuries +among the insane. + +_Care of Wounds of the Extremities with Hemorrhage._--The hemorrhage from +most simple wounds involving the cutting of skin and flesh or small +arteries, can usually be controlled by direct and continued pressure. This +may be done by a pad made of cloth, packed and pressed into the wound, or +lint may be used in the same way. Water as hot as can be borne poured into +the wound will frequently stop a hemorrhage when other means fail; cold +applications and ice are also useful. If dirty, a wound should be +thoroughly cleaned, being washed, and, if necessary, soaked in warm water. +Iodoform sprinkled so as to cover wounds, is the best dressing for all +attendants or nurses to apply, while awaiting directions from a +physician. It keeps them clean, promotes healing, and lessens the danger +of inflammation or the formation of pus. + +When the arteries of the extremities are cut, pressure should be made on +the large artery leading to the part. When the wound is high up on the +arm, pressure is made by the fingers or a padded key upon the artery that +lies back of the collar bone, and the attempt should be made to press it +against the bone. This is a difficult thing to do, but nevertheless it +should be attempted. When the wound is lower down, pressure is to be made +by the fingers on the inner side of the upper arm, at about the middle +point and against the bone. The artery runs downward, near the inner +border of the biceps muscle, which is the large, bulging muscle of the +upper arm, and can, with a little care, be felt beating by the fingers. +Patients in breaking glass often cut one or both arteries at the +wrist-joint where the pulse is felt. These are large and bleed rapidly, +and when cut need the care just described. + +When the artery in the leg is wounded, pressure is to be made on the inner +side of the thigh, just below the groin. The position of these large +arteries, and how to press against the bone, is best learned by +instruction and demonstration from a physician, and with a little practice +attendants will be able to easily and successfully do the act. + +It is very tiresome to continue pressure with the fingers for a long time, +and attendants should relieve one another till the physician comes. + +_The Care of Sprains._--Sprains are a common accident and easily produced. +The great end of treatment is to keep the sprained joint quiet. If the +ankle or knee is sprained, the patient should be carried to bed. Perhaps +the best early treatment, and the one that gives the greatest relief to +pain, is to place the joint in a tub of water as hot as can be borne, and +keep it hot by pouring in more. The part should be kept in the water until +it is parboiled. The skin of some feeble or paralytic patients is easily +scalded, and some cannot tell when it is too hot; the water therefore +should never be uncomfortable to the hand of the attendant. + +_Care of Patients Choking._--This is a frequent accident, and in order to +know what to do when it occurs, it is necessary to have a knowledge of the +air passages of the throat. + +We breathe through the mouth and nose. They open into a common passage, +the pharynx, which can be seen by looking into the mouth, lying back of +the tonsils. Passing downward, it divides by branching into two tubes; one +the windpipe, which is in front, behind it is the oesophagus or gullet. + +The point of division is just beyond the tongue, and is almost within +reach of the forefinger when crowded into the mouth. + +The air we breathe passes through the mouth and nose to the pharynx, +thence to the lungs by the windpipe. The food we eat passes from the mouth +to the pharynx, and thence to the stomach by the oesophagus. + +There is at the opening of the windpipe a cover, the epiglottis, which is +generally open, but which closes when food is swallowed and helps to keep +food from entering. When a substance touches the opening of the windpipe, +we instantly cough to expel it. + +A person may choke, when the mouth and the pharynx back of it are filled +with food; or when a piece is lodged in the wind-pipe, or a large piece in +the oesophagus at the point of division, and which crowds upon the +windpipe, or covers the opening. Food gets into the windpipe, by being +drawn in by a sudden and unexpected inspiration of air. This may happen +while eating or in vomiting solid food. With this accidental exception all +breathing stops during the act of swallowing. + +Some patients, from paralysis, especially paretics, do not feel food when +it is lodged in the throat; others, from great dementia, may not know when +they are choking, and show no emotional signs of distress. Paretics are +particularly liable to bolt their food, and cram the mouth and throat +full. + +The symptoms of choking are immediate, and if no relief is obtained, the +sufferer will die in a few minutes. If the patient knows any thing, he +will show immediate signs of distress, violent but ineffectual attempts to +breathe, and the face quickly becomes a dark blue color, from the +accumulation of carbonic acid in the blood. + +Immediate effects should be made to remove the obstruction, and continued +until the physician arrives, who is to be sent for at once. Whatever is in +the mouth and throat can be easily removed by the fingers; the forefinger +should then be crowded down the throat to feel for other obstructions, +care being taken not to push a piece of food into the windpipe. If any +thing is felt, it can sometimes be pulled out by the fingers, or a +hair-pin may be straightened and bent, or a piece of wire, and an effort +made to fish it out. When in the gullet and beyond the fingers, it may be +pushed into the stomach by a feeding-tube. Artificial respiration may be +needed, but attendants must remember it is of no use until the obstruction +to breathing is removed. + +Marbles, coins, buttons, pieces of pencils, needles, pins, and fish-bones, +are frequently swallowed. The physician should be informed at once. + +_Directions how to Perform Artificial Respiration._--What is to be done +must be done quickly; tight clothing about the neck and chest must be +removed, and the mouth should be cleaned of dirt, water, or any +obstruction to the flow of air. The body is then laid out flat on the +back, covered, if possible, with light warm blankets, and some article +should be folded and placed under the shoulders, so as to raise them three +or four inches. The mouth must be kept open, and the tongue pulled well +forward, as it is liable to fall backwards, and cover the opening of the +wind-pipe. One person, kneeling behind the head, should grasp each arm at +the elbow, and, draw them steadily around so that the arms will meet above +the head. A strong pull should be made upon them, and they should be held +a few seconds. These movements elevate the ribs and enlarge the chest and +produce an inspiration. + +The arms are then to be brought to the side, and pressed strongly against +the lower ribs. This last movement drives the air out of the lungs, and +makes an expiration. These manipulations should be repeated, slowly and +regularly, about sixteen times a minute, and should, when there is the +slightest hope of life, be continued at least thirty minutes. The heart +should be listened to, in order to hear if it still beats. Warmth, by +hot-water bags, bricks, and soapstones should be secured, care being taken +not to burn the skin. The limbs may be gently rubbed with warm cloths, +though it is not so important as some well-meaning people think. The +rubbing should be towards the heart. + +As the breathing begins, it should be still aided by the artificial means +as long as necessary. When the patient can swallow, teaspoonful doses of +brandy or whiskey, to two or three of water, may be given and repeated +several times. As soon as possible the patient should be put in a warm +bed, and milk and light food given. + +_Care of Patients when First Burned._--When a patient's clothing is first +on fire, dash water over him if near at hand, if not wrap him in a blanket +or some heavy woollen garment, and smother the fire. Then unroll the +patient and extinguish the smouldering pieces of clothing. The clothing +must be cut and clipped off. Great care must be taken not to tear open the +blisters. If any application is made, it may be by linen cloths soaked in +sweet or castor oil, or equal parts of linseed oil and lime-water, or a +layer of flour and molasses may be applied over the burned surface. These +bland substances act largely by excluding the air, which, if blowing ever +so quietly, is always painful and irritating, and they also protect the +wound from the irritation of the bed and body clothing. Burns from +scalding are practically treated in the same way as burns from fire. + +_Care of Frost-bites._--Toes, fingers, ears, and noses are most frequently +frozen. They will sometimes freeze in a few minutes on a very cold day. +After a part is frozen there is no feeling of cold or pain, and it looks +perfectly white, and is so stiff it may be broken. + +Persons who are frost-bitten should not be taken into a warm room. They +should be left in a cool room, and the frozen part rubbed with cold water, +or ice, or snow. As these last melt they melt the frozen flesh. If the +parts are thawed too quickly gangrene is liable to follow. + +_Care of Patients in States of Unconsciousness._--This is not an accident, +but a frequent emergency. The medical word for unconsciousness is _coma_. +It may be partial or complete, may come on suddenly or slowly, or may be +accompanied by convulsions or paralysis. The more frequent causes of coma, +are epilepsy, the convulsions of paresis, blows on the head, hemorrhage in +the brain or apoplexy, some diseases of the brain, sunstroke, and some +poisons. + +When coma comes on, attendants should observe, if it is slow or sudden; if +the patient complains of pain in the head; if the respirations are +changed, and how; the condition of the pupils, whether large, contracted, +uneven, or changeable; if the mouth and face are drawn to one side; if +there is any paralysis of the arms or legs; if there are any convulsions, +or twitching of muscles; if the patient can be aroused, and from time to +time observe and count the pulse. + +Apoplexy is a term that is much used, and is a condition of coma, caused +by pressure on the brain. This organ is in a tight, rigid box, the skull. +If the fluid of the brain is much increased, or blood-vessels ruptured, +pressure is the result, and the soft tissues yield, rather than the bony +covering. This pressure may destroy or injure the cells and fibres, and so +interfere with the function of the part. Another way that apoplexy occurs +is by plugging of an artery of the brain, so that it cannot deliver blood +to the part to which it goes, and consequently the part loses its ability +to perform its function. The plugging is most frequently due to a small +clot floating in the blood, and which is usually formed in the heart. + +Paralysis and apoplexy are often, through ignorance, used synonymously, +but they really mean very different conditions. Paralysis is a loss of +power of contracting a muscle, due to disease or injury of the nervous +system; it frequently follows or is associated with apoplexy. + +In the case of apoplexy, and most conditions of coma, there is generally +little for the attendant to do. The patient should be put to bed, with +light coverings, and the head raised on pillows. Do not annoy the patient +by trying to rouse him, and do not give stimulants. + +_Care of Sunstroke._--A sunstroke is a very serious condition, and when it +occurs, requires immediate efforts to save the life of the one suffering +from it. It generally comes on suddenly, the patient first complaining of +the head; he soon becomes unconscious, the skin hot and dry, and the pulse +full and bounding. The treatment consists of taking the patient to a cool, +shaded place, removing all unnecessary clothing, applying ice or cold +water to the head, and bathing or sponging the body in cold water. If the +patient recovers, the temperature will fall under this treatment. If the +heart begins to fail, or the pulse becomes weak or fluttering, small doses +of whiskey and water may be given and repeated. + +Patients should not be taken out in the fields nor exposed places on very +hot days, except as ordered by the physicians; they should wear light +clothing and a straw hat; if permitted to go out, they should not +overwork, and should be allowed frequently to rest in the shade. Patients +are easily injured by working in the sun; headache caused, recovery +retarded, and bad symptoms brought back, without having the alarming +conditions of sunstroke. + +_Unconsciousness from Poisoning._--Opium and its preparations, including +morphine, chloral, and the two extracts of hyoscyamus, now so much +employed in asylums, namely, hyoscine and hyoscyamine, are medicines +frequently given, that poison in over-doses and produce coma. + +These medicines and their effects will be described in the next chapter, +and at the same time the symptoms of poisoning by them, and the treatment. + +_Poisoning._--Poisonous drugs are not kept upon the wards. Attendants +frequently have strong ammonia in their rooms to clean their clothing, and +a patient may get it and drink it. It is a strong alkali, and burns the +throat and mouth. Vinegar is the best ready antidote, but should be given +immediately or not at all. Soft soap is a strong alkali, and if eaten +becomes an irritating poison. Again vinegar is the best antidote. + +The best antidotes for acids are soda, lime-water, soap-suds, and chalk; +for alkalies, weak acids, such as lemons, oranges, vinegar, or cider. +Olive oil, eggs, and mucilaginous drinks are the most bland and soothing +remedies to give. To vomit a person who has taken poison, give a pint or a +quart of lukewarm water; to it may be added one or two teaspoonfuls of +mustard. Syrup of ipecac is a common remedy, the dose is a teaspoonful, +and repeated in ten minutes if necessary. It assists vomiting to tickle +the throat with a finger or a feather. If after poisoning there is +depression or approaching coma, very strong tea or coffee is the best +stimulant, and it is as well an antidote to many poisons. If the heart and +pulse are very weak, whiskey diluted with water may be given and repeated. + +_Injury from Eating Glass._--Patients sometimes eat glass. This injures by +the edges cutting and inflaming the walls of the stomach and intestines. +This may be so severe as to cause death. In the treatment do not give an +emetic or a cathartic. Such food as has a tendency to constipate the +bowels, and such as will also enclose the glass and coat its sharp edges, +is to be given. Potatoes, especially sweet, oatmeal, or thick indian-meal +pudding, are appropriate. Cotton, which is generally at hand, will, if +swallowed, engage the glass in its fibres, and so protect from injury. + +_Injury with Needles._--This is a self-injury, but it may be severe and +require immediate attention. Patients may open a vein or an artery with a +needle, or plunge it into the eye. But the more common way is for a +patient to stick many needles under the skin, sometimes to the number of +several hundred. Sometimes patients introduce them near the heart or +lungs, and as a needle will often "travel" when in the flesh, it may work +its way into a deeper part, and so a number get into the lungs or the +heart, causing death. Within a few weeks I saw two needles taken from a +man's heart, who died in consequence of their presence there. An attempt +or desire to so injure one's self should be guarded against by the +attendants, and if accomplished should be at once reported to the +physician, that efforts may be made to extract the needle. + + + + +CHAPTER X. + +SOME SERVICES FREQUENTLY DEMANDED OF ATTENDANTS, AND HOW TO DO THEM. + + +_The Administration and Effect of Medicine._--The only proper way of +giving medicine is by using standard weights and measures. Dropping +medicine, or using spoons or cups, is not sufficiently accurate. A drop +may be half a minim, or as large as two or even three. The modern teaspoon +holds ninety or more minims, and a tablespoon more than half an ounce. + +Medicines are introduced into the system through the stomach, the lungs, +the rectum, the skin, or by being injected into the tissues, under the +skin. They are either local or general in their effects. A blister or a +poultice is a local remedy, so is an emetic, that acts by irritating the +walls of the stomach. General medicines are absorbed into the blood, and +carried to different parts of the body. + +The following are a few of the reasons for which medicine is given: to +relieve pain, to give sleep, to produce vomiting, to check vomiting, to +move the bowels, to check diarrhoea, to assist digestion, to produce a +greater or diminished flow of urine, to increase the perspiration, to +increase the red blood corpuscles, to check hemorrhage, to regulate the +action of the heart, to overcome the effects of poison, to increase or +diminish the amount of blood in the brain, to control spasm, to diminish +the temperature in fever. + +In some cases the effect desired and expected from a medicine given to a +patient is told to the attendant, who should closely observe and be able +to report the result. Sometimes medicines are left in the hand of the +attendant, to give in repeated doses, at stated intervals, till a desired +effect is produced. The attendant is also instructed to watch for certain +symptoms which show that the medicine is doing harm, when it is to be +discontinued. An attendant, who has studied and learned, "how and what to +observe" in his patient, will be able to give intelligently any medicine +ordered by a physician. + +Sometimes medicines, given in large or long-continued doses, cause +symptoms that an attendant should notice and report to the physician; some +of these are, eruptions on the face and body, puffiness about the eyes, +irritation and running of the eyes, a metallic taste in the mouth, +bleeding of the gums or soreness of the teeth and profuse flow of saliva, +nausea, vomiting, diarrhoea, constipation, indigestion, ringing of the +ears, feeling of fulness in the head, headache, dizziness, drowsiness, +coma, convulsions, or convulsive movements of muscles. + +In asylums, medicines are mostly sent to the wards in single doses, each +cup or bottle being marked with the name of the patient for whom it is +intended. The tray in which they are carried should never be set down and +left, for a mischievous or suicidal patient may poison himself by taking +every thing he can get hold of. + +No patient, unless ordered by the physician, should be allowed to keep +his cup and take his medicine at his leisure. Suicidal patients often ask +to do this, and then save the medicine, until they have enough to poison +themselves. Others will throw the medicine away. The way to administer +medicine to the insane is to give it personally to the patient, and also +see that it is swallowed. It is a frequent custom of many patients to +retain the medicine in the mouth, and, when the attendant has left, to +spit it out. + +It is often very important that patients should take the medicine ordered, +and every effort should be made to induce them to take it. Such patients +should be designated by the physician. Night medicines, or those given +about bedtime, are usually of great importance. All patients who refuse to +take their medicine should be reported to the physician. + +The reasons for refusing medicines are various; some say they are +perfectly well and need no medical treatment, others think the medicine +injures them, that it turns their skin black, or poisons them, or that it +is wrong to take it, or displeasing to God; ideas much like those that we +learned were the causes for the refusal of food. Attendants are to use +every effort to get patients to take medicine, and may employ as much +force as they were instructed to use in giving food, but no more. + +Patients should not be deceived about medicines, nor told by attendants +that it is nothing, that it is only a little water, or some nice drink +that is sent to them, nor should an attempt be made to give them, by +trying to disguise them in food or drink, except by the permission of a +physician. Patients should, on the other hand, be told that it is +medicine, that the doctor ordered it for them, that it is for their good +to take it, that it is given to help them get well. + +The giving of medicine and food is among the most important and frequent +duty that an attendant is called upon to perform, or assist others in +doing. Attendants must remember that many medicines are injurious or even +poisonous, if not properly given, or if mixed with other medicines, or if +given to the wrong patient; they should therefore, never make a mistake, +or, if by carelessness they commit one, should immediately report it. + +_Opium and Some of its Preparations._--Opium is a medicine that is very +frequently given to patients in an asylum. The ordinary dose is one grain. +_Tincture of opium, or laudanum_, is opium dissolved in alcohol. Ten +minims equal one grain of opium. _Camphorated tincture of opium, or +Paregoric_, is a weaker alcoholic solution, with some camphor, and +flavored with a pleasant aromatic. One half a fluid ounce equals a grain +of opium. _Morphine_ is a white powder extracted from opium. An eighth of +a grain about equals a grain of opium. + +Opium, in some of its forms, is a common household remedy. To an adult, +not more than one grain should be given; it should not be repeated more +than once, nor less than six hours after the first dose. It would be +better if never given, except by a physician's order. Under no +circumstances should any one but a physician give it to a weak or old +person, or to a young child. + +Opium, is given in ordinary doses to relieve pain, to check diarrhoea, +to relax spasm of muscles, and to produce sleep. The sleep from opium is +generally quiet and refreshing, and one from which the patient can be +easily aroused. + +An attendant will frequently be told when the medicine is given and +directed to note and report its effect. + +_Opium Poisoning._--The taking of opium is a frequent way of committing +suicide by persons outside of asylums. Sometimes patients manage to save +their doses, or they steal it from the tray, or, if there is some sent to +the ward for repeated doses, they secure it through the carelessness of an +attendant, or occasionally it is secretly sent to patients by officious +outside friends,--thus poisoning by opium sometimes occurs among asylum +patients. + +The full symptoms of poisoning are profound coma, pupils contracted to +pin-points, and which do not respond to light; very slow respiration, +often not more than four or six times a minute, but heavy and labored. +Sometimes the effect of the drug is but partial, the patient can be +aroused for a moment, but falls to sleep again, or the symptoms may be +even less pronounced. + +The treatment of opium poisoning, before the physician comes, consists in +giving _very_ strong coffee, or tea, an emetic, and in trying to keep the +patient awake by walking him about, or, if this is not possible, to keep +him from falling into deeper coma, by shaking, calling loudly in the ear, +and striking and slapping the body with wet towels. + +_Chloral._--This is a white crystal, with a pungent, burning taste. It is +always dispensed, dissolved in water, and should be further diluted when +given to a patient. The dose is from ten to thirty grains. It is too +powerful a drug to be given, except upon the order of a physician. +Chloral is given to produce sleep, which is usually quiet and natural. The +effect lasts about four or six hours. + +The symptoms of poisoning are not so marked as to make it easy to know +that they are caused by chloral. There is generally a weak heart and +pulse, and feeble respiration, and the patient is in a deep sleep, from +which he may be aroused; or the coma may be profound, and continue +uninterrupted till death. + +The treatment consists in giving an emetic, stimulants, coffee, and, if +necessary, performing artificial respiration. + +_Hyoscyamine and Hyoscine._--These are extracts, from the leaves and +seeds, of the plant hyoscyamus. + +These are very powerful medicines, and are never given except on the order +of a physician. They are always given in solution. + +The action of both is practically the same. In ordinary doses they quiet +restlessness, produce muscular weakness, flushing of the face, dryness of +the tongue, wide dilatation of the pupils, and frequently cause sleep. +These effects should be noticed and reported. These medicines are mostly +given to patients who are continually restless, violent, and sleepless, +and the object is to bring quiet, repose, and sleep. Large doses may +produce coma, very heavy breathing, and great muscular weakness; the pulse +however is full and strong, but if it should fail, the physician should be +at once sent for. + +_Alcohol and Stimulants._--It is the alcohol in liquors that intoxicate, +and it is that part, also, of liquor that stimulates when given as a +medicine. Whiskey, brandy, and gin are about one half alcohol. The dose is +a tablespoonful, in water, and not repeated oftener than two or three +times. Wines are about one fifth alcohol, beers and cider about one +twentieth. + +Liquors containing alcohol are never to be given to patients as a +beverage, but always as a medicine, and, except in emergencies, never +without a physician's order. Do not give them in emergencies, without a +good reason for so doing, and not simply because you feel you must do +something, for in some emergencies they may do a great deal of harm, and +perhaps, a fatal injury. + +Alcohol is mostly given to stimulate the action of the heart. A stimulant +is something "that arouses or excites to action." It is given (in the +doses just mentioned) in accidents, when the heart is very weak, the pulse +almost or quite imperceptible, the face pale and pinched, and the +extremities cold. + +In continued sickness, with exhaustion, stimulants are sometimes left with +the attendant to give, with directions about the size of the dose and its +frequency. If it quiet the patient, strengthen the heart and pulse, it is +doing good; but if restlessness comes on, the face becomes flushed, or if +the pulse is made more rapid and feeble, it is probably doing harm, and +should be discontinued, and the physician informed. + +_Dry and Moist Heat._--In applying heat, either dry or moist, to the +insane, care must always be used to protect the skin from being blistered. +This happens very easily when it is applied directly to old, feeble, +paralyzed, or paretic patients, and also to those who are too demented to +complain if they are being burned. Burns are very serious accidents among +this class of patients, and may, if they extend over a large surface, +even though not deep, heal with difficulty, and even prove fatal. + +Dry heat is applied by means of rubber bags filled with hot water, +hot-sand bags, bricks, or soapstones, and by the lamp bath. Moist heat by +hot baths, fomentations, turpentine stupes, and poultices. + +_Hot Baths and Wet Packing._--Hot baths are sometimes prescribed for +patients. The water should be about 100 degrees F., and, if ordered, +slowly increased to 110°. The patient is to be left in as long as +directed, which may be but a few minutes, or half an hour, or even longer. +Sometimes a blanket is ordered thrown over the tub, the head only being +uncovered. + +When the bath is being given, the pulse should be counted; if it become +weak and rapid, if the face become flushed, and the patient complains of +dizziness, or if the lips show venous congestion, the patient should be at +once removed, and, unless there is immediate recovery from these evil +effects, the physician should be informed. + +In giving a wet pack, the patient is wrapped in a sheet, without any +clothing, wet either in cold or warm water, as ordered, and then rolled in +a blanket, put to bed, and left in it as long as directed. + +These methods of treatment are frequently ordered by physicians for +patients who are restless, violent, and sleepless, with a view of giving +quiet and sleep. The attendant should observe and report the result. + +_Application of Cold._--The attendants are frequently ordered to apply ice +to some part of the body, for the purpose of producing local cold. The ice +should be broken into small pieces and put into a bladder, or rubber bag, +partly filling it. It remains sufficiently cold until all the ice is +melted. + +Another way is to put a piece of ice in a sponge and bathe the part. When +cold cloths or compresses are applied, the heat of the body soon warms +them, when they become warm applications and act as a poultice; they +should therefore be frequently changed. In applying moist dressings care +must be used not to have any leaking nor wetting of the bed or clothing. + +_Hypodermic Injections._--Morphine, hyoscyamine, or hyoscine, in solution, +are frequently injected under the skin. The direction to do this, and the +quantity to be given, will, in every case, be ordered by the physician. A +fold of the skin is held between the finger and thumb, while the needle +held in the other hand is quickly pushed straight under the skin to the +depth of about half an inch. Care should be used to inject no air, and not +to inject the contents of the syringe, into a vein. + +_Forcible Feeding with the Stomach-Tube._--Attendants are frequently +called upon to assist in the forcible feeding of patients, and in some +cases may themselves be directed to do it. The dangers of feeding are that +the pharynx may be filled with fluid, and the patient choke, or it may be +drawn into the lungs, that the wedge with which the mouth is held open may +be so loosely held that in the struggle of the patient the soft parts of +the mouth may be injured, and occasionally it happens that the mere +pressure of the tube causes choking. + +Attendants should watch the process of feeding, and particularly the face, +for symptoms of venous congestion, and report to the physician any thing +they see that denotes danger. + +In preparing for feeding, attendants must see that the food is properly +made ready. If any thing is to be mixed with milk, it should be mixed so +as to be perfectly smooth, without lumps, and so it will run easily +through the tube. If some concentrated food is used, it is better to put +it in a small quantity of milk, just enough to make it liquid, that it may +be given first. Medicines ordered for feeding are not to be mixed with a +large quantity of milk, but saved, that they may be given directly from +the dispensing bottle whenever the physician desires to do so. + +Every thing should be got ready for feeding before the physician arrives. +Upon a tray should be all the feeding apparatus--the food and medicine, +several spoons, and cups, and a pitcher. Near at hand should be plenty of +water, soap, and towels, and a tin basin. It is very provoking to have to +wait for many things to be brought after the patient has been got ready. + +Many patients are easily fed. Some like it, but some violently and +furiously resist. Such patients should be restrained to a chair fixed to +the floor, and the more securely this is done the more easily can they be +fed, and with less fatigue and danger of their being injured. + +The patient's clothing should be well protected from being soiled, by +towels about the neck, and a basin should always be held under the chin to +catch falling liquids and any thing vomited. The holding the head and +wedge is an important matter, and is some thing that belongs to the +attendant to do. The attendant stands behind the patient, and holds the +chin by the right hand, and with the left firmly grasps the wedge, which +is inserted straight into the mouth, between the back teeth, about two or +three inches. The wedge should be grasped with the palm upwards, and the +little finger and side of the hand should be pressed firmly against the +chin. If held in this way there is little danger that in violent +struggles, the wedge can be suddenly driven backward and wound and tear +the soft parts of the mouth. If the throat fills with fluid, the attendant +who holds the head should bend it far forward, that it may, if possible, +run out of the mouth. + +After feeding, patients' faces should be washed. They should be watched +for some time to see that they do not vomit, or, as is often the case, +that they do not make themselves vomit. + +There is no special difference in caring for a patient fed with a nasal +tube, except that the wedge is not used. + +If attendants are allowed to feed, they must remember all the dangers, and +guard against them. In introducing the tube, the forefinger of the right +hand is to be introduced at the same time, and, as the tube passes over +the tongue it is to be turned downward by the finger and _gently_ pushed +into the oesophagus. If there seem to be unusual difficulty in so doing, +severe and unusual struggling, or the slightest symptom of danger, cease +the effort to feed, and report to the physician. + +Of course no attendant would undertake to feed any patient unless ordered +to do so by the physician, which order would be given, if at all, only +after careful training and in cases easily fed. + +_Nutritive Enemata._--It is often necessary to feed patients by the +rectum. This is done by injecting food, to the amount of four or six +ounces. Care should be used to inject no air. The nozzle of the syringe +well oiled is to be gently introduced, and the fluid slowly forced into +the bowel. The patient should lie on the left side, near the edge of the +bed, with the knees well drawn up. If the patient resist, he must be +placed upon the back, the legs separated and firmly held. This may require +four or six attendants, but enough should always be at hand to thoroughly +and easily overcome the patient. Before giving the first injection of food +the bowels should be moved by an injection of soap and water. Sometimes +the injected food escapes from the rectum. The patient should be watched +to see if this happens. In such a case a long tube can be introduced into +the rectum, about four or six inches, and the food injected through it. +The tube should be well oiled, and introduced slowly and with gentle +force. + +Patients often thrive upon this way of feeding. The character of the food +will be ordered by the physician. + + + + +_PUBLICATIONS OF G. P. PUTNAM'S SONS._ + +STUDENTS' MANUALS. + +Manual of Prescription Writing. By MATTHEW D. MANN, M.D., late Examiner in +Materia Medica and Therapeutics in the College of Physicians and Surgeons, +New York. Revised edition. 16mo, cloth. $1.00. + +Manual of Practical Normal Histology. By T. MITCHELL PRUDDEN, M.D., +Director of the Physiologica, and Pathological Laboratory of the Alumni +Association of the College of Physicians and Surgeons, N. Y., etc. 16mo, +cloth. $1.25. + +Students' Manual of Venereal Diseases, being the University Lectures +delivered at Charity Hospital, B. I., during the Winter Session of +1879-80. By F. S. STURGIS, M.D., Clinical Lecturer on Venereal Diseases in +the Medical Department of the University of the City of New York, etc., +etc. Fourth edition. 16mo, cloth. $1.25. + +Students' Manual of Diseases of the Skin. By L. D. BULKLEY, M.D. Large +16mo. $1.25. + +Students' Manual of the Diseases of the Nose and Throat. By J. M. W. +KITCHEN, M.D. 16mo, illustrated, cloth. $1.00. + +Students' Manual of the Pharmacopoeia of the Diseases of the Throat. By +GEORGE M. LEFFERTS, M.D. $1.00. + +Students' Manual of Rational Electro-Therapeutics. By R. W. AMIDON, A.M., +M.D., Lecturer on Therapeutics at the Woman's Medical College of the N. 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Granger + +This eBook is for the use of anyone anywhere at no cost and with +almost no restrictions whatsoever. You may copy it, give it away or +re-use it under the terms of the Project Gutenberg License included +with this eBook or online at www.gutenberg.org + + +Title: How to Care for the Insane + A Manual for Nurses + +Author: William D. Granger + +Release Date: August 21, 2011 [EBook #37142] + +Language: English + +Character set encoding: ISO-8859-1 + +*** START OF THIS PROJECT GUTENBERG EBOOK HOW TO CARE FOR THE INSANE *** + + + + +Produced by The Online Distributed Proofreading Team at +https://www.pgdp.net (This file was produced from images +generously made available by The Internet Archive.) + + + + + + +</pre> + + + +<p> </p> +<div class="figcenter"><img src="images/cover.jpg" alt="" /></div> +<p> </p><p> </p> + + +<h1>HOW TO CARE FOR THE<br />INSANE</h1> +<p class="center"><span class="huge">A MANUAL FOR NURSES</span></p> +<p> </p> +<p class="center"><small>BY</small><br /> +<span class="large">WILLIAM D. GRANGER, M.D.</span><br /> +<small>PROPRIETOR-PHYSICIAN, VERNON HOUSE, MT. VERNON, N. Y.</small></p> +<p class="center"><small>FORMERLY FIRST ASSISTANT PHYSICIAN BUFFALO STATE HOSPITAL, BUFFALO, N. Y.<br /> +MEMBER AMERICAN ASSOCIATION OF SUPERINTENDENTS OF HOSPITALS FOR<br /> +THE INSANE. MEMBER NEW YORK NEUROLOGICAL SOCIETY.</small></p> +<p> </p> +<p class="center"><i>SECOND EDITION. REVISED.</i></p> +<p> </p> +<table border="0" cellpadding="0" cellspacing="0" summary="table"> +<tr><td colspan="3" align="center">G. P. PUTNAM’S SONS</td></tr> +<tr><td align="center"><small>NEW YORK</small></td><td><span class="spacer"> </span></td><td align="center"><small>LONDON</small></td></tr> +<tr><td align="center"><small>27 WEST TWENTY-THIRD ST.</small></td><td> </td><td align="center"><small>27 KING WILLIAM ST., STRAND</small></td></tr></table> +<p class="center">The Knickerbocker Press<br /> +1891</p> + +<p> </p><p> </p> +<p class="center">COPYRIGHT<br /> +G. P. PUTNAM’S SONS<br /> +1886</p> +<p> </p> +<p class="center">Press of<br /> +<span class="smcap">G. P. Putnam’s Sons</span><br /> +New York</p> + + +<p> </p><p> </p> +<hr style="width: 50%;" /> +<p><span class="pagenum"><a name="Page_i" id="Page_i">[Pg i]</a></span></p> +<h2>NOTE TO SECOND EDITION.</h2> + +<p> </p> +<p class="dropcap"><span class="caps">At</span> the time of starting a training school, in 1883, the author was unaware +that like work was commencing at the McLean Asylum, Somerville, Mass., by +Dr. Campbell Clark and others in Scotland, and in New South Wales.</p> + +<p>Each was independent, and each worked out the problem independently. Thus, +far separated efforts showed the time had come when attendants must be +evolved into trained nurses.</p> + +<p>The most gratifying feature has been the unanimous approval by American +superintendents and the establishment of training schools in almost every +asylum in the land, often under the most difficult conditions and at a +great sacrifice of the precious time and strength of the medical staff.</p> + +<p>The increasing number of these schools and pupils demands a second edition +of this little manual.</p> + +<p><span style="margin-left: 2em;"><span class="smcap">Vernon House, Mt. Vernon, N. Y.</span>,</span><br /> +<span style="margin-left: 4em;">March 21, 1891.</span></p> + +<p><span class="pagenum"><a name="Page_ii" id="Page_ii">[Pg ii]</a></span></p> + + +<p> </p><p> </p> +<hr style="width: 50%;" /> +<p><span class="pagenum"><a name="Page_iii" id="Page_iii">[Pg iii]</a></span></p> +<h2>INTRODUCTION.</h2> + +<p> </p> +<p class="dropcap"><span class="caps">The</span> writer began in October, 1883, at the Buffalo State Asylum for the +Insane, a course of instruction to the women attendants upon their duties +and how best to care for their patients. This has been regularly continued +till it has become a fixed part of the asylum life, and has developed into +a system of training, and now a class of attendants has nearly completed +its studies. Since July, 1885, instruction has been given to men +attendants.</p> + +<p>In April, 1885, the Superintendent, Dr. J. B. Andrews, who had encouraged +the school from its conception, asked the Board of Managers to officially +recognize it. They adopted the recommendation and fixed the qualifications +for admission, the pay and privileges of its members, and provided for a +certificate as a trained nurse and an attendant upon the insane, to be +given to all, who at the end of two years successfully finished the full +course of instruction.</p> + +<p>The writer believes that all attendants should be regularly instructed in +their duties, and the highest standard of care can be reached only when +this is done. He also believes that every person who is allowed to care +for the insane will be greatly benefited by such instruction, and<span class="pagenum"><a name="Page_iv" id="Page_iv">[Pg iv]</a></span> will be +able to learn every thing taught, if the teacher uses simple methods and +is patient to instruct.</p> + +<p>As a rule they enter upon the study with interest, and soon a skilled +corps is formed, who are competent to fill the responsible positions, and +control the unstable class that drift in and out of an asylum. Even the +dullest are awakened to new zeal, and are advanced to positions of trust +they could not otherwise have filled.</p> + +<p>A brief outline of the course of instruction of the school may be of +interest.</p> + +<p>The first year is spent in learning the routine of ward work and filling +minor positions. The attendants are changed from ward to ward, and have +the care of all classes of the insane.</p> + +<p>They first receive instruction in the printed rules of the asylum. Every +rule relating to the duties of attendants is read and explained, and +special attention is called to the performance of the following duties:</p> + +<div class="blockquot"><p><i>a.</i> Duties to officers.</p> + +<p><i>b.</i> Duties to each other.</p> + +<p><i>c.</i> Duties to patients.</p> + +<p><i>d.</i> Duties to the institution.</p></div> + +<p>Thus the new attendants early get an outline of their duties in the +special care of the insane.</p> + +<p>After this comes instruction in elementary anatomy and physiology. They +are taught of the bones, joints, muscles, and organs of the body, food and +digestion, the circulation and respiration, waste and repair, animal heat, +and the nervous system.</p> + +<p>In order to be ready for advanced instruction the elements of physiology +must be thoroughly learned. The<span class="pagenum"><a name="Page_v" id="Page_v">[Pg v]</a></span> teaching must be adapted to the ability +and wants of those instructed. Having fixed the limit of duties required +of an attendant, it is easy to fix the limit of instruction. It is an +error to teach too much medicine, for then we begin to make physicians. +All that is needed is attendants who are able to do their work +intelligently, and, keeping this object in mind, lectures by a physician, +devoid of too much detail, but simple, direct, and plain, are better than +instruction from any of the text-books. With notes of the lectures +furnished, and with repeated recitations, any lesson is readily learned. +This way of instructing, by lectures, notes, and recitations, is continued +throughout the entire two years.</p> + +<p>A course in hygiene follows the lectures in physiology.</p> + +<p>Instruction in these three studies occupies the first year. An attendant +who, at the end of this time, successfully passes an examination in them, +and who has been faithful in his duties, is ready to receive the advanced +instruction of the second year. This includes the nursing of the sick, the +management of emergencies, and finally the special work of caring for the +insane. The wits of an attendant upon the insane have to be sharpened in +many directions not required of a general nurse. The text-books on nursing +may properly be followed by another, which shall aid one skilled as a +nurse to perform the varied and difficult duties incident to the care of +the insane and the wards of an asylum. To furnish this is the object of +this manual.</p> + +<p>A brief review of the physiology of the nervous system is introduced for +the aid of students, in reading the chapters on the mind and insanity.</p> + +<p><span class="pagenum"><a name="Page_vi" id="Page_vi">[Pg vi]</a></span>To teach any thing metaphysical or pathological may seem questionable. The +class, however, has not only been interested in the simple study of the +phenomena of the mind, but has been able to comprehend and profit by the +lectures on this subject.</p> + +<p>The lectures on the care of the insane were given to the class almost as +they appear in these pages. The suggestion was made that if they were +printed they would find a place in the hands of attendants in other +asylums. This is the reason of their publication.</p> + +<p>To my colleague, Dr. A. W. Hurd, I wish to tender my thanks for the +valuable assistance he has given me in the preparation of this manual. I +am greatly indebted to Dr. Andrews for his ever kind but critical advice. +But for his encouragement and help neither the work of instruction nor the +preparation of these pages would have been begun, nor success, if success +be gained, achieved.</p> + + +<p> </p><p> </p> +<hr style="width: 50%;" /> +<p><span class="pagenum"><a name="Page_vii" id="Page_vii">[Pg vii]</a></span></p> +<h2>CONTENTS.</h2> + +<table width="65%" border="0" cellpadding="0" cellspacing="5" summary="table"> +<tr><td> </td><td align="right"><small>PAGE</small></td></tr> +<tr><td><span class="smcap">Introduction</span></td><td align="right"><a href="#Page_iii">iii</a></td></tr> +<tr><td> </td></tr> +<tr><td align="center"><a href="#CHAPTER_I">CHAPTER I.</a></td></tr> +<tr><td><span class="smcap">The Nervous System and Some of its More Important Functions</span></td> + <td align="right"><a href="#Page_1">1</a></td></tr> +<tr><td class="dent">Nerve Centres.—Brain and Spinal Cord.—The Nerves.—Nerve +Cells and Fibres.—Motor and Sensory Nerves.—The Five Organs of Special Sense.—Nerve Impulses.—The +Brain and Nervous System Always Busy.—Need of Rest.</td></tr> +<tr><td> </td></tr> +<tr><td align="center"><a href="#CHAPTER_II">CHAPTER II.</a></td></tr> +<tr><td><span class="smcap">The Mind and Some of its Faculties</span></td> + <td align="right"><a href="#Page_7">7</a></td></tr> +<tr><td class="dent">Mind and Matter.—Life.—Relation of Mind and Brain.—Faculties +of the Mind.—Intellectual Faculties.—Will.—Emotions.—Instincts.—Moral Faculties.</td></tr> +<tr><td> </td></tr> +<tr><td align="center"><a href="#CHAPTER_III">CHAPTER III.</a></td></tr> +<tr><td><span class="smcap">Insanity; or, Disease of the Mind</span></td> + <td align="right"><a href="#Page_13">13</a></td></tr> +<tr><td class="dent">Insanity a Change.—Involves Disease of the Brain.—Delusions.—Hallucinations.—Illusions.—Incoherence.—Mental +States.—Mania.—Melancholia.—Dementia.—Monomania.—Emotional Insanity.—Dipsomania.—Moral Insanity.