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.

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.

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, 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, diarrhœa, 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 diarrhœa, 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 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.

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.