HANDBOOK FOFrTHE I"l4sTRUCTION OF ApfENT^ANTS On Tt^Jn^ANE IfJIP ..-.'.. �999999999999999999999� NATIONAL LIBRARY OF MEDICINE Bethesda, Maryland Gift of The New York Academy of Medicine 22-. The New Y By-A-i- oi Medicine 19 Vol. No................. ......... Library WITHDRAWN MAY 0 5 20D8 THE NEW YORK ACADEMY OP MEDICINE LIBRARY HANDBOOK Instruction of Attendants The Insane BOSTON l-< DAMRELL & UPHAM'S^u ftfje #lir Comer §oobtore ■JQOQ / 7 7 OPS''." Prepared by a sub-committee of the Medico-Psychological Association appointed at a branch meeting held in Glasgow on February 21, 1884. '. .'-F.t'.« ,; INTRODUCTION. THIS Handbook has been prepared in the hope of helping attendants on the insane to a due understanding of the work in which they are engaged. It is sought to give them such simple notions of the body and mind in health and disease, such instructions for the management of those maladies with which they are usually brought in contact, and such rules for their guidance in matters of every day experi- ence, as will enable them to do their work with greater intelligence and watchfulness. It is de- signed that these instructions should aid attend- ants to carry out the orders of the physicians; but it is to be distinctly understood that in no case is anything contained in this book to over- ride the special rules of any institution, or special orders in regard to any individual case. A. Campbell Clark, Convener. C. M'Ivor Campbell, \ A. R. Turn bull, ? Sub-Committee. A. R. Urquhart, ) 3 CONTENTS. CHAPTER PAGB I. The Body: its General Functions and Disorders............ 7 II. The Nursing of the Sick......45 III. Mind, and its Disorders.......72 IV. The Care of the Insane.......98 V. The General Duties of Attendants . . 121 5 HANDBOOK INSTRUCTION OF ATTENDANTS ON THE INSANE. CHAPTER I. THE BODY, ITS GENERAL FUNCTIONS AND DISORDERS. ALTHOUGH all animals having a back- How man bone are fashioned on the same general the lower aX plan, man differs from the lower animals in hism s" outward appearance, internal structure, habits of life, and faculties of mind. In outward appearance there is this notice- able difference, that of all animals man only walks erect; in internal structure, his brain is more highly elaborated, — consequently, in his habits of life he is widely different, and in the development of his mental faculties he is supe- rior to all other animals. We see in a healthy man a uniform plan, a His external shapeliness of form, and an arrangement 0faPpearance parts closely knit and working in harmony. The parts are the head, the trunk (or body), Hispartsand and the limbs; and they are jointed together)oms' 7 8 THE BODY. so as to form one complete fabric, the human body. These parts are themselves made up of smaller parts. The head is composed of many small bones firmly welded together; the trunk is many-jointed; and the limbs have elbows, wrists, hips, knees, ankles, etc. A.11 these are the joints of the skeleton or bony framework, which is composed of nearly three hundred bones arranged and jointed together in human form, strong to withstand muscular strain, to resist external violence, and to protect internal parts. internal A deeper inspection reveals that the body sructure. .g ^Q^ SQ]Q ag -j. appears fa J->e from with- out; but that it is hollow, and divided into two cavities, the one large and the other small. Cavities and The larger is the cavity of the trunk (or body proper), and contains the organs of nutrition; the smaller is the cavity of the head and back- bone, and contains the organs of the nervous system. The body cavity is divided by a parti- tion into an upper (chest or thorax), which lodges the heart and lungs, and a lower (the belly or abdomen), which lodges the ITS GENERAL FUNCTIONS. 9 liver, stomach, kidneys, bowels, and other organs. The cavity of the nervous system consists of two divisions : First, the skull, which accommo- dates the brain ; and second, the back-bone, which lodges the spinal cord. The contents of these cavities have been called organs; each organ is implanted there for a special purpose or duty, and the duty of the organ is called its function. These cavities contain the greater part of The.machin- 0 l ery in mo- the machinery of life ; and could we but peep tion>."wheels within, what a busy scene would present itself ! wheels." the pumping of the heart, the respiration of the lungs, the digestion of food, and the other movements necessary to life. These move- ments are complementary to each other : the organs of digestion and respiration supply nourishment to the circulation ; the circulation distributes nourishment to all parts of the body; the hungry tissues feed upon this nour- ishment, and throw their refuse back into the circulation; the circulation discharges its waste matter into the channels provided for draining it away; and, last of all, these movements are regulated by the nervous system, which exer- cises a direction of all the other functions. 