</td></tr> +<tr><td> <span class="pagenum"><a name="Page_viii" id="Page_viii">[Pg viii]</a></span></td></tr> +<tr><td align="center"><a href="#CHAPTER_IV">CHAPTER IV.</a></td></tr> +<tr><td><span class="smcap">The Duties of an Attendant</span></td> + <td align="right"><a href="#Page_22">22</a></td></tr> +<tr><td class="dent">What an Attendant Should First Learn.—The Relation of Attendants to Patients.—The Character of an Attendant.—Relation +to the Institution.—How and What to Observe.—Systematized Plan of Observation.—Control and Influence +of Attendants over Patients.—Care and Study of the Individual.—Liberty to be Allowed Patients.—Self-Control of Patients to be Encouraged.</td></tr> +<tr><td> </td></tr> +<tr><td align="center"><a href="#CHAPTER_V">CHAPTER V.</a></td></tr> +<tr><td><span class="smcap">General Care of the Insane</span></td> + <td align="right"><a href="#Page_33">33</a></td></tr> +<tr><td class="dent">Reception of New Patients.—Work and Employment.—Patients’ +Care of Themselves.—Walking.—Clothing.—Bathing.—Serving of Food.—Bed and Rising Time.—Night Care.</td></tr> +<tr><td> </td></tr> +<tr><td align="center"><a href="#CHAPTER_VI">CHAPTER VI.</a></td></tr> +<tr><td><span class="smcap">Care of the Violent Insane</span></td> + <td align="right"><a href="#Page_45">45</a></td></tr> +<tr><td class="dent">Need of Studying Each Case.—Constant Attention and Oversight.—Value of Employment and Out-Door Exercise.—Restriction +and Idleness.—Paroxysms of Violence; How Cared For.—How to Hold or Carry a Patient.—Danger of +Injury.—Struggles to be Avoided.—Care of Destructive Patients.—Use of Restraint, Seclusion, and Covered Bed.</td></tr> +<tr><td> </td></tr> +<tr><td align="center"><a href="#CHAPTER_VII">CHAPTER VII.</a></td></tr> +<tr><td><span class="smcap">Care of the Homicidal and Suicidal Insane, and of Those Inclined to Acts of Violence</span></td> + <td align="right"><a href="#Page_53">53</a></td></tr> +<tr><td class="dent">Delusions of Suspicion.—Homicidal Patients.—Suicidal Patients.—Self-Mutilation.—Incendiary Patients.</td></tr> +<tr><td> <span class="pagenum"><a name="Page_ix" id="Page_ix">[Pg ix]</a></span></td></tr> +<tr><td align="center"><a href="#CHAPTER_VIII">CHAPTER VIII.</a></td></tr> +<tr><td><span class="smcap">Care of Some of the Common Mental States and the Accompanying Bodily Conditions</span></td> + <td align="right"><a href="#Page_60">60</a></td></tr> +<tr><td class="dent">Care in the Earlier Stages.—Insanity with Exhaustion.—Symptoms of Danger.—Care of Dementia, Early Dementia, +Chronic or Terminal Dementia.—Convalescence.—Relapse.—Epilepsy.—Paresis.—Care +of Paralytics, the Helpless, the Bed-ridden.—Bed-Sores.</td></tr> +<tr><td> </td></tr> +<tr><td align="center"><a href="#CHAPTER_IX">CHAPTER IX.</a></td></tr> +<tr><td><span class="smcap">Some of the Common Accidents among the Insane, and the Treatment of Emergencies</span></td> + <td align="right"><a href="#Page_71">71</a></td></tr> +<tr><td class="dent">Certain Classes of Insane Liable to Injury.—Fractures.—Wounds.—Bites.—Blows on the Head—Cut Throat.—Wounds +of the Extremities with Hemorrhage.—Sprains.—Choking.—Artificial Respiration.—Burns.—Frost-bites.—States +of Unconsciousness.—Apoplexy.—Sunstroke.—Poisoning.—Eating Glass.—Injury with Needles.</td></tr> +<tr><td> </td></tr> +<tr><td align="center"><a href="#CHAPTER_X">CHAPTER X.</a></td></tr> +<tr><td><span class="smcap">Some Services Frequently Demanded of Attendants and How to do Them</span></td> + <td align="right"><a href="#Page_85">85</a></td></tr> +<tr><td class="dent">Administration and Effects of Medicine.—Opium, Chloral, Hyoscine, and Hyoscyamine; Doses, Effects, Poisoning, +Treatment.—Stimulants.—Applications of Heat and Cold.—Baths and Wet Packing.—Hypodermic Injections.—Forcible +Feeding with Stomach-Tube.—Nutritive Enemata.</td></tr></table> + + +<p> </p><p> </p> +<hr style="width: 50%;" /> +<p><span class="pagenum"><a name="Page_1" id="Page_1">[Pg 1]</a></span></p> +<p class="center"><span class="giant">HOW TO CARE FOR THE<br />INSANE.</span></p> +<p> </p> +<h2><a name="CHAPTER_I" id="CHAPTER_I"></a>CHAPTER I.</h2> +<p class="center"><span class="large">THE NERVOUS SYSTEM AND SOME OF ITS MORE IMPORTANT FUNCTIONS.</span></p> + +<p> </p> +<p class="dropcap"><span class="caps">The</span> nervous system is made up of a nerve centre and nerves.</p> + +<p>The great nerve centre is the <i>Brain</i> and <i>Spinal Cord</i>.</p> + +<p>The brain is a body weighing about forty ounces, and fills a cavity in the +upper part of the skull. The spinal cord, commonly called spinal marrow, +is directly connected with the brain. The skull rests upon the spinal +column, or backbone, and there is a cavity inside the whole length of this +column, which contains the cord. There is an opening through the base of +the skull where it rests upon the spinal column, and it is through this +opening that the fibres of the cord go, to pass into and become a part of +the brain. These most important parts are carefully protected by a strong +bony covering.</p> + +<p>Many nerves are given off from the brain and cord and go practically +everywhere, so that every part of the body is supplied with them. These +nerves are white cords of different sizes; the largest nerve of the body, +the one<span class="pagenum"><a name="Page_2" id="Page_2">[Pg 2]</a></span> that goes to the leg, called the sciatic, is as large as the +little finger.</p> + +<p>There are really two brains and two cords, as along the central line of +the body there is a division of the brain and cord, making two halves +exactly alike. These halves are connected together, the division not being +complete.</p> + +<p>Nerves are given off in pairs; for example, from either side of the brain +arises a nerve that goes to each eye. So two nerves exactly alike spring +from the two sides of the spinal cord, going to each arm.</p> + +<p>A nerve is composed of a bundle of fibres, microscopic in size. As a nerve +passes to the extremities it divides by branching much as does an artery, +and thus a bundle of fibres is distributed to a muscle, or a part of the +skin, or to an organ, and every part of the body has a direct nerve +supply, much as you saw in the microscope it was supplied with blood by +means of the capillaries. We cannot prick our finger with the finest +needle but nerve, fibres are irritated, and we feel it, and capillaries +are injured and we get a drop of blood.</p> + +<p>Most of the nerves that go to the arms, legs, and organs of the chest and +abdomen, arise in and proceed from the spinal cord, but some of the fibres +begin in the brain and are continued down the cord, where, joining with +fibres that originate in the cord itself, both go to make up the nerve, +thus connecting all parts of the body with the great centre.</p> + +<p>The brain and cord are made up of blood-vessels, nerve cells, nerve +fibres, and, holding them all together, connective tissue. The cells are +very small, being microscopic in size; there are an immense number of +them,<span class="pagenum"><a name="Page_3" id="Page_3">[Pg 3]</a></span> and they make up most of the gray matter or outside of the brain, +but in the spinal cord the gray matter is in the centre. The fibres that +go to make up the nerves begin and spring from the cells, and they also +unite them together.</p> + +<p>The cells are gathered into groups, which have each a separate function to +perform. There is a group from which the nerve of the eye proceeds; +another for the nerve that goes to the ear; another for the nerve that +goes to the arm; and another for the nerve of the heart. There is a group +that presides over speech, and other groups that preside over mental +action, while all of these are connected together by fibres. Thus it +appears that the brain is a true “centre,” and the nerves but the means of +connection between different parts of the body and the brain, and also +between different parts of the brain.</p> + +<p>Nerves have two special functions: one to carry impressions made upon the +fibres, that end in the different parts and organs of the body, to the +brain; another to carry from the nerve cells so-called “nerve impulses,” +to the different parts and organs of the body. Some nerves have in +themselves these two functions, as the nerves that go to the arm or leg; +others have but one, as the optic or eye nerve, which can only carry the +sensation of sight from the eye to the brain.</p> + +<p>The nerves that carry sensations to the brain are called <i>Sensory Nerves</i>. +The nerves that carry motor impulses from the brain are called <i>Motor +Nerves</i>.</p> + +<p>There are five special organs of sense, each receiving different +impressions, and sending by its sensory nerve or<span class="pagenum"><a name="Page_4" id="Page_4">[Pg 4]</a></span> nerves a different +character of sensation to the brain, namely:</p> + +<div class="blockquot"><p>The eye, giving sensations of light and color.</p> + +<p>The ear, giving sensations of sound.</p> + +<p>The nose, giving sensations of smell.</p> + +<p>The mouth, giving sensations of taste.</p> + +<p>The skin, giving sensations of touch, with ideas of roughness, +smoothness, hardness, softness, heat, and cold.</p></div> + +<p>There must be, in every case, a direct nerve connection from the organ of +special sense to the special group of cells in the brain to which the +nerve goes. If the connection is broken at any point, the impression made +upon the fibres in the organ of sense cannot reach the brain. Only after +the impression reaches the brain and the cells are affected, do we become +conscious of a sensation. We then say, as the case may be, I see, or hear, +or smell, or taste, or feel something.</p> + +<p>It thus appears that these organs of sense simply receive the impressions +made upon them to transmit to the brain, and it is really the brain that +sees, hears, smells, tastes, and feels. By the action of the organs and +nerves of special sense we get all our knowledge of the external world, +and, probably, if we had no organs of sense, we would have no +consciousness of our existence.</p> + +<p>Pain is due to abnormal action of sensory nerves, caused by disease, +injury, or pressure, and the irritation made, being carried to the brain +makes us conscious of the peculiar sensation we call pain. So the want of +food or water makes an impression upon nerves, which being carried to the +brain causes a peculiar sensation, and we say we feel hungry or thirsty.</p> + +<p><span class="pagenum"><a name="Page_5" id="Page_5">[Pg 5]</a></span>The <i>Motor Nerves</i> arise in the cells of the brain and cord. Those which +go to the voluntary muscles cause them to contract, and are under the +control of the will. If the cells are diseased, if they do not get enough +arterial blood, or are poisoned by carbonic acid, or if the nerves are +diseased, injured, or cut, so that nerve impulses cannot be sent from the +brain to the muscles, we have paralysis of a muscle or a group of muscles, +according to the extent of the injury. Now we can appreciate the force of +this teaching in the physiology of the muscular system, that “paralysis is +a loss of power, either partial or complete, to contract muscles, due to +disease of the nerves.”</p> + +<p>By the ready action of our mind, the quick working of our will, we direct +and control the action of our muscles, so as to perform with the utmost +skill and ease the varied and innumerable movements of our body.</p> + +<p>It seems very easy to do this, but watch a child learning to walk; it is +educating its mind and will to control the muscles, and it is a slow and +difficult education.</p> + +<p>But all motor impulses and bodily activities are not under the control of +the will. The heart is supplied with motor nerves, but we cannot by our +will stop its beating or control its action. The taking of food makes a +mental impression, and without the will being involved, impulses are sent +to the glands of the mouth, setting them actively at work, and saliva +flows. So the stomach begins to churn food when it is introduced, and the +liver is kept at work making bile and sugar, and we breathe when we are +asleep.</p> + +<p>All the organs of the body are supplied with motor<span class="pagenum"><a name="Page_6" id="Page_6">[Pg 6]</a></span> nerves, that regulate +their action and give them the power to do their function or work, but +with the exception of the muscles, this power is sent without the action +of the will.</p> + +<p>Our brains are very busy. While we are awake we are constantly receiving +sensations, we are thinking, remembering, willing, and sending many +messages every minute, and directing power to all parts of the body. The +brain works and gets tired, just as the rest of the body gets tired, and, +if abused, injured, or overworked, may become diseased as may any part. +Its tissues wear out, are burned up, and require the same supply of +material to repair them that any other part of the body requires. It needs +then rest, good food, good blood, and plenty of oxygen.</p> + +<p>No wonder some brains give out, and fail to do their work properly, and so +cause insanity.</p> + + +<p> </p><p> </p> +<hr style="width: 50%;" /> +<p><span class="pagenum"><a name="Page_7" id="Page_7">[Pg 7]</a></span></p> +<h2><a name="CHAPTER_II" id="CHAPTER_II"></a>CHAPTER II.</h2> +<p class="center"><span class="large">THE MIND AND SOME OF ITS FACULTIES.</span></p> + +<p> </p> +<p class="dropcap"><span class="caps">We</span> know there is something we call mind, because we know something of its +way of working, or its faculties. What mind is we do not know, but we know +it is not matter, because matter is something that occupies space, and has +qualities that do not belong to mind. We say of mind, it reasons, +remembers, or wills; of matter, that it is hard or soft, or cold or +elastic, or that it has color; speaking always of the faculties of mind or +what it does, and of the qualities of matter, or what it is. We do not +know what matter is, only how it appears to us; we know it is not mind +because mind is something spiritual, and possessed of faculties or powers +that do not belong to matter.</p> + +<p><i>Mind and Matter</i> are the only forms of existence of which we have any +knowledge.</p> + +<p>We speak of matter as inorganic—that is, without life, as iron, water, +oxygen; and as organic, or matter plus something we call life. Life +appears in two forms, namely, vegetable and animal. The lowest forms of +animal life have no nervous system, but as we ascend in the scale the +nervous system appears, and becomes more and more complete.</p> + +<p>Man possesses the most perfect nervous system, has<span class="pagenum"><a name="Page_8" id="Page_8">[Pg 8]</a></span> the most perfect +brain, and also an intelligence far above that of any other animal, and is +endowed with some mental faculties that belong to him alone. The brain may +be said to be the organ of the mind, but we do not know what is the true +relation between them; that is, how the brain is acted upon by the mind, +or how the action of the mind affects the brain. Brain is matter, and very +solid matter as well, mind is immaterial, or spiritual, and the exact +connection between something material and something spiritual has never +been made out and never will be.</p> + +<p>Some say the brain makes mind a good deal as liver makes bile, or the +glands of the mouth make saliva, or the cells of the brain make motor +impulses, and if the brain does not act there is no mind made; so much +cell action, so much memory, reason, or will produced. But how, it is +immediately asked, is something material to make something immaterial? +Others say that mind is something, and has an existence of its own, and, +though spiritual, acts upon its organ, the brain, and by so doing, we are +conscious that we see, reason, remember, and will. But how, it is +immediately asked, does something immaterial act upon something material? +We do not know, and we probably never shall know. This intimate connection +between mind and matter exists during life only; it begins with life and +ends with life.</p> + +<p>We must then come back to the starting-point—there are two forms of +existence, mind and matter. We do not know what either really is, but only +the faculties or working of our minds, and the qualities or appearance of +matter.</p> + +<p><span class="pagenum"><a name="Page_9" id="Page_9">[Pg 9]</a></span>Mind thinks or remembers, reasons or wills, but these are faculties of the +mind; it is what the mind does, not mind itself. Gold is yellow, but +yellow is not gold; gold is hard, but hardness is not gold; these are +qualities of gold, and not gold itself.</p> + +<p>In the study of physiology you found the body divided into many parts, and +that these parts had each a separate function or duty to perform. In the +study of the mind, we find it has many different faculties or ways of +working. We did not study all the functions of the body, so we will not +study all the faculties of the mind.</p> + +<p>The mind is very complicated in its action, and difficult to understand. +Men study it all their lives and are not agreed about some of its simple +manifestations, and argue and even contend about their differences. There +are, however, some seemingly natural divisions of the faculties of the +mind, and a knowledge of these is sufficient for our purposes.</p> + +<p>We may say of the mind that it possesses:</p> + +<div class="blockquot"><p><i>a.</i> Intellectual faculties.</p> + +<p><i>b.</i> Will.</p> + +<p><i>c.</i> Emotions or feelings.</p> + +<p><i>d.</i> Instincts.</p> + +<p><i>e.</i> Moral faculties or conscience.</p></div> + +<p>The first three are commonly given as divisions of the mind; the last two +are included for convenience of teaching.</p> + +<p><i>The Intellectual Faculties</i> include those powers which in common language +are called “mind.” A few only will be considered—namely, the perceptive +faculty, consciousness, memory, and reason.</p> + +<p><span class="pagenum"><a name="Page_10" id="Page_10">[Pg 10]</a></span><i>The Perceptive Faculty</i> is the power of the mind to perceive or know the +sensations brought to the brain by the sensory nerves, from the organs of +sense, and the action of this faculty gives us a knowledge of the +existence and qualities of matter.</p> + +<p><i>Consciousness</i> is that faculty by which we know we perceive, reason, +remember, will, or possess emotions. By its operation we know that we +exist, have a mind, and what that mind does.</p> + +<p><i>Memory</i> is that faculty by which we are able to recall to consciousness +the knowledge we possess of past events.</p> + +<p><i>Reason</i> is that faculty by which we are able to make use of what we know +and to acquire new knowledge. For instance, I know the distance between +two places is sixty miles, and I know that the cars, going between the +places, travel at the rate of twenty miles an hour, and that they leave at +four o’clock. Without reason, I could never of myself, know the two new +facts, that it would require three hours to make the journey, and that the +arrival will be at seven o’clock. The faculty of reason is one of the most +distinctive of the human mind.</p> + +<p><i>The Will.</i>—In consequence of our perceptions, our consciousness, our +memory, our reason, we are in a condition to know a good deal of what is +about us, and of ourselves, and we desire to bring ourselves into relation +with the outside world, and therefore we act. There is a faculty of mind +that allows us to choose how to act, and this is called the will, or that +faculty of the mind “by which we are capable of choosing.” By the action +of the will, we direct and control the voluntary muscles and motions of +the body, while the action of the mind is also largely under its control.</p> + +<p><span class="pagenum"><a name="Page_11" id="Page_11">[Pg 11]</a></span>It may truly be said that unless we are under the compulsion of some +physical force, we always choose to do whatever we most wish to do. This +liberty of choosing is called “freedom of the will,” and because we are +free to choose, we are responsible for the consequences of our choice. We +say, in common language, a person is responsible for what he does, and +both human and divine law holds each to a strict accountability for his +conduct, because all are free to choose how they will conduct themselves.</p> + +<p><i>The Emotions or Feelings.</i>—The emotions are joy, love, grief, hatred, +anger, jealousy, and other like conditions, and we speak of them as +“natural,” because they appear without the operation of our intellect or +will, and the capacity for them seems to be a part of our existence. They +should, however, be under the control of reason and will, and a person who +gives way to his feelings, as of jealousy, and murders, is held +responsible by human and divine law. But though we control them, we cannot +prevent their action, and we must, as long as we live, feel love and joy, +be affected by grief, suffer from anger, or be jealous.</p> + +<p><i>Instincts.</i>—These belong largely to our animal nature; our appetites and +desires are instincts, and we speak of them as “natural.” Children want +food and drink before they know what it is they want, and birds in the +nest, open their little mouths for the worm their mother brings them.</p> + +<p>Appetites indulged in become strong, and are often uncontrolled by the +reason and will; as the indulged appetite for liquor. A strong and healthy +mind should<span class="pagenum"><a name="Page_12" id="Page_12">[Pg 12]</a></span> control the appetites, as we have learned it should control +the emotions, and we are justly held responsible for the consequences of +an indulged appetite.</p> + +<p><i>Moral Faculties.</i>—There exists in the mind of man a knowledge of right +and wrong, and a feeling of obligation to respect the rights of others. We +can hardly conceive of a man in his right mind who does not know it is +wrong to lie, or steal, or murder. The capacity to know right from wrong +is called conscience.</p> + +<p>Most people, perhaps all, have a feeling of relation and obligation to a +higher moral being than man. The feeling to do right because it is +pleasing to a God to whom we are directly responsible, is the foundation +of our religious convictions.</p> + +<p>The mind is a most complex affair, it is always active, nor is one faculty +at work and the rest idle, but many parts are at work at the same time, +and act and react upon each other. We may exercise our perceptive faculty, +or reason, memory, and will, and be affected by our feelings at the same +time. There is with it all a regulating power that coördinates or brings +these different actions into harmony, and we get the working of a healthy +mind.</p> + + + +<p> </p><p> </p> +<hr style="width: 50%;" /> +<p><span class="pagenum"><a name="Page_13" id="Page_13">[Pg 13]</a></span></p> +<h2><a name="CHAPTER_III" id="CHAPTER_III"></a>CHAPTER III.</h2> +<p class="center"><span class="large">INSANITY; OR, DISEASE OF THE MIND.</span></p> + +<p> </p> +<p class="dropcap"><span class="caps">In</span> common language we speak of the mind diseased.</p> + +<p>This is not strictly true, as it is the brain that is diseased and, in +consequence, we get disturbed mental action.</p> + +<p>Every person has individual characteristics. As no two faces are alike, so +the mind, character, and manner of no two are alike, and it is by the +manifestation of these, that each is known.</p> + +<p>When a person becomes insane there is always a change from his natural way +of thinking, feeling, and acting, due to disease of the brain. Sometimes +the change is slight, or concealed by the patient, and is apparent only to +near friends, or after a careful examination. Sometimes it is so great as +to attract immediate attention, when it may present the features of raving +madness, or of the most abject melancholy.</p> + +<p>To illustrate this change, we may suppose both a king and a pauper to +become insane: there is, of course, a vast difference between them, but +the king may be so changed by the disease as to believe that he is a +pauper, and himself and his family starving, and he may also wish and even +try to work and dig like a laborer to support them; or a pauper may think +himself a king, and try to act like one. Such conditions show a <i>marked</i> +change in<span class="pagenum"><a name="Page_14" id="Page_14">[Pg 14]</a></span> the manner of thinking, feeling, and acting, which involves +diseased action of the intellect, the emotions, and the will.</p> + +<p>Sometimes the appetites are also changed, or control over them is lost, +and sometimes the moral nature is affected as well, sometimes a single +faculty of the mind appears more disturbed than do others; it is, however, +doubtful, or at least denied, that one faculty can show such disturbed +mental action as to indicate insanity, and the rest of the mind appear +perfectly healthy and normal. With the changes that have been spoken of, +there is generally disturbances of the physical health, and often of a +marked character. It must be remembered that mere oddity of appearance or +eccentricity of conduct, however marked, if natural, do not of themselves +constitute signs of insanity.</p> + +<p><i>Some Mental Symptoms of Insanity.</i>—There are some important mental +symptoms which quite generally accompany insanity, and are found either +alone or combined in the individual case. These are:</p> + +<div class="blockquot"><p><i>a.</i> Delusions.</p> + +<p><i>b.</i> Hallucinations.</p> + +<p><i>c.</i> Illusions.</p> + +<p><i>d.</i> Incoherence of speech.</p></div> + +<p><i>Delusions</i> are false beliefs. We think a belief in the religion of +Mahomet is a delusion, but not an insane one. Insane delusions arise from +disease of the brain, and are a part of those mental changes that appear +during its progress. The king, who, under the influence of disease, thinks +himself a pauper and that he and his family are starving, and the pauper, +who thinks himself a king, with<span class="pagenum"><a name="Page_15" id="Page_15">[Pg 15]</a></span> all the wealth and power of one, have +each insane delusions.</p> + +<p>Some delusions are fleeting and changeable, lasting a few days, weeks, or +months, while others are fixed, lasting a lifetime; some are impossible +and beyond rational belief, as when a man thinks himself Queen Victoria, +or that his head is made of brass, or that he is dead, and yet sleeps and +eats and talks; other delusions are possible, as when a king thinks +himself a pauper, because such a thing may and even has happened, or when +a pauper thinks himself a king, because people of very low degree have +risen to such a station, but they are very improbable, and we do not +expect such things among Americans, much less among our patients. Other +delusions are not only possible, but relate to things that may or do +happen, or are within the bounds of a rational belief, as that of a person +who insists he has a cancer, or that he has committed the unpardonable +sin, or that poverty is impending and the poorhouse not far off; or that +of a woman that she has been violated, or that, when her child was sick +she so neglected it, that it died. Such beliefs as these are delusions, +when they have no other reason for their existence than that they are +caused by disease.</p> + +<p>Some delusions are called homicidal, suicidal, or dangerous, because they +cause a patient to do, or want to do, acts that are dangerous to himself +or others, or property.</p> + +<p><i>Hallucinations.</i>—When a patient has hallucinations, he thinks he sees, +hears, smells, tastes, or feels something, when there is really nothing to +cause the sensations or ideas except diseased action of the brain; nothing +being sent to the brain from any special organ of sense, he<span class="pagenum"><a name="Page_16" id="Page_16">[Pg 16]</a></span> really sees, +hears, smells, tastes, or feels nothing, it is all imagination, though +seemingly very real.</p> + +<p>For instance, a person thinks he hears a voice, perhaps that of God, or of +some one who is dead, or of an absent friend, or thinks he sees these +persons, when there is nothing external to the brain to excite the +sensation or give the idea.</p> + +<p><i>Illusions.</i>—When illusions are present, the mind fails to perceive +correctly what the eye sees, or the ear hears, or the impressions that are +brought to the brain from any of the organs of sense. For instance, a +person looks at a row of trees, and they appear to him to be a row of +soldiers; or the whistle of a locomotive may be so changed as to seem to +be the voice of God; or the odor of a rose, burning sulphur; food may +taste like poison, or the hand of a friend feel like a piece of ice or a +red-hot iron, and is so believed to be. These are deceptions of the +senses.</p> + +<p>In insanity, the truth and existence of delusions, hallucinations, and +illusions are fully believed in, and the patient cannot be argued out of +the belief, however absurd or unreal it may be.</p> + +<p><i>Incoherence of Speech.</i>—When a person is incoherent, he rambles in talk; +there is little connection between different sentences, or the sentence +itself is meaningless, being a mere jumble of words; sometimes ideas come +too rapidly into the mind, and some new subject is begun and talked about +before the first is finished; sometimes the mind is slow, and memory +forgets what is being talked about.</p> + +<p><i>General States of Insanity.</i>—There are a few general mental states in +insanity, one of which being present<span class="pagenum"><a name="Page_17" id="Page_17">[Pg 17]</a></span> gives the character and name to the +disease. These are:</p> + +<div class="blockquot"><p><i>a.</i> A state of exaltation of mind, or mania.</p> + +<p><i>b.</i> A state of depression of mind, or melancholia.</p> + +<p><i>c.</i> A state of enfeeblement of mind, or dementia.</p></div> + +<p>But one of these first two states of feeling can be present at the same +time, for a person cannot at any one moment be both exalted and depressed, +though he have mania to day, and afterward be so changed in his feeling as +to have melancholia to-morrow, or next week, or next month.</p> + +<p>In a general way all disease is divided into acute and chronic forms. An +acute disease is one of recent origin, and from which recovery is to be +hoped for; a chronic disease is prolonged and does not tend to recovery; +an acute disease may become chronic.</p> + +<p>Mania and melancholia are at first considered acute and curable, but, if +recovery does not take place, they pass into either chronic mania or +chronic melancholia, or, if the mind is much enfeebled, into a condition +of dementia.</p> + +<p><i>Mania.</i>—In mania the mind is generally very active, though lacking in +control, and is irregular and illogical in its action; the patient talks +rapidly, and upon many subjects, and is often incoherent, or he laughs, +sings, dances, or cries, perhaps in turn; he is often irritable and +unreasonable, and perhaps threatening, and becomes more violent if +interfered with.</p> + +<p>Accompanying this mental excitement there is frequently persistent loss of +sleep, constant restlessness, and great bodily activity, and indifference +to or refusal of<span class="pagenum"><a name="Page_18" id="Page_18">[Pg 18]</a></span> food. Sometimes the brain excitement is so great that +all self-control is lost, and the patient becomes a raving maniac.</p> + +<p>The delusions of mania are largely of grandeur and self-exaltation; the +patient thinks himself in the best of health, and very strong, or of a +superior mind, or, that he is a great singer, poet, actor, or preacher; +perhaps, taking a higher flight, he thinks himself possessed of the wealth +of Vanderbilt, or that he is the Pope, or the President, or even God +himself.</p> + +<p>Sometimes the excitement comes on in paroxysms, lasting a few days or +weeks, with periods, more or less prolonged, of comparative mental quiet.</p> + +<p><i>Melancholia.</i>—In melancholia the expression of the face often tells the +character of the disease; the eyes are downcast, the lines of the face are +lengthened, and the whole appearance is that of unhappiness.</p> + +<p>In this form of insanity the patient may refuse to speak or interest +himself in any thing, or he may moan, groan and cry, and walk back and +forth wringing his hands; when he is quiet, the mind, however, may be very +active and full of delusions, which occupy it to the exclusion of every +thing, driving away sleep, and making him indifferent to the taking of +food or attending to his most necessary wants; sometimes the patient talks +a great deal, but always about his delusions, which are generally +connected with himself, his family, or his affairs.</p> + +<p>Melancholiacs are often tortured by fears, and, therefore, become frenzied +and as wild and violent as in mania; or they may be very suspicious, +thinking that some one is persecuting them, or poisoning their food, or<span class="pagenum"><a name="Page_19" id="Page_19">[Pg 19]</a></span> +following to kill them. On account of their delusions they frequently +refuse food, they generally sleep poorly, and are often very suicidal.</p> + +<p><i>Dementia.</i>—This form of insanity is most frequently the result of acute +mania or melancholia, and comes after the force and intensity of the +disease has spent itself, leaving the mind crippled and weakened. The +perceptions are blunted and distorted, memory fails, the reasoning powers +are weakened, the will has ceased to control, the emotions and appetites +are dormant or changed, and the mind may become almost a blank, though in +the narrow circle of thought there is left remains of delusions, +illusions, and hallucinations. The patient is frequently careless of the +ordinary necessities and decencies of life, and requires constant care.</p> + +<p>There are degrees of dementia: it may be slight, partial, or nearly +complete. During the first few months or years dementia often ends in +recovery, but, as it continues, the case becomes more and more hopeless.</p> + +<p><i>Monomania.</i>—This is a term belonging to common speech, but there is not +an agreement of opinion as to the existence of such a special form of +insanity, nor among those who believe in it, as to what it is and what are +its symptoms.</p> + +<p>Monomania really means an insanity with but one, or, at most, a small +class of delusions of the same character, the rest of the mind showing no +disease. Hardly any one believes in the existence of such a narrow limit +to insanity, and, getting beyond this point, there is no agreement where +the limit should be set up to mark and bound it.</p> + +<p><span class="pagenum"><a name="Page_20" id="Page_20">[Pg 20]</a></span>Some think there is a special insanity of the emotions only, and call it +“emotional insanity.” There is not an agreement of opinion as to what +emotional insanity is; the idea seems to be that the emotions, or one of +them, so overpower reason and will as to make the person irresponsible. +This condition is supposed to exist without disturbances of the +intellectual faculties, and to be unaccompanied by delusions, +hallucinations, or illusions. Others see in these cases no evidence of +insanity; nothing but over-indulgence of the emotions, or a want of +exercise of self-control, or an excuse for crime.</p> + +<p>Some persons believe that the appetites over-indulged become morbid and +produce disease of the nervous system, and as a consequence the reason and +will are weakened in relation to this indulged appetite, and the opinion +is reached that it is a form of insanity. An indulged appetite for drink +is called dipsomania. Others believe that unless there are present the +usual symptoms, associated as they generally appear in insanity, these +cases are nothing but unbridled appetites or vices.</p> + +<p><i>Moral Insanity.</i>—There are those who claim that the moral nature alone +may be diseased, and the persons in whom this occurs are said to lose the +appreciation of right and wrong, or have an uncontrollable propensity to +do some wrong act, and take a peculiar pleasure in so doing. Special names +are given to these acts, according to their character, as “kleptomania, an +impulse that prompts to steal”; or “pyromania, love of setting things on +fire”; or “homicidal mania, an intense desire to kill.” Other persons +considering these cases and finding no delusions, or intellectual +disturbances, or change<span class="pagenum"><a name="Page_21" id="Page_21">[Pg 21]</a></span> in feeling, thinking, or acting due to disease, +call the condition one of crime only.</p> + +<p>These are difficult matters to understand, and those who make a life-study +of insanity do not fully understand them, or agree together as to what +they know. They are, however, terms of common speech, and it is well to +have some idea of them, as it will add interest to the study of the +patients under care and charge.</p> + + +<p> </p><p> </p> +<hr style="width: 50%;" /> +<p><span class="pagenum"><a name="Page_22" id="Page_22">[Pg 22]</a></span></p> +<h2><a name="CHAPTER_IV" id="CHAPTER_IV"></a>CHAPTER IV.</h2> +<p class="center"><span class="large">THE DUTIES OF AN ATTENDANT.</span></p> + +<p> </p> +<p class="dropcap"><span class="caps"><i>What</i></span> <i>an Attendant Should First Learn.</i>—The duties of an attendant upon +the insane are varied, arduous, and exacting; they are associated with +irritations, perplexities, and anxieties, bring grave responsibilities, +and call for the exercise of tact, judgment, and self-control.</p> + +<p>These many duties are not quickly nor easily learned, and the new +attendant must be willing to fill, at first, a minor position, to begin at +the beginning and learn gradually all the details of ward work; he must +acquire habits of caution and watchfulness, and learn in a general way the +care of the insane, before he can assume a position of authority over +other attendants, the control of a ward, and the responsibility of the +direct care of patients.</p> + +<p>This last duty is the most difficult of all, because it brings the +attendant into intimate relations with a class of persons, whose true +appreciation of themselves, of their conditions and surroundings, is +changed, whose thoughts and desires are unreasonable, whose conduct is +unnatural, and who are largely controlled by insane delusions, +hallucinations, and illusions.</p> + +<p>It requires an intimate association with the insane, and a careful study +of their manner of thought and conduct, to be able to successfully guide, +direct, and control them.</p> + +<p><span class="pagenum"><a name="Page_23" id="Page_23">[Pg 23]</a></span><i>The Relation of Attendants to Patients.</i>—The position of attendants is +often a trying one; they are liable to misrepresentation when they have +faithfully done their duty; they must learn to receive with calmness a +blow or an insult, or even so great an indignity as being spit upon; they +must bear with provocations that come day after day, and are seemingly as +malicious as they are ingenious and designing; they must watch over the +suicidal with tireless vigilance, control the violent, and keep the +unclean clean.</p> + +<p>To do all this requires the exercise of self-control and kindness; the +putting a curb upon the temper; the education of judgment and tact; +faithfulness in the performance of duty, and a knowledge of what to do and +what to avoid.</p> + +<p>These trials are, however, but a part of the experience of an attendant in +caring for the insane, for there is associated in this care much that is +satisfactory and pleasurable. It is a satisfaction to know that duty has +been well done; to be able to care for the sick; to do something to +alleviate suffering; to tenderly watch over and soothe the dying; it is a +pleasure to see a patient improving, going on to recovery, and finally +able to return home cured.</p> + +<p>Many delightful friendships are formed between attendants and patients, +some lasting for years within the asylum, and some for a lifetime, with +those who have recovered. Most of the insane appreciate the services +rendered them, and have a feeling of gratitude for those who care for +them.</p> + +<p>Attendants should always treat patients with politeness<span class="pagenum"><a name="Page_24" id="Page_24">[Pg 24]</a></span> and respect; it +is something that is never thrown away, and exerts a good influence, +however rude and disrespectful a patient may behave.</p> + +<p>Patients should not be ridiculed, their mental weakness and peculiarities +made light of, nor should they be made a show to inquisitive visitors.</p> + +<p>It is useless for attendants to try to argue patients out of a belief in +their delusions, and to do so often results in fixing them more firmly in +the mind. We should not however pretend to believe them, nor humor their +belief, nor allow them to carry out their delusions in their dress, +conduct, and general behavior.</p> + +<p><i>The Character of an Attendant.</i>—The insane should always be treated with +kindness, and nowhere is the golden rule “thou shalt love thy neighbor as +thyself” more necessary of application than in caring for them; and it is +well for attendants, when tempted, to stop and think how, under like +circumstances, they would want their mother or sister or brother treated.</p> + +<p>Keeping this noble teaching and this high motive for right-doing ever in +mind, an attendant cannot go far astray.</p> + +<p>It is a development of character to care for the insane, and instead of +being brutalizing, as some ignorant people say, it is elevating and +humanizing.</p> + +<p>Attendants should never gossip, either among or about themselves, or of +their patients. It is a mean and degrading habit to indulge in; it will +undermine a good character, and often become overpowering and malicious.</p> + +<p>On the other hand, never be afraid to speak the truth, and never let a +lie, or the semblance of a lie, pass your<span class="pagenum"><a name="Page_25" id="Page_25">[Pg 25]</a></span> lips, or remain for a moment in +your heart. Of all things be truthful.</p> + +<p>Attendants must acquire a spirit of willing obedience, of cheerful +execution of all commands and directions, and of faithful performance of +every duty that devolves upon them. Unless they have this spirit, they +will be unable to successfully assume positions where obedience is to be +exacted from others.</p> + +<p>They should preserve their own self-respect; in all things set a good +example; be neat and tidy in their dress, gentlemanly or ladylike in their +conduct; considerate of the wants and feelings of other attendants; they +should “cherish a high sense of moral obligation; cultivate an humble, +self-denying spirit; seek to be useful; and maintain at all hazards their +purity, truthfulness, economy, faithfulness, and honesty” (Utica Asylum +Rules and Regulations).</p> + +<p>In their relation to the institution, attendants should fulfil all their +engagements with the same sense of right, that they expect will be +observed towards them by those who employ them. It is a business contract +that is assumed, and brings with it mutual legal responsibilities, rights, +and obligations. Attendants should strive to so conduct themselves, that +when they leave their employment they can go away with the respect of +every one, and bear with them the reputation of a good character and of +work well done.</p> + +<p><i>How and What to Observe in the Care of Patients.</i>—It is important that +attendants should early learn habits of close observation. The exercise of +the habit increases the ability to observe, and one soon comes to see and<span class="pagenum"><a name="Page_26" id="Page_26">[Pg 26]</a></span> +know things he never saw, or thought of before. It is necessary to learn +first the physical condition, mental symptoms, and habits of a patient, +before we are able to observe and appreciate any change.</p> + +<p>Observation, to be of value, should be systematically made, and only one +thing at a time can be noticed, which must be understood before passing to +another, otherwise every thing is confused.</p> + +<p>The condition and appearance of a single part should be looked at to see +what is natural, and what is evidence of disease.</p> + +<p>In practice, written notes taken at the time, are extremely valuable in +teaching close and accurate observation, and cultivating an ability to +clearly express to others the result.</p> + +<p>For the purpose of suggestion and guidance, the following system for +observation is given:</p> + +<p>Observe the effect of medicine.</p> + +<p>The face.—Observe if it is pale, and if the pallor is sudden, temporary +or permanent; if flushed, if congested, if blue with venous blood, if +there are any eruptions, bruises, or scars. Observe the expression of the +face.</p> + +<p>The tongue.—Observe if it is coated, and if so, if white, brown, red, +black, glazed, dry, or cracked; if it is tremulous, or drawn to one side, +or protruded with difficulty.</p> + +<p>The lips.—Observe if pale, blue, dry and cracked, if there is +tremulousness about the corners of the mouth; the teeth, if covered with +sordes; the gums, if bleeding.</p> + +<p>The breath.—Observe if sweet, sour, foul, or offensive.</p> + +<p>The respiration.—Observe if slow or fast, quiet and natural, or loud, +labored, and difficult, if puffing, wheezing, shallow, or irregular.</p> + +<p><span class="pagenum"><a name="Page_27" id="Page_27">[Pg 27]</a></span>The eyes.—Observe if congested, the color, if any blindness; the pupils, +if contracted, dilated, irregular, unequal, or if they respond readily to +light.</p> + +<p>If there is cough, observe if moist or dry, if croupy, if with pain, or if +prolonged.</p> + +<p>If any expectoration, observe if it is bloody or streaked with blood, if +thin and frothy, thick and purulent, or if it sticks to the cup.</p> + +<p>The pulse.—Observe if it is slow or rapid, full, weak and thin, if +irregular or intermitting. Count it.</p> + +<p>The temperature.—Observe by the hand or thermometer.</p> + +<p>The body.—Observe for eruptions of the skin, for sores, bruises, or +deformities, or if there is any paralysis.</p> + +<p>The appetite.—Observe if it is poor, changeable, if food is relished or +disliked; if refused, if it is constantly or occasionally, and if from +delusions or indifference; if there is overeating and gluttony, if food is +bolted, or chewed, or if the patient has teeth to eat with.</p> + +<p>The digestion.—Observe if natural, or painful, and if so, whether upon +taking food, or if the pain is delayed; if gas is discharged from the +mouth, if the stomach is sour, if the food is heavy and distressing; also +observe what kinds of food give dyspepsia, and what seem to be well borne.</p> + +<p>Of vomiting.—Observe if occasional or constant, if immediately after +food, or delayed, if sour or bitter, if preceded by pain or nausea, if it +contains any undigested food.