How to Care for the Insane: A Manual for Nurses

CHAPTER V.

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.

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.

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.

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.

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 œsophagus 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 œsophagus.

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.