10 THE BODY. THE CIRCULATION OF THE BLOOD. Of these functions, let us first understand the circulation of the blood, "the river of life." Theheartthe The heart is the beginning and end of the centre of the . . circulation, circulation. Placed in the thorax, between the lungs, it is a hollow organ, the size of a closed fist, and shaped like a pear. It contains four its s«e, small chambers, quite enclosed and separate payments?"" from each other ; two of these are upper, and t^nswittTar- two lower. It has been compared to a force- vebs9. abd pump, for, like a pump, it is a receiver and dis- charger, and is fitted with valves. It receives blood and discharges blood. The two upper chambers (called auricles) are the receivers; the two lower (called ventricles) are the dis- chargers. Now, from the heart to all parts of the body, two sets of pipes are laid down, which dimin- ish in size the further they lie from the heart. They are not unlike india-rubber tubes to the touch, but many are so small as to be seen only under the microscope. Those pipes which convey blood from the heart are called arteries, those which convey blood to the heart are call veins, and there is an intermediate or THE CIRCULATION OF THE BLOOD. II junction set called capillaries, which are the smallest of all. The upper chambers of the heart, being the blood receivers, are connected with the veins. These chambers lie side by side, and are there- fore right and left; two large veins open into the right, and two into the left. In like man- ner, the two lower chambers, being dischargers of blood, are connected with arteries, one artery passing from each ; and the lower cham- bers are also placed right and left. The right upper chamber communicates with the lower chamber of the same side by an opening in the partition. This opening is guarded by valves, which prevent blood passing back- wards after it has once entered the lower chamber. Precisely the same arrangement is seen in the left side. The veins which pour their blood into the right upper chamber have drained blood from every part of the body; this blood is dark red, and impure ; it passes downwards from the right upper chamber to the lower, and is prevented from returning by the valves. It is then forced by the muscle of the heart out of the right lower chamber into a lung artery ; this lung artery divides into two, one branch going to each lung. In the 12 THE BODY. lungs the blood is purified, and it comes back The blood is by veins bright and red to the left upper cham- the lungs, ber of the heart. It then passes to the left lower chamber, which forces it into a great artery called the aorta. This artery breaks up into many branches, which carry the pure, healthy blood to every part of the body. Bleeding When a vein is opened, dark red blood flows from arteries . and veins dif-in a continuous stream from it; but when an ferent. artery is wounded, bright red blood squirts out with every pulsation of the heart, for, while the flow in the veins is slow and constant, in the arteries it is quick and jerky. The struc- The healthy lung resembles a sponge, for it ture of the . i • „ , ,, lungs. can be squeezed into small bulk, and when pressure is removed it expands. clusters of The chief cause of the expansion is elasti- sembieS diis-city, and this elasticity is mainly due to a g^pes. peculiar structure, which is only seen in the lungs, and which consists in the grouping to- gether in clusters (like grapes) of extremely minute air-cells which are elastic. These air- cells are connected with the wind-pipe, and when air is breathed it rushes into all the air- Howthe Cells. Now, over the surface of the air-cells blood is pun- fun I"the run very sma^ arteries carrying impure blood. The air and the blood make an exchange ; the THE CIRCULATION OF THE BLOOD. 13 air gives oxygen gas to the blood, and the blood gives-carbonic acid gas to the air. Fresh air contains a large supply of oxygen gas ; respired air is impure, for it contains a poisonous quantity of carbonic acid gas. Thor-The necessity .7 . , . 1 •/• 1 1 rfor tnorougn ough ventilation admits a plentiful supply ot ventilation. fresh air, and expels an equal quantity of bad air. It is therefore important to secure free movements of air — of fresh inwards, and im- pure outwards. In this way only can the lungs be well supplied, and do their work thor- oughly. As the chest rises the lungs expand and fill with air; as it falls they contract and expel air. The lungs, in order to work their best, must expand well; and therefore not only must the chest rise well, but there must be no choking up of air-tubes or air-cells. Here, then, is the plan of the circulation and The circuia- x tion and res- the respiration, for these cannot well be con- ph-ation are . . intimately sidered separately. The great centre ot the connected. circulation is the Heart; the great centre of the respiration is the Langs. Every drop of blood is pumped out of the Two rircuia- . r, v tions, a lung heart twice for once that it flows through the circulation ...-,. and a body body. Where does it go the second time ? It circulation. goes to the lungs to be purified. We have 14 THE BODY. therefore to distinguish two circulations, a lung circulation and a body circulation. If we follow the blood from the heart, where it flows into the aorta, and trace it passing from larger into smaller arteries, thence into capillaries, and then into veins, we will find that as it flows along it distributes nourishment, and in ex- change for the nourishment it drains away waste matter from the various organs through which it flows. In proportion as it receives does it give forth nourishment, but having reached the veins its supply is exhausted, the bright red color is gone, it is loaded with waste, and therefore impure. The circuia- The blood which has left the heart pure, tion is to the x body both a therefore, comes back impure; the oxygen tem and a which it took from the lungs is given to the drainage sys-. . ..... . tem. body to maintain life; the carbonic acid taken from the body must be carried to the lungs, to be thrown off at every breath. Therefore it leaves the heart a second time and passes into the lung circulation, and if we follow it there, we find that it becomes purified by taking up oxygen from the fresh air, and throwing off a great deal of its waste matter, which is breathed into the outer air by the lungs. It then returns to the heart, and THE CIRCULATION OF THE BLOOD. 