</p> + +<p>Of diarrhœa.—Observe how frequent the discharges, if with pain, and +where it is situated, the color, the <span class="pagenum"><a name="Page_28" id="Page_28">[Pg 28]</a></span>consistency, if there is any blood +or mucus, if it alternates with constipation.</p> + +<p>Of constipation.—Observe if alternating with diarrhœa, if habitual, +the effect of medicine and food; if there are any piles.</p> + +<p>The menses.—The quantity, if there is any pain, its cessation and +reappearance, if any effect upon the mental condition.</p> + +<p>Of pain.—Observe the character and severity, its location, and any +evidence of a cause.</p> + +<p>Of dropsy.—Observe if it is general or local, if in the chest, face, +abdomen, arms, or legs; if there are any varicose veins.</p> + +<p>Of sleep.—Observe the length of time, if quiet and natural, if restless, +if deep or light, if there is great drowsiness or continued wakefulness, +and the effects of medicine.</p> + +<p>Of unconsciousness.—Observe if it comes on slowly or suddenly, if partial +or complete, if the patient can be aroused.</p> + +<p>Of convulsions.—Observe if slight or severe, if of short or long +duration, if continued or interrupted, if general or of one side, or of an +arm or a leg, or the face, or of a few muscles only.</p> + +<p>Of the mental condition.—Observe if fixed or changeable, the nature of +delusions, illusions, or hallucinations; dangerous attempts or threats +toward himself or others; any change in the mental state.</p> + +<p>Of habits.—Observe if fixed or changeable, how formed or how corrected.</p> + +<p>Of the general conduct.—Observe the dress, if neat<span class="pagenum"><a name="Page_29" id="Page_29">[Pg 29]</a></span> and tidy, or +otherwise, private habits, care of personal wants, improvement in conduct, +the influence of attendants and other patients, or the influence the +patient himself exerts on others.</p> + +<p>This by no means includes all that it is necessary to observe, but it +contains much that is important, and the system, if studied and used +practically, will suggest to the observer whatever may require attention.</p> + +<p><i>The Control and Influence of Attendants over Patients.</i>—By a “smart +attendant” is meant one who sees little to do beyond having a control of +the ward by a rule that is close and exacting, who maintains a strict +discipline, and who has a love for cleanliness, order, work, and +scrubbing. But a “useful attendant” is one who tempers these mentioned +traits, by striving to gain the confidence of his patients, by exerting +over them a beneficial influence, who is able to bring the individual +patient into accord with his surroundings in the asylum, so as to help his +improvement or recovery, meet his wants, and increase his comfort and +enjoyment. In order to do this it is necessary that the attendant should +give careful study and attention to each patient. Such a study will soon +demonstrate to, and teach the attendant the fact, that the insane are very +individual in their habits, and while no two are alike, there are +resemblances that in an asylum are made the basis of classification by +wards: there is the convalescent, the suicidal, the demented, the sick and +feeble, and the noisy or violent wards.</p> + +<p>Attendants must first learn that patients are not to be treated merely as +a ward full of people to be kept in order, to be clothed, fed, and put to +bed, but that the <span class="pagenum"><a name="Page_30" id="Page_30">[Pg 30]</a></span>peculiarities of each patient are to be studied, and +that it is their duty to know thoroughly the wants, and condition of each +case, and how best to care for and control it. The better knowledge an +attendant has of the individual, the better he can care for a ward full of +individuals.</p> + +<p>The persons who are under our care are always to be considered as +patients, and it must be remembered that these sick people are sent away +from their homes and given over to us, though strangers, because it is +supposed that we can do better by them than their friends are able to do.</p> + +<p>Their position is one of helplessness and dependence upon those who are +placed in charge, and we are properly held responsible by the friends and +the public, for a judicious exercise of the power and influence we possess +over them.</p> + +<p>Patients are not rightly influenced by the mere exercise of authority or +by dictation or command; these they fear and obey, or resent and resist; +but we should always appeal to the highest motives for obedience and +correct conduct, and we should lead our patients to trust and not to fear +us. In our dealings with them we should be truthful, straightforward, and +strictly upright, and exercise over ourselves patience and self-control.</p> + +<p>We can generally control our patients by the exercise of sympathy, +kindness, and tact, joined with a reason for what is required, and where +more is needed, a firm, kind authority and command will suffice.</p> + +<p>The use of authority, restriction, and restraint is to be avoided, while +on the other hand patients are to be allowed all the liberty and freedom +they can safely enjoy,<span class="pagenum"><a name="Page_31" id="Page_31">[Pg 31]</a></span> and taught to exercise all the self-control they +are capable of.</p> + +<p>The granting of more freedom and liberty of action than was formerly +accorded the insane, does not imply a change in the character of the +disease, but improved methods of care, and places more responsibility upon +the attendants. The degree of liberty to be allowed must, in each case, be +decided by the physician, and the attendants should closely observe the +patient, and report any symptoms which makes the enlarged freedom +dangerous to the patient or to others.</p> + +<p>Patients being sick, are sent to the asylum that they may be kindly and +judiciously cared for, and, if possible, cured. As many patients who may +never fully recover may so improve as to be able to return to their homes, +and, as it is impossible to say that any given patient will not recover, +each case deserves and should receive our best care and efforts to this +end.</p> + +<p>Because our patients are sick they must be nursed, and nursing means +tender care. And it is a nurse’s duty to do all in his power to alleviate +pain and promote bodily comfort. The insane are subject to all the ills +that flesh is heir to, and there is always among our patients much +sickness and bodily suffering. Many patients cannot tell when they are +sick, nor when they suffer pain, but they show sickness and pain, and +often appeal by their manner for that care and sympathy, we all feel in +need of at such times.</p> + +<p>These silent symptoms should be observed by the attendants, who should +always see and know when their patients are sick. Some of these symptoms +are, crying,<span class="pagenum"><a name="Page_32" id="Page_32">[Pg 32]</a></span> moaning, weakness, going to bed, or lying down, cough, +changes in respiration, signs of fever, a flushed face, quick pulse, or +chills, a pale face, vomiting, or diarrhœa, and loss of appetite.</p> + +<p>Much insanity is associated with great physical disturbances which require +careful nursing. The old and feeble, the paralytic and bedridden also +require special attention and care.</p> + +<p>From this it appears that the care of the insane calls for the exercise of +self-control, habits of close observation, the using of good judgment, the +putting forth of ennobling influences, and the tender care of the nurse.</p> + + +<p> </p><p> </p> +<hr style="width: 50%;" /> +<p><span class="pagenum"><a name="Page_33" id="Page_33">[Pg 33]</a></span></p> +<h2><a name="CHAPTER_V" id="CHAPTER_V"></a>CHAPTER V.</h2> +<p class="center"><span class="large">THE GENERAL CARE OF THE INSANE.</span></p> + +<p> </p> +<p class="dropcap"><span class="caps"><i>The</i></span> <i>Reception of New Patients.</i>—Attendants must at once study the +peculiarities, the physical condition, and the mental symptoms of a new +patient, so as to know the case thoroughly.</p> + +<p>New patients should receive special attention; their fears quieted; they +should, if in a proper condition, be introduced to the other patients; the +effect of being in so large and strange a place, where the doors are +locked and the windows guarded should be noticed, and unpleasant +impressions overcome; they must be told they have come among friends and +will be kindly treated.</p> + +<p>The necessary rules of the ward should be explained; they should be +invited to their meals, shown to their rooms and told at bedtime the night +watch will visit them, and they must be assured that no harm will come to +them.</p> + +<p>The first impressions a new patient receives may be the lasting ones, and +influence their whole conduct in the asylum. If they resist what is +necessary to do for them, do not struggle and contend with them, and force +them to bed, or to the bath, but first seek advice from the supervisor, or +the physician.</p> + +<p>Always search new patients, unless otherwise ordered,<span class="pagenum"><a name="Page_34" id="Page_34">[Pg 34]</a></span> for money, jewelry, +weapons, medicine, and other like articles, or if in doubt what to do ask +for directions. The head, body, and clothing should be examined for +vermin, and the body for injuries and bruises. If what is wished to be +done in this particular is explained, patients will generally quietly +allow it.</p> + +<p><i>Work, Employment, and Occupation.</i>—By this is meant whatever occupies +the patient’s time and mind, in useful and pleasant ways.</p> + +<p>Of all things idleness and loafing are the worst; even games, such as +billiards and cards, if indulged in to the exclusion of useful employment, +will degenerate a patient.</p> + +<p>Some willing patients are kept in a tread-mill of daily work, their +monotonous life never broken by a diversion, an enjoyment, or a hope. It +is very questionable if it is beneficial to make a patient drudge through +such a daily routine.</p> + +<p>Asylum life should be made as home-like, pleasant, and natural as +possible; as a rule every patient who is able should do some useful work +every day, and to this should be added the diversion, that comes from +amusements and the enjoyment of innocent pleasures.</p> + +<p>Occupation then means a great deal more than work; it is the way a patient +spends his time. Unless encouraged and directed, patients may occupy +themselves in thinking of their delusions, in noise, violence, or +destructiveness, in idly walking up and down the wards, in the indulgence +of secret vices, in gossip, in spreading discontent, in prayer, or in +constant Bible reading. Some patients really work hard trying to do +nothing, and have no more ambition than to sit around on the ward, and +chew tobacco, and indulge in idleness.</p> + +<p><span class="pagenum"><a name="Page_35" id="Page_35">[Pg 35]</a></span>Patients should be encouraged to do something for themselves, the women to +make and mend their own clothes, to keep their rooms in good order, and +assist about the ward. They should be made to feel that they can add to +their own comfortable surroundings by their own efforts.</p> + +<p>For the men, ward work is not so natural or tasteful, but they will do +with interest much of this kind of work; to this may be added employment +in decorating their own rooms or the ward, and in caring for plants and +flowers.</p> + +<p>The women can add to ward work, sewing, knitting, mending, embroidery, +artificial flower making, quilting, care of flowers in the ward, and it is +often a real enjoyment for patients to make some little present for their +outside friends. The laundry offers an inviting field for some patients, +but it is often too hard work, especially when they are sent twice a day +to the wash-tub, or kept in the hot ironing room. A half day is enough for +most patients, and many are not strong enough to go there.</p> + +<p>Out-of-door work is well suited for the men. The farm, garden, lawn, +barns, and machine-shops offer much that can be made useful for the +patients’ employment; the different mechanics and artisans about the +asylum should have patients working with them.</p> + +<p>Thus it appears there are many directions for patients to work, and it is +also true that all patients are not suited to do the same work nor the +same amount of work. Whatever they do should be for their benefit alone, +otherwise we might take a contract for a given number of<span class="pagenum"><a name="Page_36" id="Page_36">[Pg 36]</a></span> patients to work +a given number of hours every day, a good deal as has been done in prisons +and reformatories, but no one would believe such a course for the +interest, improvement, or recovery of the patients.</p> + +<p>The only rule to go by is, that the work and occupation shall be for their +own good, and, that they shall not be made or encouraged to work for any +other purpose.</p> + +<p>As a rule, patients should be allowed to employ themselves in ways that +most interest them, provided it is useful and seems to be beneficial.</p> + +<p>Over-work is as bad as idleness; too much sewing will often give a +sleepless night.</p> + +<p>Generally all patients may be allowed to engage in light work, without +special directions; new patients, however, should not be sent off the +ward, or given tools that may become weapons, unless by order of a +physician.</p> + +<p>It is a bad habit for attendants to sit idly by, or stand around with +their hands in their pockets, and have patients do all the work. It may be +so necessary to watch the patients that the attendant cannot work +steadily, but he should have the appearance of doing something, and if +possible join with them in work.</p> + +<p>A party of women sewing, should be laughing, talking, telling stories, +perhaps singing; they should be made to enjoy the time, and not to look +upon it as something irksome.</p> + +<p>Some patients are too feeble in mind, and some too feeble in body to work; +many need rest, quiet, and nursing, and directions for the care and +occupation of such patients should come from the physician.</p> + +<p><span class="pagenum"><a name="Page_37" id="Page_37">[Pg 37]</a></span>Many of these patients will do a little, others can be amused, or read to, +and their minds thus diverted from their troubles, and turned into +pleasant and cheerful directions of thought.</p> + +<p>It has been shown that work is not the only useful way that patients may +occupy their time, that nothing but work is as bad as no work, and that +they should have diversion, enjoyment, and entertainment.</p> + +<p>For the entertainment and occupation of patients, there are furnished, +dances, concerts, theatricals, billiards, cards, pianos, books and papers, +schools, chapel services, walks, rides, and excursions, and they also +receive visits from friends, and write and receive letters.</p> + +<p>Patients should be encouraged and sometimes made to take part in these +natural and pleasant amusements; of course every patient cannot play the +piano, or billiards, but among these many forms of recreation, all +patients can find ways of diversion and means of enjoyment.</p> + +<p>Thus early in the study of the care of the insane, it is learned that the +life of patients is to be stripped, as much as possible, of restriction +and restraint; that self-control is to be taught; that useful work is to +be encouraged; that amusements and innocent pleasures are to be enjoyed; +in a word, attendants are to learn, that the characteristics of +institutional life are to be lessened, and those of a home life made +prominent.</p> + +<p><i>The Patients’ Care of Themselves.</i>—The general tendency of the insane is +to mental enfeeblement, to neglect of person, and to slovenly habits. +Patients should be encouraged as much as possible to care for themselves; +to be helpful towards others; to do such work as they are<span class="pagenum"><a name="Page_38" id="Page_38">[Pg 38]</a></span> able; to seek +amusements, and to live as much as possible such a life as we ordinarily +are accustomed to outside the asylum.</p> + +<p>Patients should be encouraged to keep themselves tidy, and nicely dressed, +to have the care of their clothing; if possible, they should be given a +room of their own, which they should take a pride in keeping in order, and +ornamenting with pictures and flowers; and should be allowed to do +whatever will help maintain their self-respect, self-care, and a feeling +of individuality.</p> + +<p>There is great difference in patients as shown in their capacity for +self-help. Some seem to be able to do nothing, some everything. Nothing +can lighten the burdens of attendants so much as to make the helpless +self-helpful. Nothing benefits the patients more. Do not abandon effort +for any patient. Unexpected and gratifying results are the rewards of +earnest efforts.</p> + +<p><i>Out of Door Exercise—Walking.</i>—If possible, patients should be out of +doors every day. In the summer much time can be spent in the fields, on +the lawn, either walking or sitting under the trees; in the winter time +shorter walks only can be taken, but on pleasant days, often an hour may +be spent out of doors. Warm clothing and good shoes must never be +neglected, and the person must be thoroughly protected, because the insane +are frequently “cold-blooded,” that is, the circulation is poor, the hands +and feet congested, blue, and cold, they make animal warmth slowly and +with difficulty, and easily suffer from the cold.</p> + +<p>Many patients go out to walk on parole. Those who are allowed this liberty +will be designated by the <span class="pagenum"><a name="Page_39" id="Page_39">[Pg 39]</a></span>physicians; any change in the patient that +makes such liberty dangerous should at once be reported. Others go out in +large parties, with few attendants to care for them, while the old, sick, +and feeble, the homicidal and suicidal, the noisy and violent, require +special care and attention in their exercise and walks.</p> + +<p><i>Clothing of Patients.</i>—In many asylums each patient has his own +clothing. Every article should be plainly marked with his own name, and +should be used only by the patient to whom it belongs, and never given to +any one else to wear. All clothing should be kept clean and well mended, +and should be properly put on and kept on during the day. There should +always be enough to keep the patient warm, and changed with the changes in +the weather, or the temperature of the ward, or the needs of the patient. +The sick, feeble, and old always need extra clothing; that worn next the +skin should be changed at least once a week, and all clothing should be +changed as often as soiled.</p> + +<p><i>Bathing of Patients.</i>—Every patient should be bathed once a week and as +much oftener as is necessary. The tub should be cleaned and the water +changed for each patient; the temperature should be about ninety-five +degrees, or not hot to the hand, and the tub should be about two-thirds +full. The head, neck, and body should be washed with soap; each patient +should have a clean towel, be wiped dry, and given a change of clean +clothing.</p> + +<p>Some patients object to bathing; they fear the tub, but will wash with +water and a sponge, and they should be allowed to do so. Others want to +bathe first; let them, if possible. Others will not bathe the day the rest +do; it is sometimes best to humor them.</p> + +<p><span class="pagenum"><a name="Page_40" id="Page_40">[Pg 40]</a></span>Some patients have to be forcibly bathed. In such cases always wait, use +every art to induce them to bathe, and before acting send for advice.</p> + +<p>Attendants are too prone to think that every thing should be done by rule, +and that all must be forced to obey the rule. Most will observe it without +trouble, and the object sought can generally be gained by patience, tact, +and kindness.</p> + +<p><i>Serving of Food.</i>—The dining-tables should be neatly set and made +attractive; the food should be promptly served, and while hot; all +patients should be at meals, unless excused by the physicians. Economy +should be practised, and every thing should be used or saved. Each person +should have enough, but no one should be allowed to make a meal of a +delicacy, or take all of the best of a dish. Some patients would waste a +pound of butter or sugar at each meal; enough is sufficient for anybody.</p> + +<p>The old and feeble should be served by attendants; those without teeth +should have their food prepared, and the meat should be cut very fine. +Those who will not eat must be kept in the dining-room and fed; the +attendants may use force by holding the hands, and placing food in or to +the mouth; but it is dangerous to do more, and holding the nose is +something that is never allowable. If these efforts to get them to take +food do not succeed, report to the physician. Some patients from delusions +will eat certain kinds of food, and either not get enough or not a +sufficient variety.</p> + +<p>A mixed diet is the best, and patients should if possible be made to eat +bread, butter, meat, vegetables, and<span class="pagenum"><a name="Page_41" id="Page_41">[Pg 41]</a></span> drink milk and plenty of water. No +patient should be allowed to lose in flesh and strength on account of +failure to take sufficient, or proper food; before these things happen it +should be reported to the physician. Some patients will only eat enough if +they are allowed to eat it in their own way; they will eat it perhaps +standing, or after the others have finished, or alone, or in their room, +or they may steal it, if given the opportunity. Such peculiarities often +have to be indulged.</p> + +<p>Some patients will take nothing but milk, then about three quarts a day +are needed; eggs may be added and are often readily taken, and some may be +got to eat bread and milk, which is a very nutritious diet.</p> + +<p>The food of the sick should be nicely and invitingly served, and efforts +should be made to meet their whims and fancies.</p> + +<p>Patients who are so profane, violent, or noisy, that they are not allowed +to come to the dining-room, must always be fed by, and in the presence of +an attendant, and meals should not be passed into a patient’s room and +left there.</p> + +<p>Knives and forks should always be counted by an attendant before and after +each meal; care should be used that they are not lost, secreted, or +carried out of the dining-room by patients. No one but an attendant should +ever handle the carving knife and fork, or the bread knife.</p> + +<p><i>Care of Patients when Going to Bed, or Rising.</i>—The beds should be daily +aired, and always clean and nicely made up; for a filthy patient a straw +bed, that can be changed, alone is clean.</p> + +<p>All patients do not need to go to bed at the same time, and while some are +able to care for themselves, most<span class="pagenum"><a name="Page_42" id="Page_42">[Pg 42]</a></span> need care, attention, and watching. The +helpless should be dressed and undressed, and put to bed first: the +violent and homicidal need to be watched, and should be put to bed early, +while the suicidal should be kept under supervision, and put to bed at the +most convenient time. After a patient is in bed, an attendant should go +into the room, with a lantern, so as to see that every thing is in order +and safe, and, with a cheerful “good-night” close the door. Patients who +need care should be visited during the evening, and left clean and in good +condition to be cared for by the night watch.</p> + +<p>In the morning patients need attention before any thing else is done. +First, the suicidal, sick and feeble, the violent, and those likely to be +filthy should be visited, and every patient should be washed and dressed +before breakfast; or, if for any reason they do not come to this meal, +their faces and hands should be washed, the bed put in order, and the room +made clean and aired.</p> + +<p>After these things have been attended to, the ward work should be done, +though generally the two can go on together.</p> + +<p><i>Care of Patients during the Night.</i>—After the patients have gone to bed +the ward should be quiet, doors should be quietly closed, voices lowered, +and loud calls and laughter not indulged in, squeaking boots should not be +worn, and heavy walking avoided. Many patients go to sleep early, but are +easily awakened, and may remain sleepless till morning, or at least a part +of the night.</p> + +<p>The night watchers have responsible, arduous, and trying duties. +Attendants should always, during the night, quickly respond whenever a +demand is made upon them<span class="pagenum"><a name="Page_43" id="Page_43">[Pg 43]</a></span> for assistance, though an unnecessary call +should never be made. The night watchers should be informed of any changes +that have occurred during the day, that will require their attention +during the night; they should see new patients and be made acquainted with +their peculiarities; they should visit the wards during the evening before +they come to the medical office to receive instructions from the +physicians.</p> + +<p>It is the duty of a night watch to visit regularly all the wards under his +charge; to see and know the condition of the sick, the helpless, feeble, +the suicidal, and the epileptic; to attend to, by taking up, those who are +inclined to be filthy, and wash those who need it, and make them, their +beds, and rooms perfectly clean. He should observe the conduct of new +patients, be watchful of the violent, know how much wakeful patients +sleep, visit all associated dormitories, wait upon all those who need +attention, and guard against fire and accident. The night watch should +place each day on the medical office table, a detailed account of every +patient that needed care or attention, who was disturbed, or did not sleep +during the previous night.</p> + +<p>Patients should be left clean for the night watch, who should leave them +in as good condition in the morning, for the day attendants, and any +neglect in these directions should be reported by either party. Sick +patients frequently have to receive special night service, to be watched, +and given food and medicine. When this cannot be done by the night watch, +it devolves upon the day attendants, and is a duty that should be +cheerfully rendered.</p> + +<p><span class="pagenum"><a name="Page_44" id="Page_44">[Pg 44]</a></span>During the night, any accident, attempt at suicide or to escape, or +unusual violence, persistent sleeplessness, or being out of bed, a serious +sickness or change for the worse, or the approach of death, should be +reported to the physician. It is, in many institutions, the duty of the +night watch to report any neglect or misconduct on the part of an +attendant or employé, and it is something that should be faithfully and +impartially done.</p> + +<p>Having briefly sketched the general duties of an attendant, it seems best +to again remind them, that an asylum is built and maintained for no other +purpose than for caring for the insane; that each patient is entitled to +the best our means can afford; that while the attendants are not +responsible for the medical treatment, they are for that kind and +intelligent care it is within their province to give; and they are also +reminded that, so far as it can be done, such personal attention is to be +given to each patient as will assist in recovery or improvement, or +promote his well-being.</p> + + +<p> </p><p> </p> +<hr style="width: 50%;" /> +<p><span class="pagenum"><a name="Page_45" id="Page_45">[Pg 45]</a></span></p> +<h2><a name="CHAPTER_VI" id="CHAPTER_VI"></a>CHAPTER VI.</h2> +<p class="center"><span class="large">THE CARE OF THE VIOLENT INSANE.</span></p> + +<p> </p> +<p class="dropcap"><span class="caps">A careful</span> study of each violent patient, of his habits, delusions, and +hallucinations, of his peculiar manner of showing violence, and a +knowledge of what is likely to provoke outbursts is necessary to properly +care for him. An attendant’s ability to successfully manage a ward full of +patients will depend largely upon the study given to, and the thorough +understanding of, each case. Such study will soon teach him that every +violent patient has peculiar and pretty constant ways of showing and +exercising violence, and that the same rule of individuality holds good +among this, as it does among other classes of the insane.</p> + +<p>Having learned what will cause violence, it can often be avoided by +removing the cause; having learned the symptoms that precede a patient’s +outbursts of violence, they can sometimes be averted, or preparations made +to control them; having learned in what direction violence is shown, how +sudden, blind, or furious it may be, or how slow, deliberate, and planned, +the attendant is better able to meet, manage, and control it.</p> + +<p>Few patients are so continuously and furiously violent as to need constant +repression, and the directions how to care for such patients can always be +given by the physician.<span class="pagenum"><a name="Page_46" id="Page_46">[Pg 46]</a></span> Most violent patients are subject to the firm, +kind control of attendants, and can be kept sufficiently quiet and +orderly; they should never be left alone, and mops, pails, brooms, +chambers, and all other articles, that may become weapons should not be +left within reach. Strong comfortable clothing can generally be kept on +the most violent and destructive, with care and attention from attendants, +but not without.</p> + +<p>Many violent patients will employ themselves and be the quieter for so +doing. Light out-of-door work is the best employment for this class, and +out-of-door walking and exercise should never be neglected. On the woman’s +ward knitting, sewing, mending, and ward work are suitable for many, while +some will work at the laundry, and others will go quietly to church and +entertainment; books and illustrated papers should be furnished and will +be much read and enjoyed.</p> + +<p>As a rule the more violent patients are restricted, kept continuously on +the ward, or in a small room, and given no work, amusements, walks, and +exercise, the more noisy and violent do they become.</p> + +<p>Attendants must learn that mere noise, and much of maniacal activity, such +as running about, jumping, or pounding, is not in itself harmful, and that +unless such patients are doing themselves injury, or so disturbing the +ward and other patients as to require interference, it is better to +control than to repress and restrict them.</p> + +<p>Many violent patients are subject to such paroxysms of great violence as +to require immediate care and often temporary control at the hands of +attendants. Generally these paroxysms spend themselves after a short<span class="pagenum"><a name="Page_47" id="Page_47">[Pg 47]</a></span> +time, but if they do not, advice and help can be called for.</p> + +<p>By careful watching, the approach of these paroxysms can be known and +often avoided. This may be done by removing the cause, which is often the +irritation of another patient or an attendant, by a word, a joke, by +simply letting the patient alone, or by a firm show of authority, or by +any other means experience has taught to be useful in the particular case.</p> + +<p>If necessary to hold a patient, three persons should be able to care for +the most violent. This can be done by grasping each arm at the wrist and +elbow, and holding it out straight, the attendants standing behind while +another passes the arm about the neck and holds the chin, to prevent +biting and spitting; the patient may then be walked backward and seated in +a chair.</p> + +<p>After the violence has subsided, though the patient should continue to +scold, swear, threaten, or cry, he should, as soon as possible, be left +alone, the attendants walking away, but remaining watchful. Do not, unless +it is necessary, interfere to stop the noise, for it is often a substitute +for the violence, and the attack wears itself out in this way.</p> + +<p>If necessary to carry a violent patient, it can be done by four or six +attendants. The face should be turned downward, thereby lessening the +power to resist, and, to prevent dislocating the arms, the patient should +be carried by the shoulders and chest; the bands about the neck should be +loosened.</p> + +<p>In using force in the care of violent patients, it should always be done +as gently as possible, and struggling<span class="pagenum"><a name="Page_48" id="Page_48">[Pg 48]</a></span> should be avoided; he should never +be choked or kicked, receive a blow, or be knocked down; the arms should +never be twisted, nor a towel held over the mouth, but if the patient +persists in spitting it may be held in front of the face.</p> + +<p>Care must always be used not to injure a patient while exercising +necessary control. In the violence of a patient innocent injuries are +sometimes received. The attendant is excusable if he can show that he used +necessary force only, without malice.</p> + +<p>A violent patient should never be struggled with alone, and on a +well-managed ward help will always be within call. It may be necessary, +however, to break this rule in order to prevent homicide or suicide, or +serious injury to another patient, or setting the house on fire.</p> + +<p>It is better not to visit the room of a violent patient alone, and if an +attack is feared, especially with a weapon, the door should be slowly +opened, and held so it can be quickly closed. The patient usually makes an +immediate attack, and, before he has recovered for a second, can generally +be disarmed and controlled.</p> + +<p>Violence usually consists of noise, tearing the clothing, breaking glass +or furniture, biting, scratching, striking, hair pulling, kicking, or +attacking others with weapons. It is sometimes secretly and deliberately +planned and skilfully executed, though generally without reasoning or +direction, but blind and fierce.</p> + +<p>The care of the violent insane involves the careful study of each case, +with constant watchfulness, and the exercise of a control that is kind, +but firm and unyielding, that does not repress except when necessary, nor +restrict without reason, that indulges whenever possible,<span class="pagenum"><a name="Page_49" id="Page_49">[Pg 49]</a></span> that never +drives, scolds, or threatens, but influences, guides, and directs. The +greatest liberty possible should be allowed, and self-control encouraged, +and work, occupation, and amusement should be furnished. An attendant must +always remember that fear is the lowest motive to govern by, and that +kindness will often be appreciated and returned.</p> + +<p><i>Care of the Destructive Patients.</i>—Besides the violently destructive +patients, there are some who are maliciously destructive, and who exercise +all their ingenuity to escape the watchfulness of the attendants; who +glory in their wrong-doing; who openly say they cannot be punished, and +exultantly tell the physician how they have outwitted the attendant, or +proclaim before him his shortcomings and neglect. Such patients will +destroy their own or others clothing, they will steal and hide, or throw +it out the window or down the water-closet, or erase the name by which it +is marked. They will destroy bedding, windows, crockery, pictures, or +furniture. With a pin, a nail, or a bit of glass or wood, they will mar +and deface their room or the ward, and often do damage that cannot be +repaired. The only way to meet such cases is by watchfulness. They should +be kept, if possible, at work, or at least with a company of workers, and +therefore under constant observation. When put to bed their clothing, +mouth, hair, and person should be thoroughly searched. Kindness often has +but little effect, but a threat is apt to make them more determined to +destroy.</p> + +<p><i>The Care of Patients by Mechanical Restraint and Seclusion.</i>—All the +restriction of an asylum is restraint. The locking of bedroom doors at +night is very restricted <span class="pagenum"><a name="Page_50" id="Page_50">[Pg 50]</a></span>restraint. Most patients in an asylum have a +feeling that they are under great compulsion and restraint, in being +deprived of their liberty. It has already been taught that patients are to +be given all the liberty possible, that restraint over their freedom is to +be exercised no more than is absolutely necessary, and that the greatest +good of the patients alone is to be thought of.</p> + +<p>These teachings are equally true of special forms of restraint. If used at +all they are to be used for the good of the patient alone, and an +attendant should be able to care for any case without restraint.</p> + +<p>Restraining apparatus should never be kept on the ward. An attendant +should never ask that it be used, nor say he cannot get along without it.</p> + +<p>If ordered by the physician it is the attendant’s duty to see that it is +so applied as to do no injury, that it does not bind or tie the patient +down, that it does not irritate and make the skin sore, nor restrict the +free movement of the limbs.</p> + +<p>Patients who are restrained are not to be further confined to a chair +without specific order. Restraint used during the day is not, unless so +ordered, to be continued at night nor reapplied the next day. Patients are +to be taken frequently to the closet. Restraint should be taken off +several times a day, and kept off long enough to give relief to any +feeling of discomfort, and free movement should be allowed. When patients +are restrained they need unusual care and watching, and should never be +left alone.</p> + +<p>The attendant should be informed why restraint is used, and what is hoped +to be gained by its use. He<span class="pagenum"><a name="Page_51" id="Page_51">[Pg 51]</a></span> should closely observe the effect upon the +patient and compare his condition with what it is when not restrained. The +result of these observations should be reported.</p> + +<p>Thus used, an attendant will soon learn that it is not the easiest way to +care for a patient, that its use involves increased watchfulness and care, +and greater discretion, and that it is strictly a form of medical +treatment. It is a harsh remedy at its best, and needs to be used with +kindness, intelligence, and judgment, and it is to be applied but for one +purpose, namely, that the patient may be benefited.</p> + +<p><i>The Use of the Covered Bed.</i>—Like restraint it is never to be used +except by the orders of a physician, nor is its use to be repeated without +special orders; it is always to be considered a method of treatment and +something the attendant has no interest in, except to know how best to use +it when ordered to do so.</p> + +<p>When in a covered bed the patient should be frequently visited; he should +be taken up at least once in three hours, unless asleep; the bed and the +patient should be kept perfectly clean. If used in the daytime an +attendant should sit beside the patient for some hours and try to keep him +quietly in bed, and the same should be done in the evening when the +patient is put to bed. An attendant should be able to report how much the +patient sleeps, how much quiet and rest is obtained, the effect of the +treatment, and compare the condition of the patient when in the bed with +what it is when not used.</p> + +<p><i>The Use of Seclusion.</i>—Seclusion is shutting a patient alone in a room +in the daytime. If allowed to be done<span class="pagenum"><a name="Page_52" id="Page_52">[Pg 52]</a></span> without orders from the physician +it should be immediately reported. If ordered to be continued the patient +should be seen at least once in fifteen minutes, while many need to be +seen once in five minutes, and an attendant should never be far from the +door. The patient should be frequently taken to the closet. The effect and +result of seclusion should be observed and reported.</p> + +<p>Many physicians never use any form of restraint, while others make +considerable use of it as a means of treatment. An attendant should be +able to successfully care for any case, so as to meet the wishes and +directions of the physician, and only as he is able to do this can he give +the patient the highest standard of attention, care, and nursing.</p> + + +<p> </p><p> </p> +<hr style="width: 50%;" /> +<p><span class="pagenum"><a name="Page_53" id="Page_53">[Pg 53]</a></span></p> +<h2><a name="CHAPTER_VII" id="CHAPTER_VII"></a>CHAPTER VII.</h2> +<p class="center"><span class="large">THE CARE OF THE HOMICIDAL, SUICIDAL, AND THOSE INCLINED TO ACTS OF VIOLENCE.</span></p> + +<p> </p> +<p class="dropcap"><span class="caps">Patients</span> with Delusions of Suspicion demand special care, and are properly +classed with those inclined to commit acts of violence, because they are +frequently fully under the control of delusions, which make them dangerous +and difficult to manage.</p> + +<p>Many patients have ideas that make them suspicious of those about them; +these may relate to the patients, but more frequently to the attendants +and physicians, and they may arise from delusions, hallucinations or +illusions. This class of patients is apt to be morose, cross, and +irritable; they sit brooding over their fancied wrongs; repulse advances +and friendly intercourse; they refuse to employ themselves, and do not +respond willingly to the requirements of the attendants.</p> + +<p>Our most trifling and unmeaning acts may give rise to the most intense +suspicions and hatred. A look, a shrug of the shoulder, the manner of +shaking the head, a cough, the squeaking of our boots, are frequently +enough to arouse, these feelings.</p> + +<p>Suspicious patients often think they are the subjects of ridicule; that +their thoughts are read and proclaimed to the ward; that their virtue, +truth, or honor is called<span class="pagenum"><a name="Page_54" id="Page_54">[Pg 54]</a></span> in question, and the accusations openly told to +others, or that they are called vile and insulting names. They often have +delusions of conspiracy to do them or their families harm, and connect the +attendants and physicians with them, thinking, as they keep them locked in +the asylum, they are associated in the conspiracy. Sometimes these +patients think themselves some great persons, perhaps that they are a +member of the Deity, or a ruler, or prophet, or that they have some great +mission to perform, and that they are deprived of their rights, or their +work interfered with, by being kept in the asylum, and that those in +authority are imprisoning and persecuting them. Such persons may be, on +account of their fancied wrongs, very suspicious, and even violent towards +those who care for them.</p> + +<p>Other patients have suspicions and fears of bodily harm. They may think +they are to be tortured, that they are to be burned alive, or that some +one is trying to kill them. To-day, as I wrote these lines, a patient told +me she did not sleep last night for fear the night-watch would kill +her—saying that God told her the watch was armed with a knife for that +purpose, and she threatened homicidal violence in defending herself.</p> + +<p>Many patients mistake ordinary sensations of pain and bodily discomfort, +and have delusions that they are being injured. The feelings of dyspepsia +may make patients think they have been poisoned; ordinary pains or aches, +that they have been shot, stabbed, or pounded; women may, for some such +causes, think they have been violated or are pregnant. Peculiar sensations +of various kinds<span class="pagenum"><a name="Page_55" id="Page_55">[Pg 55]</a></span> may make patients think some one is affecting them by +electricity or mesmerizing them.</p> + +<p>It is very easy to trace from such ideas of persecution and suspicion, the +origin of homicidal, suicidal, incendiary and other violent tendencies and +acts.</p> + +<p><i>Homicidal Patients.</i>—Patients are sometimes both homicidal and suicidal, +and sometimes they are inclined to only one of these forms of violence. +Homicides are not of frequent occurrence in an asylum. The better the care +the less is the liability to homicide. But there are always a great many +homicidal patients, and many more who have delusions and ideas that may +cause such tendencies to arise.</p> + +<p>Many patients are homicidal merely from violence and frenzy, and without +any settled plan, any fixed delusion, or intense suspicion. They may +attack others suddenly and furiously; they may commit the act while trying +to escape, or it may be the result of the violence of acute mania. Other +patients become homicidal under the desire to protect themselves from +supposed assaults. They may think a person who is approaching them is +coming to kill or torture them. Others are homicidal from any of the ideas +of persecution and suspicion that have just been spoken of. Sometimes +patients hear voices telling them to commit the act, perhaps it is God’s + +voice commanding a father to offer up his only son as a sacrifice, or a +mother to kill her little children to save their souls, or keep them from +some misery or crime that awaits them. Patients may think themselves God, +or a king, or ruler, and therefore have a right to take life. Homicidal +patients are often among the quietest, and are found in<span class="pagenum"><a name="Page_56" id="Page_56">[Pg 56]</a></span> the quiet wards. +They frequently lay careful plans, are secretive, and only try to commit +the act when they feel sure it will succeed.</p> + +<p>Patients who are homicidal should be especially watched. They should, if +possible, be kept employed, but never given tools that may become weapons. +They should sleep in a room by themselves. All persons against whom they +have delusions should be warned. Patients against whom they harbor +suspicious or homicidal ideas should be separated from them.</p> + +<p>Attendants should remember that a mop, a pail, or a chair, may become a +dangerous weapon, or that a knife, scissors, or a sharpened piece of iron +or tin, may make a fatal wound.</p> + +<p><i>Suicidal Patients.</i>—Patients with this tendency will generally talk +freely of their suicidal ideas, tell why they wish to commit it, what +provokes the idea, and how they would do the act. They are frequently +grateful for the care bestowed to help them resist the impulse, and will +sometimes tell the attendants when they feel the suicidal ideas coming on, +that they may be the more surely watched.