15 is now fresh for nourishing the body again. It does not derive all its nourishment from the lungs, nor does it give all its waste to them, but this will be explained by and by. You will therefore understand that there are two distinct and separate streams of blood in the body, a short circular stream between the heart and lungs, called the lung circulation, and a longer stream and wider circle, called the body circulation. We must now inquire whether the heart alone is sufficient to keep up this perpetual circulation of blood day and night. Is a pump all that is required ? Our an- The heart swer is No. Although the heart is as neces- wo^without sary for the circulation as our limbs are for from flings, movement, it requires to be assisted, andmusdes'et& could not do its work without assistance. The heart is the force which sends the blood out of the heart, but muscular exercise and bodily vigor must help it back again. If the heart receives blood slowly and feebly, it must pour out blood slowly and feebly, and thus the circulation loses its vigor and the body is not well nourished. Three things are necessary for a vigorous, healthy circulation: First, a sound heart and vessels. Second, vigorous i6 THE BODY. functions in every organ, especially in the lungs. Third, muscular exercise. The pulse, Let us now consider the state of the circula- how it is pro- . ... duced,its tion as we may observe it in our patients; and value as a guide to in order to understand the differences that know how . . . . . the heart and are seen in different patients,, let us consider work. the pulse. Every volume of blood pumped by the heart into the arteries produces a pulse, so that for every heart-beat we should have a pulse-beat. The pulse is therefore a valuable guide to the study of the circulation ; it en- ables us to judge how the heart does its work, whether it pumps too slowly or too quickly, whether it is strong or weak, steady or un- steady. The average pulse for a man is 70; for a woman, 80. signs of If you examine your patients carefully, you lation ob-rcU" will find that some have small, languid, or in- as^iums" termitting pulses, cold, blue, and swollen hands and feet. These are signs of a feeble circulation; and, as you might expect, there Feeble circu-is no vigor in their systems, the respiration is lation may be due to the shallow and feeble, the muscles are idle,— mental con- . ... dition, weak everything that makes a vigorous circulation health, heart . . _ . , . .. , disease, or is wanting. Rub that patient all over and ob- serve how the skin glows, how warmth comes to the surface, and how the pulse gains force ; THE CIRCULATION OF THE BLOOD. 17 or put him in bed and you find that the circu- lation improves, because there is less obstruc- tion to it when lying down. Again, give him half an hour's vigorous exercise, so that every muscle comes into play and propels the blood along the veins towards the heart, and you get the same result; the circulation quickens, the body calls out for more nourishment, the brain is wakened up, and the patient's whole condition is very much improved. But your patient may have been excited and gone through much exercise; he has not had enough of food, nor enough of sleep; his heart is faint, and his breath short from sheer exhaustion; his circulation is feeble and he needs rest in bed. He may be old and fee- ble, or suffering from heart disease, and there- fore unable for vigorous exercise, as his heart cannot stand the strain. The doctor will di- rect in these cases what is best for him. You will frequently observe how shallow signs of the respiration is, and how blue or gray the rationoriung face, hands, and feet appear. You will ob- serve sometimes a bright red spot on each cheek, a cough, a spit, a shortness of breath, a wasting of the body, pain in the chest, and night-sweats. These you will do well to notice 18 THE BODY. and report; they usually mean disease of the or- gans of respiration. There may be merely a fee- bleness of respiration, just as there is a feeble- ness of circulation, because of the stupor of mind into which a patient has fallen, and you will be told that your patient wants rous- The causes of ing and muscular exercise. But there are lung disease. caseg a]so of actual iung disease, and such diseases are common in asylums ; they may be due to bad ventilation, to cold and damp, insufficient exercise when out in the open air, sitting exposed to cold biting winds or lying on damp grass, or against wet supports, es- pecially after perspiring. Lung diseases are especially apt to attack miners, masons, and persons who work in a dusty atmosphere, or people who are confined all day long in un- healthy rooms or in a stooping posture, and who therefore do not get a sufficiency of pure air, and free play for the lungs. The insane Prevention is are verv liable to lung diseases for some of better than J . ° .... cure. these reasons. Patients who are in delicate health, who have narrow chests, very little fat, and feeble circulations, should be specially guarded against the risks of lung disease. Two duties here devolve on you. First, pre- vention is better than cure ; therefore protect NUTRITION. *9 your patient from the causes of lung disease, Symptoms , ... ° shouldbeob- or, better still, prevent or remove the causes, served earhr if possible. Second, be on the lookout for symptoms, and report them at once. NUTRITION. The exercise of the bodily functions is, While we live we waste accompanied by wear and tear, and requires and undergo to be sustained by nourishment. Thus the body is the seat of two opposite processes which ought to balance each other: the one is waste, the other is repair. Idleness means rust and decay, work means Every organ wear and tear; so that in every case the bodya small fur- loses substance, and the harder it works it Tributes its"" loses the more. It lives and labors at a sacri-he"6 of the fice of itself; for every tissue while it lives con- ° y" sumes, and is fed with fresh fuel. This burn- ing is the cause of the heat of the body. As the intensity of the fire so is the temperature, and, to reason upside down, as the temperature so is the burning or waste. A high tempera- ture, therefore, means increased waste, and proves the necessity for extra repair. Every organ, every muscle, every tissue, has its ash or waste, and these ashes require to be col- lected and drained away by the circulation, so 20 THE BODY. that the working of the system may not be clogged and thrown out of gear. The circuia- The circulation is the drainage system, and anddiLects it empties the refuse in three ways: into the refuT the lungs, the sweat-glands, and the kidneys. The lungs expire it, the sweat-glands perspire it, and the kidneys flush it as urine into the blad- der, thence to be passed at intervals. Hence the advantage of free and easy respiration, of a clean, healthy skin, and a proper discharge of urine, all of which ought to be seen to by attendants. The food we eat is the raw material out of which repairs are executed. In order to ren- der the process easier, it is first cooked, and being introduced into the mouth the machinery of repairs is set in motion. Repairs pro- Repairs are executed in four stages. The first steages,y(i) is chewing and swallowing. The mouth is the swaHowingf mill which grinds the food and softens it into §fS°n'pulp. The smaller it grinds and the moister KfS&the pulp, the easier will the food digest. In wnve^ion. this stage five things are necessary if the mill is to work well: these are a good array of teeth, busy jaws, abundance of saliva, plenty of time, and a healthy swallowing apparatus. The second stage is digestion, which is carried on NUTRITION. 21 in the mouth, stomach, and bowels. Digestion is performed by five juices, which attack the food, each in turn as it is propelled along, until at last it is very finely divided and so altered in chemical character as to be easily absorbed and fit for nourishing the body. The digestive juices are (i) the saliva, which acts on the starchy foods ; (2) the gastric or stomach juice, digesting such things as white of egg, lean meat, and other albumens; (3) the bile, which enters the bowel by a passage from the liver and reduces fats to a state fit for absorp- tion ; (4) the pancreatic juice, which enters the bowel by a passage from the pancreas (or sweetbread), and acts on albumens, changes starch into sugar, and reduces fats to a state fit for absorption ; (5) the intestinal or bowel juice, which acts on the food in a way similar to the pancreatic juice. These juices are pre- pared in little pouches called secreting glands, which extract from the blood the material necessary for the manufacture of the juices. After the food is swallowed, we find it in the stomach, and the gastric juice playing over it. The stomach is kept in unperceived motion, for it is a muscular bag, so that every particle of food is rolled about, and freely ex- 22 THE BODY. posed to the action of the juice, which having finished its work, the food passes into the bowel, to be subjected to a further process of Six things digestion. Six things are necessary for a good a good di- digestion: (i) the food must be finely divided and soaked with saliva; (2) the muscular move- ments of the food passages (mouth, gullet, stom- ach, and bowels) must be active and ready at call; (3) the blood must abundantly supply the secreting glands which manufacture digestive juices, and therefore the circulation must be rich and vigorous; (4) the secreting glands must prepare an abundance of juice, but they cannot do this if the stomach is disordered and their function sluggish; (5) the body must rest before and after meals; (6) the mind should be tranquil, and the patient should, as far as pos- sible, have bright and cheerful surroundings. Next comes the stage of absorption or strain- The process ing. The digested food is strained through the tion. lining of the stomach and bowels, taken up by the blood-vessels and carried into the circula- tion. The undigested food and other refuse are expelled from the bowels as stools or fagces. The fourth and last is the stage of assimilation The stage of or conversion, or, in other words, the taking from the blood of particles of nourishment to repair NUTRITION. 23 waste places in the organs or tissues of the body. These particles become converted into part and parcel of the tissue itself, and are, therefore, said to be assimilated or made simi- lar to the rest of the tissue. A word may conveniently be inserted here The appetites , ., , • . its import- respecttng the appetite, a most important mat-ance. ter for us to consider, as it is often an index of good digestion. Indeed there is no necessity for a good digestion if there is nothing to di- gest, and there will of course be nothing to digest unless the patient feeds. The appetite is influenced by the state of it is inftu- ,, ,, j- 1 1 j enced by the the mind as well as by the state ot the body, state of the , iii • r mind as well You scarcely require to be told that gnet para- as the state J , . . ^ . of the body. lyzes the appetite; that joy or excitement is apt to create a hasty, impulsive appetite that bolts food, half chewed and difficult of diges- tion, into the stomach. Some are over-greedy, others are small and dainty of appetite. A few cannot eat at all if distracted by the presence of other patients. Some prefer to eat out of sight, and others cannot eat if they are hurried at meals. We must not forget that delusions may