</p> + +<p>Melancholic patients are most inclined to suicide, but any insane person, +whatever the mental state, may commit the act. Delusions of depression +generally cause the suicidal ideas, but hallucinations sometimes play an +important part. Some persons are simply tired of life, and see no hope in +living; some think they are a burden to their friends, and that they are +taking food away from their children; others wish to die to escape from +their misery, which is generally a mental, and not a physical<span class="pagenum"><a name="Page_57" id="Page_57">[Pg 57]</a></span> suffering; +others that by so doing they may get forgiveness of their sins; others +because they think they will save their children from a fate like theirs; +sometimes it is the result of hallucination, as a direct command from God, +telling them to commit the act.</p> + +<p>But few patients are constantly determined to commit suicide. The +opportunity offered, as a bath-room door left open, a rope, a knife, often +prompts the desire and allows the accomplishment of the deed.</p> + +<p>Attendants must remember that it takes but a few minutes to commit +suicide, by drowning or hanging—but a moment to cut the throat; that +persons can drown themselves in a pail of water, hang themselves by the +hem of the sheets, cut their throat with a piece of glass or tin. +Sometimes patients slyly save their medicine until they get enough to +poison themselves.</p> + +<p>About dusk in the evening, or at early morning, is the time when patients +are most inclined to commit suicide. When patients are rising, going to +bed, or to their meals, when going to chapel, amusements, or to walk, when +all is busy and astir on the ward, are the times that offer the most +favorable opportunities for the act.</p> + +<p>Often patients have a certain way by which they will commit suicide, and +they will do it in no other; one wishes to drown himself, another to hang, +and another to take poison. Sometimes patients will appear cheerful to +avoid suspicion and so find their opportunity, while others may suddenly +and while convalescent commit the act.</p> + +<p>The only way to care for patients who are suicidal, is by constant +watchfulness day and night. During the day<span class="pagenum"><a name="Page_58" id="Page_58">[Pg 58]</a></span> they should be employed and +kept with other patients, they should be especially looked after at those +times when opportunities for suicide are increased. At night it is better +to have them sleep in an associated dormitory with some one to watch them. +If a patient is found hanging he should at once be cut down, all +restriction about the neck removed and artificial respiration set up, or +if drowning, the mouth and lungs should be first emptied of water; if +there is hemorrhage compression should be made upon the artery, or if this +is not possible, then directly upon the wound. How to control hemorrhage +and do artificial respiration will be described in the chapter on +emergencies.</p> + +<p><i>Patients Who Have Tendencies to Self-Mutilation.</i>—Some patients horribly +mutilate themselves. They may gouge out an eye, cut off a hand, pull out +their tongue, or even disembowel or dreadfully burn themselves. Some +patients persistently beat their heads against the wall or floor, others +scratch the skin, making large sores. Such patients frequently think +certain passages from the Scriptures apply to them, and they must obey the +application and command. They quote in justification of the acts, “An eye +for an eye,” “And if thy right eye offend thee, pluck it out,” “And if thy +right hand offend thee, cut it off.” Talk of this kind should make an +attendant very careful and watchful of the patient.</p> + +<p>The origin of the ideas that lead to the attempts at self-mutilation is to +be found in delusions, and arise in the same way as do ideas of suicide +and homicide. These patients are all of the same class and need the same +character of care, attention, and watching.</p> + +<p><span class="pagenum"><a name="Page_59" id="Page_59">[Pg 59]</a></span><i>Patients with Tendencies to Setting Things on Fire.</i>—Patients with these +tendencies generally desire to commit incendiary acts under the influence +of delusions or hallucinations; added to these there are frequently +suspicions and feelings of wrong treatment, and the patient takes this way +of showing revenge, or, as he may say, of repaying the wrong. Sometimes +patients are so feeble in mind that they light a fire because they think +it is a pretty sight to see it burn. There are some conditions +accompanying epilepsy where patients are liable to commit any of the class +of violent acts described in this chapter. The special care demanded by +these patients will be fully spoken of hereafter.</p> + +<p>There are some patients whose minds are so distorted by disease that they +seem to take a pleasure in wrong-doing, and are much inclined to do great +mischief, and sometimes to commit acts against life or property.</p> + +<p>The care demanded by patients who are inclined to acts of violence is +practically the same for all. The attendant should thoroughly know the +habits, peculiarities, and delusions of each person under his care; he +should exercise constant watchfulness, and remember that a moment of +thoughtless inattention may give the opportunity for a patient to commit +some violent act, that will cause him lasting regret. The mind of a +faithful attendant will, when upon duty, always be full of anxiety, and +there should be in the care of very troublesome patients of this class +frequent relief.</p> + + +<p> </p><p> </p> +<hr style="width: 50%;" /> +<p><span class="pagenum"><a name="Page_60" id="Page_60">[Pg 60]</a></span></p> +<h2><a name="CHAPTER_VIII" id="CHAPTER_VIII"></a>CHAPTER VIII.</h2> +<p class="center"><span class="large">THE CARE OF SOME COMMON MENTAL STATES, AND ACCOMPANYING BODILY DISORDERS.</span></p> + +<p> </p> +<p class="dropcap"><span class="caps"><i>Care</i></span> <i>of Patients in the Earlier Stages of Insanity.</i>—Patients in the +earlier stages of insanity act differently, one from the other, when first +brought to the asylum and placed under care and restriction. Sometimes +patients accept the situation and fit into asylum life without any +friction. They may even come willingly, knowing they need care and +treatment, or from confidence in their friends or their physician’s +advice.</p> + +<p>To some patients the restrictions of an asylum are irksome and +misunderstood; the quiet, regularity, and routine of the life on the ward +does not at first affect them; they may, and often do, become fretful, are +irritated by their confinement, sleep poorly, eat little, and may make +violent efforts to escape.</p> + +<p>These conditions, if nothing is done to occupy the patient’s time and +mind, and so relieve them, will often be sufficient to provoke violence. +These patients should be carefully watched and their condition studied; +they should be brought under the kind control and influence of attendants, +induced to take part in the regular order of the ward, and, if strong +enough, should be furnished with proper work and occupation.</p> + +<p><span class="pagenum"><a name="Page_61" id="Page_61">[Pg 61]</a></span>Patients, when first brought to the asylum, frequently have much anxiety +about their homes, their families, or their business affairs. This is +particularly true in recent cases of insanity, because such patients often +have cares and responsibilities, or they have tried to continue to assume +them, up to the time of coming to the asylum. Special care should be taken +to quiet fears in these directions; they should be assured that they are +groundless, told they will be allowed to communicate with their friends, +that they will be visited by their family, and that all their interests +will be cared for.</p> + +<p>It is impossible to speak of the varied causes of insanity, or of the +equally varied manifestations of the disease and conduct of the patient at +its onset, but there are a few conditions which, being present, give a +character to a particular case, and suggest the care required.</p> + +<p>Sometimes, as has been said, the patient partly realizes his condition, +and is willing to come to the asylum, and in every way to conduct himself +in accordance with the rules and requirements.</p> + +<p>Sometimes the onset is slow and the symptoms so obscure as to attract +little attention. Following this, more decided symptoms may appear; the +patient may become violent, noisy, destructive, or sleepless, or he may +try to commit suicide or homicide, or do some other act of violence; or +the great restlessness, moaning, crying, and sleeplessness of melancholia +may come on, or the patient may refuse, for several days, all food. The +reason for bringing such patients to the asylum is that they can no longer +be kept at home.</p> + +<p>Following the treatment that has been described, these<span class="pagenum"><a name="Page_62" id="Page_62">[Pg 62]</a></span> patients will +frequently in a short time become more quiet, self-controlled, and more +easily influenced and cared for.</p> + +<p>The earlier stages of insanity are frequently accompanied by considerable +disturbance of bodily health. The appetite is poor, the digestion +disordered, the bowels constipated, the breath foul, the secretions of the +skin changed and often offensive, the temperature a little elevated, the +pulse rapid, and the heart weak. Sometimes, on the other hand, the +temperature is normal, or a little below, while the hands are cold and +clammy. In addition, nutrition is frequently impaired, so that the food +taken by patients does not seem to properly nourish and strengthen. All of +these symptoms are not present in a given case; sometimes most of them may +be, and again but few are to be noticed.</p> + +<p>The important lesson to learn in the care of these cases is that such +patients may rapidly pass into a more serious condition, in which there is +great exhaustion, which is always alarming, and may even result fatally.</p> + +<p>Recent cases, such as have been spoken of, need our best care, closest +attention, and kindest nursing. The patient should daily take sufficient +food, which, if necessary, should be enforced, and the opportunity for +sleep promoted. A few days, or a day, without food and sleep may bring on +alarming symptoms.</p> + +<p>For these patients, milk is the best article of diet; it is most easily +given and readily taken; it should be given by the glassful, or if not +able to do this by the spoonful. Some patients, for reasons not always +known, will refuse food one hour and take it freely the next; it<span class="pagenum"><a name="Page_63" id="Page_63">[Pg 63]</a></span> should, +therefore, be frequently offered. With milk as a basis, we may add to it, +as we are able. Raw egg, gruel, boiled rice, oatmeal, custard, and bread +are adjuncts that are nutritious and easily given.</p> + +<p>It makes but little difference why patients refuse food, except that a +knowledge of the reasons may enable us to overcome their disinclinations. +The thing to remember is that they must in some way be made to get enough.</p> + +<p><i>Care of Patients with Insanity, Accompanied by Exhaustion.</i>—There is a +condition associated with acute mania or melancholia—though it is +sometimes seen in connection with the more chronic forms of insanity,—of +exhaustion so overpowering, that it may be rightly compared with the +exhaustion of typhoid fever. It may last a few days or a month, or more, +if it does not sooner terminate fatally. Instead of the quiet delirium of +typhoid fever there is generally violent mania or frenzy. Neither mind nor +body is quiet; sleep seems to have fled. The patient may be destructive, +constantly out of bed, fighting care, refusing food, and wetting and +dirtying himself. With these unfortunate conditions there generally is +fever, often to a considerable degree, the heart is feeble, the pulse +rapid, the tongue and lips dry and cracked, the teeth covered with sordes, +and the body emaciated. Every case does not present all these symptoms, +nor show such alarming exhaustion. There are many degrees of severity in +this sickness.</p> + +<p>Such patients must never be left alone and need constant nursing day and +night. They must have food, even if it is given forcibly. They must, if +possible, be kept in bed, and covered with clothing, and they must be +kept<span class="pagenum"><a name="Page_64" id="Page_64">[Pg 64]</a></span> clean. If wakeful, food must be administered during the night, and +especially towards morning, which is the time of greatest weakness and +physical depression.</p> + +<p>Hot baths may be ordered for these patients, and stimulants and medicine +to produce sleep left in the care of attendants. How to give the baths and +medicine, what results are to be expected, and what dangers are to be +feared, will be described later, in the chapter on the administration of +medicine.</p> + +<p>There are certain symptoms which should warn the attendant of danger, and +which often precede death. When any of these are present they should be +reported to the physician. They are: partial or complete unconsciousness, +slow and labored, rapid, shallow, or irregular breathing, increased +weakness and rapidity of heart or pulse, cold hands and feet. Picking at +the bedclothes, or at imaginary objects in the air, or vacant staring, are +bad symptoms.</p> + +<p><i>The Care of Patients in a Condition of Dementia.</i>—It is to be remembered +that dementia may be either, a condition of chronic insanity without +recovery, or a less permanent state of mental enfeeblement following the +acute attack, and from which recovery may be hoped. In the first of these +conditions there is little to be done except to care for the patient. Many +are able to do some work, and should be allowed, encouraged, and taught to +do it. Others do not know enough to dress, feed, or care for themselves. +These must be kept neatly dressed, taken to the table and their food +prepared, taken to the bath and closet, taken to walk, and put to bed. If +not so attended to, they will degenerate into a ragged, dirty, and<span class="pagenum"><a name="Page_65" id="Page_65">[Pg 65]</a></span> even +filthy state, and the ward upon which they live will be offensive to the +smell. They should be frequently examined for body vermin, as these pests +are liable to breed and flourish among these patients. The condition of +the demented affords the best evidence of the care given to the patients +in an institution. Attendants will often be gratified to see some of these +apparently hopeless cases greatly improve and sometimes recover.</p> + +<p>If attendants will watch their patients as they come out of acute mania or +melancholia and become quiet, they will often notice that they gain in +flesh and become demented. The dementia may be but partial, or so very +complete that the patient knows nothing. From this they may gradually go +on to improvement, or even recovery. They need all the care demanded by +the confirmed dement, and, in addition, advantage must be taken of every +means to promote recovery. They must be well fed, regularly taken out for +exercise, and, as they are able, encouraged to employ themselves. Any +symptoms of a return of their more violent condition, any failure to +sleep, or change noticed in the health of the patient, should be at once +reported.</p> + +<p><i>Care of the Convalescent Patients.</i>—This is the period that precedes +recovery from disease. With the insane it is often a critical time, and if +not properly cared for they may fail to get well, and become chronic +lunatics. The patients, and frequently their friends, think they are well +and should be at home. It is the attendant’s duty to encourage the +patient, and to promote his confidence in the physician. They should not +be told of their past conditions, or the disagreeable features of their +sickness called<span class="pagenum"><a name="Page_66" id="Page_66">[Pg 66]</a></span> to mind, and their last, as well as their first +impressions of the asylum should be made pleasant. Sometimes there is a +slight return of depression or mania, and the patient may suddenly begin +to lose sleep. These conditions must be observed and reported, for it is +very easy for patients who are recovering to become as disturbed as when +they were first insane, and to suffer a relapse from which they may never +recover. It is hardly necessary to remind the attendant that employment, +amusement, and all the healthful means of occupation afforded by the +asylum, should be judiciously allowed these patients.</p> + +<p>Sometimes patients feel too well. They are too contented, happy, and +indifferent, and are very active in body and mind. They want to work all +day, from early in the morning until late at night. They sing as they +work, and talk rather loud and fast. These patients need restriction; they +should not be allowed to work too much, so as to overtax their strength. +So long, however, as they continue to gain, and sleep well, little is to +be feared, and they generally become quieter and recover.</p> + +<p><i>The Care of the Epileptic Insane.</i>—Not all epileptics are insane, but +they are all liable to insanity. Generally the most hopeless and difficult +to be cared for are brought to the asylum. Epileptics are liable to have +fits at any time, but some patients have them at night only. The attack is +generally sudden, though sometimes patients have feelings that warn them +of their approach. This may precede the fit for a very short time, or the +patient may know during the day that he will have a fit during the night.</p> + +<p>Epileptic fits are accompanied by convulsions and <span class="pagenum"><a name="Page_67" id="Page_67">[Pg 67]</a></span>unconsciousness, and +are the type of all convulsions. The unconsciousness may be but momentary, +or last an hour or longer, and even prolonged several days; the +convulsions may be but the twitching of a few muscles, as of the face, or +may consist of the most terrible writhings, and last for several minutes, +and be often repeated. Sometimes the fits are ushered in by a scream.</p> + +<p>The fit itself is not dangerous to life, but patients may at night turn +their face downward and so smother; they may fall from high places, or +down stairs, or into the water, or into the fire, and so injure +themselves. There is little to do during an epileptic attack. Patients +should not be held to prevent the convulsions, but so that they shall not +injure themselves. A pillow should be placed under the head and the bands +about the neck loosened. The nurse is sometimes given remedies which, if +properly administered when the attack is felt to be coming on, may ward +off the fit. Nitrite of amyl in small glass pearls is a common remedy. It +is to be broken in a handkerchief and several strong breathfuls taken.</p> + +<p>At their best, epileptics are cross, irritable, quick-tempered, +unreasonable, and quarrelsome, and they will often give a blow at slight, +or even for no provocation. After a fit they are frequently dangerous and +always require guarded care and watching. As has been said, they may soon +recover their natural condition, or remain in a more or less prolonged +state of unconsciousness, or they may pass into a condition that appears +natural, but in which they have but little or no appreciation of their +situation or surroundings, or remember afterwards what they do. In these +states they may, without warning, make<span class="pagenum"><a name="Page_68" id="Page_68">[Pg 68]</a></span> violent assaults, commit murder or +suicide, or set things on fire. Sometimes they do outrageous acts, such as +beating their own children to death against the wall, or mutilating them, +or roasting them to death on the stove. Many often suffer from +hallucinations or illusions of sight or hearing, and have delusions of +impending harm or assaults, and think they must defend themselves.</p> + +<p><i>Care of Patients with Paresis.</i>—This is a form of insanity characterized +by progressive dementia and increasing bodily enfeeblement and paralysis. +The paralysis is partial, not complete; the patient’s walk is feeble, +unsteady, and shuffling; the hands are tremulous, lose their fineness of +touch and ability to do work and write; there is twitching in the muscles +of the tongue and about the mouth, and the speech is thick and indistinct. +As the disease progresses the patient becomes helpless, bedridden, wet, +and filthy. The result is always death. Convulsions like those of epilepsy +are liable to occur, from which the patients may rally, or in which they +may die or linger a few days. In the earlier stages the patients are often +strong, and controlled by delusions and hallucinations that make them +violent. Sometimes they are simply good-natured and easily managed. They +generally have very exalted and extravagant delusions, and are without +appreciation of their condition or surroundings, and are irritated at the +control of the asylum, and on account of their unreasonableness they can +rarely be allowed the liberty others enjoy.</p> + +<p>Paretics often eat ravenously and rapidly, they stuff their mouths full of +food and so choke themselves. Their condition of paralysis may render them +unconscious<span class="pagenum"><a name="Page_69" id="Page_69">[Pg 69]</a></span> of danger and powerless to help themselves. The care needed +by bedridden, filthy paretics is practically the same demanded by helpless +paralytics, the old, feeble, or demented class, and all others who cannot +care for themselves.</p> + +<p><i>Care of the Paralytic, Helpless, Bedridden, and Filthy Patients.</i>—There +are many patients in an asylum who are indifferent to all the wants of +nature, who wet and dirty themselves. Some of these patients are +bedridden; some are about the ward, but demented; some are violent and +maniacal, and some from delusions make their persons and rooms as filthy +as possible. Much can be done with many of these patients by regularly +taking them to the closet, and their bad habits may in this way be broken +up. Patients of this class should be visited during the evening, attended +to frequently by the night watch, and seen the first thing in the morning. +Patients, when dirty, should be thoroughly washed and carefully dried. +Their beds should be cleaned and changed, and during the day clean +clothing should be given them as often as required.</p> + +<p>The greatest danger that comes from not keeping patients clean is the +formation of bed-sores.</p> + +<p><i>Bed-Sores.</i>—Bed-sores occur in patients long confined to bed, and who +suffer from exhaustive diseases. Paralytics and paretics are particularly +liable to them, the diseased condition of the nerves allowing the tissues +to break down easily. Sometimes the fingers or toes of a paretic become +gangrenous or large surfaces of the skin die, and sometimes deeper tissues +slough away rapidly. These conditions may come on in a day or a night.</p> + +<p><span class="pagenum"><a name="Page_70" id="Page_70">[Pg 70]</a></span>Patients who are wet and dirty are more liable to have bed-sores. They +will always appear in a bedridden paretic in a few days if not kept +perfectly clean. They most frequently occur over bony projections where +the weight comes in lying, as upon the hips, back, or shoulders.</p> + +<p>Such patients, should, if possible, be made to sit up several hours every +day, or placed first on one side, then on the back, and then on the other +side. If it can be done, they should, as they lie in bed, rest their hips +on an inflated rubber ring, and if the skin is red the part should be +bathed in diluted alcohol. After being bathed and dried the skin about the +hips should be dusted with some dry powder. Powdered oxide of zinc is +perhaps the best, but ordinary corn-starch flour is valuable and serves a +good purpose. Insane patients frequently will resist all care and every +effort to prevent bed-sores, tearing off the bandages and dressings and +picking and irritating the sores.</p> + +<p>Bed-sores should never be allowed to come because of want of attention or +cleanliness, but there are conditions in which they will appear in spite +of every preventive.</p> + +<p>Bed-sores once formed should be treated as ulcers and according to the +direction of the physician.</p> + + +<p> </p><p> </p> +<hr style="width: 50%;" /> +<p><span class="pagenum"><a name="Page_71" id="Page_71">[Pg 71]</a></span></p> +<h2><a name="CHAPTER_IX" id="CHAPTER_IX"></a>CHAPTER IX.</h2> +<p class="center"><span class="large">SOME OF THE COMMON ACCIDENTS AMONG THE INSANE, AND THE TREATMENT OF EMERGENCIES.</span></p> + +<p> </p> +<p class="dropcap"><span class="caps">The</span> insane, like others, may suffer from almost any accident. It is not +intended to treat of all accidents, nor how to care for every emergency. +This is so large a subject as to demand a separate text-book, and there +are several excellent ones, that attendants would do well to read. But +there are among the insane certain kinds of accidents that are likely to +occur, certain classes who are liable to receive accidents, and certain +emergencies that frequently have to be cared for by the attendant, and +these will be described. Every injury received by a patient should be +immediately reported to a physician.</p> + +<p>Attendants, in the care of the insane should always remember the liability +to accident and guard against it. The old, the feeble, the paralytic, and +paretic need special care. They are weak, easily pushed over, or stumble +and fall, and they cannot break the weight of their fall, or so defend +themselves; they are irritable, childish, and often provokingly +troublesome to the other patients, and their bones seem to be easily +fractured. Some injuries are self-inflicted, some come to the patient in +consequence of his own or others’ violence, and some, as has been said, +from the very weakness of the patient.</p> + +<p><span class="pagenum"><a name="Page_72" id="Page_72">[Pg 72]</a></span><i>Care of Fractured Bones.</i>—Any of the bones may be fractured, and from +slight cause. The bones most frequently fractured are: the collar bones, +the ribs, the bones of the forearm just above the wrist, the bones of the +lower leg and of the thigh. This last bone, the femur, is among old people +most frequently broken at its neck, which is the constriction of the bone +just below the rounded end that fits into the joint at the hip.</p> + +<p>Fractures should, as much as possible, be let alone till the physician +comes. The parts should be kept quiet so as not to cause unnecessary pain, +and do further injury. By rough handling it is very easy to push a +fragment of bone through the skin, thus making a simple fracture a +compound one. When a rib is fractured a sharp end may pierce the skin or +the lung; either complication is serious. If the lung is injured the sputa +will be bloody, and the appearance of such a condition should be at once +reported. Sometimes patients are violent after the injury and need to be +firmly held, and sometimes they have to be carried to the ward from the +outside, or placed upon a bed. Always carry the fractured limb as well as +the patient.</p> + +<p>If temporary splints are put on do not make them too tight, and loosen +them from time to time as needed. The extremities sometimes swell rapidly +after a fracture, and the splints may so stop the circulation that, in a +few hours, gangrene may be caused by them. Besides, many patients cannot +tell us if the part is swollen or painful.</p> + +<p><i>The Care of Wounds.</i>—Bites. Insane patients often bite others and +penetrate the skin. They may be very<span class="pagenum"><a name="Page_73" id="Page_73">[Pg 73]</a></span> angry, their mouths foul and running +with saliva, and this irritating substance introduced into the wound by +the teeth may set up an ugly inflammation. The wound should be immediately +and thoroughly washed. It should be well cleaned with a wet sponge or +cloth, and soaked in warm water. A good after-dressing is powdered +iodoform, sprinkled over the wound.</p> + +<p><i>Wounds of the Head.</i>—These wounds are quite common. They should be +thoroughly washed and cleaned from dirt and hair. Hemorrhage may be +controlled by continued pressure upon the bones of the skull, and if an +artery is cut, it can in this way be kept from bleeding till the physician +arrives. Most wounds of the head, even though large, generally heal +quickly, but the most trifling ones may assume serious proportions, and +even prove fatal. If within two or three days heat, pain, redness, and +swelling appear, pus is probably forming beneath the scalp, and this, +within a few hours, may spread under a large surface and do serious +injury, or erysipelas may be set up.</p> + +<p><i>Injuries from Blows on the Head.</i>—Persons are sometimes stunned by blows +on the head. They should be placed in bed with the head elevated, and kept +perfectly quiet till the doctor comes. Efforts should not be made to +arouse them, they should not be given liquor of any kind, but ice may be +applied to the head. The danger to be feared is from the skull being +fractured, or from bleeding vessels inside of the skull. Either of these +conditions may, by pressure upon the brain, cause unconsciousness, +paralysis, and death.</p> + +<p><i>The Care of a Cut Throat.</i>—Patients may cut their<span class="pagenum"><a name="Page_74" id="Page_74">[Pg 74]</a></span> throats from ear to +ear and do really little injury, or they may make a small stabbing wound +and divide a large blood-vessel and die almost immediately, or they may +cut the windpipe and not cut the blood-vessels. The windpipe you can +notice upon yourselves as a large, stiff tube, prominently situated in the +middle and front of the neck; the blood-vessels are together on each side +of the windpipe, and situated quite deep down among the muscles, and the +carotid artery may be felt beating by the finger. Little can be done by +the attendants to stop the flow of blood, even if the great blood-vessels +are not cut. The head should be kept bent forward and the chin pressed +against the chest.</p> + +<p>After the physician has dressed the wound, constant watching day and night +may be required to prevent the patient tearing off the bandages and +reopening it. This same rule of watchfulness applies to the after-care +needed to be given to many cases of fracture, and other serious injuries +among the insane.</p> + +<p><i>Care of Wounds of the Extremities with Hemorrhage.</i>—The hemorrhage from +most simple wounds involving the cutting of skin and flesh or small +arteries, can usually be controlled by direct and continued pressure. This +may be done by a pad made of cloth, packed and pressed into the wound, or +lint may be used in the same way. Water as hot as can be borne poured into +the wound will frequently stop a hemorrhage when other means fail; cold +applications and ice are also useful. If dirty, a wound should be +thoroughly cleaned, being washed, and, if necessary, soaked in warm water. +Iodoform sprinkled so as to cover wounds, is the best dressing for all +attendants<span class="pagenum"><a name="Page_75" id="Page_75">[Pg 75]</a></span> or nurses to apply, while awaiting directions from a +physician. It keeps them clean, promotes healing, and lessens the danger +of inflammation or the formation of pus.</p> + +<p>When the arteries of the extremities are cut, pressure should be made on +the large artery leading to the part. When the wound is high up on the +arm, pressure is made by the fingers or a padded key upon the artery that +lies back of the collar bone, and the attempt should be made to press it +against the bone. This is a difficult thing to do, but nevertheless it +should be attempted. When the wound is lower down, pressure is to be made +by the fingers on the inner side of the upper arm, at about the middle +point and against the bone. The artery runs downward, near the inner +border of the biceps muscle, which is the large, bulging muscle of the +upper arm, and can, with a little care, be felt beating by the fingers. +Patients in breaking glass often cut one or both arteries at the +wrist-joint where the pulse is felt. These are large and bleed rapidly, +and when cut need the care just described.</p> + +<p>When the artery in the leg is wounded, pressure is to be made on the inner +side of the thigh, just below the groin. The position of these large +arteries, and how to press against the bone, is best learned by +instruction and demonstration from a physician, and with a little practice +attendants will be able to easily and successfully do the act.</p> + +<p>It is very tiresome to continue pressure with the fingers for a long time, +and attendants should relieve one another till the physician comes.</p> + +<p><span class="pagenum"><a name="Page_76" id="Page_76">[Pg 76]</a></span><i>The Care of Sprains.</i>—Sprains are a common accident and easily produced. +The great end of treatment is to keep the sprained joint quiet. If the +ankle or knee is sprained, the patient should be carried to bed. Perhaps +the best early treatment, and the one that gives the greatest relief to +pain, is to place the joint in a tub of water as hot as can be borne, and +keep it hot by pouring in more. The part should be kept in the water until +it is parboiled. The skin of some feeble or paralytic patients is easily +scalded, and some cannot tell when it is too hot; the water therefore +should never be uncomfortable to the hand of the attendant.</p> + +<p><i>Care of Patients Choking.</i>—This is a frequent accident, and in order to +know what to do when it occurs, it is necessary to have a knowledge of the +air passages of the throat.</p> + +<p>We breathe through the mouth and nose. They open into a common passage, +the pharynx, which can be seen by looking into the mouth, lying back of +the tonsils. Passing downward, it divides by branching into two tubes; one +the windpipe, which is in front, behind it is the œsophagus or gullet.</p> + +<p>The point of division is just beyond the tongue, and is almost within +reach of the forefinger when crowded into the mouth.</p> + +<p>The air we breathe passes through the mouth and nose to the pharynx, +thence to the lungs by the windpipe. The food we eat passes from the mouth +to the pharynx, and thence to the stomach by the œsophagus.</p> + +<p>There is at the opening of the windpipe a cover, the epiglottis, which is +generally open, but which closes when<span class="pagenum"><a name="Page_77" id="Page_77">[Pg 77]</a></span> food is swallowed and helps to keep +food from entering. When a substance touches the opening of the windpipe, +we instantly cough to expel it.</p> + +<p>A person may choke, when the mouth and the pharynx back of it are filled +with food; or when a piece is lodged in the wind-pipe, or a large piece in +the œsophagus at the point of division, and which crowds upon the +windpipe, or covers the opening. Food gets into the windpipe, by being +drawn in by a sudden and unexpected inspiration of air. This may happen +while eating or in vomiting solid food. With this accidental exception all +breathing stops during the act of swallowing.</p> + +<p>Some patients, from paralysis, especially paretics, do not feel food when +it is lodged in the throat; others, from great dementia, may not know when +they are choking, and show no emotional signs of distress. Paretics are +particularly liable to bolt their food, and cram the mouth and throat +full.</p> + +<p>The symptoms of choking are immediate, and if no relief is obtained, the +sufferer will die in a few minutes. If the patient knows any thing, he +will show immediate signs of distress, violent but ineffectual attempts to +breathe, and the face quickly becomes a dark blue color, from the +accumulation of carbonic acid in the blood.</p> + +<p>Immediate effects should be made to remove the obstruction, and continued +until the physician arrives, who is to be sent for at once. Whatever is in +the mouth and throat can be easily removed by the fingers; the forefinger +should then be crowded down the throat to feel for other obstructions, +care being taken not to push a piece of food into the windpipe. If any +thing is<span class="pagenum"><a name="Page_78" id="Page_78">[Pg 78]</a></span> felt, it can sometimes be pulled out by the fingers, or a +hair-pin may be straightened and bent, or a piece of wire, and an effort +made to fish it out. When in the gullet and beyond the fingers, it may be +pushed into the stomach by a feeding-tube. Artificial respiration may be +needed, but attendants must remember it is of no use until the obstruction +to breathing is removed.</p> + +<p>Marbles, coins, buttons, pieces of pencils, needles, pins, and fish-bones, +are frequently swallowed. The physician should be informed at once.</p> + +<p><i>Directions how to Perform Artificial Respiration.</i>—What is to be done +must be done quickly; tight clothing about the neck and chest must be +removed, and the mouth should be cleaned of dirt, water, or any +obstruction to the flow of air. The body is then laid out flat on the +back, covered, if possible, with light warm blankets, and some article +should be folded and placed under the shoulders, so as to raise them three +or four inches. The mouth must be kept open, and the tongue pulled well +forward, as it is liable to fall backwards, and cover the opening of the +wind-pipe. One person, kneeling behind the head, should grasp each arm at +the elbow, and, draw them steadily around so that the arms will meet above +the head. A strong pull should be made upon them, and they should be held +a few seconds. These movements elevate the ribs and enlarge the chest and +produce an inspiration.</p> + +<p>The arms are then to be brought to the side, and pressed strongly against +the lower ribs. This last movement drives the air out of the lungs, and +makes an expiration. These manipulations should be repeated, slowly and<span class="pagenum"><a name="Page_79" id="Page_79">[Pg 79]</a></span> +regularly, about sixteen times a minute, and should, when there is the +slightest hope of life, be continued at least thirty minutes. The heart +should be listened to, in order to hear if it still beats. Warmth, by +hot-water bags, bricks, and soapstones should be secured, care being taken +not to burn the skin. The limbs may be gently rubbed with warm cloths, +though it is not so important as some well-meaning people think. The +rubbing should be towards the heart.</p> + +<p>As the breathing begins, it should be still aided by the artificial means +as long as necessary. When the patient can swallow, teaspoonful doses of +brandy or whiskey, to two or three of water, may be given and repeated +several times. As soon as possible the patient should be put in a warm +bed, and milk and light food given.</p> + +<p><i>Care of Patients when First Burned.</i>—When a patient’s clothing is first +on fire, dash water over him if near at hand, if not wrap him in a blanket +or some heavy woollen garment, and smother the fire. Then unroll the +patient and extinguish the smouldering pieces of clothing. The clothing +must be cut and clipped off. Great care must be taken not to tear open the +blisters. If any application is made, it may be by linen cloths soaked in +sweet or castor oil, or equal parts of linseed oil and lime-water, or a +layer of flour and molasses may be applied over the burned surface. These +bland substances act largely by excluding the air, which, if blowing ever +so quietly, is always painful and irritating, and they also protect the +wound from the irritation of the bed and body clothing. Burns from +scalding are practically treated in the same way as burns from fire.</p> + +<p><span class="pagenum"><a name="Page_80" id="Page_80">[Pg 80]</a></span><i>Care of Frost-bites.</i>—Toes, fingers, ears, and noses are most frequently +frozen. They will sometimes freeze in a few minutes on a very cold day. +After a part is frozen there is no feeling of cold or pain, and it looks +perfectly white, and is so stiff it may be broken.</p> + +<p>Persons who are frost-bitten should not be taken into a warm room. They +should be left in a cool room, and the frozen part rubbed with cold water, +or ice, or snow. As these last melt they melt the frozen flesh. If the +parts are thawed too quickly gangrene is liable to follow.</p> + +<p><i>Care of Patients in States of Unconsciousness.</i>—This is not an accident, +but a frequent emergency. The medical word for unconsciousness is <i>coma</i>. +It may be partial or complete, may come on suddenly or slowly, or may be +accompanied by convulsions or paralysis. The more frequent causes of coma, +are epilepsy, the convulsions of paresis, blows on the head, hemorrhage in +the brain or apoplexy, some diseases of the brain, sunstroke, and some +poisons.</p> + +<p>When coma comes on, attendants should observe, if it is slow or sudden; if +the patient complains of pain in the head; if the respirations are +changed, and how; the condition of the pupils, whether large, contracted, +uneven, or changeable; if the mouth and face are drawn to one side; if +there is any paralysis of the arms or legs; if there are any convulsions, +or twitching of muscles; if the patient can be aroused, and from time to +time observe and count the pulse.</p> + +<p>Apoplexy is a term that is much used, and is a condition of coma, caused +by pressure on the brain. This organ is in a tight, rigid box, the skull. +If the fluid of<span class="pagenum"><a name="Page_81" id="Page_81">[Pg 81]</a></span> the brain is much increased, or blood-vessels ruptured, +pressure is the result, and the soft tissues yield, rather than the bony +covering. This pressure may destroy or injure the cells and fibres, and so +interfere with the function of the part. Another way that apoplexy occurs +is by plugging of an artery of the brain, so that it cannot deliver blood +to the part to which it goes, and consequently the part loses its ability +to perform its function. The plugging is most frequently due to a small +clot floating in the blood, and which is usually formed in the heart.</p> + +<p>Paralysis and apoplexy are often, through ignorance, used synonymously, +but they really mean very different conditions. Paralysis is a loss of +power of contracting a muscle, due to disease or injury of the nervous +system; it frequently follows or is associated with apoplexy.</p> + +<p>In the case of apoplexy, and most conditions of coma, there is generally +little for the attendant to do. The patient should be put to bed, with +light coverings, and the head raised on pillows. Do not annoy the patient +by trying to rouse him, and do not give stimulants.</p> + +<p><i>Care of Sunstroke.</i>—A sunstroke is a very serious condition, and when it +occurs, requires immediate efforts to save the life of the one suffering +from it. It generally comes on suddenly, the patient first complaining of +the head; he soon becomes unconscious, the skin hot and dry, and the pulse +full and bounding. The treatment consists of taking the patient to a cool, +shaded place, removing all unnecessary clothing, applying ice or cold +water to the head, and bathing or sponging the body in cold water. If the +patient recovers, the temperature<span class="pagenum"><a name="Page_82" id="Page_82">[Pg 82]</a></span> will fall under this treatment. If the +heart begins to fail, or the pulse becomes weak or fluttering, small doses +of whiskey and water may be given and repeated.</p> + +<p>Patients should not be taken out in the fields nor exposed places on very +hot days, except as ordered by the physicians; they should wear light +clothing and a straw hat; if permitted to go out, they should not +overwork, and should be allowed frequently to rest in the shade. Patients +are easily injured by working in the sun; headache caused, recovery +retarded, and bad symptoms brought back, without having the alarming +conditions of sunstroke.</p> + +<p><i>Unconsciousness from Poisoning.</i>—Opium and its preparations, including +morphine, chloral, and the two extracts of hyoscyamus, now so much +employed in asylums, namely, hyoscine and hyoscyamine, are medicines +frequently given, that poison in over-doses and produce coma.</p> + +<p>These medicines and their effects will be described in the next chapter, +and at the same time the symptoms of poisoning by them, and the treatment.</p> + +<p><i>Poisoning.</i>—Poisonous drugs are not kept upon the wards. Attendants +frequently have strong ammonia in their rooms to clean their clothing, and +a patient may get it and drink it. It is a strong alkali, and burns the +throat and mouth. Vinegar is the best ready antidote, but should be given +immediately or not at all. Soft soap is a strong alkali, and if eaten +becomes an irritating poison. Again vinegar is the best antidote.</p> + +<p>The best antidotes for acids are soda, lime-water, soap-suds, and chalk; +for alkalies, weak acids, such as lemons, oranges, vinegar, or cider. +Olive oil, eggs, and mucilaginous<span class="pagenum"><a name="Page_83" id="Page_83">[Pg 83]</a></span> drinks are the most bland and soothing +remedies to give. To vomit a person who has taken poison, give a pint or a +quart of lukewarm water; to it may be added one or two teaspoonfuls of +mustard. Syrup of ipecac is a common remedy, the dose is a teaspoonful, +and repeated in ten minutes if necessary. It assists vomiting to tickle +the throat with a finger or a feather. If after poisoning there is +depression or approaching coma, very strong tea or coffee is the best +stimulant, and it is as well an antidote to many poisons. If the heart and +pulse are very weak, whiskey diluted with water may be given and repeated.</p> + +<p><i>Injury from Eating Glass.</i>—Patients sometimes eat glass. This injures by +the edges cutting and inflaming the walls of the stomach and intestines. +This may be so severe as to cause death. In the treatment do not give an +emetic or a cathartic. Such food as has a tendency to constipate the +bowels, and such as will also enclose the glass and coat its sharp edges, +is to be given. Potatoes, especially sweet, oatmeal, or thick indian-meal +pudding, are appropriate. Cotton, which is generally at hand, will, if +swallowed, engage the glass in its fibres, and so protect from injury.</p> + +<p><i>Injury with Needles.</i>—This is a self-injury, but it may be severe and +require immediate attention. Patients may open a vein or an artery with a +needle, or plunge it into the eye. But the more common way is for a +patient to stick many needles under the skin, sometimes to the number of +several hundred. Sometimes patients introduce them near the heart or +lungs, and as a needle will often “travel” when in the flesh, it may work +its way<span class="pagenum"><a name="Page_84" id="Page_84">[Pg 84]</a></span> into a deeper part, and so a number get into the lungs or the +heart, causing death. Within a few weeks I saw two needles taken from a +man’s heart, who died in consequence of their presence there. An attempt +or desire to so injure one’s self should be guarded against by the +attendants, and if accomplished should be at once reported to the +physician, that efforts may be made to extract the needle.