have a bad effect on the appetite; a pa- tient may be hungry and yet refuse food, believ- ing that it is poisoned, or he may refuse food 24 THE BODY. from the belief that he has no stomach at all. If we now turn to examine the bodily causes of want of appetite, we shall find that they are equally numerous. As examples, we would men- tion lack of energy and of open-air exercise, sluggish liver and bowels, and disorders of the stomach. Enough has been said to prove the importance of studying the appetite and search- ing carefully for the causes of want of appetite. Sleep is a Sleep has been well described as "closing " closing for . ,, . repairs'5; the for repairs. A ship while sailing is more or body requires . , ,, . . - to " lay up" less undergoing small repairs; but in order to tervafs.arm*receive a thorough overhaul she requires "to lay up." So is it with our bodies. While we are awake and active, repairs are going on, but the supply soon falls short of the demand, and the body requires to lay up when night comes, so as to make good the deficiency in time for the next day's work. During sleep the body rests from its labors ; the brain ceases to think, feel, and will; the muscles and nerves rest themselves, and the circulation, respiration, and digestion, " take it easy." And now repairs go on more quickly, gaining ground on the rav- ages of the day, until man rises from his slum- bers in good repair, fresh for new work and another voyage. Sleep is clearly a necessity NUTRITION. 25 of life. No man can afford to neglect it, and all will do well, by attention to nature's laws, to secure a needful supply of it. Sleep is encouraged by exercise in the open Practical air. The old proverb is worth remembering : — " After dinner rest a while, After supper walk a mile." It is also encouraged by regular hours, quiet-The body is a .,,.,, bank-account ness, calmness of mind, a cool, airy bed-room, of waste and and a comfortable bed, etc. A man's body, then, is simply a bank-account a man cannot c , , . . , rjT, afford to be of loss and gain, of waste and repair. 1 he miserly or more he takes out of himself, the less he has wthhfs'bodi- to spare, and the more he requires to make up. y su stance- But a man must not be a miser with his sub- stance ; he must not go on feeding full time, and only working half or quarter time. Nor, on the other hand, must he be profligate, work- ing double tides, and only patching his repairs. Every organ must have reasonable exercise, He may 1 1 1 1 waste too and waste and repair should regulate each much or too other. We are here again face to face with our ' duties to the insane ; for many of them have overdrawn their bank-account, and we must try to recover the balance. A great deal lies in our power to remedy this state of matters. The risk of death from ex- 26 THE BODY. haustion is often great; and sound, refreshing sleep and frequent meals are absolutely neces- sary to tide over the crisis. How much Appetite and sleep must be promoted ; and attendants . t can help in on attendants carefully observing any causes where ex- which hinder these, and faithfully reporting haustion is ., ,, ... threatened, them, as well as conscientiously carrying out the doctor's orders, will depend the recovery of the patient if it is at all possible. In deal- ing with patients who waste quickly, the re- sponsibility of the attendant is increased ; but when every effort is put forth for the patient, recovery is so often a certainty that in the end the attendant's satisfaction exceeds his respon- sibility. Here is placed side by side a scale of waste and a scale of repair, which should be as carefully calculated as possible : — Scales of waste and repair. SCALE OF WASTE. (Signs of Increased Waste?) i. Loss of weight and ap- petite. 2. Excitement, if severe or prolonged. 3. Loss of sleep. 4. Increase of temperature. 5. Discharges, such as diar- rhoea, vomiting, matter from sores, spit, etc. 6. Loss of blood. SCALE OF REPAIR. (Signs of Increased Repair.} 1. Increase of weight and appetite. 2. Excitement ceasing. 3. Sleep gaining ground. 4. Temperature reduced. 5. Arrest of discharges. 6. Arrest of bleeding. NUTRITION. 27 THINGS TO BE SPECIALLY OBSERVED. Two may differ as to what a good meal is, Loose state- J ° ments to be but a plate of porridge is always a plate of avoided by r r o ^ attendants in porridge, and a pint of custard is always a pint reporting ob- r ° * . servations. of custard. A man may not seem to be gam- ing or losing weight, but the steelyard will tell to a pound yes or no. We do not always know Details to be 1 j 1 i_ inquired for what an attendant means by a good sleep, but and commu- we know what " seven hours " mean. Themt habit of careful observation and statement must go into other details, as well. (1) The appetite. Various causes affect it, (0 ofgthe and these should be carefully looked for. The association with other patients sometimes wor- ries or excites, so as to paralyze appetite. Some patients appear never to miss a meal, and yet, having appetites little better than a bird's, are too easily satisfied. Others are slow or timid, and hurry over their meals when they are served by an attendant whose whole thought is to clear the table with the greatest possible despatch. An observant attendant will distinguish be- tween the patient who eats till he is sick and the patient who works hard and requires an extra allowance. Lastly, great care and pa- 28 THE BODY. tience are required with those who have few or bad teeth, epileptics, paralytics, and those who "bolt" their food. These should never be hurried, and their food should be cut small, to make digestion easy, and to prevent choking. Refusal of food may be the outcome of de- lusions, and attendants