</p> + + +<p> </p><p> </p> +<hr style="width: 50%;" /> +<p><span class="pagenum"><a name="Page_85" id="Page_85">[Pg 85]</a></span></p> +<h2><a name="CHAPTER_X" id="CHAPTER_X"></a>CHAPTER X.</h2> +<p class="center"><span class="large">SOME SERVICES FREQUENTLY DEMANDED OF ATTENDANTS, AND HOW TO DO THEM.</span></p> + +<p> </p> +<p class="dropcap"><span class="caps"><i>The</i></span> <i>Administration and Effect of Medicine.</i>—The only proper way of +giving medicine is by using standard weights and measures. Dropping +medicine, or using spoons or cups, is not sufficiently accurate. A drop +may be half a minim, or as large as two or even three. The modern teaspoon +holds ninety or more minims, and a tablespoon more than half an ounce.</p> + +<p>Medicines are introduced into the system through the stomach, the lungs, +the rectum, the skin, or by being injected into the tissues, under the +skin. They are either local or general in their effects. A blister or a +poultice is a local remedy, so is an emetic, that acts by irritating the +walls of the stomach. General medicines are absorbed into the blood, and +carried to different parts of the body.</p> + +<p>The following are a few of the reasons for which medicine is given: to +relieve pain, to give sleep, to produce vomiting, to check vomiting, to +move the bowels, to check diarrhœa, to assist digestion, to produce a +greater or diminished flow of urine, to increase the perspiration, to +increase the red blood corpuscles, to check hemorrhage, to regulate the +action of the heart,<span class="pagenum"><a name="Page_86" id="Page_86">[Pg 86]</a></span> to overcome the effects of poison, to increase or +diminish the amount of blood in the brain, to control spasm, to diminish +the temperature in fever.</p> + +<p>In some cases the effect desired and expected from a medicine given to a +patient is told to the attendant, who should closely observe and be able +to report the result. Sometimes medicines are left in the hand of the +attendant, to give in repeated doses, at stated intervals, till a desired +effect is produced. The attendant is also instructed to watch for certain +symptoms which show that the medicine is doing harm, when it is to be +discontinued. An attendant, who has studied and learned, “how and what to +observe” in his patient, will be able to give intelligently any medicine +ordered by a physician.</p> + +<p>Sometimes medicines, given in large or long-continued doses, cause +symptoms that an attendant should notice and report to the physician; some +of these are, eruptions on the face and body, puffiness about the eyes, +irritation and running of the eyes, a metallic taste in the mouth, +bleeding of the gums or soreness of the teeth and profuse flow of saliva, +nausea, vomiting, diarrhœa, constipation, indigestion, ringing of the +ears, feeling of fulness in the head, headache, dizziness, drowsiness, +coma, convulsions, or convulsive movements of muscles.</p> + +<p>In asylums, medicines are mostly sent to the wards in single doses, each +cup or bottle being marked with the name of the patient for whom it is +intended. The tray in which they are carried should never be set down and +left, for a mischievous or suicidal patient may poison himself by taking +every thing he can get hold of.</p> + +<p>No patient, unless ordered by the physician, should be<span class="pagenum"><a name="Page_87" id="Page_87">[Pg 87]</a></span> allowed to keep +his cup and take his medicine at his leisure. Suicidal patients often ask +to do this, and then save the medicine, until they have enough to poison +themselves. Others will throw the medicine away. The way to administer +medicine to the insane is to give it personally to the patient, and also +see that it is swallowed. It is a frequent custom of many patients to +retain the medicine in the mouth, and, when the attendant has left, to +spit it out.</p> + +<p>It is often very important that patients should take the medicine ordered, +and every effort should be made to induce them to take it. Such patients +should be designated by the physician. Night medicines, or those given +about bedtime, are usually of great importance. All patients who refuse to +take their medicine should be reported to the physician.</p> + +<p>The reasons for refusing medicines are various; some say they are +perfectly well and need no medical treatment, others think the medicine +injures them, that it turns their skin black, or poisons them, or that it +is wrong to take it, or displeasing to God; ideas much like those that we +learned were the causes for the refusal of food. Attendants are to use +every effort to get patients to take medicine, and may employ as much +force as they were instructed to use in giving food, but no more.</p> + +<p>Patients should not be deceived about medicines, nor told by attendants +that it is nothing, that it is only a little water, or some nice drink +that is sent to them, nor should an attempt be made to give them, by +trying to disguise them in food or drink, except by the permission of a +physician. Patients should, on the other hand, be told<span class="pagenum"><a name="Page_88" id="Page_88">[Pg 88]</a></span> that it is +medicine, that the doctor ordered it for them, that it is for their good +to take it, that it is given to help them get well.</p> + +<p>The giving of medicine and food is among the most important and frequent +duty that an attendant is called upon to perform, or assist others in +doing. Attendants must remember that many medicines are injurious or even +poisonous, if not properly given, or if mixed with other medicines, or if +given to the wrong patient; they should therefore, never make a mistake, +or, if by carelessness they commit one, should immediately report it.</p> + +<p><i>Opium and Some of its Preparations.</i>—Opium is a medicine that is very +frequently given to patients in an asylum. The ordinary dose is one grain. +<i>Tincture of opium, or laudanum</i>, is opium dissolved in alcohol. Ten +minims equal one grain of opium. <i>Camphorated tincture of opium, or +Paregoric</i>, is a weaker alcoholic solution, with some camphor, and +flavored with a pleasant aromatic. One half a fluid ounce equals a grain +of opium. <i>Morphine</i> is a white powder extracted from opium. An eighth of +a grain about equals a grain of opium.</p> + +<p>Opium, in some of its forms, is a common household remedy. To an adult, +not more than one grain should be given; it should not be repeated more +than once, nor less than six hours after the first dose. It would be +better if never given, except by a physician’s order. Under no +circumstances should any one but a physician give it to a weak or old +person, or to a young child.</p> + +<p>Opium, is given in ordinary doses to relieve pain, to check diarrhœa, +to relax spasm of muscles, and to produce sleep. The sleep from opium is +generally quiet and <span class="pagenum"><a name="Page_89" id="Page_89">[Pg 89]</a></span>refreshing, and one from which the patient can be +easily aroused.</p> + +<p>An attendant will frequently be told when the medicine is given and +directed to note and report its effect.</p> + +<p><i>Opium Poisoning.</i>—The taking of opium is a frequent way of committing +suicide by persons outside of asylums. Sometimes patients manage to save +their doses, or they steal it from the tray, or, if there is some sent to +the ward for repeated doses, they secure it through the carelessness of an +attendant, or occasionally it is secretly sent to patients by officious +outside friends,—thus poisoning by opium sometimes occurs among asylum +patients.</p> + +<p>The full symptoms of poisoning are profound coma, pupils contracted to +pin-points, and which do not respond to light; very slow respiration, +often not more than four or six times a minute, but heavy and labored. +Sometimes the effect of the drug is but partial, the patient can be +aroused for a moment, but falls to sleep again, or the symptoms may be +even less pronounced.</p> + +<p>The treatment of opium poisoning, before the physician comes, consists in +giving <i>very</i> strong coffee, or tea, an emetic, and in trying to keep the +patient awake by walking him about, or, if this is not possible, to keep +him from falling into deeper coma, by shaking, calling loudly in the ear, +and striking and slapping the body with wet towels.</p> + +<p><i>Chloral.</i>—This is a white crystal, with a pungent, burning taste. It is +always dispensed, dissolved in water, and should be further diluted when +given to a patient. The dose is from ten to thirty grains. It is too +powerful a drug to be given, except upon the order of a physician.<span class="pagenum"><a name="Page_90" id="Page_90">[Pg 90]</a></span> +Chloral is given to produce sleep, which is usually quiet and natural. The +effect lasts about four or six hours.</p> + +<p>The symptoms of poisoning are not so marked as to make it easy to know +that they are caused by chloral. There is generally a weak heart and +pulse, and feeble respiration, and the patient is in a deep sleep, from +which he may be aroused; or the coma may be profound, and continue +uninterrupted till death.</p> + +<p>The treatment consists in giving an emetic, stimulants, coffee, and, if +necessary, performing artificial respiration.</p> + +<p><i>Hyoscyamine and Hyoscine.</i>—These are extracts, from the leaves and +seeds, of the plant hyoscyamus.</p> + +<p>These are very powerful medicines, and are never given except on the order +of a physician. They are always given in solution.</p> + +<p>The action of both is practically the same. In ordinary doses they quiet +restlessness, produce muscular weakness, flushing of the face, dryness of +the tongue, wide dilatation of the pupils, and frequently cause sleep. +These effects should be noticed and reported. These medicines are mostly +given to patients who are continually restless, violent, and sleepless, +and the object is to bring quiet, repose, and sleep. Large doses may +produce coma, very heavy breathing, and great muscular weakness; the pulse +however is full and strong, but if it should fail, the physician should be +at once sent for.</p> + +<p><i>Alcohol and Stimulants.</i>—It is the alcohol in liquors that intoxicate, +and it is that part, also, of liquor that stimulates when given as a +medicine. Whiskey, brandy, and gin are about one half alcohol. The dose is +a <span class="pagenum"><a name="Page_91" id="Page_91">[Pg 91]</a></span>tablespoonful, in water, and not repeated oftener than two or three +times. Wines are about one fifth alcohol, beers and cider about one +twentieth.</p> + +<p>Liquors containing alcohol are never to be given to patients as a +beverage, but always as a medicine, and, except in emergencies, never +without a physician’s order. Do not give them in emergencies, without a +good reason for so doing, and not simply because you feel you must do +something, for in some emergencies they may do a great deal of harm, and +perhaps, a fatal injury.</p> + +<p>Alcohol is mostly given to stimulate the action of the heart. A stimulant +is something “that arouses or excites to action.” It is given (in the +doses just mentioned) in accidents, when the heart is very weak, the pulse +almost or quite imperceptible, the face pale and pinched, and the +extremities cold.</p> + +<p>In continued sickness, with exhaustion, stimulants are sometimes left with +the attendant to give, with directions about the size of the dose and its +frequency. If it quiet the patient, strengthen the heart and pulse, it is +doing good; but if restlessness comes on, the face becomes flushed, or if +the pulse is made more rapid and feeble, it is probably doing harm, and +should be discontinued, and the physician informed.</p> + +<p><i>Dry and Moist Heat.</i>—In applying heat, either dry or moist, to the +insane, care must always be used to protect the skin from being blistered. +This happens very easily when it is applied directly to old, feeble, +paralyzed, or paretic patients, and also to those who are too demented to +complain if they are being burned. Burns are very serious accidents among +this class of patients, and<span class="pagenum"><a name="Page_92" id="Page_92">[Pg 92]</a></span> may, if they extend over a large surface, +even though not deep, heal with difficulty, and even prove fatal.</p> + +<p>Dry heat is applied by means of rubber bags filled with hot water, +hot-sand bags, bricks, or soapstones, and by the lamp bath. Moist heat by +hot baths, fomentations, turpentine stupes, and poultices.</p> + +<p><i>Hot Baths and Wet Packing.</i>—Hot baths are sometimes prescribed for +patients. The water should be about 100 degrees F., and, if ordered, +slowly increased to 110°. The patient is to be left in as long as +directed, which may be but a few minutes, or half an hour, or even longer. +Sometimes a blanket is ordered thrown over the tub, the head only being +uncovered.</p> + +<p>When the bath is being given, the pulse should be counted; if it become +weak and rapid, if the face become flushed, and the patient complains of +dizziness, or if the lips show venous congestion, the patient should be at +once removed, and, unless there is immediate recovery from these evil +effects, the physician should be informed.</p> + +<p>In giving a wet pack, the patient is wrapped in a sheet, without any +clothing, wet either in cold or warm water, as ordered, and then rolled in +a blanket, put to bed, and left in it as long as directed.</p> + +<p>These methods of treatment are frequently ordered by physicians for +patients who are restless, violent, and sleepless, with a view of giving +quiet and sleep. The attendant should observe and report the result.</p> + +<p><i>Application of Cold.</i>—The attendants are frequently ordered to apply ice +to some part of the body, for the purpose of producing local cold. The ice +should be broken into small pieces and put into a bladder, or rubber bag,<span class="pagenum"><a name="Page_93" id="Page_93">[Pg 93]</a></span> +partly filling it. It remains sufficiently cold until all the ice is +melted.</p> + +<p>Another way is to put a piece of ice in a sponge and bathe the part. When +cold cloths or compresses are applied, the heat of the body soon warms +them, when they become warm applications and act as a poultice; they +should therefore be frequently changed. In applying moist dressings care +must be used not to have any leaking nor wetting of the bed or clothing.</p> + +<p><i>Hypodermic Injections.</i>—Morphine, hyoscyamine, or hyoscine, in solution, +are frequently injected under the skin. The direction to do this, and the +quantity to be given, will, in every case, be ordered by the physician. A +fold of the skin is held between the finger and thumb, while the needle +held in the other hand is quickly pushed straight under the skin to the +depth of about half an inch. Care should be used to inject no air, and not +to inject the contents of the syringe, into a vein.</p> + +<p><i>Forcible Feeding with the Stomach-Tube.</i>—Attendants are frequently +called upon to assist in the forcible feeding of patients, and in some +cases may themselves be directed to do it. The dangers of feeding are that +the pharynx may be filled with fluid, and the patient choke, or it may be +drawn into the lungs, that the wedge with which the mouth is held open may +be so loosely held that in the struggle of the patient the soft parts of +the mouth may be injured, and occasionally it happens that the mere +pressure of the tube causes choking.</p> + +<p>Attendants should watch the process of feeding, and particularly the face, +for symptoms of venous congestion, and report to the physician any thing +they see that denotes danger.</p> + +<p><span class="pagenum"><a name="Page_94" id="Page_94">[Pg 94]</a></span>In preparing for feeding, attendants must see that the food is properly +made ready. If any thing is to be mixed with milk, it should be mixed so +as to be perfectly smooth, without lumps, and so it will run easily +through the tube. If some concentrated food is used, it is better to put +it in a small quantity of milk, just enough to make it liquid, that it may +be given first. Medicines ordered for feeding are not to be mixed with a +large quantity of milk, but saved, that they may be given directly from +the dispensing bottle whenever the physician desires to do so.</p> + +<p>Every thing should be got ready for feeding before the physician arrives. +Upon a tray should be all the feeding apparatus—the food and medicine, +several spoons, and cups, and a pitcher. Near at hand should be plenty of +water, soap, and towels, and a tin basin. It is very provoking to have to +wait for many things to be brought after the patient has been got ready.</p> + +<p>Many patients are easily fed. Some like it, but some violently and +furiously resist. Such patients should be restrained to a chair fixed to +the floor, and the more securely this is done the more easily can they be +fed, and with less fatigue and danger of their being injured.</p> + +<p>The patient’s clothing should be well protected from being soiled, by +towels about the neck, and a basin should always be held under the chin to +catch falling liquids and any thing vomited. The holding the head and +wedge is an important matter, and is some thing that belongs to the +attendant to do. The attendant stands behind the patient, and holds the +chin by the right hand, and with the left firmly grasps the wedge, which +is inserted straight into the mouth, between the back teeth,<span class="pagenum"><a name="Page_95" id="Page_95">[Pg 95]</a></span> about two or +three inches. The wedge should be grasped with the palm upwards, and the +little finger and side of the hand should be pressed firmly against the +chin. If held in this way there is little danger that in violent +struggles, the wedge can be suddenly driven backward and wound and tear +the soft parts of the mouth. If the throat fills with fluid, the attendant +who holds the head should bend it far forward, that it may, if possible, +run out of the mouth.</p> + +<p>After feeding, patients’ faces should be washed. They should be watched +for some time to see that they do not vomit, or, as is often the case, +that they do not make themselves vomit.</p> + +<p>There is no special difference in caring for a patient fed with a nasal +tube, except that the wedge is not used.</p> + +<p>If attendants are allowed to feed, they must remember all the dangers, and +guard against them. In introducing the tube, the forefinger of the right +hand is to be introduced at the same time, and, as the tube passes over +the tongue it is to be turned downward by the finger and <i>gently</i> pushed +into the œsophagus. If there seem to be unusual difficulty in so doing, +severe and unusual struggling, or the slightest symptom of danger, cease +the effort to feed, and report to the physician.</p> + +<p>Of course no attendant would undertake to feed any patient unless ordered +to do so by the physician, which order would be given, if at all, only +after careful training and in cases easily fed.</p> + +<p><i>Nutritive Enemata.</i>—It is often necessary to feed patients by the +rectum. This is done by injecting food, to the amount of four or six +ounces. Care should be used to<span class="pagenum"><a name="Page_96" id="Page_96">[Pg 96]</a></span> inject no air. The nozzle of the syringe +well oiled is to be gently introduced, and the fluid slowly forced into +the bowel. The patient should lie on the left side, near the edge of the +bed, with the knees well drawn up. If the patient resist, he must be +placed upon the back, the legs separated and firmly held. This may require +four or six attendants, but enough should always be at hand to thoroughly +and easily overcome the patient. Before giving the first injection of food +the bowels should be moved by an injection of soap and water. Sometimes +the injected food escapes from the rectum. The patient should be watched +to see if this happens. In such a case a long tube can be introduced into +the rectum, about four or six inches, and the food injected through it. +The tube should be well oiled, and introduced slowly and with gentle +force.</p> + +<p>Patients often thrive upon this way of feeding. The character of the food +will be ordered by the physician.</p> + + +<p> </p><p> </p> +<hr style="width: 50%;" /> +<div class="verts"> +<p class="center"><span class="huge"><i>PUBLICATIONS OF G. P. PUTNAM’S SONS.</i></span></p> + +<p class="center"><span class="large">STUDENTS’ MANUALS.</span></p> + +<p class="hang"><b>Manual of Prescription Writing.</b> By <span class="smcap">Matthew D. Mann</span>, M.D., late Examiner in +Materia Medica and Therapeutics in the College of Physicians and Surgeons, +New York. Revised edition. 16mo, cloth. $1.00.</p> + +<p class="hang"><b>Manual of Practical Normal Histology.</b> By <span class="smcap">T. Mitchell Prudden</span>, M.D., +Director of the Physiologica, and Pathological Laboratory of the Alumni +Association of the College of Physicians and Surgeons, N. Y., etc. 16mo, +cloth. $1.25.</p> + +<p class="hang"><b>Students’ Manual of Venereal Diseases</b>, being the University Lectures +delivered at Charity Hospital, B. I., during the Winter Session of +1879-80. By <span class="smcap">F. S. Sturgis</span>, M.D., Clinical Lecturer on Venereal Diseases in +the Medical Department of the University of the City of New York, etc., +etc. Fourth edition. 16mo, cloth. $1.25.</p> + +<p class="hang"><b>Students’ Manual of Diseases of the Skin.</b> By <span class="smcap">L. D. Bulkley</span>, M.D. Large +16mo. $1.25.</p> + +<p class="hang"><b>Students’ Manual of the Diseases of the Nose and Throat.</b> By <span class="smcap">J. M. W. +Kitchen</span>, M.D. 16mo, illustrated, cloth. $1.00.</p> + +<p class="hang"><b>Students’ Manual of the Pharmacopœia of the Diseases of the Throat.</b> By +<span class="smcap">George M. Lefferts</span>, M.D. $1.00.</p> + +<p class="hang"><b>Students’ Manual of Rational Electro-Therapeutics.</b> By <span class="smcap">R. W. Amidon</span>, A.M., +M.D., Lecturer on Therapeutics at the Woman’s Medical College of the N. Y. +Infirmary, etc., etc. 16mo. $1.00.</p> + +<p class="hang"><b>Students’ Manual of Diseases of the Nerves.</b> By <span class="smcap">E. C. Seguin</span>, M.D. (<i>In +preparation.</i>)</p> + + +<p> </p><p> </p> +<p class="hang"><b>SUGGESTIVE THERAPEUTICS.</b> A Treatise on the Nature and Uses of Hypnotism. +By <span class="smcap">H. Bernheim</span>, M.D., Professor in the Faculty of Medicine at Nancy. +Translated from the second and revised French edition, by <span class="smcap">Christian A. +Herter</span>, M.D., of New York. Octavo, cloth $3.50</p> + +<p class="blockquot">“I present this volume to the English-speaking medical public in the +belief that it throws important light upon a subject which has too +long been misunderstood and ignored.”—<span class="smcap">Extract from Translator’s +Preface.</span></p> + +<p class="hang"><b>PSYCHIATRY. A Clinical Treatise on Diseases of the Fore-Brain, Based upon +a Study of its Structure, Functions, and Nutrition.</b> By <span class="smcap">Theodor Meynert</span>, +M.D., Professor of Nervous Diseases and Chief of the Psychiatrical Clinic +in Vienna. Translated (under authority of the author) by <span class="smcap">B. Sachs</span>, M.D. +Octavo, cloth $2.75</p> + +<p class="blockquot">“We most earnestly urge our readers to put this work in their +libraries as one that will prove indispensable.”—<i>Quarterly Journal +of Inebriety</i>, Jan., 1886.</p> + +<p class="hang"><b>THE INSANE IN FOREIGN COUNTRIES.</b> By <span class="smcap">William P. Letchworth</span>, President of +the New York State Board of Charities. Octavo, cloth $3.00</p> + +<p class="hang"><b>THE ERRORS OF REFRACTION.</b> By <span class="smcap">Francis Valk</span>, M.D., New York. 245 pages. +Numerous illustrations (some in color) $3.00</p> + +<p class="hang"><b>PHYSIOLOGICAL NOTES ON PRIMARY EDUCATION AND THE STUDY OF LANGUAGE.</b> By +<span class="smcap">Mary Putnam Jacobi</span>, M.D. 12mo, cloth. $1.00</p> + +<p class="hang"><b>ESSENTIALS OF PHYSICS AND CHEMISTRY.</b> By <span class="smcap">Condict W. Cutler</span>, M.S., M.D. +Third edition, enlarged and revised. Cloth $2.00</p> + +<p class="hang"><b>THE STORY OF THE BACTERIA.</b> By <span class="smcap">T. M. Prudden</span>, M.D., author of “A Manual of +Practical Normal Histology.” 16mo, cloth .75</p> + +<p class="hang"><b>HYSTERIA AND OTHER NERVOUS AFFECTIONS.</b> A Series of Essays, by <span class="smcap">Mary Putnam +Jacobi</span>, M.D. $2.00</p> + +<p class="blockquot"><span class="smcap">Contents</span>—1. Loss of Nouns in Aphasia. 2. Case of Nocturnal Rotary +Spasm. 3. The Prophylaxis of Insanity. 4. Antagonism between +Medicines, and between Remedies and Disease. 5. Hysterical Locomotor +Ataxia. 6. Consideration on Tumors of the Brain.</p> + +<p class="hang"><b>ALT. The Human Eye in its Normal and Pathological Conditions.</b> By <span class="smcap">Adolph +Alt</span>, M.D., Lecturer on Ophthalmology in Trinity Medical College, Toronto, +with the editorial assistance of <span class="smcap">T. R. Pooley</span>, M.D. 8vo, illustrated. +$3.00.</p> + +<p class="hang"><b>ALTHAUS. On Sclerosis of the Spinal Cord.</b> Including Locomotor Ataxy, +Spastic Spinal Paralysis, and other System Diseases of the Spinal Cord; +their Pathology, Symptoms, Diagnosis, and Treatment. By <span class="smcap">Julius Althaus</span>, +M.D. With nine illustrations. 8vo, cloth. $2.75.</p> + +<p class="hang"><b>BROWNE AND BEHNKE. Voice, Song, and Speech.</b> A Practical Guide for Singers +and Speakers, from the Combined View of the Vocal Surgeon and the +Voice-Trainer. By <span class="smcap">Lennox Browne</span>, F.R.C.S., Surgeon to the Throat and Ear +Hospital, London, and <span class="smcap">Emil Behnke</span>, author of “The Mechanism of the Human +Voice.” With numerous illustrations by wood-cutting and photography. 8vo, +cloth. $4.50.</p> + +<p class="hang"><b>BUHL. Inflammation of the Lungs, Tuberculosis, and Consumption.</b> By +Professor <span class="smcap">Ludwig Buhl</span>, of Munich. Translated by Drs. <span class="smcap">M. D. Mann</span> and <span class="smcap">S. B. +St. John</span>. 8vo, cloth. $1.50.</p> + +<p class="hang"><b>BULKLEY. Eczema and its Management.</b> A Practical Treatise Based on the +Analysis of Two Thousand Five Hundred Cases of the Disease. New and +Revised Edition. By <span class="smcap">L. D. Bulkley</span>, M.D. Large 8vo. $3.00.</p> + +<p class="hang"><b>—— Acne and its Treatment.</b> A Practical Treatise Based on the Study of +One Thousand Five Hundred Cases of Diseases of the Sebaceous Glands. 8vo, +illustrated. $2.00.</p> + +<p class="hang"><b>CLARKE. A Manual of the Practice of Surgery.</b> By <span class="smcap">Fairlie Clarke</span>, M.D., +F.R.C.S., late Assistant Surgeon to Charing Cross Hospital. Third Edition, +Revised, Enlarged, and Illustrated by 190 Engravings on Wood. $2.50.</p> + +<p class="hang"><b>CORNING. Brain-Rest.</b> By <span class="smcap">J. Leonard Corning</span>, M.D. 16mo, cloth. $1.00.</p> + +<p class="hang"><b>CROOM. Manual of the Minor Gynecological Operations and Appliances.</b> By <span class="smcap">J. +Halliday Croom</span>, Physician to the Royal Maternity Hospital, Edinburgh. +Second Edition, Revised and Enlarged, with 12 Plates and 40 Wood-cuts. +$2.25.</p> + +<p class="hang"><b>CUTTER. A Dictionary of the German Terms Used in Medicine.</b> By <span class="smcap">George R. +Cutter</span>, M.D., Surgeon of the N. Y. Eye and Ear Infirmary, etc., etc. 8vo, +cloth extra. $3.00.</p> + +<p class="hang"><b>DARLING & RANNEY. The Essentials of Anatomy</b>, prepared as a Text-book for +Students, and a Work of Easy Reference for the General Practitioner. By +<span class="smcap">Wm. Darling</span>, Professor of Anatomy, and <span class="smcap">A. L. Ranney</span>, Adjunct Professor of +Anatomy, in the Medical Department of the New York University. 8vo. $3.00.</p> + +<p class="hang"><b>RANNEY</b> (A. L., <i>Editor</i>). <b>Anatomical Plates.</b> Arranged as a companion +volume for “The Essentials of Anatomy,” and for all works upon Descriptive +Anatomy. Comprising 439 designs on steel by Prof. <span class="smcap">J. N. Masse</span>, of Paris, +and numerous diagrammatic cuts selected or designed by the Editor, +together with explanatory letter-press. Large 8vo, cloth extra. $3.00.</p> + +<p class="hang"><b>DOWSE. Syphilis of the Brain and Spinal Cord.</b> Showing the part which this +agent plays in its production of Paralysis, Epilepsy, Insanity, Headache, +Neuralgia, Hysteria, Hypochondriasis, and other Mental and Nervous +derangements. By <span class="smcap">Thomas Stretch Dowse</span>, M.D., Fellow of the Royal College +of Physicians in Edinburgh, President of the North London Medical Society, +etc., etc. 8vo, illustrated. $3.00.</p> + +<p class="hang"><b>—— Neuralgia: Its Nature and Curative Treatment.</b> Forming Part II. of +“Diseases of the Brain and Nervous System.” 8vo, cloth extra. $2.25.</p> + +<p class="hang"><b>—— The Brain and the Nerves.</b> 8vo, cloth. $1.50.</p> + +<p class="hang"><b>JACOBI. Infant Diet.</b> By <span class="smcap">A. Jacobi</span>, M.D., Clinical Professor of Diseases of +Children, College of Physicians and Surgeons, New York. Revised, enlarged, +and adapted for popular use by <span class="smcap">Mary Putnam Jacobi</span>, M.D. 12mo, boards. 50 +cents.</p> + +<p class="hang"><b>KITCHEN. Consumption: Its Nature, Causes, Prevention, and Cure.</b> By <span class="smcap">J. M. +W. Kitchen</span>, M.D. 12mo, cloth. $1.25.</p> + +<p class="hang"><b>KNAPP. 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You may copy it, give it away or +re-use it under the terms of the Project Gutenberg License included +with this eBook or online at www.gutenberg.org + + +Title: How to Care for the Insane + A Manual for Nurses + +Author: William D. Granger + +Release Date: August 21, 2011 [EBook #37142] + +Language: English + +Character set encoding: ASCII + +*** START OF THIS PROJECT GUTENBERG EBOOK HOW TO CARE FOR THE INSANE *** + + + + +Produced by The Online Distributed Proofreading Team at +https://www.pgdp.net (This file was produced from images +generously made available by The Internet Archive.) + + + + + + + + + + HOW TO CARE FOR THE INSANE + + A MANUAL FOR NURSES + + + BY WILLIAM D. GRANGER, M.D. + PROPRIETOR-PHYSICIAN, VERNON HOUSE, MT. VERNON, N. Y. + + FORMERLY FIRST ASSISTANT PHYSICIAN BUFFALO STATE + HOSPITAL, BUFFALO, N. Y. MEMBER AMERICAN ASSOCIATION + OF SUPERINTENDENTS OF HOSPITALS FOR THE INSANE. MEMBER + NEW YORK NEUROLOGICAL SOCIETY. + + + _SECOND EDITION. REVISED._ + + + G. P. PUTNAM'S SONS + + NEW YORK + 27 WEST TWENTY-THIRD ST. + + LONDON + 27 KING WILLIAM ST., STRAND + + The Knickerbocker Press + 1891 + + + + + COPYRIGHT + G. P. PUTNAM'S SONS + 1886 + + + Press of + G. P. PUTNAM'S SONS + New York + + + + +NOTE TO SECOND EDITION. + + +At the time of starting a training school, in 1883, the author was unaware +that like work was commencing at the McLean Asylum, Somerville, Mass., by +Dr. Campbell Clark and others in Scotland, and in New South Wales. + +Each was independent, and each worked out the problem independently. Thus, +far separated efforts showed the time had come when attendants must be +evolved into trained nurses. + +The most gratifying feature has been the unanimous approval by American +superintendents and the establishment of training schools in almost every +asylum in the land, often under the most difficult conditions and at a +great sacrifice of the precious time and strength of the medical staff. + +The increasing number of these schools and pupils demands a second edition +of this little manual. + + VERNON HOUSE, MT. VERNON, N. Y., + March 21, 1891. + + + + +INTRODUCTION. + + +The writer began in October, 1883, at the Buffalo State Asylum for the +Insane, a course of instruction to the women attendants upon their duties +and how best to care for their patients. This has been regularly continued +till it has become a fixed part of the asylum life, and has developed into +a system of training, and now a class of attendants has nearly completed +its studies. Since July, 1885, instruction has been given to men +attendants. + +In April, 1885, the Superintendent, Dr. J. B. Andrews, who had encouraged +the school from its conception, asked the Board of Managers to officially +recognize it. They adopted the recommendation and fixed the qualifications +for admission, the pay and privileges of its members, and provided for a +certificate as a trained nurse and an attendant upon the insane, to be +given to all, who at the end of two years successfully finished the full +course of instruction. + +The writer believes that all attendants should be regularly instructed in +their duties, and the highest standard of care can be reached only when +this is done. He also believes that every person who is allowed to care +for the insane will be greatly benefited by such instruction, and will be +able to learn every thing taught, if the teacher uses simple methods and +is patient to instruct. + +As a rule they enter upon the study with interest, and soon a skilled +corps is formed, who are competent to fill the responsible positions, and +control the unstable class that drift in and out of an asylum. Even the +dullest are awakened to new zeal, and are advanced to positions of trust +they could not otherwise have filled. + +A brief outline of the course of instruction of the school may be of +interest. + +The first year is spent in learning the routine of ward work and filling +minor positions. The attendants are changed from ward to ward, and have +the care of all classes of the insane. + +They first receive instruction in the printed rules of the asylum. Every +rule relating to the duties of attendants is read and explained, and +special attention is called to the performance of the following duties: + + _a._ Duties to officers. + + _b._ Duties to each other. + + _c._ Duties to patients. + + _d._ Duties to the institution. + +Thus the new attendants early get an outline of their duties in the +special care of the insane. + +After this comes instruction in elementary anatomy and physiology. They +are taught of the bones, joints, muscles, and organs of the body, food and +digestion, the circulation and respiration, waste and repair, animal heat, +and the nervous system. + +In order to be ready for advanced instruction the elements of physiology +must be thoroughly learned. The teaching must be adapted to the ability +and wants of those instructed. Having fixed the limit of duties required +of an attendant, it is easy to fix the limit of instruction. It is an +error to teach too much medicine, for then we begin to make physicians. +All that is needed is attendants who are able to do their work +intelligently, and, keeping this object in mind, lectures by a physician, +devoid of too much detail, but simple, direct, and plain, are better than +instruction from any of the text-books. With notes of the lectures +furnished, and with repeated recitations, any lesson is readily learned. +This way of instructing, by lectures, notes, and recitations, is continued +throughout the entire two years. + +A course in hygiene follows the lectures in physiology. + +Instruction in these three studies occupies the first year. An attendant +who, at the end of this time, successfully passes an examination in them, +and who has been faithful in his duties, is ready to receive the advanced +instruction of the second year. This includes the nursing of the sick, the +management of emergencies, and finally the special work of caring for the +insane. The wits of an attendant upon the insane have to be sharpened in +many directions not required of a general nurse. The text-books on nursing +may properly be followed by another, which shall aid one skilled as a +nurse to perform the varied and difficult duties incident to the care of +the insane and the wards of an asylum. To furnish this is the object of +this manual. + +A brief review of the physiology of the nervous system is introduced for +the aid of students, in reading the chapters on the mind and insanity. + +To teach any thing metaphysical or pathological may seem questionable. The +class, however, has not only been interested in the simple study of the +phenomena of the mind, but has been able to comprehend and profit by the +lectures on this subject. + +The lectures on the care of the insane were given to the class almost as +they appear in these pages. The suggestion was made that if they were +printed they would find a place in the hands of attendants in other +asylums. This is the reason of their publication. + +To my colleague, Dr. A. W. Hurd, I wish to tender my thanks for the +valuable assistance he has given me in the preparation of this manual. I +am greatly indebted to Dr. Andrews for his ever kind but critical advice. +But for his encouragement and help neither the work of instruction nor the +preparation of these pages would have been begun, nor success, if success +be gained, achieved. + + + + +CONTENTS. + + + PAGE + + INTRODUCTION v + + + CHAPTER I. + + THE NERVOUS SYSTEM AND SOME OF ITS MORE IMPORTANT FUNCTIONS 1 + + Nerve Centres.--Brain and Spinal Cord.--The Nerves.--Nerve + Cells and Fibres.--Motor and Sensory Nerves.--The Five + Organs of Special Sense.--Nerve Impulses.--The Brain and + Nervous System Always Busy.--Need of Rest. + + + CHAPTER II. + + THE MIND AND SOME OF ITS FACULTIES 7 + + Mind and Matter.--Life.--Relation of Mind and Brain.-- + Faculties of the Mind.--Intellectual Faculties.--Will.-- + Emotions.--Instincts.--Moral Faculties. + + + CHAPTER III. + + INSANITY; OR, DISEASE OF THE MIND 13 + + Insanity a Change.--Involves Disease of the Brain.-- + Delusions.--Hallucinations.--Illusions.--Incoherence.-- + Mental States.--Mania.--Melancholia.--Dementia.-- + Monomania.--Emotional Insanity.--Dipsomania.--Moral + Insanity. + + + CHAPTER IV. + + THE DUTIES OF AN ATTENDANT 22 + + What an Attendant Should First Learn.--The Relation of + Attendants to Patients.--The Character of an Attendant.-- + Relation to the Institution.--How and What to Observe.-- + Systematized Plan of Observation.--Control and Influence + of Attendants over Patients.--Care and Study of the + Individual.--Liberty to be Allowed Patients.--Self-Control + of Patients to be Encouraged. + + + CHAPTER V. + + GENERAL CARE OF THE INSANE 33 + + Reception of New Patients.--Work and Employment.--Patients' + Care of Themselves.--Walking.--Clothing.--Bathing.--Serving + of Food.--Bed and Rising Time.--Night Care. + + + CHAPTER VI. + + CARE OF THE VIOLENT INSANE 45 + + Need of Studying Each Case.--Constant Attention and + Oversight.--Value of Employment and Out-Door Exercise.-- + Restriction and Idleness.--Paroxysms of Violence; How Cared + For.--How to Hold or Carry a Patient.--Danger of Injury.-- + Struggles to be Avoided.--Care of Destructive Patients.-- + Use of Restraint, Seclusion, and Covered Bed. + + + CHAPTER VII. + + CARE OF THE HOMICIDAL AND SUICIDAL INSANE, AND OF THOSE + INCLINED TO ACTS OF VIOLENCE 53 + + Delusions of Suspicion.--Homicidal Patients.--Suicidal + Patients.--Self-Mutilation.--Incendiary Patients. + + + CHAPTER VIII. + + CARE OF SOME OF THE COMMON MENTAL STATES AND THE ACCOMPANYING + BODILY CONDITIONS 60 + + Care in the Earlier Stages.--Insanity with Exhaustion.-- + Symptoms of Danger.--Care of Dementia, Early Dementia, + Chronic or Terminal Dementia.--Convalescence.--Relapse.-- + Epilepsy.--Paresis.--Care of Paralytics, the Helpless, the + Bed-ridden.--Bed-Sores. + + + CHAPTER IX. + + SOME OF THE COMMON ACCIDENTS AMONG THE INSANE, AND THE + TREATMENT OF EMERGENCIES 71 + + Certain Classes of Insane Liable to Injury.--Fractures.-- + Wounds.--Bites.--Blows on the Head--Cut Throat.--Wounds of + the Extremities with Hemorrhage.--Sprains.--Choking.-- + Artificial Respiration.--Burns.--Frost-bites.--States of + Unconsciousness.--Apoplexy.--Sunstroke.--Poisoning.--Eating + Glass.--Injury with Needles. + + + CHAPTER X. + + SOME SERVICES FREQUENTLY DEMANDED OF ATTENDANTS AND HOW TO + DO THEM 85 + + Administration and Effects of Medicine.--Opium, Chloral, + Hyoscine, and Hyoscyamine; Doses, Effects, Poisoning, + Treatment.--Stimulants.--Applications of Heat and Cold.-- + Baths and Wet Packing.--Hypodermic Injections.--Forcible + Feeding with Stomach-Tube.