should find out whether such a cause exists. If so, it ought to be re- ported. Perverted appetite is illustrated in the case of those who eat filth, rags, pig's meat, gravel, etc. Such cases call for constant ob- servation, and should be immediately reported. (2) Of the (2) Digestion. The appetite itself is often digestion. .,iv 1 , ■ a sign of good digestion, but among the insane it often exceeds the digestive powers. If diges- tion is disordered, signs will be observed, and ought to be reported, especially abstinence from food. Such are foul breath (which may also be due to other causes), a foul tongue, bitter taste, vomiting, pain or fulness in the region of the stomach, heartburn, wind, waterbrash, head- ache, etc. (3) Of the (3) The bowels. Their condition should be bowels. daily observed, and the attendant should not be satisfied with merely noting that a patient goes to the closet; he should observe whether he has a stool or not, and how often, whether NUTRITION. 29 it is abundant, easy or difficult, watery or hard, light, dark, or bloody, and whether there is present any indigestible or undigested matter, buttons, coins, etc., and whether there are tyorms. Lastly, patients who suffer from rup- ture require always to be easy in their bowels, else death may ensue after a few hours' notice, Or a serious surgical operation be necessary. The mental condition is often affected by the state of the bowels, and among the insane careful attention in this respect is necessary. (4) The urine may not be passed often (4) of the enough, or it may come too often ; it may be abundant or scanty, pale, high-colored, or bloody, or its flow may be attended with diffi- culty or pain. If the urine is not voided for twenty-four hours or more, the patient's condi- tion becomes serious till relief is obtained. It is to be noticed that paralyzed patients may suffer from such retention, and patients like- wise who are in a state of stupor. (c.) The skin should be noticed when bath-(5). Of the w/ skin. ing is being conducted. Observe whether dry, or moist, or bathed in perspiration, and at what times. Examine for lice, eruptions, sores, or marks of injury. From what has now been said, other hints 30 THE BODY. may be suggested to you, which, in the course of your experience, can be acted on. Enough has been stated to enlarge your knowledge and to quicken your intelligence. Act up to it and you will learn more, and, greatest comfort of all, .you will immensely benefit the patients under your charge. THE NERVOUS SYSTEM. The Nervous We now pass on to the nervous system, the chief parts of which, as already stated, are en- The position closed within the skull and back-bone. The and Spina?' brain lies in the top and back parts of the head,. and connected with it is the spinal cord, which lies in the back-bone. From them proceed nerves, which branch in all directions into the organs and through the tissues, and in this way the brain and cord are brought into intimate The Nervous relation with all parts of the body. The ner- Jde-s^read^s vous system is therefore as far-reaching as the mg branches. circulation, and its influence is everywhere The materials manifest. It is composed of three materials poseh.00"1" —Srav matter, white matter, and cement sub- stance. In the brain the gray matter forms the outer layer, and encloses the white matter, through which are scattered clusters of gray matter. The gray matter consists of small THE NERVOUS SYSTEM. 31 nerve-cells, and the white of nerve-threads, which communicate with the nerve-cells. The cells and threads are embedded in cement sub- stance, which is soft and yielding, and yet acts as a protective to the nerve structure. In the spinal cord the composition is similar, but the gray matter is in the inside, and the white matter on the outside. The fibres which branch from the cord and brain consist merely of nerve-threads enclosed in protecting sheaths. The whole nervous system is well supplied with blood-vessels, which are more numerous in the gray than in the white matter. The functions of the nervous system bear a its functions resemblance to the operations of the telegraph thosT of the telegraph System. system. The gray skin of the brain may be compared to a great city, the headquarters of the tele- graph system, and the gray clusters scattered through the white substance of the brain are the suburbs of the city, the gray clusters of the spinal cord are the towns, and the points of skin, muscle, organs, etc., where nerve-fibres end are the villages. The nerve-fibres con- nect villages, towns, suburbs, and the great city .with one another; for no station can exist with- out a connection. The fibres are of three 32 THE BODY. Three kinds kinds : first, inward messengers; second, out' Fibres. e ward messengers ; third, internal messengers. Inward messengers may pass from any sur- face or organ of the body to the cord or to the brain. Outward messengers emerge from the brain and cord and pass outward in many directions, but they chiefly supply muscular tis- sue and cause movements. Internal messen- gers carry messages between the brain and its suburbs or the cord, or between different sta- tions within the city itself. The nervous system operates in a variety of ways, of which the Examples of following are examples: (i) If the skin is Nervous pricked, the nearest village at once sends a ates.em°per" message by an inward messenger to the brain, and the message is immediately registered as we at once become conscious of the sensation (the messenger so exercised is called a sensory nerve); (2) when the brain wills to move a muscle, a message is sent outwards to the muscle, and at once the muscle contracts (the messenger so employed is called a motor nerve); (3) various operations of the mind take place within the brain independently of these ingo- ing and outgoing messengers,— and these opera tions consist of communications between centres within the brain itself, and are conducted along THE NERVOUS SYSTEM. 33 internal nerves; (4) when the foot is tickled, the nearest nerve-terminus sends a message to one of the gray centres (towns) of the cord, and this centre sends back a message to the muscle of the leg to draw away the foot. In this case the communication is only a half-way communication, and the mind may be quite unconscious of it, and because it is sent back in the direction from which it came it is called reflex (thrown back), and this kind of nervous action is called reflex action. These examples illustrate some of the principal functions of the nervous system, but there are nerve-currents of other kinds besides these, which are chiefly varieties of reflex action. To these four, how- ever, we will do well to pay some further at- tention. Sensations are the result of messages con- (0 The fuho- .... ii-i tions of Sen- duCted by the sensory nerves to the brain, and sation. they vary in kind according to the impression applied to the nerve-ends. An impression of the finger excites a sensation of touch ; a warm bottle to the feet sends a sensation of warmth; a mustard blister a sensation of burning; a lump of ice applied to the skin sends a sensa- tion of cold ; and a prick by a needle a sensa- tion of pain. The skin, as you know, is very 34 THE BODY. sensitive, and the reason is this, that it is crowded by nerves which connect it with the cord and the brain, and collect impressions for the information of the brain. In this way we feel changes of heat and cold, comfort and discomfort, cramps and pains; and not only so, but we can put our finger on the spot where the feeling comes from. It is easy to under- stand, therefore, that sensation can be pre- vented in three ways : (i) By destroying or separating the skin so that it ceases to conduct an impression; (2) by disease or injury of the sensory nerves; (3) by disease or injury of the brain. To make sensation perfect, these three links of the chain must be joined to- gether, and be free from disease or injury. (2) The Mo- Motor nerves convey messages from the tor func- . . . tion». brain to the muscles, which contract in conse- quence. The nerves receive their impressions from the will, and respond accordingly. If the will is paralyzed, the motor nerves receive no impressions and the muscles are not called into action. If the nerves are diseased or in- jured, the will and the muscles are of no avail; and if the muscles are destroyed or discon- nected from the nerve, muscular movement is equally impossible. Hence the necessity for THE NERVOUS SYSTEM. 35 an unbroken line of connection in good repair. When the connection is complete and healthy, the will has at its command about five hundred muscles, which are arranged in groups accord- ing to the movements which they are designed to execute. These movements are numerous, and of endless variety, and include the delicate and difficult movements of speech and writing, as well as the coarser movements of walking, wrestling, swimming, etc. Running side by side, therefore, are two sets of nerves, the one sensory, and the other motor, the one conduct- ing impressions to the brain, the other con- ducting impressions from the brain. But within the brain itself there is a third The function of mind and set of nerves, which begin where sensation the functions . . .of internal ceases and the mind comes into operation, nerves and cells. These are the internal nerves, and their func- tion is to conduct messages within the brain from one centre to another, messages of mem- ory, of thought and feeling. The internal nerves and the nerve-cells of the mind connect with each other so as to form a network, which, while we are awake or dream- ing, is in a state of busy activity, telegraphing ideas from cell to cell. In proportion as this network becomes 36 THE BODY. broken or weakened does the mind fail in its functions; the snapping of a few fibres, the sickening of a few cells, makes a serious dif- ference ; and because of the delicacy of it, the structure requires constant repair and care- ful preservation. The internal nerves, and the brain-cells which they connect, vary in number in different brains. In the idiot and the im- becile they are less numerous, and their num- ber is greater in the brains of more perfect development. Reflex Reflex action is a most important function of the nervous system. It is independent of consciousness, and for this reason is applied to regulate functions which, if left to our own will and guidance, would be imperfectly per- formed, and frequently forgotten. The will is not concerned with the movements of the heart and lungs; the function of digestion it is scarcely responsible for; and the drainage of the human system has no direct relation to consciousness or will. Reflex action alone is the responsible mainspring of these functions. When food enters the mouth, saliva flows over it; when it enters the stomach, gastric juice is poured forth. The preparation and the flow of these juices are not intrusted to the will, but THE NERVOUS SYSTEM. 