--Nutritive Enemata. + + + + +HOW TO CARE FOR THE INSANE. + + + + +CHAPTER I. + +THE NERVOUS SYSTEM AND SOME OF ITS MORE IMPORTANT FUNCTIONS. + + +The nervous system is made up of a nerve centre and nerves. + +The great nerve centre is the _Brain_ and _Spinal Cord_. + +The brain is a body weighing about forty ounces, and fills a cavity in the +upper part of the skull. The spinal cord, commonly called spinal marrow, +is directly connected with the brain. The skull rests upon the spinal +column, or backbone, and there is a cavity inside the whole length of this +column, which contains the cord. There is an opening through the base of +the skull where it rests upon the spinal column, and it is through this +opening that the fibres of the cord go, to pass into and become a part of +the brain. These most important parts are carefully protected by a strong +bony covering. + +Many nerves are given off from the brain and cord and go practically +everywhere, so that every part of the body is supplied with them. These +nerves are white cords of different sizes; the largest nerve of the body, +the one that goes to the leg, called the sciatic, is as large as the +little finger. + +There are really two brains and two cords, as along the central line of +the body there is a division of the brain and cord, making two halves +exactly alike. These halves are connected together, the division not being +complete. + +Nerves are given off in pairs; for example, from either side of the brain +arises a nerve that goes to each eye. So two nerves exactly alike spring +from the two sides of the spinal cord, going to each arm. + +A nerve is composed of a bundle of fibres, microscopic in size. As a nerve +passes to the extremities it divides by branching much as does an artery, +and thus a bundle of fibres is distributed to a muscle, or a part of the +skin, or to an organ, and every part of the body has a direct nerve +supply, much as you saw in the microscope it was supplied with blood by +means of the capillaries. We cannot prick our finger with the finest +needle but nerve, fibres are irritated, and we feel it, and capillaries +are injured and we get a drop of blood. + +Most of the nerves that go to the arms, legs, and organs of the chest and +abdomen, arise in and proceed from the spinal cord, but some of the fibres +begin in the brain and are continued down the cord, where, joining with +fibres that originate in the cord itself, both go to make up the nerve, +thus connecting all parts of the body with the great centre. + +The brain and cord are made up of blood-vessels, nerve cells, nerve +fibres, and, holding them all together, connective tissue. The cells are +very small, being microscopic in size; there are an immense number of +them, and they make up most of the gray matter or outside of the brain, +but in the spinal cord the gray matter is in the centre. The fibres that +go to make up the nerves begin and spring from the cells, and they also +unite them together. + +The cells are gathered into groups, which have each a separate function to +perform. There is a group from which the nerve of the eye proceeds; +another for the nerve that goes to the ear; another for the nerve that +goes to the arm; and another for the nerve of the heart. There is a group +that presides over speech, and other groups that preside over mental +action, while all of these are connected together by fibres. Thus it +appears that the brain is a true "centre," and the nerves but the means of +connection between different parts of the body and the brain, and also +between different parts of the brain. + +Nerves have two special functions: one to carry impressions made upon the +fibres, that end in the different parts and organs of the body, to the +brain; another to carry from the nerve cells so-called "nerve impulses," +to the different parts and organs of the body. Some nerves have in +themselves these two functions, as the nerves that go to the arm or leg; +others have but one, as the optic or eye nerve, which can only carry the +sensation of sight from the eye to the brain. + +The nerves that carry sensations to the brain are called _Sensory Nerves_. +The nerves that carry motor impulses from the brain are called _Motor +Nerves_. + +There are five special organs of sense, each receiving different +impressions, and sending by its sensory nerve or nerves a different +character of sensation to the brain, namely: + + The eye, giving sensations of light and color. + + The ear, giving sensations of sound. + + The nose, giving sensations of smell. + + The mouth, giving sensations of taste. + + The skin, giving sensations of touch, with ideas of roughness, + smoothness, hardness, softness, heat, and cold. + +There must be, in every case, a direct nerve connection from the organ of +special sense to the special group of cells in the brain to which the +nerve goes. If the connection is broken at any point, the impression made +upon the fibres in the organ of sense cannot reach the brain. Only after +the impression reaches the brain and the cells are affected, do we become +conscious of a sensation. We then say, as the case may be, I see, or hear, +or smell, or taste, or feel something. + +It thus appears that these organs of sense simply receive the impressions +made upon them to transmit to the brain, and it is really the brain that +sees, hears, smells, tastes, and feels. By the action of the organs and +nerves of special sense we get all our knowledge of the external world, +and, probably, if we had no organs of sense, we would have no +consciousness of our existence. + +Pain is due to abnormal action of sensory nerves, caused by disease, +injury, or pressure, and the irritation made, being carried to the brain +makes us conscious of the peculiar sensation we call pain. So the want of +food or water makes an impression upon nerves, which being carried to the +brain causes a peculiar sensation, and we say we feel hungry or thirsty. + +The _Motor Nerves_ arise in the cells of the brain and cord. Those which +go to the voluntary muscles cause them to contract, and are under the +control of the will. If the cells are diseased, if they do not get enough +arterial blood, or are poisoned by carbonic acid, or if the nerves are +diseased, injured, or cut, so that nerve impulses cannot be sent from the +brain to the muscles, we have paralysis of a muscle or a group of muscles, +according to the extent of the injury. Now we can appreciate the force of +this teaching in the physiology of the muscular system, that "paralysis is +a loss of power, either partial or complete, to contract muscles, due to +disease of the nerves." + +By the ready action of our mind, the quick working of our will, we direct +and control the action of our muscles, so as to perform with the utmost +skill and ease the varied and innumerable movements of our body. + +It seems very easy to do this, but watch a child learning to walk; it is +educating its mind and will to control the muscles, and it is a slow and +difficult education. + +But all motor impulses and bodily activities are not under the control of +the will. The heart is supplied with motor nerves, but we cannot by our +will stop its beating or control its action. The taking of food makes a +mental impression, and without the will being involved, impulses are sent +to the glands of the mouth, setting them actively at work, and saliva +flows. So the stomach begins to churn food when it is introduced, and the +liver is kept at work making bile and sugar, and we breathe when we are +asleep. + +All the organs of the body are supplied with motor nerves, that regulate +their action and give them the power to do their function or work, but +with the exception of the muscles, this power is sent without the action +of the will. + +Our brains are very busy. While we are awake we are constantly receiving +sensations, we are thinking, remembering, willing, and sending many +messages every minute, and directing power to all parts of the body. The +brain works and gets tired, just as the rest of the body gets tired, and, +if abused, injured, or overworked, may become diseased as may any part. +Its tissues wear out, are burned up, and require the same supply of +material to repair them that any other part of the body requires. It needs +then rest, good food, good blood, and plenty of oxygen. + +No wonder some brains give out, and fail to do their work properly, and so +cause insanity. + + + + +CHAPTER II. + +THE MIND AND SOME OF ITS FACULTIES. + + +We know there is something we call mind, because we know something of its +way of working, or its faculties. What mind is we do not know, but we know +it is not matter, because matter is something that occupies space, and has +qualities that do not belong to mind. We say of mind, it reasons, +remembers, or wills; of matter, that it is hard or soft, or cold or +elastic, or that it has color; speaking always of the faculties of mind or +what it does, and of the qualities of matter, or what it is. We do not +know what matter is, only how it appears to us; we know it is not mind +because mind is something spiritual, and possessed of faculties or powers +that do not belong to matter. + +_Mind and Matter_ are the only forms of existence of which we have any +knowledge. + +We speak of matter as inorganic--that is, without life, as iron, water, +oxygen; and as organic, or matter plus something we call life. Life +appears in two forms, namely, vegetable and animal. The lowest forms of +animal life have no nervous system, but as we ascend in the scale the +nervous system appears, and becomes more and more complete. + +Man possesses the most perfect nervous system, has the most perfect +brain, and also an intelligence far above that of any other animal, and is +endowed with some mental faculties that belong to him alone. The brain may +be said to be the organ of the mind, but we do not know what is the true +relation between them; that is, how the brain is acted upon by the mind, +or how the action of the mind affects the brain. Brain is matter, and very +solid matter as well, mind is immaterial, or spiritual, and the exact +connection between something material and something spiritual has never +been made out and never will be. + +Some say the brain makes mind a good deal as liver makes bile, or the +glands of the mouth make saliva, or the cells of the brain make motor +impulses, and if the brain does not act there is no mind made; so much +cell action, so much memory, reason, or will produced. But how, it is +immediately asked, is something material to make something immaterial? +Others say that mind is something, and has an existence of its own, and, +though spiritual, acts upon its organ, the brain, and by so doing, we are +conscious that we see, reason, remember, and will. But how, it is +immediately asked, does something immaterial act upon something material? +We do not know, and we probably never shall know. This intimate connection +between mind and matter exists during life only; it begins with life and +ends with life. + +We must then come back to the starting-point--there are two forms of +existence, mind and matter. We do not know what either really is, but only +the faculties or working of our minds, and the qualities or appearance of +matter. + +Mind thinks or remembers, reasons or wills, but these are faculties of the +mind; it is what the mind does, not mind itself. Gold is yellow, but +yellow is not gold; gold is hard, but hardness is not gold; these are +qualities of gold, and not gold itself. + +In the study of physiology you found the body divided into many parts, and +that these parts had each a separate function or duty to perform. In the +study of the mind, we find it has many different faculties or ways of +working. We did not study all the functions of the body, so we will not +study all the faculties of the mind. + +The mind is very complicated in its action, and difficult to understand. +Men study it all their lives and are not agreed about some of its simple +manifestations, and argue and even contend about their differences. There +are, however, some seemingly natural divisions of the faculties of the +mind, and a knowledge of these is sufficient for our purposes. + +We may say of the mind that it possesses: + + _a._ Intellectual faculties. + + _b._ Will. + + _c._ Emotions or feelings. + + _d._ Instincts. + + _e._ Moral faculties or conscience. + +The first three are commonly given as divisions of the mind; the last two +are included for convenience of teaching. + +_The Intellectual Faculties_ include those powers which in common language +are called "mind." A few only will be considered--namely, the perceptive +faculty, consciousness, memory, and reason. + +_The Perceptive Faculty_ is the power of the mind to perceive or know the +sensations brought to the brain by the sensory nerves, from the organs of +sense, and the action of this faculty gives us a knowledge of the +existence and qualities of matter. + +_Consciousness_ is that faculty by which we know we perceive, reason, +remember, will, or possess emotions. By its operation we know that we +exist, have a mind, and what that mind does. + +_Memory_ is that faculty by which we are able to recall to consciousness +the knowledge we possess of past events. + +_Reason_ is that faculty by which we are able to make use of what we know +and to acquire new knowledge. For instance, I know the distance between +two places is sixty miles, and I know that the cars, going between the +places, travel at the rate of twenty miles an hour, and that they leave at +four o'clock. Without reason, I could never of myself, know the two new +facts, that it would require three hours to make the journey, and that the +arrival will be at seven o'clock. The faculty of reason is one of the most +distinctive of the human mind. + +_The Will._--In consequence of our perceptions, our consciousness, our +memory, our reason, we are in a condition to know a good deal of what is +about us, and of ourselves, and we desire to bring ourselves into relation +with the outside world, and therefore we act. There is a faculty of mind +that allows us to choose how to act, and this is called the will, or that +faculty of the mind "by which we are capable of choosing." By the action +of the will, we direct and control the voluntary muscles and motions of +the body, while the action of the mind is also largely under its control. + +It may truly be said that unless we are under the compulsion of some +physical force, we always choose to do whatever we most wish to do. This +liberty of choosing is called "freedom of the will," and because we are +free to choose, we are responsible for the consequences of our choice. We +say, in common language, a person is responsible for what he does, and +both human and divine law holds each to a strict accountability for his +conduct, because all are free to choose how they will conduct themselves. + +_The Emotions or Feelings._--The emotions are joy, love, grief, hatred, +anger, jealousy, and other like conditions, and we speak of them as +"natural," because they appear without the operation of our intellect or +will, and the capacity for them seems to be a part of our existence. They +should, however, be under the control of reason and will, and a person who +gives way to his feelings, as of jealousy, and murders, is held +responsible by human and divine law. But though we control them, we cannot +prevent their action, and we must, as long as we live, feel love and joy, +be affected by grief, suffer from anger, or be jealous. + +_Instincts._--These belong largely to our animal nature; our appetites and +desires are instincts, and we speak of them as "natural." Children want +food and drink before they know what it is they want, and birds in the +nest, open their little mouths for the worm their mother brings them. + +Appetites indulged in become strong, and are often uncontrolled by the +reason and will; as the indulged appetite for liquor. A strong and healthy +mind should control the appetites, as we have learned it should control +the emotions, and we are justly held responsible for the consequences of +an indulged appetite. + +_Moral Faculties._--There exists in the mind of man a knowledge of right +and wrong, and a feeling of obligation to respect the rights of others. We +can hardly conceive of a man in his right mind who does not know it is +wrong to lie, or steal, or murder. The capacity to know right from wrong +is called conscience. + +Most people, perhaps all, have a feeling of relation and obligation to a +higher moral being than man. The feeling to do right because it is +pleasing to a God to whom we are directly responsible, is the foundation +of our religious convictions. + +The mind is a most complex affair, it is always active, nor is one faculty +at work and the rest idle, but many parts are at work at the same time, +and act and react upon each other. We may exercise our perceptive faculty, +or reason, memory, and will, and be affected by our feelings at the same +time. There is with it all a regulating power that coordinates or brings +these different actions into harmony, and we get the working of a healthy +mind. + + + + +CHAPTER III. + +INSANITY; OR, DISEASE OF THE MIND. + + +In common language we speak of the mind diseased. + +This is not strictly true, as it is the brain that is diseased and, in +consequence, we get disturbed mental action. + +Every person has individual characteristics. As no two faces are alike, so +the mind, character, and manner of no two are alike, and it is by the +manifestation of these, that each is known. + +When a person becomes insane there is always a change from his natural way +of thinking, feeling, and acting, due to disease of the brain. Sometimes +the change is slight, or concealed by the patient, and is apparent only to +near friends, or after a careful examination. Sometimes it is so great as +to attract immediate attention, when it may present the features of raving +madness, or of the most abject melancholy. + +To illustrate this change, we may suppose both a king and a pauper to +become insane: there is, of course, a vast difference between them, but +the king may be so changed by the disease as to believe that he is a +pauper, and himself and his family starving, and he may also wish and even +try to work and dig like a laborer to support them; or a pauper may think +himself a king, and try to act like one. Such conditions show a _marked_ +change in the manner of thinking, feeling, and acting, which involves +diseased action of the intellect, the emotions, and the will. + +Sometimes the appetites are also changed, or control over them is lost, +and sometimes the moral nature is affected as well, sometimes a single +faculty of the mind appears more disturbed than do others; it is, however, +doubtful, or at least denied, that one faculty can show such disturbed +mental action as to indicate insanity, and the rest of the mind appear +perfectly healthy and normal. With the changes that have been spoken of, +there is generally disturbances of the physical health, and often of a +marked character. It must be remembered that mere oddity of appearance or +eccentricity of conduct, however marked, if natural, do not of themselves +constitute signs of insanity. + +_Some Mental Symptoms of Insanity._--There are some important mental +symptoms which quite generally accompany insanity, and are found either +alone or combined in the individual case. These are: + + _a._ Delusions. + + _b._ Hallucinations. + + _c._ Illusions. + + _d._ Incoherence of speech. + +_Delusions_ are false beliefs. We think a belief in the religion of +Mahomet is a delusion, but not an insane one. Insane delusions arise from +disease of the brain, and are a part of those mental changes that appear +during its progress. The king, who, under the influence of disease, thinks +himself a pauper and that he and his family are starving, and the pauper, +who thinks himself a king, with all the wealth and power of one, have +each insane delusions. + +Some delusions are fleeting and changeable, lasting a few days, weeks, or +months, while others are fixed, lasting a lifetime; some are impossible +and beyond rational belief, as when a man thinks himself Queen Victoria, +or that his head is made of brass, or that he is dead, and yet sleeps and +eats and talks; other delusions are possible, as when a king thinks +himself a pauper, because such a thing may and even has happened, or when +a pauper thinks himself a king, because people of very low degree have +risen to such a station, but they are very improbable, and we do not +expect such things among Americans, much less among our patients. Other +delusions are not only possible, but relate to things that may or do +happen, or are within the bounds of a rational belief, as that of a person +who insists he has a cancer, or that he has committed the unpardonable +sin, or that poverty is impending and the poorhouse not far off; or that +of a woman that she has been violated, or that, when her child was sick +she so neglected it, that it died. Such beliefs as these are delusions, +when they have no other reason for their existence than that they are +caused by disease. + +Some delusions are called homicidal, suicidal, or dangerous, because they +cause a patient to do, or want to do, acts that are dangerous to himself +or others, or property. + +_Hallucinations._--When a patient has hallucinations, he thinks he sees, +hears, smells, tastes, or feels something, when there is really nothing to +cause the sensations or ideas except diseased action of the brain; nothing +being sent to the brain from any special organ of sense, he really sees, +hears, smells, tastes, or feels nothing, it is all imagination, though +seemingly very real. + +For instance, a person thinks he hears a voice, perhaps that of God, or of +some one who is dead, or of an absent friend, or thinks he sees these +persons, when there is nothing external to the brain to excite the +sensation or give the idea. + +_Illusions._--When illusions are present, the mind fails to perceive +correctly what the eye sees, or the ear hears, or the impressions that are +brought to the brain from any of the organs of sense. For instance, a +person looks at a row of trees, and they appear to him to be a row of +soldiers; or the whistle of a locomotive may be so changed as to seem to +be the voice of God; or the odor of a rose, burning sulphur; food may +taste like poison, or the hand of a friend feel like a piece of ice or a +red-hot iron, and is so believed to be. These are deceptions of the +senses. + +In insanity, the truth and existence of delusions, hallucinations, and +illusions are fully believed in, and the patient cannot be argued out of +the belief, however absurd or unreal it may be. + +_Incoherence of Speech._--When a person is incoherent, he rambles in talk; +there is little connection between different sentences, or the sentence +itself is meaningless, being a mere jumble of words; sometimes ideas come +too rapidly into the mind, and some new subject is begun and talked about +before the first is finished; sometimes the mind is slow, and memory +forgets what is being talked about. + +_General States of Insanity._--There are a few general mental states in +insanity, one of which being present gives the character and name to the +disease. These are: + + _a._ A state of exaltation of mind, or mania. + + _b._ A state of depression of mind, or melancholia. + + _c._ A state of enfeeblement of mind, or dementia. + +But one of these first two states of feeling can be present at the same +time, for a person cannot at any one moment be both exalted and depressed, +though he have mania to day, and afterward be so changed in his feeling as +to have melancholia to-morrow, or next week, or next month. + +In a general way all disease is divided into acute and chronic forms. An +acute disease is one of recent origin, and from which recovery is to be +hoped for; a chronic disease is prolonged and does not tend to recovery; +an acute disease may become chronic. + +Mania and melancholia are at first considered acute and curable, but, if +recovery does not take place, they pass into either chronic mania or +chronic melancholia, or, if the mind is much enfeebled, into a condition +of dementia. + +_Mania._--In mania the mind is generally very active, though lacking in +control, and is irregular and illogical in its action; the patient talks +rapidly, and upon many subjects, and is often incoherent, or he laughs, +sings, dances, or cries, perhaps in turn; he is often irritable and +unreasonable, and perhaps threatening, and becomes more violent if +interfered with. + +Accompanying this mental excitement there is frequently persistent loss of +sleep, constant restlessness, and great bodily activity, and indifference +to or refusal of food. Sometimes the brain excitement is so great that +all self-control is lost, and the patient becomes a raving maniac. + +The delusions of mania are largely of grandeur and self-exaltation; the +patient thinks himself in the best of health, and very strong, or of a +superior mind, or, that he is a great singer, poet, actor, or preacher; +perhaps, taking a higher flight, he thinks himself possessed of the wealth +of Vanderbilt, or that he is the Pope, or the President, or even God +himself. + +Sometimes the excitement comes on in paroxysms, lasting a few days or +weeks, with periods, more or less prolonged, of comparative mental quiet. + +_Melancholia._--In melancholia the expression of the face often tells the +character of the disease; the eyes are downcast, the lines of the face are +lengthened, and the whole appearance is that of unhappiness. + +In this form of insanity the patient may refuse to speak or interest +himself in any thing, or he may moan, groan and cry, and walk back and +forth wringing his hands; when he is quiet, the mind, however, may be very +active and full of delusions, which occupy it to the exclusion of every +thing, driving away sleep, and making him indifferent to the taking of +food or attending to his most necessary wants; sometimes the patient talks +a great deal, but always about his delusions, which are generally +connected with himself, his family, or his affairs. + +Melancholiacs are often tortured by fears, and, therefore, become frenzied +and as wild and violent as in mania; or they may be very suspicious, +thinking that some one is persecuting them, or poisoning their food, or +following to kill them. On account of their delusions they frequently +refuse food, they generally sleep poorly, and are often very suicidal. + +_Dementia._--This form of insanity is most frequently the result of acute +mania or melancholia, and comes after the force and intensity of the +disease has spent itself, leaving the mind crippled and weakened. The +perceptions are blunted and distorted, memory fails, the reasoning powers +are weakened, the will has ceased to control, the emotions and appetites +are dormant or changed, and the mind may become almost a blank, though in +the narrow circle of thought there is left remains of delusions, +illusions, and hallucinations. The patient is frequently careless of the +ordinary necessities and decencies of life, and requires constant care. + +There are degrees of dementia: it may be slight, partial, or nearly +complete. During the first few months or years dementia often ends in +recovery, but, as it continues, the case becomes more and more hopeless. + +_Monomania._--This is a term belonging to common speech, but there is not +an agreement of opinion as to the existence of such a special form of +insanity, nor among those who believe in it, as to what it is and what are +its symptoms. + +Monomania really means an insanity with but one, or, at most, a small +class of delusions of the same character, the rest of the mind showing no +disease. Hardly any one believes in the existence of such a narrow limit +to insanity, and, getting beyond this point, there is no agreement where +the limit should be set up to mark and bound it. + +Some think there is a special insanity of the emotions only, and call it +"emotional insanity." There is not an agreement of opinion as to what +emotional insanity is; the idea seems to be that the emotions, or one of +them, so overpower reason and will as to make the person irresponsible. +This condition is supposed to exist without disturbances of the +intellectual faculties, and to be unaccompanied by delusions, +hallucinations, or illusions. Others see in these cases no evidence of +insanity; nothing but over-indulgence of the emotions, or a want of +exercise of self-control, or an excuse for crime. + +Some persons believe that the appetites over-indulged become morbid and +produce disease of the nervous system, and as a consequence the reason and +will are weakened in relation to this indulged appetite, and the opinion +is reached that it is a form of insanity. An indulged appetite for drink +is called dipsomania. Others believe that unless there are present the +usual symptoms, associated as they generally appear in insanity, these +cases are nothing but unbridled appetites or vices. + +_Moral Insanity._--There are those who claim that the moral nature alone +may be diseased, and the persons in whom this occurs are said to lose the +appreciation of right and wrong, or have an uncontrollable propensity to +do some wrong act, and take a peculiar pleasure in so doing. Special names +are given to these acts, according to their character, as "kleptomania, an +impulse that prompts to steal"; or "pyromania, love of setting things on +fire"; or "homicidal mania, an intense desire to kill." Other persons +considering these cases and finding no delusions, or intellectual +disturbances, or change in feeling, thinking, or acting due to disease, +call the condition one of crime only. + +These are difficult matters to understand, and those who make a life-study +of insanity do not fully understand them, or agree together as to what +they know. They are, however, terms of common speech, and it is well to +have some idea of them, as it will add interest to the study of the +patients under care and charge. + + + + +CHAPTER IV. + +THE DUTIES OF AN ATTENDANT. + + +_What an Attendant Should First Learn._--The duties of an attendant upon +the insane are varied, arduous, and exacting; they are associated with +irritations, perplexities, and anxieties, bring grave responsibilities, +and call for the exercise of tact, judgment, and self-control. + +These many duties are not quickly nor easily learned, and the new +attendant must be willing to fill, at first, a minor position, to begin at +the beginning and learn gradually all the details of ward work; he must +acquire habits of caution and watchfulness, and learn in a general way the +care of the insane, before he can assume a position of authority over +other attendants, the control of a ward, and the responsibility of the +direct care of patients. + +This last duty is the most difficult of all, because it brings the +attendant into intimate relations with a class of persons, whose true +appreciation of themselves, of their conditions and surroundings, is +changed, whose thoughts and desires are unreasonable, whose conduct is +unnatural, and who are largely controlled by insane delusions, +hallucinations, and illusions. + +It requires an intimate association with the insane, and a careful study +of their manner of thought and conduct, to be able to successfully guide, +direct, and control them. + +_The Relation of Attendants to Patients._--The position of attendants is +often a trying one; they are liable to misrepresentation when they have +faithfully done their duty; they must learn to receive with calmness a +blow or an insult, or even so great an indignity as being spit upon; they +must bear with provocations that come day after day, and are seemingly as +malicious as they are ingenious and designing; they must watch over the +suicidal with tireless vigilance, control the violent, and keep the +unclean clean. + +To do all this requires the exercise of self-control and kindness; the +putting a curb upon the temper; the education of judgment and tact; +faithfulness in the performance of duty, and a knowledge of what to do and +what to avoid. + +These trials are, however, but a part of the experience of an attendant in +caring for the insane, for there is associated in this care much that is +satisfactory and pleasurable. It is a satisfaction to know that duty has +been well done; to be able to care for the sick; to do something to +alleviate suffering; to tenderly watch over and soothe the dying; it is a +pleasure to see a patient improving, going on to recovery, and finally +able to return home cured. + +Many delightful friendships are formed between attendants and patients, +some lasting for years within the asylum, and some for a lifetime, with +those who have recovered. Most of the insane appreciate the services +rendered them, and have a feeling of gratitude for those who care for +them. + +Attendants should always treat patients with politeness and respect; it +is something that is never thrown away, and exerts a good influence, +however rude and disrespectful a patient may behave. + +Patients should not be ridiculed, their mental weakness and peculiarities +made light of, nor should they be made a show to inquisitive visitors. + +It is useless for attendants to try to argue patients out of a belief in +their delusions, and to do so often results in fixing them more firmly in +the mind. We should not however pretend to believe them, nor humor their +belief, nor allow them to carry out their delusions in their dress, +conduct, and general behavior. + +_The Character of an Attendant._--The insane should always be treated with +kindness, and nowhere is the golden rule "thou shalt love thy neighbor as +thyself" more necessary of application than in caring for them; and it is +well for attendants, when tempted, to stop and think how, under like +circumstances, they would want their mother or sister or brother treated. + +Keeping this noble teaching and this high motive for right-doing ever in +mind, an attendant cannot go far astray. + +It is a development of character to care for the insane, and instead of +being brutalizing, as some ignorant people say, it is elevating and +humanizing. + +Attendants should never gossip, either among or about themselves, or of +their patients. It is a mean and degrading habit to indulge in; it will +undermine a good character, and often become overpowering and malicious. + +On the other hand, never be afraid to speak the truth, and never let a +lie, or the semblance of a lie, pass your lips, or remain for a moment in +your heart. Of all things be truthful. + +Attendants must acquire a spirit of willing obedience, of cheerful +execution of all commands and directions, and of faithful performance of +every duty that devolves upon them. Unless they have this spirit, they +will be unable to successfully assume positions where obedience is to be +exacted from others. + +They should preserve their own self-respect; in all things set a good +example; be neat and tidy in their dress, gentlemanly or ladylike in their +conduct; considerate of the wants and feelings of other attendants; they +should "cherish a high sense of moral obligation; cultivate an humble, +self-denying spirit; seek to be useful; and maintain at all hazards their +purity, truthfulness, economy, faithfulness, and honesty" (Utica Asylum +Rules and Regulations). + +In their relation to the institution, attendants should fulfil all their +engagements with the same sense of right, that they expect will be +observed towards them by those who employ them. It is a business contract +that is assumed, and brings with it mutual legal responsibilities, rights, +and obligations. Attendants should strive to so conduct themselves, that +when they leave their employment they can go away with the respect of +every one, and bear with them the reputation of a good character and of +work well done. + +_How and What to Observe in the Care of Patients._--It is important that +attendants should early learn habits of close observation. The exercise of +the habit increases the ability to observe, and one soon comes to see and +know things he never saw, or thought of before. It is necessary to learn +first the physical condition, mental symptoms, and habits of a patient, +before we are able to observe and appreciate any change. + +Observation, to be of value, should be systematically made, and only one +thing at a time can be noticed, which must be understood before passing to +another, otherwise every thing is confused. + +The condition and appearance of a single part should be looked at to see +what is natural, and what is evidence of disease. + +In practice, written notes taken at the time, are extremely valuable in +teaching close and accurate observation, and cultivating an ability to +clearly express to others the result. + +For the purpose of suggestion and guidance, the following system for +observation is given: + +Observe the effect of medicine. + +The face.--Observe if it is pale, and if the pallor is sudden, temporary +or permanent; if flushed, if congested, if blue with venous blood, if +there are any eruptions, bruises, or scars. Observe the expression of the +face. + +The tongue.--Observe if it is coated, and if so, if white, brown, red, +black, glazed, dry, or cracked; if it is tremulous, or drawn to one side, +or protruded with difficulty. + +The lips.--Observe if pale, blue, dry and cracked, if there is +tremulousness about the corners of the mouth; the teeth, if covered with +sordes; the gums, if bleeding. + +The breath.--Observe if sweet, sour, foul, or offensive. + +The respiration.--Observe if slow or fast, quiet and natural, or loud, +labored, and difficult, if puffing, wheezing, shallow, or irregular. + +The eyes.--Observe if congested, the color, if any blindness; the pupils, +if contracted, dilated, irregular, unequal, or if they respond readily to +light. + +If there is cough, observe if moist or dry, if croupy, if with pain, or if +prolonged. + +If any expectoration, observe if it is bloody or streaked with blood, if +thin and frothy, thick and purulent, or if it sticks to the cup. + +The pulse.--Observe if it is slow or rapid, full, weak and thin, if +irregular or intermitting. Count it. + +The temperature.--Observe by the hand or thermometer. + +The body.--Observe for eruptions of the skin, for sores, bruises, or +deformities, or if there is any paralysis. + +The appetite.--Observe if it is poor, changeable, if food is relished or +disliked; if refused, if it is constantly or occasionally, and if from +delusions or indifference; if there is overeating and gluttony, if food is +bolted, or chewed, or if the patient has teeth to eat with. + +The digestion.--Observe if natural, or painful, and if so, whether upon +taking food, or if the pain is delayed; if gas is discharged from the +mouth, if the stomach is sour, if the food is heavy and distressing; also +observe what kinds of food give dyspepsia, and what seem to be well borne. + +Of vomiting.--Observe if occasional or constant, if immediately after +food, or delayed, if sour or bitter, if preceded by pain or nausea, if it +contains any undigested food. + +Of diarrhoea.--Observe how frequent the discharges, if with pain, and +where it is situated, the color, the consistency, if there is any blood +or mucus, if it alternates with constipation. + +Of constipation.--Observe if alternating with diarrhoea, if habitual, +the effect of medicine and food; if there are any piles. + +The menses.--The quantity, if there is any pain, its cessation and +reappearance, if any effect upon the mental condition. + +Of pain.--Observe the character and severity, its location, and any +evidence of a cause. + +Of dropsy.--Observe if it is general or local, if in the chest, face, +abdomen, arms, or legs; if there are any varicose veins. + +Of sleep.--Observe the length of time, if quiet and natural, if restless, +if deep or light, if there is great drowsiness or continued wakefulness, +and the effects of medicine. + +Of unconsciousness.--Observe if it comes on slowly or suddenly, if partial +or complete, if the patient can be aroused. + +Of convulsions.--Observe if slight or severe, if of short or long +duration, if continued or interrupted, if general or of one side, or of an +arm or a leg, or the face, or of a few muscles only. + +Of the mental condition.--Observe if fixed or changeable, the nature of +delusions, illusions, or hallucinations; dangerous attempts or threats +toward himself or others; any change in the mental state. + +Of habits.--Observe if fixed or changeable, how formed or how corrected. + +Of the general conduct.--Observe the dress, if neat and tidy, or +otherwise, private habits, care of personal wants, improvement in conduct, +the influence of attendants and other patients, or the influence the +patient himself exerts on others. + +This by no means includes all that it is necessary to observe, but it +contains much that is important, and the system, if studied and used +practically, will suggest to the observer whatever may require attention. + +_The Control and Influence of Attendants over Patients._--By a "smart +attendant" is meant one who sees little to do beyond having a control of +the ward by a rule that is close and exacting, who maintains a strict +discipline, and who has a love for cleanliness, order, work, and +scrubbing. But a "useful attendant" is one who tempers these mentioned +traits, by striving to gain the confidence of his patients, by exerting +over them a beneficial influence, who is able to bring the individual +patient into accord with his surroundings in the asylum, so as to help his +improvement or recovery, meet his wants, and increase his comfort and +enjoyment. In order to do this it is necessary that the attendant should +give careful study and attention to each patient. Such a study will soon +demonstrate to, and teach the attendant the fact, that the insane are very +individual in their habits, and while no two are alike, there are +resemblances that in an asylum are made the basis of classification by +wards: there is the convalescent, the suicidal, the demented, the sick and +feeble, and the noisy or violent wards. + +Attendants must first learn that patients are not to be treated merely as +a ward full of people to be kept in order, to be clothed, fed, and put to +bed, but that the peculiarities of each patient are to be studied, and +that it is their duty to know thoroughly the wants, and condition of each +case, and how best to care for and control it. The better knowledge an +attendant has of the individual, the better he can care for a ward full of +individuals. + +The persons who are under our care are always to be considered as +patients, and it must be remembered that these sick people are sent away +from their homes and given over to us, though strangers, because it is +supposed that we can do better by them than their friends are able to do. + +Their position is one of helplessness and dependence upon those who are +placed in charge, and we are properly held responsible by the friends and +the public, for a judicious exercise of the power and influence we possess +over them. + +Patients are not rightly influenced by the mere exercise of authority or +by dictation or command; these they fear and obey, or resent and resist; +but we should always appeal to the highest motives for obedience and +correct conduct, and we should lead our patients to trust and not to fear +us. In our dealings with them we should be truthful, straightforward, and +strictly upright, and exercise over ourselves patience and self-control. + +We can generally control our patients by the exercise of sympathy, +kindness, and tact, joined with a reason for what is required, and where +more is needed, a firm, kind authority and command will suffice. + +The use of authority, restriction, and restraint is to be avoided, while +on the other hand patients are to be allowed all the liberty and freedom +they can safely enjoy, and taught to exercise all the self-control they +are capable of. + +The granting of more freedom and liberty of action than was formerly +accorded the insane, does not imply a change in the character of the +disease, but improved methods of care, and places more responsibility upon +the attendants. The degree of liberty to be allowed must, in each case, be +decided by the physician, and the attendants should closely observe the +patient, and report any symptoms which makes the enlarged freedom +dangerous to the patient or to others. + +Patients being sick, are sent to the asylum that they may be kindly and +judiciously cared for, and, if possible, cured. As many patients who may +never fully recover may so improve as to be able to return to their homes, +and, as it is impossible to say that any given patient will not recover, +each case deserves and should receive our best care and efforts to this +end. + +Because our patients are sick they must be nursed, and nursing means +tender care. And it is a nurse's duty to do all in his power to alleviate +pain and promote bodily comfort. The insane are subject to all the ills +that flesh is heir to, and there is always among our patients much +sickness and bodily suffering. Many patients cannot tell when they are +sick, nor when they suffer pain, but they show sickness and pain, and +often appeal by their manner for that care and sympathy, we all feel in +need of at such times. + +These silent symptoms should be observed by the attendants, who should +always see and know when their patients are sick. Some of these symptoms +are, crying, moaning, weakness, going to bed, or lying down, cough, +changes in respiration, signs of fever, a flushed face, quick pulse, or +chills, a pale face, vomiting, or diarrhoea, and loss of appetite. + +Much insanity is associated with great physical disturbances which require +careful nursing. The old and feeble, the paralytic and bedridden also +require special attention and care. + +From this it appears that the care of the insane calls for the exercise of +self-control, habits of close observation, the using of good judgment, the +putting forth of ennobling influences, and the tender care of the nurse. + + + + +CHAPTER V. + +THE GENERAL CARE OF THE INSANE. + + +_The Reception of New Patients._--Attendants must at once study the +peculiarities, the physical condition, and the mental symptoms of a new +patient, so as to know the case thoroughly. + +New patients should receive special attention; their fears quieted; they +should, if in a proper condition, be introduced to the other patients; the +effect of being in so large and strange a place, where the doors are +locked and the windows guarded should be noticed, and unpleasant +impressions overcome; they must be told they have come among friends and +will be kindly treated. + +The necessary rules of the ward should be explained; they should be +invited to their meals, shown to their rooms and told at bedtime the night +watch will visit them, and they must be assured that no harm will come to +them. + +The first impressions a new patient receives may be the lasting ones, and +influence their whole conduct in the asylum. If they resist what is +necessary to do for them, do not struggle and contend with them, and force +them to bed, or to the bath, but first seek advice from the supervisor, or +the physician. + +Always search new patients, unless otherwise ordered, for money, jewelry, +weapons, medicine, and other like articles, or if in doubt what to do ask +for directions. The head, body, and clothing should be examined for +vermin, and the body for injuries and bruises. If what is wished to be +done in this particular is explained, patients will generally quietly +allow it. + +_Work, Employment, and Occupation._--By this is meant whatever occupies +the patient's time and mind, in useful and pleasant ways. + +Of all things idleness and loafing are the worst; even games, such as +billiards and cards, if indulged in to the exclusion of useful employment, +will degenerate a patient. + +Some willing patients are kept in a tread-mill of daily work, their +monotonous life never broken by a diversion, an enjoyment, or a hope. It +is very questionable if it is beneficial to make a patient drudge through +such a daily routine. + +Asylum life should be made as home-like, pleasant, and natural as +possible; as a rule every patient who is able should do some useful work +every day, and to this should be added the diversion, that comes from +amusements and the enjoyment of innocent pleasures. + +Occupation then means a great deal more than work; it is the way a patient +spends his time. Unless encouraged and directed, patients may occupy +themselves in thinking of their delusions, in noise, violence, or +destructiveness, in idly walking up and down the wards, in the indulgence +of secret vices, in gossip, in spreading discontent, in prayer, or in +constant Bible reading. Some patients really work hard trying to do +nothing, and have no more ambition than to sit around on the ward, and +chew tobacco, and indulge in idleness. + +Patients should be encouraged to do something for themselves, the women to +make and mend their own clothes, to keep their rooms in good order, and +assist about the ward. They should be made to feel that they can add to +their own comfortable surroundings by their own efforts. + +For the men, ward work is not so natural or tasteful, but they will do +with interest much of this kind of work; to this may be added employment +in decorating their own rooms or the ward, and in caring for plants and +flowers. + +The women can add to ward work, sewing, knitting, mending, embroidery, +artificial flower making, quilting, care of flowers in the ward, and it is +often a real enjoyment for patients to make some little present for their +outside friends. The laundry offers an inviting field for some patients, +but it is often too hard work, especially when they are sent twice a day +to the wash-tub, or kept in the hot ironing room. A half day is enough for +most patients, and many are not strong enough to go there. + +Out-of-door work is well suited for the men. The farm, garden, lawn, +barns, and machine-shops offer much that can be made useful for the +patients' employment; the different mechanics and artisans about the +asylum should have patients working with them. + +Thus it appears there are many directions for patients to work, and it is +also true that all patients are not suited to do the same work nor the +same amount of work. Whatever they do should be for their benefit alone, +otherwise we might take a contract for a given number of patients to work +a given number of hours every day, a good deal as has been done in prisons +and reformatories, but no one would believe such a course for the +interest, improvement, or recovery of the patients. + +The only rule to go by is, that the work and occupation shall be for their +own good, and, that they shall not be made or encouraged to work for any +other purpose. + +As a rule, patients should be allowed to employ themselves in ways that +most interest them, provided it is useful and seems to be beneficial. + +Over-work is as bad as idleness; too much sewing will often give a +sleepless night. + +Generally all patients may be allowed to engage in light work, without +special directions; new patients, however, should not be sent off the +ward, or given tools that may become weapons, unless by order of a +physician. + +It is a bad habit for attendants to sit idly by, or stand around with +their hands in their pockets, and have patients do all the work. It may be +so necessary to watch the patients that the attendant cannot work +steadily, but he should have the appearance of doing something, and if +possible join with them in work. + +A party of women sewing, should be laughing, talking, telling stories, +perhaps singing; they should be made to enjoy the time, and not to look +upon it as something irksome. + +Some patients are too feeble in mind, and some too feeble in body to work; +many need rest, quiet, and nursing, and directions for the care and +occupation of such patients should come from the physician. + +Many of these patients will do a little, others can be amused, or read to, +and their minds thus diverted from their troubles, and turned into +pleasant and cheerful directions of thought. + +It has been shown that work is not the only useful way that patients may +occupy their time, that nothing but work is as bad as no work, and that +they should have diversion, enjoyment, and entertainment. + +For the entertainment and occupation of patients, there are furnished, +dances, concerts, theatricals, billiards, cards, pianos, books and papers, +schools, chapel services, walks, rides, and excursions, and they also +receive visits from friends, and write and receive letters. + +Patients should be encouraged and sometimes made to take part in these +natural and pleasant amusements; of course every patient cannot play the +piano, or billiards, but among these many forms of recreation, all +patients can find ways of diversion and means of enjoyment. + +Thus early in the study of the care of the insane, it is learned that the +life of patients is to be stripped, as much as possible, of restriction +and restraint; that self-control is to be taught; that useful work is to +be encouraged; that amusements and innocent pleasures are to be enjoyed; +in a word, attendants are to learn, that the characteristics of +institutional life are to be lessened, and those of a home life made +prominent. + +_The Patients' Care of Themselves._--The general tendency of the insane is +to mental enfeeblement, to neglect of person, and to slovenly habits. +Patients should be encouraged as much as possible to care for themselves; +to be helpful towards others; to do such work as they are able; to seek +amusements, and to live as much as possible such a life as we ordinarily +are accustomed to outside the asylum. + +Patients should be encouraged to keep themselves tidy, and nicely dressed, +to have the care of their clothing; if possible, they should be given a +room of their own, which they should take a pride in keeping in order, and +ornamenting with pictures and flowers; and should be allowed to do +whatever will help maintain their self-respect, self-care, and a feeling +of individuality. + +There is great difference in patients as shown in their capacity for +self-help. Some seem to be able to do nothing, some everything. Nothing +can lighten the burdens of attendants so much as to make the helpless +self-helpful. Nothing benefits the patients more. Do not abandon effort +for any patient. Unexpected and gratifying results are the rewards of +earnest efforts. + +_Out of Door Exercise--Walking._--If possible, patients should be out of +doors every day. In the summer much time can be spent in the fields, on +the lawn, either walking or sitting under the trees; in the winter time +shorter walks only can be taken, but on pleasant days, often an hour may +be spent out of doors. Warm clothing and good shoes must never be +neglected, and the person must be thoroughly protected, because the insane +are frequently "cold-blooded," that is, the circulation is poor, the hands +and feet congested, blue, and cold, they make animal warmth slowly and +with difficulty, and easily suffer from the cold. + +Many patients go out to walk on parole. Those who are allowed this liberty +will be designated by the physicians; any change in the patient that +makes such liberty dangerous should at once be reported. Others go out in +large parties, with few attendants to care for them, while the old, sick, +and feeble, the homicidal and suicidal, the noisy and violent, require +special care and attention in their exercise and walks. + +_Clothing of Patients._--In many asylums each patient has his own +clothing. Every article should be plainly marked with his own name, and +should be used only by the patient to whom it belongs, and never given to +any one else to wear. All clothing should be kept clean and well mended, +and should be properly put on and kept on during the day. There should +always be enough to keep the patient warm, and changed with the changes in +the weather, or the temperature of the ward, or the needs of the patient. +The sick, feeble, and old always need extra clothing; that worn next the +skin should be changed at least once a week, and all clothing should be +changed as often as soiled. + +_Bathing of Patients._--Every patient should be bathed once a week and as +much oftener as is necessary. The tub should be cleaned and the water +changed for each patient; the temperature should be about ninety-five +degrees, or not hot to the hand, and the tub should be about two-thirds +full. The head, neck, and body should be washed with soap; each patient +should have a clean towel, be wiped dry, and given a change of clean +clothing. + +Some patients object to bathing; they fear the tub, but will wash with +water and a sponge, and they should be allowed to do so. Others want to +bathe first; let them, if possible. Others will not bathe the day the rest +do; it is sometimes best to humor them. + +Some patients have to be forcibly bathed. In such cases always wait, use +every art to induce them to bathe, and before acting send for advice. + +Attendants are too prone to think that every thing should be done by rule, +and that all must be forced to obey the rule. Most will observe it without +trouble, and the object sought can generally be gained by patience, tact, +and kindness. + +_Serving of Food._--The dining-tables should be neatly set and made +attractive; the food should be promptly served, and while hot; all +patients should be at meals, unless excused by the physicians. Economy +should be practised, and every thing should be used or saved. Each person +should have enough, but no one should be allowed to make a meal of a +delicacy, or take all of the best of a dish. Some patients would waste a +pound of butter or sugar at each meal; enough is sufficient for anybody. + +The old and feeble should be served by attendants; those without teeth +should have their food prepared, and the meat should be cut very fine. +Those who will not eat must be kept in the dining-room and fed; the +attendants may use force by holding the hands, and placing food in or to +the mouth; but it is dangerous to do more, and holding the nose is +something that is never allowable. If these efforts to get them to take +food do not succeed, report to the physician. Some patients from delusions +will eat certain kinds of food, and either not get enough or not a +sufficient variety. + +A mixed diet is the best, and patients should if possible be made to eat +bread, butter, meat, vegetables, and drink milk and plenty of water. No +patient should be allowed to lose in flesh and strength on account of +failure to take sufficient, or proper food; before these things happen it +should be reported to the physician. Some patients will only eat enough if +they are allowed to eat it in their own way; they will eat it perhaps +standing, or after the others have finished, or alone, or in their room, +or they may steal it, if given the opportunity. Such peculiarities often +have to be indulged. + +Some patients will take nothing but milk, then about three quarts a day +are needed; eggs may be added and are often readily taken, and some may be +got to eat bread and milk, which is a very nutritious diet. + +The food of the sick should be nicely and invitingly served, and efforts +should be made to meet their whims and fancies. + +Patients who are so profane, violent, or noisy, that they are not allowed +to come to the dining-room, must always be fed by, and in the presence of +an attendant, and meals should not be passed into a patient's room and +left there. + +Knives and forks should always be counted by an attendant before and after +each meal; care should be used that they are not lost, secreted, or +carried out of the dining-room by patients. No one but an attendant should +ever handle the carving knife and fork, or the bread knife. + +_Care of Patients when Going to Bed, or Rising._--The beds should be daily +aired, and always clean and nicely made up; for a filthy patient a straw +bed, that can be changed, alone is clean. + +All patients do not need to go to bed at the same time, and while some are +able to care for themselves, most need care, attention, and watching. The +helpless should be dressed and undressed, and put to bed first: the +violent and homicidal need to be watched, and should be put to bed early, +while the suicidal should be kept under supervision, and put to bed at the +most convenient time. After a patient is in bed, an attendant should go +into the room, with a lantern, so as to see that every thing is in order +and safe, and, with a cheerful "good-night" close the door. Patients who +need care should be visited during the evening, and left clean and in good +condition to be cared for by the night watch. + +In the morning patients need attention before any thing else is done. +First, the suicidal, sick and feeble, the violent, and those likely to be +filthy should be visited, and every patient should be washed and dressed +before breakfast; or, if for any reason they do not come to this meal, +their faces and hands should be washed, the bed put in order, and the room +made clean and aired. + +After these things have been attended to, the ward work should be done, +though generally the two can go on together. + +_Care of Patients during the Night._--After the patients have gone to bed +the ward should be quiet, doors should be quietly closed, voices lowered, +and loud calls and laughter not indulged in, squeaking boots should not be +worn, and heavy walking avoided. Many patients go to sleep early, but are +easily awakened, and may remain sleepless till morning, or at least a part +of the night. + +The night watchers have responsible, arduous, and trying duties. +Attendants should always, during the night, quickly respond whenever a +demand is made upon them for assistance, though an unnecessary call +should never be made. The night watchers should be informed of any changes +that have occurred during the day, that will require their attention +during the night; they should see new patients and be made acquainted with +their peculiarities; they should visit the wards during the evening before +they come to the medical office to receive instructions from the +physicians. + +It is the duty of a night watch to visit regularly all the wards under his +charge; to see and know the condition of the sick, the helpless, feeble, +the suicidal, and the epileptic; to attend to, by taking up, those who are +inclined to be filthy, and wash those who need it, and make them, their +beds, and rooms perfectly clean. He should observe the conduct of new +patients, be watchful of the violent, know how much wakeful patients +sleep, visit all associated dormitories, wait upon all those who need +attention, and guard against fire and accident. The night watch should +place each day on the medical office table, a detailed account of every +patient that needed care or attention, who was disturbed, or did not sleep +during the previous night. + +Patients should be left clean for the night watch, who should leave them +in as good condition in the morning, for the day attendants, and any +neglect in these directions should be reported by either party. Sick +patients frequently have to receive special night service, to be watched, +and given food and medicine. When this cannot be done by the night watch, +it devolves upon the day attendants, and is a duty that should be +cheerfully rendered. + +During the night, any accident, attempt at suicide or to escape, or +unusual violence, persistent sleeplessness, or being out of bed, a serious +sickness or change for the worse, or the approach of death, should be +reported to the physician. It is, in many institutions, the duty of the +night watch to report any neglect or misconduct on the part of an +attendant or employe, and it is something that should be faithfully and +impartially done. + +Having briefly sketched the general duties of an attendant, it seems best +to again remind them, that an asylum is built and maintained for no other +purpose than for caring for the insane; that each patient is entitled to +the best our means can afford; that while the attendants are not +responsible for the medical treatment, they are for that kind and +intelligent care it is within their province to give; and they are also +reminded that, so far as it can be done, such personal attention is to be +given to each patient as will assist in recovery or improvement, or +promote his well-being. + + + + +CHAPTER VI. + +THE CARE OF THE VIOLENT INSANE. + + +A careful study of each violent patient, of his habits, delusions, and +hallucinations, of his peculiar manner of showing violence, and a +knowledge of what is likely to provoke outbursts is necessary to properly +care for him. An attendant's ability to successfully manage a ward full of +patients will depend largely upon the study given to, and the thorough +understanding of, each case. Such study will soon teach him that every +violent patient has peculiar and pretty constant ways of showing and +exercising violence, and that the same rule of individuality holds good +among this, as it does among other classes of the insane. + +Having learned what will cause violence, it can often be avoided by +removing the cause; having learned the symptoms that precede a patient's +outbursts of violence, they can sometimes be averted, or preparations made +to control them; having learned in what direction violence is shown, how +sudden, blind, or furious it may be, or how slow, deliberate, and planned, +the attendant is better able to meet, manage, and control it. + +Few patients are so continuously and furiously violent as to need constant +repression, and the directions how to care for such patients can always be +given by the physician. Most violent patients are subject to the firm, +kind control of attendants, and can be kept sufficiently quiet and +orderly; they should never be left alone, and mops, pails, brooms, +chambers, and all other articles, that may become weapons should not be +left within reach. Strong comfortable clothing can generally be kept on +the most violent and destructive, with care and attention from attendants, +but not without. + +Many violent patients will employ themselves and be the quieter for so +doing. Light out-of-door work is the best employment for this class, and +out-of-door walking and exercise should never be neglected. On the woman's +ward knitting, sewing, mending, and ward work are suitable for many, while +some will work at the laundry, and others will go quietly to church and +entertainment; books and illustrated papers should be furnished and will +be much read and enjoyed. + +As a rule the more violent patients are restricted, kept continuously on +the ward, or in a small room, and given no work, amusements, walks, and +exercise, the more noisy and violent do they become. + +Attendants must learn that mere noise, and much of maniacal activity, such +as running about, jumping, or pounding, is not in itself harmful, and that +unless such patients are doing themselves injury, or so disturbing the +ward and other patients as to require interference, it is better to +control than to repress and restrict them. + +Many violent patients are subject to such paroxysms of great violence as +to require immediate care and often temporary control at the hands of +attendants. Generally these paroxysms spend themselves after a short +time, but if they do not, advice and help can be called for. + +By careful watching, the approach of these paroxysms can be known and +often avoided. This may be done by removing the cause, which is often the +irritation of another patient or an attendant, by a word, a joke, by +simply letting the patient alone, or by a firm show of authority, or by +any other means experience has taught to be useful in the particular case. + +If necessary to hold a patient, three persons should be able to care for +the most violent. This can be done by grasping each arm at the wrist and +elbow, and holding it out straight, the attendants standing behind while +another passes the arm about the neck and holds the chin, to prevent +biting and spitting; the patient may then be walked backward and seated in +a chair. + +After the violence has subsided, though the patient should continue to +scold, swear, threaten, or cry, he should, as soon as possible, be left +alone, the attendants walking away, but remaining watchful. Do not, unless +it is necessary, interfere to stop the noise, for it is often a substitute +for the violence, and the attack wears itself out in this way. + +If necessary to carry a violent patient, it can be done by four or six +attendants. The face should be turned downward, thereby lessening the +power to resist, and, to prevent dislocating the arms, the patient should +be carried by the shoulders and chest; the bands about the neck should be +loosened. + +In using force in the care of violent patients, it should always be done +as gently as possible, and struggling should be avoided; he should never +be choked or kicked, receive a blow, or be knocked down; the arms should +never be twisted, nor a towel held over the mouth, but if the patient +persists in spitting it may be held in front of the face. + +Care must always be used not to injure a patient while exercising +necessary control. In the violence of a patient innocent injuries are +sometimes received. The attendant is excusable if he can show that he used +necessary force only, without malice. + +A violent patient should never be struggled with alone, and on a +well-managed ward help will always be within call. It may be necessary, +however, to break this rule in order to prevent homicide or suicide, or +serious injury to another patient, or setting the house on fire. + +It is better not to visit the room of a violent patient alone, and if an +attack is feared, especially with a weapon, the door should be slowly +opened, and held so it can be quickly closed. The patient usually makes an +immediate attack, and, before he has recovered for a second, can generally +be disarmed and controlled. + +Violence usually consists of noise, tearing the clothing, breaking glass +or furniture, biting, scratching, striking, hair pulling, kicking, or +attacking others with weapons. It is sometimes secretly and deliberately +planned and skilfully executed, though generally without reasoning or +direction, but blind and fierce. + +The care of the violent insane involves the careful study of each case, +with constant watchfulness, and the exercise of a control that is kind, +but firm and unyielding, that does not repress except when necessary, nor +restrict without reason, that indulges whenever possible, that never +drives, scolds, or threatens, but influences, guides, and directs. The +greatest liberty possible should be allowed, and self-control encouraged, +and work, occupation, and amusement should be furnished. An attendant must +always remember that fear is the lowest motive to govern by, and that +kindness will often be appreciated and returned. + +_Care of the Destructive Patients._--Besides the violently destructive +patients, there are some who are maliciously destructive, and who exercise +all their ingenuity to escape the watchfulness of the attendants; who +glory in their wrong-doing; who openly say they cannot be punished, and +exultantly tell the physician how they have outwitted the attendant, or +proclaim before him his shortcomings and neglect. Such patients will +destroy their own or others clothing, they will steal and hide, or throw +it out the window or down the water-closet, or erase the name by which it +is marked. They will destroy bedding, windows, crockery, pictures, or +furniture. With a pin, a nail, or a bit of glass or wood, they will mar +and deface their room or the ward, and often do damage that cannot be +repaired. The only way to meet such cases is by watchfulness. They should +be kept, if possible, at work, or at least with a company of workers, and +therefore under constant observation. When put to bed their clothing, +mouth, hair, and person should be thoroughly searched. Kindness often has +but little effect, but a threat is apt to make them more determined to +destroy. + +_The Care of Patients by Mechanical Restraint and Seclusion._--All the +restriction of an asylum is restraint. The locking of bedroom doors at +night is very restricted restraint. Most patients in an asylum have a +feeling that they are under great compulsion and restraint, in being +deprived of their liberty. It has already been taught that patients are to +be given all the liberty possible, that restraint over their freedom is to +be exercised no more than is absolutely necessary, and that the greatest +good of the patients alone is to be thought of. + +These teachings are equally true of special forms of restraint. If used at +all they are to be used for the good of the patient alone, and an +attendant should be able to care for any case without restraint. + +Restraining apparatus should never be kept on the ward. An attendant +should never ask that it be used, nor say he cannot get along without it. + +If ordered by the physician it is the attendant's duty to see that it is +so applied as to do no injury, that it does not bind or tie the patient +down, that it does not irritate and make the skin sore, nor restrict the +free movement of the limbs. + +Patients who are restrained are not to be further confined to a chair +without specific order. Restraint used during the day is not, unless so +ordered, to be continued at night nor reapplied the next day. Patients are +to be taken frequently to the closet. Restraint should be taken off +several times a day, and kept off long enough to give relief to any +feeling of discomfort, and free movement should be allowed. When patients +are restrained they need unusual care and watching, and should never be +left alone. + +The attendant should be informed why restraint is used, and what is hoped +to be gained by its use. He should closely observe the effect upon the +patient and compare his condition with what it is when not restrained. The +result of these observations should be reported. + +Thus used, an attendant will soon learn that it is not the easiest way to +care for a patient, that its use involves increased watchfulness and care, +and greater discretion, and that it is strictly a form of medical +treatment. It is a harsh remedy at its best, and needs to be used with +kindness, intelligence, and judgment, and it is to be applied but for one +purpose, namely, that the patient may be benefited. + +_The Use of the Covered Bed._--Like restraint it is never to be used +except by the orders of a physician, nor is its use to be repeated without +special orders; it is always to be considered a method of treatment and +something the attendant has no interest in, except to know how best to use +it when ordered to do so. + +When in a covered bed the patient should be frequently visited; he should +be taken up at least once in three hours, unless asleep; the bed and the +patient should be kept perfectly clean. If used in the daytime an +attendant should sit beside the patient for some hours and try to keep him +quietly in bed, and the same should be done in the evening when the +patient is put to bed. An attendant should be able to report how much the +patient sleeps, how much quiet and rest is obtained, the effect of the +treatment, and compare the condition of the patient when in the bed with +what it is when not used. + +_The Use of Seclusion._--Seclusion is shutting a patient alone in a room +in the daytime. If allowed to be done without orders from the physician +it should be immediately reported. If ordered to be continued the patient +should be seen at least once in fifteen minutes, while many need to be +seen once in five minutes, and an attendant should never be far from the +door. The patient should be frequently taken to the closet. The effect and +result of seclusion should be observed and reported. + +Many physicians never use any form of restraint, while others make +considerable use of it as a means of treatment. An attendant should be +able to successfully care for any case, so as to meet the wishes and +directions of the physician, and only as he is able to do this can he give +the patient the highest standard of attention, care, and nursing. + + + + +CHAPTER VII. + +THE CARE OF THE HOMICIDAL, SUICIDAL, AND THOSE INCLINED TO ACTS OF +VIOLENCE. + + +Patients with Delusions of Suspicion demand special care, and are properly +classed with those inclined to commit acts of violence, because they are +frequently fully under the control of delusions, which make them dangerous +and difficult to manage. + +Many patients have ideas that make them suspicious of those about them; +these may relate to the patients, but more frequently to the attendants +and physicians, and they may arise from delusions, hallucinations or +illusions. This class of patients is apt to be morose, cross, and +irritable; they sit brooding over their fancied wrongs; repulse advances +and friendly intercourse; they refuse to employ themselves, and do not +respond willingly to the requirements of the attendants. + +Our most trifling and unmeaning acts may give rise to the most intense +suspicions and hatred. A look, a shrug of the shoulder, the manner of +shaking the head, a cough, the squeaking of our boots, are frequently +enough to arouse, these feelings. + +Suspicious patients often think they are the subjects of ridicule; that +their thoughts are read and proclaimed to the ward; that their virtue, +truth, or honor is called in question, and the accusations openly told to +others, or that they are called vile and insulting names. They often have +delusions of conspiracy to do them or their families harm, and connect the +attendants and physicians with them, thinking, as they keep them locked in +the asylum, they are associated in the conspiracy. Sometimes these +patients think themselves some great persons, perhaps that they are a +member of the Deity, or a ruler, or prophet, or that they have some great +mission to perform, and that they are deprived of their rights, or their +work interfered with, by being kept in the asylum, and that those in +authority are imprisoning and persecuting them. Such persons may be, on +account of their fancied wrongs, very suspicious, and even violent towards +those who care for them. + +Other patients have suspicions and fears of bodily harm. They may think +they are to be tortured, that they are to be burned alive, or that some +one is trying to kill them. To-day, as I wrote these lines, a patient told +me she did not sleep last night for fear the night-watch would kill +her--saying that God told her the watch was armed with a knife for that +purpose, and she threatened homicidal violence in defending herself. + +Many patients mistake ordinary sensations of pain and bodily discomfort, +and have delusions that they are being injured. The feelings of dyspepsia +may make patients think they have been poisoned; ordinary pains or aches, +that they have been shot, stabbed, or pounded; women may, for some such +causes, think they have been violated or are pregnant. Peculiar sensations +of various kinds may make patients think some one is affecting them by +electricity or mesmerizing them. + +It is very easy to trace from such ideas of persecution and suspicion, the +origin of homicidal, suicidal, incendiary and other violent tendencies and +acts. + +_Homicidal Patients._--Patients are sometimes both homicidal and suicidal, +and sometimes they are inclined to only one of these forms of violence. +Homicides are not of frequent occurrence in an asylum. The better the care +the less is the liability to homicide. But there are always a great many +homicidal patients, and many more who have delusions and ideas that may +cause such tendencies to arise. + +Many patients are homicidal merely from violence and frenzy, and without +any settled plan, any fixed delusion, or intense suspicion. They may +attack others suddenly and furiously; they may commit the act while trying +to escape, or it may be the result of the violence of acute mania. Other +patients become homicidal under the desire to protect themselves from +supposed assaults. They may think a person who is approaching them is +coming to kill or torture them. Others are homicidal from any of the ideas +of persecution and suspicion that have just been spoken of. Sometimes +patients hear voices telling them to commit the act, perhaps it is God's +voice commanding a father to offer up his only son as a sacrifice, or a +mother to kill her little children to save their souls, or keep them from +some misery or crime that awaits them. Patients may think themselves God, +or a king, or ruler, and therefore have a right to take life. Homicidal +patients are often among the quietest, and are found in the quiet wards. +They frequently lay careful plans, are secretive, and only try to commit +the act when they feel sure it will succeed. + +Patients who are homicidal should be especially watched. They should, if +possible, be kept employed, but never given tools that may become weapons. +They should sleep in a room by themselves. All persons against whom they +have delusions should be warned. Patients against whom they harbor +suspicious or homicidal ideas should be separated from them. + +Attendants should remember that a mop, a pail, or a chair, may become a +dangerous weapon, or that a knife, scissors, or a sharpened piece of iron +or tin, may make a fatal wound. + +_Suicidal Patients._--Patients with this tendency will generally talk +freely of their suicidal ideas, tell why they wish to commit it, what +provokes the idea, and how they would do the act. They are frequently +grateful for the care bestowed to help them resist the impulse, and will +sometimes tell the attendants when they feel the suicidal ideas coming on, +that they may be the more surely watched. + +Melancholic patients are most inclined to suicide, but any insane person, +whatever the mental state, may commit the act. Delusions of depression +generally cause the suicidal ideas, but hallucinations sometimes play an +important part. Some persons are simply tired of life, and see no hope in +living; some think they are a burden to their friends, and that they are +taking food away from their children; others wish to die to escape from +their misery, which is generally a mental, and not a physical suffering; +others that by so doing they may get forgiveness of their sins; others +because they think they will save their children from a fate like theirs; +sometimes it is the result of hallucination, as a direct command from God, +telling them to commit the act. + +But few patients are constantly determined to commit suicide. The +opportunity offered, as a bath-room door left open, a rope, a knife, often +prompts the desire and allows the accomplishment of the deed. + +Attendants must remember that it takes but a few minutes to commit +suicide, by drowning or hanging--but a moment to cut the throat; that +persons can drown themselves in a pail of water, hang themselves by the +hem of the sheets, cut their throat with a piece of glass or tin. +Sometimes patients slyly save their medicine until they get enough to +poison themselves. + +About dusk in the evening, or at early morning, is the time when patients +are most inclined to commit suicide. When patients are rising, going to +bed, or to their meals, when going to chapel, amusements, or to walk, when +all is busy and astir on the ward, are the times that offer the most +favorable opportunities for the act. + +Often patients have a certain way by which they will commit suicide, and +they will do it in no other; one wishes to drown himself, another to hang, +and another to take poison. Sometimes patients will appear cheerful to +avoid suspicion and so find their opportunity, while others may suddenly +and while convalescent commit the act. + +The only way to care for patients who are suicidal, is by constant +watchfulness day and night. During the day they should be employed and +kept with other patients, they should be especially looked after at those +times when opportunities for suicide are increased. At night it is better +to have them sleep in an associated dormitory with some one to watch them. +If a patient is found hanging he should at once be cut down, all +restriction about the neck removed and artificial respiration set up, or +if drowning, the mouth and lungs should be first emptied of water; if +there is hemorrhage compression should be made upon the artery, or if this +is not possible, then directly upon the wound. How to control hemorrhage +and do artificial respiration will be described in the chapter on +emergencies. + +_Patients Who Have Tendencies to Self-Mutilation._--Some patients horribly +mutilate themselves. They may gouge out an eye, cut off a hand, pull out +their tongue, or even disembowel or dreadfully burn themselves. Some +patients persistently beat their heads against the wall or floor, others +scratch the skin, making large sores. Such patients frequently think +certain passages from the Scriptures apply to them, and they must obey the +application and command. They quote in justification of the acts, "An eye +for an eye," "And if thy right eye offend thee, pluck it out," "And if thy +right hand offend thee, cut it off." Talk of this kind should make an +attendant very careful and watchful of the patient. + +The origin of the ideas that lead to the attempts at self-mutilation is to +be found in delusions, and arise in the same way as do ideas of suicide +and homicide. These patients are all of the same class and need the same +character of care, attention, and watching. + +_Patients with Tendencies to Setting Things on Fire._--Patients with these +tendencies generally desire to commit incendiary acts under the influence +of delusions or hallucinations; added to these there are frequently +suspicions and feelings of wrong treatment, and the patient takes this way +of showing revenge, or, as he may say, of repaying the wrong. Sometimes +patients are so feeble in mind that they light a fire because they think +it is a pretty sight to see it burn. There are some conditions +accompanying epilepsy where patients are liable to commit any of the class +of violent acts described in this chapter. The special care demanded by +these patients will be fully spoken of hereafter. + +There are some patients whose minds are so distorted by disease that they +seem to take a pleasure in wrong-doing, and are much inclined to do great +mischief, and sometimes to commit acts against life or property. + +The care demanded by patients who are inclined to acts of violence is +practically the same for all. The attendant should thoroughly know the +habits, peculiarities, and delusions of each person under his care; he +should exercise constant watchfulness, and remember that a moment of +thoughtless inattention may give the opportunity for a patient to commit +some violent act, that will cause him lasting regret. The mind of a +faithful attendant will, when upon duty, always be full of anxiety, and +there should be in the care of very troublesome patients of this class +frequent relief. + + + + +CHAPTER VIII. + +THE CARE OF SOME COMMON MENTAL STATES, AND ACCOMPANYING BODILY DISORDERS. + + +_Care of Patients in the Earlier Stages of Insanity._--Patients in the +earlier stages of insanity act differently, one from the other, when first +brought to the asylum and placed under care and restriction. Sometimes +patients accept the situation and fit into asylum life without any +friction. They may even come willingly, knowing they need care and +treatment, or from confidence in their friends or their physician's +advice. + +To some patients the restrictions of an asylum are irksome and +misunderstood; the quiet, regularity, and routine of the life on the ward +does not at first affect them; they may, and often do, become fretful, are +irritated by their confinement, sleep poorly, eat little, and may make +violent efforts to escape. + +These conditions, if nothing is done to occupy the patient's time and +mind, and so relieve them, will often be sufficient to provoke violence. +These patients should be carefully watched and their condition studied; +they should be brought under the kind control and influence of attendants, +induced to take part in the regular order of the ward, and, if strong +enough, should be furnished with proper work and occupation. + +Patients, when first brought to the asylum, frequently have much anxiety +about their homes, their families, or their business affairs. This is +particularly true in recent cases of insanity, because such patients often +have cares and responsibilities, or they have tried to continue to assume +them, up to the time of coming to the asylum. Special care should be taken +to quiet fears in these directions; they should be assured that they are +groundless, told they will be allowed to communicate with their friends, +that they will be visited by their family, and that all their interests +will be cared for. + +It is impossible to speak of the varied causes of insanity, or of the +equally varied manifestations of the disease and conduct of the patient at +its onset, but there are a few conditions which, being present, give a +character to a particular case, and suggest the care required. + +Sometimes, as has been said, the patient partly realizes his condition, +and is willing to come to the asylum, and in every way to conduct himself +in accordance with the rules and requirements. + +Sometimes the onset is slow and the symptoms so obscure as to attract +little attention. Following this, more decided symptoms may appear; the +patient may become violent, noisy, destructive, or sleepless, or he may +try to commit suicide or homicide, or do some other act of violence; or +the great restlessness, moaning, crying, and sleeplessness of melancholia +may come on, or the patient may refuse, for several days, all food. The +reason for bringing such patients to the asylum is that they can no longer +be kept at home. + +Following the treatment that has been described, these patients will +frequently in a short time become more quiet, self-controlled, and more +easily influenced and cared for. + +The earlier stages of insanity are frequently accompanied by considerable +disturbance of bodily health. The appetite is poor, the digestion +disordered, the bowels constipated, the breath foul, the secretions of the +skin changed and often offensive, the temperature a little elevated, the +pulse rapid, and the heart weak. Sometimes, on the other hand, the +temperature is normal, or a little below, while the hands are cold and +clammy. In addition, nutrition is frequently impaired, so that the food +taken by patients does not seem to properly nourish and strengthen. All of +these symptoms are not present in a given case; sometimes most of them may +be, and again but few are to be noticed. + +The important lesson to learn in the care of these cases is that such +patients may rapidly pass into a more serious condition, in which there is +great exhaustion, which is always alarming, and may even result fatally. + +Recent cases, such as have been spoken of, need our best care, closest +attention, and kindest nursing. The patient should daily take sufficient +food, which, if necessary, should be enforced, and the opportunity for +sleep promoted. A few days, or a day, without food and sleep may bring on +alarming symptoms. + +For these patients, milk is the best article of diet; it is most easily +given and readily taken; it should be given by the glassful, or if not +able to do this by the spoonful. Some patients, for reasons not always +known, will refuse food one hour and take it freely the next; it should, +therefore, be frequently offered. With milk as a basis, we may add to it, +as we are able. Raw egg, gruel, boiled rice, oatmeal, custard, and bread +are adjuncts that are nutritious and easily given. + +It makes but little difference why patients refuse food, except that a +knowledge of the reasons may enable us to overcome their disinclinations. +The thing to remember is that they must in some way be made to get enough. + +_Care of Patients with Insanity, Accompanied by Exhaustion._--There is a +condition associated with acute mania or melancholia--though it is +sometimes seen in connection with the more chronic forms of insanity,--of +exhaustion so overpowering, that it may be rightly compared with the +exhaustion of typhoid fever. It may last a few days or a month, or more, +if it does not sooner terminate fatally. Instead of the quiet delirium of +typhoid fever there is generally violent mania or frenzy. Neither mind nor +body is quiet; sleep seems to have fled. The patient may be destructive, +constantly out of bed, fighting care, refusing food, and wetting and +dirtying himself. With these unfortunate conditions there generally is +fever, often to a considerable degree, the heart is feeble, the pulse +rapid, the tongue and lips dry and cracked, the teeth covered with sordes, +and the body emaciated. Every case does not present all these symptoms, +nor show such alarming exhaustion. There are many degrees of severity in +this sickness. + +Such patients must never be left alone and need constant nursing day and +night. They must have food, even if it is given forcibly. They must, if +possible, be kept in bed, and covered with clothing, and they must be +kept clean. If wakeful, food must be administered during the night, and +especially towards morning, which is the time of greatest weakness and +physical depression. + +Hot baths may be ordered for these patients, and stimulants and medicine +to produce sleep left in the care of attendants. How to give the baths and +medicine, what results are to be expected, and what dangers are to be +feared, will be described later, in the chapter on the administration of +medicine. + +There are certain symptoms which should warn the attendant of danger, and +which often precede death. When any of these are present they should be +reported to the physician. They are: partial or complete unconsciousness, +slow and labored, rapid, shallow, or irregular breathing, increased +weakness and rapidity of heart or pulse, cold hands and feet. Picking at +the bedclothes, or at imaginary objects in the air, or vacant staring, are +bad symptoms. + +_The Care of Patients in a Condition of Dementia._--It is to be remembered +that dementia may be either, a condition of chronic insanity without +recovery, or a less permanent state of mental enfeeblement following the +acute attack, and from which recovery may be hoped. In the first of these +conditions there is little to be done except to care for the patient. Many +are able to do some work, and should be allowed, encouraged, and taught to +do it. Others do not know enough to dress, feed, or care for themselves. +These must be kept neatly dressed, taken to the table and their food +prepared, taken to the bath and closet, taken to walk, and put to bed. If +not so attended to, they will degenerate into a ragged, dirty, and even +filthy state, and the ward upon which they live will be offensive to the +smell. They should be frequently examined for body vermin, as these pests +are liable to breed and flourish among these patients. The condition of +the demented affords the best evidence of the care given to the patients +in an institution. Attendants will often be gratified to see some of these +apparently hopeless cases greatly improve and sometimes recover. + +If attendants will watch their patients as they come out of acute mania or +melancholia and become quiet, they will often notice that they gain in +flesh and become demented. The dementia may be but partial, or so very +complete that the patient knows nothing. From this they may gradually go +on to improvement, or even recovery. They need all the care demanded by +the confirmed dement, and, in addition, advantage must be taken of every +means to promote recovery. They must be well fed, regularly taken out for +exercise, and, as they are able, encouraged to employ themselves. Any +symptoms of a return of their more violent condition, any failure to +sleep, or change noticed in the health of the patient, should be at once +reported. + +_Care of the Convalescent Patients._--This is the period that precedes +recovery from disease. With the insane it is often a critical time, and if +not properly cared for they may fail to get well, and become chronic +lunatics. The patients, and frequently their friends, think they are well +and should be at home. It is the attendant's duty to encourage the +patient, and to promote his confidence in the physician. They should not +be told of their past conditions, or the disagreeable features of their +sickness called to mind, and their last, as well as their first +impressions of the asylum should be made pleasant. Sometimes there is a +slight return of depression or mania, and the patient may suddenly begin +to lose sleep. These conditions must be observed and reported, for it is +very easy for patients who are recovering to become as disturbed as when +they were first insane, and to suffer a relapse from which they may never +recover. It is hardly necessary to remind the attendant that employment, +amusement, and all the healthful means of occupation afforded by the +asylum, should be judiciously allowed these patients. + +Sometimes patients feel too well. They are too contented, happy, and +indifferent, and are very active in body and mind. They want to work all +day, from early in the morning until late at night. They sing as they +work, and talk rather loud and fast. These patients need restriction; they +should not be allowed to work too much, so as to overtax their strength. +So long, however, as they continue to gain, and sleep well, little is to +be feared, and they generally become quieter and recover. + +_The Care of the Epileptic Insane._--Not all epileptics are insane, but +they are all liable to insanity. Generally the most hopeless and difficult +to be cared for are brought to the asylum. Epileptics are liable to have +fits at any time, but some patients have them at night only. The attack is +generally sudden, though sometimes patients have feelings that warn them +of their approach. This may precede the fit for a very short time, or the +patient may know during the day that he will have a fit during the night. + +Epileptic fits are accompanied by convulsions and unconsciousness, and +are the type of all convulsions. The unconsciousness may be but momentary, +or last an hour or longer, and even prolonged several days; the +convulsions may be but the twitching of a few muscles, as of the face, or +may consist of the most terrible writhings, and last for several minutes, +and be often repeated. Sometimes the fits are ushered in by a scream. + +The fit itself is not dangerous to life, but patients may at night turn +their face downward and so smother; they may fall from high places, or +down stairs, or into the water, or into the fire, and so injure +themselves. There is little to do during an epileptic attack. Patients +should not be held to prevent the convulsions, but so that they shall not +injure themselves. A pillow should be placed under the head and the bands +about the neck loosened. The nurse is sometimes given remedies which, if +properly administered when the attack is felt to be coming on, may ward +off the fit. Nitrite of amyl in small glass pearls is a common remedy. It +is to be broken in a handkerchief and several strong breathfuls taken. + +At their best, epileptics are cross, irritable, quick-tempered, +unreasonable, and quarrelsome, and they will often give a blow at slight, +or even for no provocation. After a fit they are frequently dangerous and +always require guarded care and watching. As has been said, they may soon +recover their natural condition, or remain in a more or less prolonged +state of unconsciousness, or they may pass into a condition that appears +natural, but in which they have but little or no appreciation of their +situation or surroundings, or remember afterwards what they do. In these +states they may, without warning, make violent assaults, commit murder or +suicide, or set things on fire. Sometimes they do outrageous acts, such as +beating their own children to death against the wall, or mutilating them, +or roasting them to death on the stove. Many often suffer from +hallucinations or illusions of sight or hearing, and have delusions of +impending harm or assaults, and think they must defend themselves. + +_Care of Patients with Paresis._--This is a form of insanity characterized +by progressive dementia and increasing bodily enfeeblement and paralysis. +The paralysis is partial, not complete; the patient's walk is feeble, +unsteady, and shuffling; the hands are tremulous, lose their fineness of +touch and ability to do work and write; there is twitching in the muscles +of the tongue and about the mouth, and the speech is thick and indistinct. +As the disease progresses the patient becomes helpless, bedridden, wet, +and filthy. The result is always death. Convulsions like those of epilepsy +are liable to occur, from which the patients may rally, or in which they +may die or linger a few days. In the earlier stages the patients are often +strong, and controlled by delusions and hallucinations that make them +violent. Sometimes they are simply good-natured and easily managed. They +generally have very exalted and extravagant delusions, and are without +appreciation of their condition or surroundings, and are irritated at the +control of the asylum, and on account of their unreasonableness they can +rarely be allowed the liberty others enjoy. + +Paretics often eat ravenously and rapidly, they stuff their mouths full of +food and so choke themselves. Their condition of paralysis may render them +unconscious of danger and powerless to help themselves. The care needed +by bedridden, filthy paretics is practically the same demanded by helpless +paralytics, the old, feeble, or demented class, and all others who cannot +care for themselves. + +_Care of the Paralytic, Helpless, Bedridden, and Filthy Patients._--There +are many patients in an asylum who are indifferent to all the wants of +nature, who wet and dirty themselves. Some of these patients are +bedridden; some are about the ward, but demented; some are violent and +maniacal, and some from delusions make their persons and rooms as filthy +as possible. Much can be done with many of these patients by regularly +taking them to the closet, and their bad habits may in this way be broken +up. Patients of this class should be visited during the evening, attended +to frequently by the night watch, and seen the first thing in the morning. +Patients, when dirty, should be thoroughly washed and carefully dried. +Their beds should be cleaned and changed, and during the day clean +clothing should be given them as often as required. + +The greatest danger that comes from not keeping patients clean is the +formation of bed-sores. + +_Bed-Sores._--Bed-sores occur in patients long confined to bed, and who +suffer from exhaustive diseases. Paralytics and paretics are particularly +liable to them, the diseased condition of the nerves allowing the tissues +to break down easily. Sometimes the fingers or toes of a paretic become +gangrenous or large surfaces of the skin die, and sometimes deeper tissues +slough away rapidly. These conditions may come on in a day or a night. + +Patients who are wet and dirty are more liable to have bed-sores. They +will always appear in a bedridden paretic in a few days if not kept +perfectly clean. They most frequently occur over bony projections where +the weight comes in lying, as upon the hips, back, or shoulders. + +Such patients, should, if possible, be made to sit up several hours every +day, or placed first on one side, then on the back, and then on the other +side. If it can be done, they should, as they lie in bed, rest their hips +on an inflated rubber ring, and if the skin is red the part should be +bathed in diluted alcohol. After being bathed and dried the skin about the +hips should be dusted with some dry powder. Powdered oxide of zinc is +perhaps the best, but ordinary corn-starch flour is valuable and serves a +good purpose. Insane patients frequently will resist all care and every +effort to prevent bed-sores, tearing off the bandages and dressings and +picking and irritating the sores. + +Bed-sores should never be allowed to come because of want of attention or +cleanliness, but there are conditions in which they will appear in spite +of every preventive. + +Bed-sores once formed should be treated as ulcers and according to the +direction of the physician. + + + + +CHAPTER IX. + +SOME OF THE COMMON ACCIDENTS AMONG THE INSANE, AND THE TREATMENT OF +EMERGENCIES. + + +The insane, like others, may suffer from almost any accident. It is not +intended to treat of all accidents, nor how to care for every emergency. +This is so large a subject as to demand a separate text-book, and there +are several excellent ones, that attendants would do well to read. But +there are among the insane certain kinds of accidents that are likely to +occur, certain classes who are liable to receive accidents, and certain +emergencies that frequently have to be cared for by the attendant, and +these will be described. Every injury received by a patient should be +immediately reported to a physician. + +Attendants, in the care of the insane should always remember the liability +to accident and guard against it. The old, the feeble, the paralytic, and +paretic need special care. They are weak, easily pushed over, or stumble +and fall, and they cannot break the weight of their fall, or so defend +themselves; they are irritable, childish, and often provokingly +troublesome to the other patients, and their bones seem to be easily +fractured. Some injuries are self-inflicted, some come to the patient in +consequence of his own or others' violence, and some, as has been said, +from the very weakness of the patient. + +_Care of Fractured Bones._--Any of the bones may be fractured, and from +slight cause. The bones most frequently fractured are: the collar bones, +the ribs, the bones of the forearm just above the wrist, the bones of the +lower leg and of the thigh. This last bone, the femur, is among old people +most frequently broken at its neck, which is the constriction of the bone +just below the rounded end that fits into the joint at the hip. + +Fractures should, as much as possible, be let alone till the physician +comes. The parts should be kept quiet so as not to cause unnecessary pain, +and do further injury. By rough handling it is very easy to push a +fragment of bone through the skin, thus making a simple fracture a +compound one. When a rib is fractured a sharp end may pierce the skin or +the lung; either complication is serious. If the lung is injured the sputa +will be bloody, and the appearance of such a condition should be at once +reported. Sometimes patients are violent after the injury and need to be +firmly held, and sometimes they have to be carried to the ward from the +outside, or placed upon a bed. Always carry the fractured limb as well as +the patient. + +If temporary splints are put on do not make them too tight, and loosen +them from time to time as needed. The extremities sometimes swell rapidly +after a fracture, and the splints may so stop the circulation that, in a +few hours, gangrene may be caused by them. Besides, many patients cannot +tell us if the part is swollen or painful. + +_The Care of Wounds._--Bites. Insane patients often bite others and +penetrate the skin. They may be very angry, their mouths foul and running +with saliva, and this irritating substance introduced into the wound by +the teeth may set up an ugly inflammation. The wound should be immediately +and thoroughly washed. It should be well cleaned with a wet sponge or +cloth, and soaked in warm water. A good after-dressing is powdered +iodoform, sprinkled over the wound. + +_Wounds of the Head._--These wounds are quite common. They should be +thoroughly washed and cleaned from dirt and hair. Hemorrhage may be +controlled by continued pressure upon the bones of the skull, and if an +artery is cut, it can in this way be kept from bleeding till the physician +arrives. Most wounds of the head, even though large, generally heal +quickly, but the most trifling ones may assume serious proportions, and +even prove fatal. If within two or three days heat, pain, redness, and +swelling appear, pus is probably forming beneath the scalp, and this, +within a few hours, may spread under a large surface and do serious +injury, or erysipelas may be set up. + +_Injuries from Blows on the Head._--Persons are sometimes stunned by blows +on the head. They should be placed in bed with the head elevated, and kept +perfectly quiet till the doctor comes. Efforts should not be made to +arouse them, they should not be given liquor of any kind, but ice may be +applied to the head. The danger to be feared is from the skull being +fractured, or from bleeding vessels inside of the skull. Either of these +conditions may, by pressure upon the brain, cause unconsciousness, +paralysis, and death. + +_The Care of a Cut Throat._--Patients may cut their throats from ear to +ear and do really little injury, or they may make a small stabbing wound +and divide a large blood-vessel and die almost immediately, or they may +cut the windpipe and not cut the blood-vessels. The windpipe you can +notice upon yourselves as a large, stiff tube, prominently situated in the +middle and front of the neck; the blood-vessels are together on each side +of the windpipe, and situated quite deep down among the muscles, and the +carotid artery may be felt beating by the finger. Little can be done by +the attendants to stop the flow of blood, even if the great blood-vessels +are not cut. The head should be kept bent forward and the chin pressed +against the chest. + +After the physician has dressed the wound, constant watching day and night +may be required to prevent the patient tearing off the bandages and +reopening it. This same rule of watchfulness applies to the after-care +needed to be given to many cases of fracture, and other serious injuries +among the insane. + +_Care of Wounds of the Extremities with Hemorrhage._--The hemorrhage from +most simple wounds involving the cutting of skin and flesh or small +arteries, can usually be controlled by direct and continued pressure. This +may be done by a pad made of cloth, packed and pressed into the wound, or +lint may be used in the same way. Water as hot as can be borne poured into +the wound will frequently stop a hemorrhage when other means fail; cold +applications and ice are also useful. If dirty, a wound should be +thoroughly cleaned, being washed, and, if necessary, soaked in warm water. +Iodoform sprinkled so as to cover wounds, is the best dressing for all +attendants or nurses to apply, while awaiting directions from a +physician. It keeps them clean, promotes healing, and lessens the danger +of inflammation or the formation of pus. + +When the arteries of the extremities are cut, pressure should be made on +the large artery leading to the part. When the wound is high up on the +arm, pressure is made by the fingers or a padded key upon the artery that +lies back of the collar bone, and the attempt should be made to press it +against the bone. This is a difficult thing to do, but nevertheless it +should be attempted. When the wound is lower down, pressure is to be made +by the fingers on the inner side of the upper arm, at about the middle +point and against the bone. The artery runs downward, near the inner +border of the biceps muscle, which is the large, bulging muscle of the +upper arm, and can, with a little care, be felt beating by the fingers. +Patients in breaking glass often cut one or both arteries at the +wrist-joint where the pulse is felt. These are large and bleed rapidly, +and when cut need the care just described. + +When the artery in the leg is wounded, pressure is to be made on the inner +side of the thigh, just below the groin. The position of these large +arteries, and how to press against the bone, is best learned by +instruction and demonstration from a physician, and with a little practice +attendants will be able to easily and successfully do the act. + +It is very tiresome to continue pressure with the fingers for a long time, +and attendants should relieve one another till the physician comes. + +_The Care of Sprains._--Sprains are a common accident and easily produced. +The great end of treatment is to keep the sprained joint quiet. If the +ankle or knee is sprained, the patient should be carried to bed. Perhaps +the best early treatment, and the one that gives the greatest relief to +pain, is to place the joint in a tub of water as hot as can be borne, and +keep it hot by pouring in more. The part should be kept in the water until +it is parboiled. The skin of some feeble or paralytic patients is easily +scalded, and some cannot tell when it is too hot; the water therefore +should never be uncomfortable to the hand of the attendant. + +_Care of Patients Choking._--This is a frequent accident, and in order to +know what to do when it occurs, it is necessary to have a knowledge of the +air passages of the throat. + +We breathe through the mouth and nose. They open into a common passage, +the pharynx, which can be seen by looking into the mouth, lying back of +the tonsils. Passing downward, it divides by branching into two tubes; one +the windpipe, which is in front, behind it is the oesophagus or gullet. + +The point of division is just beyond the tongue, and is almost within +reach of the forefinger when crowded into the mouth. + +The air we breathe passes through the mouth and nose to the pharynx, +thence to the lungs by the windpipe. The food we eat passes from the mouth +to the pharynx, and thence to the stomach by the oesophagus. + +There is at the opening of the windpipe a cover, the epiglottis, which is +generally open, but which closes when food is swallowed and helps to keep +food from entering. When a substance touches the opening of the windpipe, +we instantly cough to expel it. + +A person may choke, when the mouth and the pharynx back of it are filled +with food; or when a piece is lodged in the wind-pipe, or a large piece in +the oesophagus at the point of division, and which crowds upon the +windpipe, or covers the opening. Food gets into the windpipe, by being +drawn in by a sudden and unexpected inspiration of air. This may happen +while eating or in vomiting solid food. With this accidental exception all +breathing stops during the act of swallowing. + +Some patients, from paralysis, especially paretics, do not feel food when +it is lodged in the throat; others, from great dementia, may not know when +they are choking, and show no emotional signs of distress. Paretics are +particularly liable to bolt their food, and cram the mouth and throat +full. + +The symptoms of choking are immediate, and if no relief is obtained, the +sufferer will die in a few minutes. If the patient knows any thing, he +will show immediate signs of distress, violent but ineffectual attempts to +breathe, and the face quickly becomes a dark blue color, from the +accumulation of carbonic acid in the blood. + +Immediate effects should be made to remove the obstruction, and continued +until the physician arrives, who is to be sent for at once. Whatever is in +the mouth and throat can be easily removed by the fingers; the forefinger +should then be crowded down the throat to feel for other obstructions, +care being taken not to push a piece of food into the windpipe. If any +thing is felt, it can sometimes be pulled out by the fingers, or a +hair-pin may be straightened and bent, or a piece of wire, and an effort +made to fish it out. When in the gullet and beyond the fingers, it may be +pushed into the stomach by a feeding-tube. Artificial respiration may be +needed, but attendants must remember it is of no use until the obstruction +to breathing is removed. + +Marbles, coins, buttons, pieces of pencils, needles, pins, and fish-bones, +are frequently swallowed. The physician should be informed at once. + +_Directions how to Perform Artificial Respiration._--What is to be done +must be done quickly; tight clothing about the neck and chest must be +removed, and the mouth should be cleaned of dirt, water, or any +obstruction to the flow of air. The body is then laid out flat on the +back, covered, if possible, with light warm blankets, and some article +should be folded and placed under the shoulders, so as to raise them three +or four inches. The mouth must be kept open, and the tongue pulled well +forward, as it is liable to fall backwards, and cover the opening of the +wind-pipe. One person, kneeling behind the head, should grasp each arm at +the elbow, and, draw them steadily around so that the arms will meet above +the head. A strong pull should be made upon them, and they should be held +a few seconds. These movements elevate the ribs and enlarge the chest and +produce an inspiration. + +The arms are then to be brought to the side, and pressed strongly against +the lower ribs. This last movement drives the air out of the lungs, and +makes an expiration. These manipulations should be repeated, slowly and +regularly, about sixteen times a minute, and should, when there is the +slightest hope of life, be continued at least thirty minutes. The heart +should be listened to, in order to hear if it still beats. Warmth, by +hot-water bags, bricks, and soapstones should be secured, care being taken +not to burn the skin. The limbs may be gently rubbed with warm cloths, +though it is not so important as some well-meaning people think. The +rubbing should be towards the heart. + +As the breathing begins, it should be still aided by the artificial means +as long as necessary. When the patient can swallow, teaspoonful doses of +brandy or whiskey, to two or three of water, may be given and repeated +several times. As soon as possible the patient should be put in a warm +bed, and milk and light food given. + +_Care of Patients when First Burned._--When a patient's clothing is first +on fire, dash water over him if near at hand, if not wrap him in a blanket +or some heavy woollen garment, and smother the fire. Then unroll the +patient and extinguish the smouldering pieces of clothing. The clothing +must be cut and clipped off. Great care must be taken not to tear open the +blisters. If any application is made, it may be by linen cloths soaked in +sweet or castor oil, or equal parts of linseed oil and lime-water, or a +layer of flour and molasses may be applied over the burned surface. These +bland substances act largely by excluding the air, which, if blowing ever +so quietly, is always painful and irritating, and they also protect the +wound from the irritation of the bed and body clothing. Burns from +scalding are practically treated in the same way as burns from fire. + +_Care of Frost-bites._--Toes, fingers, ears, and noses are most frequently +frozen. They will sometimes freeze in a few minutes on a very cold day. +After a part is frozen there is no feeling of cold or pain, and it looks +perfectly white, and is so stiff it may be broken. + +Persons who are frost-bitten should not be taken into a warm room. They +should be left in a cool room, and the frozen part rubbed with cold water, +or ice, or snow. As these last melt they melt the frozen flesh. If the +parts are thawed too quickly gangrene is liable to follow. + +_Care of Patients in States of Unconsciousness._--This is not an accident, +but a frequent emergency. The medical word for unconsciousness is _coma_. +It may be partial or complete, may come on suddenly or slowly, or may be +accompanied by convulsions or paralysis. The more frequent causes of coma, +are epilepsy, the convulsions of paresis, blows on the head, hemorrhage in +the brain or apoplexy, some diseases of the brain, sunstroke, and some +poisons. + +When coma comes on, attendants should observe, if it is slow or sudden; if +the patient complains of pain in the head; if the respirations are +changed, and how; the condition of the pupils, whether large, contracted, +uneven, or changeable; if the mouth and face are drawn to one side; if +there is any paralysis of the arms or legs; if there are any convulsions, +or twitching of muscles; if the patient can be aroused, and from time to +time observe and count the pulse. + +Apoplexy is a term that is much used, and is a condition of coma, caused +by pressure on the brain. This organ is in a tight, rigid box, the skull. +If the fluid of the brain is much increased, or blood-vessels ruptured, +pressure is the result, and the soft tissues yield, rather than the bony +covering. This pressure may destroy or injure the cells and fibres, and so +interfere with the function of the part. Another way that apoplexy occurs +is by plugging of an artery of the brain, so that it cannot deliver blood +to the part to which it goes, and consequently the part loses its ability +to perform its function. The plugging is most frequently due to a small +clot floating in the blood, and which is usually formed in the heart. + +Paralysis and apoplexy are often, through ignorance, used synonymously, +but they really mean very different conditions. Paralysis is a loss of +power of contracting a muscle, due to disease or injury of the nervous +system; it frequently follows or is associated with apoplexy. + +In the case of apoplexy, and most conditions of coma, there is generally +little for the attendant to do. The patient should be put to bed, with +light coverings, and the head raised on pillows. Do not annoy the patient +by trying to rouse him, and do not give stimulants. + +_Care of Sunstroke._--A sunstroke is a very serious condition, and when it +occurs, requires immediate efforts to save the life of the one suffering +from it. It generally comes on suddenly, the patient first complaining of +the head; he soon becomes unconscious, the skin hot and dry, and the pulse +full and bounding. The treatment consists of taking the patient to a cool, +shaded place, removing all unnecessary clothing, applying ice or cold +water to the head, and bathing or sponging the body in cold water. If the +patient recovers, the temperature will fall under this treatment. If the +heart begins to fail, or the pulse becomes weak or fluttering, small doses +of whiskey and water may be given and repeated. + +Patients should not be taken out in the fields nor exposed places on very +hot days, except as ordered by the physicians; they should wear light +clothing and a straw hat; if permitted to go out, they should not +overwork, and should be allowed frequently to rest in the shade. Patients +are easily injured by working in the sun; headache caused, recovery +retarded, and bad symptoms brought back, without having the alarming +conditions of sunstroke. + +_Unconsciousness from Poisoning._--Opium and its preparations, including +morphine, chloral, and the two extracts of hyoscyamus, now so much +employed in asylums, namely, hyoscine and hyoscyamine, are medicines +frequently given, that poison in over-doses and produce coma. + +These medicines and their effects will be described in the next chapter, +and at the same time the symptoms of poisoning by them, and the treatment. + +_Poisoning._--Poisonous drugs are not kept upon the wards. Attendants +frequently have strong ammonia in their rooms to clean their clothing, and +a patient may get it and drink it. It is a strong alkali, and burns the +throat and mouth. Vinegar is the best ready antidote, but should be given +immediately or not at all. Soft soap is a strong alkali, and if eaten +becomes an irritating poison. Again vinegar is the best antidote. + +The best antidotes for acids are soda, lime-water, soap-suds, and chalk; +for alkalies, weak acids, such as lemons, oranges, vinegar, or cider. +Olive oil, eggs, and mucilaginous drinks are the most bland and soothing +remedies to give. To vomit a person who has taken poison, give a pint or a +quart of lukewarm water; to it may be added one or two teaspoonfuls of +mustard. Syrup of ipecac is a common remedy, the dose is a teaspoonful, +and repeated in ten minutes if necessary. It assists vomiting to tickle +the throat with a finger or a feather. If after poisoning there is +depression or approaching coma, very strong tea or coffee is the best +stimulant, and it is as well an antidote to many poisons. If the heart and +pulse are very weak, whiskey diluted with water may be given and repeated. + +_Injury from Eating Glass._--Patients sometimes eat glass. This injures by +the edges cutting and inflaming the walls of the stomach and intestines. +This may be so severe as to cause death. In the treatment do not give an +emetic or a cathartic. Such food as has a tendency to constipate the +bowels, and such as will also enclose the glass and coat its sharp edges, +is to be given. Potatoes, especially sweet, oatmeal, or thick indian-meal +pudding, are appropriate. Cotton, which is generally at hand, will, if +swallowed, engage the glass in its fibres, and so protect from injury. + +_Injury with Needles._--This is a self-injury, but it may be severe and +require immediate attention. Patients may open a vein or an artery with a +needle, or plunge it into the eye. But the more common way is for a +patient to stick many needles under the skin, sometimes to the number of +several hundred. Sometimes patients introduce them near the heart or +lungs, and as a needle will often "travel" when in the flesh, it may work +its way into a deeper part, and so a number get into the lungs or the +heart, causing death. Within a few weeks I saw two needles taken from a +man's heart, who died in consequence of their presence there. An attempt +or desire to so injure one's self should be guarded against by the +attendants, and if accomplished should be at once reported to the +physician, that efforts may be made to extract the needle. + + + + +CHAPTER X. + +SOME SERVICES FREQUENTLY DEMANDED OF ATTENDANTS, AND HOW TO DO THEM. + + +_The Administration and Effect of Medicine._--The only proper way of +giving medicine is by using standard weights and measures. Dropping +medicine, or using spoons or cups, is not sufficiently accurate. A drop +may be half a minim, or as large as two or even three. The modern teaspoon +holds ninety or more minims, and a tablespoon more than half an ounce. + +Medicines are introduced into the system through the stomach, the lungs, +the rectum, the skin, or by being injected into the tissues, under the +skin. They are either local or general in their effects. A blister or a +poultice is a local remedy, so is an emetic, that acts by irritating the +walls of the stomach. General medicines are absorbed into the blood, and +carried to different parts of the body. + +The following are a few of the reasons for which medicine is given: to +relieve pain, to give sleep, to produce vomiting, to check vomiting, to +move the bowels, to check diarrhoea, to assist digestion, to produce a +greater or diminished flow of urine, to increase the perspiration, to +increase the red blood corpuscles, to check hemorrhage, to regulate the +action of the heart, to overcome the effects of poison, to increase or +diminish the amount of blood in the brain, to control spasm, to diminish +the temperature in fever. + +In some cases the effect desired and expected from a medicine given to a +patient is told to the attendant, who should closely observe and be able +to report the result. Sometimes medicines are left in the hand of the +attendant, to give in repeated doses, at stated intervals, till a desired +effect is produced. The attendant is also instructed to watch for certain +symptoms which show that the medicine is doing harm, when it is to be +discontinued. An attendant, who has studied and learned, "how and what to +observe" in his patient, will be able to give intelligently any medicine +ordered by a physician. + +Sometimes medicines, given in large or long-continued doses, cause +symptoms that an attendant should notice and report to the physician; some +of these are, eruptions on the face and body, puffiness about the eyes, +irritation and running of the eyes, a metallic taste in the mouth, +bleeding of the gums or soreness of the teeth and profuse flow of saliva, +nausea, vomiting, diarrhoea, constipation, indigestion, ringing of the +ears, feeling of fulness in the head, headache, dizziness, drowsiness, +coma, convulsions, or convulsive movements of muscles. + +In asylums, medicines are mostly sent to the wards in single doses, each +cup or bottle being marked with the name of the patient for whom it is +intended. The tray in which they are carried should never be set down and +left, for a mischievous or suicidal patient may poison himself by taking +every thing he can get hold of. + +No patient, unless ordered by the physician, should be allowed to keep +his cup and take his medicine at his leisure. Suicidal patients often ask +to do this, and then save the medicine, until they have enough to poison +themselves. Others will throw the medicine away. The way to administer +medicine to the insane is to give it personally to the patient, and also +see that it is swallowed. It is a frequent custom of many patients to +retain the medicine in the mouth, and, when the attendant has left, to +spit it out. + +It is often very important that patients should take the medicine ordered, +and every effort should be made to induce them to take it. Such patients +should be designated by the physician. Night medicines, or those given +about bedtime, are usually of great importance. All patients who refuse to +take their medicine should be reported to the physician. + +The reasons for refusing medicines are various; some say they are +perfectly well and need no medical treatment, others think the medicine +injures them, that it turns their skin black, or poisons them, or that it +is wrong to take it, or displeasing to God; ideas much like those that we +learned were the causes for the refusal of food. Attendants are to use +every effort to get patients to take medicine, and may employ as much +force as they were instructed to use in giving food, but no more. + +Patients should not be deceived about medicines, nor told by attendants +that it is nothing, that it is only a little water, or some nice drink +that is sent to them, nor should an attempt be made to give them, by +trying to disguise them in food or drink, except by the permission of a +physician. Patients should, on the other hand, be told that it is +medicine, that the doctor ordered it for them, that it is for their good +to take it, that it is given to help them get well. + +The giving of medicine and food is among the most important and frequent +duty that an attendant is called upon to perform, or assist others in +doing. Attendants must remember that many medicines are injurious or even +poisonous, if not properly given, or if mixed with other medicines, or if +given to the wrong patient; they should therefore, never make a mistake, +or, if by carelessness they commit one, should immediately report it. + +_Opium and Some of its Preparations._--Opium is a medicine that is very +frequently given to patients in an asylum. The ordinary dose is one grain. +_Tincture of opium, or laudanum_, is opium dissolved in alcohol. Ten +minims equal one grain of opium. _Camphorated tincture of opium, or +Paregoric_, is a weaker alcoholic solution, with some camphor, and +flavored with a pleasant aromatic. One half a fluid ounce equals a grain +of opium. _Morphine_ is a white powder extracted from opium. An eighth of +a grain about equals a grain of opium. + +Opium, in some of its forms, is a common household remedy. To an adult, +not more than one grain should be given; it should not be repeated more +than once, nor less than six hours after the first dose. It would be +better if never given, except by a physician's order. Under no +circumstances should any one but a physician give it to a weak or old +person, or to a young child. + +Opium, is given in ordinary doses to relieve pain, to check diarrhoea, +to relax spasm of muscles, and to produce sleep. The sleep from opium is +generally quiet and refreshing, and one from which the patient can be +easily aroused. + +An attendant will frequently be told when the medicine is given and +directed to note and report its effect. + +_Opium Poisoning._--The taking of opium is a frequent way of committing +suicide by persons outside of asylums. Sometimes patients manage to save +their doses, or they steal it from the tray, or, if there is some sent to +the ward for repeated doses, they secure it through the carelessness of an +attendant, or occasionally it is secretly sent to patients by officious +outside friends,--thus poisoning by opium sometimes occurs among asylum +patients. + +The full symptoms of poisoning are profound coma, pupils contracted to +pin-points, and which do not respond to light; very slow respiration, +often not more than four or six times a minute, but heavy and labored. +Sometimes the effect of the drug is but partial, the patient can be +aroused for a moment, but falls to sleep again, or the symptoms may be +even less pronounced. + +The treatment of opium poisoning, before the physician comes, consists in +giving _very_ strong coffee, or tea, an emetic, and in trying to keep the +patient awake by walking him about, or, if this is not possible, to keep +him from falling into deeper coma, by shaking, calling loudly in the ear, +and striking and slapping the body with wet towels. + +_Chloral._--This is a white crystal, with a pungent, burning taste. It is +always dispensed, dissolved in water, and should be further diluted when +given to a patient. The dose is from ten to thirty grains. It is too +powerful a drug to be given, except upon the order of a physician. +Chloral is given to produce sleep, which is usually quiet and natural. The +effect lasts about four or six hours. + +The symptoms of poisoning are not so marked as to make it easy to know +that they are caused by chloral. There is generally a weak heart and +pulse, and feeble respiration, and the patient is in a deep sleep, from +which he may be aroused; or the coma may be profound, and continue +uninterrupted till death. + +The treatment consists in giving an emetic, stimulants, coffee, and, if +necessary, performing artificial respiration. + +_Hyoscyamine and Hyoscine._--These are extracts, from the leaves and +seeds, of the plant hyoscyamus. + +These are very powerful medicines, and are never given except on the order +of a physician. They are always given in solution. + +The action of both is practically the same. In ordinary doses they quiet +restlessness, produce muscular weakness, flushing of the face, dryness of +the tongue, wide dilatation of the pupils, and frequently cause sleep. +These effects should be noticed and reported. These medicines are mostly +given to patients who are continually restless, violent, and sleepless, +and the object is to bring quiet, repose, and sleep. Large doses may +produce coma, very heavy breathing, and great muscular weakness; the pulse +however is full and strong, but if it should fail, the physician should be +at once sent for. + +_Alcohol and Stimulants._--It is the alcohol in liquors that intoxicate, +and it is that part, also, of liquor that stimulates when given as a +medicine. Whiskey, brandy, and gin are about one half alcohol. The dose is +a tablespoonful, in water, and not repeated oftener than two or three +times. Wines are about one fifth alcohol, beers and cider about one +twentieth. + +Liquors containing alcohol are never to be given to patients as a +beverage, but always as a medicine, and, except in emergencies, never +without a physician's order. Do not give them in emergencies, without a +good reason for so doing, and not simply because you feel you must do +something, for in some emergencies they may do a great deal of harm, and +perhaps, a fatal injury. + +Alcohol is mostly given to stimulate the action of the heart. A stimulant +is something "that arouses or excites to action." It is given (in the +doses just mentioned) in accidents, when the heart is very weak, the pulse +almost or quite imperceptible, the face pale and pinched, and the +extremities cold. + +In continued sickness, with exhaustion, stimulants are sometimes left with +the attendant to give, with directions about the size of the dose and its +frequency. If it quiet the patient, strengthen the heart and pulse, it is +doing good; but if restlessness comes on, the face becomes flushed, or if +the pulse is made more rapid and feeble, it is probably doing harm, and +should be discontinued, and the physician informed. + +_Dry and Moist Heat._--In applying heat, either dry or moist, to the +insane, care must always be used to protect the skin from being blistered. +This happens very easily when it is applied directly to old, feeble, +paralyzed, or paretic patients, and also to those who are too demented to +complain if they are being burned. Burns are very serious accidents among +this class of patients, and may, if they extend over a large surface, +even though not deep, heal with difficulty, and even prove fatal. + +Dry heat is applied by means of rubber bags filled with hot water, +hot-sand bags, bricks, or soapstones, and by the lamp bath. Moist heat by +hot baths, fomentations, turpentine stupes, and poultices. + +_Hot Baths and Wet Packing._--Hot baths are sometimes prescribed for +patients. The water should be about 100 degrees F., and, if ordered, +slowly increased to 110 deg. The patient is to be left in as long as +directed, which may be but a few minutes, or half an hour, or even longer. +Sometimes a blanket is ordered thrown over the tub, the head only being +uncovered. + +When the bath is being given, the pulse should be counted; if it become +weak and rapid, if the face become flushed, and the patient complains of +dizziness, or if the lips show venous congestion, the patient should be at +once removed, and, unless there is immediate recovery from these evil +effects, the physician should be informed. + +In giving a wet pack, the patient is wrapped in a sheet, without any +clothing, wet either in cold or warm water, as ordered, and then rolled in +a blanket, put to bed, and left in it as long as directed. + +These methods of treatment are frequently ordered by physicians for +patients who are restless, violent, and sleepless, with a view of giving +quiet and sleep. The attendant should observe and report the result. + +_Application of Cold._--The attendants are frequently ordered to apply ice +to some part of the body, for the purpose of producing local cold. The ice +should be broken into small pieces and put into a bladder, or rubber bag, +partly filling it. It remains sufficiently cold until all the ice is +melted. + +Another way is to put a piece of ice in a sponge and bathe the part. When +cold cloths or compresses are applied, the heat of the body soon warms +them, when they become warm applications and act as a poultice; they +should therefore be frequently changed. In applying moist dressings care +must be used not to have any leaking nor wetting of the bed or clothing. + +_Hypodermic Injections._--Morphine, hyoscyamine, or hyoscine, in solution, +are frequently injected under the skin. The direction to do this, and the +quantity to be given, will, in every case, be ordered by the physician. A +fold of the skin is held between the finger and thumb, while the needle +held in the other hand is quickly pushed straight under the skin to the +depth of about half an inch. Care should be used to inject no air, and not +to inject the contents of the syringe, into a vein. + +_Forcible Feeding with the Stomach-Tube._--Attendants are frequently +called upon to assist in the forcible feeding of patients, and in some +cases may themselves be directed to do it. The dangers of feeding are that +the pharynx may be filled with fluid, and the patient choke, or it may be +drawn into the lungs, that the wedge with which the mouth is held open may +be so loosely held that in the struggle of the patient the soft parts of +the mouth may be injured, and occasionally it happens that the mere +pressure of the tube causes choking. + +Attendants should watch the process of feeding, and particularly the face, +for symptoms of venous congestion, and report to the physician any thing +they see that denotes danger. + +In preparing for feeding, attendants must see that the food is properly +made ready. If any thing is to be mixed with milk, it should be mixed so +as to be perfectly smooth, without lumps, and so it will run easily +through the tube. If some concentrated food is used, it is better to put +it in a small quantity of milk, just enough to make it liquid, that it may +be given first. Medicines ordered for feeding are not to be mixed with a +large quantity of milk, but saved, that they may be given directly from +the dispensing bottle whenever the physician desires to do so. + +Every thing should be got ready for feeding before the physician arrives. +Upon a tray should be all the feeding apparatus--the food and medicine, +several spoons, and cups, and a pitcher. Near at hand should be plenty of +water, soap, and towels, and a tin basin. It is very provoking to have to +wait for many things to be brought after the patient has been got ready. + +Many patients are easily fed. Some like it, but some violently and +furiously resist. Such patients should be restrained to a chair fixed to +the floor, and the more securely this is done the more easily can they be +fed, and with less fatigue and danger of their being injured. + +The patient's clothing should be well protected from being soiled, by +towels about the neck, and a basin should always be held under the chin to +catch falling liquids and any thing vomited. The holding the head and +wedge is an important matter, and is some thing that belongs to the +attendant to do. The attendant stands behind the patient, and holds the +chin by the right hand, and with the left firmly grasps the wedge, which +is inserted straight into the mouth, between the back teeth, about two or +three inches. The wedge should be grasped with the palm upwards, and the +little finger and side of the hand should be pressed firmly against the +chin. If held in this way there is little danger that in violent +struggles, the wedge can be suddenly driven backward and wound and tear +the soft parts of the mouth. If the throat fills with fluid, the attendant +who holds the head should bend it far forward, that it may, if possible, +run out of the mouth. + +After feeding, patients' faces should be washed. They should be watched +for some time to see that they do not vomit, or, as is often the case, +that they do not make themselves vomit. + +There is no special difference in caring for a patient fed with a nasal +tube, except that the wedge is not used. + +If attendants are allowed to feed, they must remember all the dangers, and +guard against them. In introducing the tube, the forefinger of the right +hand is to be introduced at the same time, and, as the tube passes over +the tongue it is to be turned downward by the finger and _gently_ pushed +into the oesophagus. If there seem to be unusual difficulty in so doing, +severe and unusual struggling, or the slightest symptom of danger, cease +the effort to feed, and report to the physician. + +Of course no attendant would undertake to feed any patient unless ordered +to do so by the physician, which order would be given, if at all, only +after careful training and in cases easily fed. + +_Nutritive Enemata._--It is often necessary to feed patients by the +rectum. This is done by injecting food, to the amount of four or six +ounces. Care should be used to inject no air. The nozzle of the syringe +well oiled is to be gently introduced, and the fluid slowly forced into +the bowel. The patient should lie on the left side, near the edge of the +bed, with the knees well drawn up. If the patient resist, he must be +placed upon the back, the legs separated and firmly held. This may require +four or six attendants, but enough should always be at hand to thoroughly +and easily overcome the patient. Before giving the first injection of food +the bowels should be moved by an injection of soap and water. Sometimes +the injected food escapes from the rectum. The patient should be watched +to see if this happens. In such a case a long tube can be introduced into +the rectum, about four or six inches, and the food injected through it. +The tube should be well oiled, and introduced slowly and with gentle +force. + +Patients often thrive upon this way of feeding. The character of the food +will be ordered by the physician. + + + + +_PUBLICATIONS OF G. P. PUTNAM'S SONS._ + +STUDENTS' MANUALS. + +Manual of Prescription Writing. By MATTHEW D. MANN, M.D., late Examiner in +Materia Medica and Therapeutics in the College of Physicians and Surgeons, +New York. Revised edition. 16mo, cloth. $1.00. + +Manual of Practical Normal Histology. By T. MITCHELL PRUDDEN, M.D., +Director of the Physiologica, and Pathological Laboratory of the Alumni +Association of the College of Physicians and Surgeons, N. Y., etc. 16mo, +cloth. $1.25. + +Students' Manual of Venereal Diseases, being the University Lectures +delivered at Charity Hospital, B. I., during the Winter Session of +1879-80. By F. S. STURGIS, M.D., Clinical Lecturer on Venereal Diseases in +the Medical Department of the University of the City of New York, etc., +etc. Fourth edition. 16mo, cloth. $1.25. + +Students' Manual of Diseases of the Skin. By L. D. BULKLEY, M.D. Large +16mo. $1.25. + +Students' Manual of the Diseases of the Nose and Throat. By J. M. W. +KITCHEN, M.D. 16mo, illustrated, cloth. $1.00. + +Students' Manual of the Pharmacopoeia of the Diseases of the Throat. By +GEORGE M. LEFFERTS, M.D. $1.00. + +Students' Manual of Rational Electro-Therapeutics. By R. W. AMIDON, A.M., +M.D., Lecturer on Therapeutics at the Woman's Medical College of the N. 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SACHS, M.D. +Octavo, cloth $2.75 + + "We most earnestly urge our readers to put this work in their + libraries as one that will prove indispensable."--_Quarterly Journal + of Inebriety_, Jan., 1886. + +THE INSANE IN FOREIGN COUNTRIES. By WILLIAM P. LETCHWORTH, President of +the New York State Board of Charities. Octavo, cloth $3.00 + +THE ERRORS OF REFRACTION. By FRANCIS VALK, M.D., New York. 245 pages. +Numerous illustrations (some in color) $3.00 + +PHYSIOLOGICAL NOTES ON PRIMARY EDUCATION AND THE STUDY OF LANGUAGE. By +MARY PUTNAM JACOBI, M.D. 12mo, cloth. $1.00 + +ESSENTIALS OF PHYSICS AND CHEMISTRY. By CONDICT W. CUTLER, M.S., M.D. +Third edition, enlarged and revised. Cloth $2.00 + +THE STORY OF THE BACTERIA. By T. M. PRUDDEN, M.D., author of "A Manual of +Practical Normal Histology." 16mo, cloth .75 + +HYSTERIA AND OTHER NERVOUS AFFECTIONS. A Series of Essays, by MARY PUTNAM +JACOBI, M.D. $2.00 + + CONTENTS--1. Loss of Nouns in Aphasia. 2. Case of Nocturnal Rotary + Spasm. 3. 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