37 rather to a simple and self-acting nervous ar- rangement, which is excited by the mildest friction, and which in turn calls into activity the juices. The respiration, the circulation, and other necessary functions of life are regu- lated in a similar way. The withdrawal of the foot when its sole is tickled, the winking of the eyelids when the hand is quickly drawn across the face, and the contraction of the pupil when light is thrown into the eye, are other and more familiar varieties of reflex ac- tion, which must serve to complete our descrip- tion. With these four functions affected by disease Disorders oi we can easily understand how helpless a man becomes. Any one may be alone disordered or paralyzed, but it is usual in serious cases to find more than one involved. Of sensation the most common affections are neuralgia (pain in a nerve) and hysteria. Pain of any kind is the result of disease or injury in the path of a nerve, or at either end of it. A nerve-end irritated by a diseased tooth, and inflammation alongside a nerve, are examples of this. But sensation may be abolished, and this is sometimes found in hysteria, with paralysis of 38 THE BODY. motion, and more or less in epileptic and apoplectic seizures. The sensibility of many insane patients to pain is more or less im- paired, and some are known to derive pleasure rather than pain from acts of self-injury, such as chopping fingers, lacerating the skin, and extracting teeth, which to others would simply be torture. Disorders of When muscular action is arrested or difficult, the Motor . System. when it occurs in spasms or quick successive jerks, and when it is manifest in trembling in place of steady movements of the hands, the tongue, or lips, we know that the motor system is somewhere affected. The seat of disease is sometimes in the cord, but usually in the brain, at the starting-point of the motor nerves. The nature of the disease varies, and the symptoms differ accordingly. These may be of the character of paralysis of arm or leg, or both, dumb palsy, shaking palsy, St. Vitus' dance, epilepsy, etc. In general paralysis of the insane we see first the motor excitement, trembling of the tongue, lips, and muscles of the face, the trembling of the hands, and the muscular restlessness of the patient. By and by the disease visibly advances, the trembling and restless movements cease, and, with the THE NERVOUS SYSTEM. 39 further progress of the malady, complete pa- ralysis and incapacity of movement signify the last stage of all. When a patient is seized with a paralytic stroke, the power of movement is more or less completely lost, and yet the disease may only affect a very limited portion of the brain. In this case the telegraph sta- tion which sends out messages to the muscles is destroyed, and, notwithstanding that the muscles and motor nerves still remain healthy, the messages on which they depend for their activity can no longer be produced. When the internal nerves and their connect- Derange- ing brain-cells become the subjects of disease, internal net- the mind soon tell its own story. The connec-nerves and tion of the brain by means of nerves with the affection of whole anatomy of the body, and its sensitive-1"111 ness to all impressions of bodily disease, render its mental functions liable to disturb- ances, which may be slight and fleeting, or serious and more lasting. But, in addition, its own diseases or disorders depend largely on the bodily health, and add also to the risks of mental diseases. The laws of health should be carefully observed, not only in the interest of the body, but still more so of the mind, which is affected for good or evil by the bodily 40 THE BODY. health. The nature of mental disorders, and how to manage them, are subjects of consider- ation so important as to require a chapter to themselves, and your attention will be specially called to them later on. Disorders of We have now to consider that reflex func- tions! unc" tions may also be altered by disease. They may be quickened, as when the soles of the feet are easily tickled, when sneezing or vomit- ing is easily excited, or when teething or worms cause convulsions in a child. On the other hand, the reflex functions may be par- alyzed, as you see in the last stage of paralysis, where swallowing is difficult and there is risk of choking, where the patient becomes of wet and dirty habits, because of his inability to retain urine or stools, and where the feet do not respond to tickling. The special Our observation of the nervous system pro- senses or "gateways of ceeds one stage further, and there it ends. We knowledge* ' have looked upon the nervous system as the groundwork of self-acting reflex functions, as the mainspring of muscular movements, as a medium of sensation, and as the organ of the mind. As a medium of sensation it contri- butes knowledge, and in this respect is a feeder of the mind; but we have yet to reflect on THE NERVOUS SYSTEM. 41 other paths of sensation, which take a higher position as mind-feeders, and are most essen- tial to the growth and development of the mental functions. These are the special senses, popularly known as the gateways of knowledge. Their names are sight, hearing, taste, smell, and touch. The eyeball is the organ of sight, and pos- The sense of sesses its lenses, chambers, refracting media, muscles and nerves, all specially constructed and arranged for the purpose of bringing to a focus rays of light reflected from any object, which is thus photographed in the eye, and the result transmitted along a nerve to the brain. Thus pictures of all we see are photographed in the brain, so that the mind can think and act regarding them. A slight derangement in the apparatus, whether in the eye, the nerve, or the brain, disturbs the functions more or less seriously; for, as with the other nervous functions, the whole line must be in good re- pair. The ear is the organ of hearing, and its con- The sense of iii- 1 • n hearins- struction is extremely delicate, and specially designed for the collecting and conveying of sound-waves, and for the perception of the nature and direction of sounds. A special 42 THE BODY. nerve passes from it to the brain, conveying the impressions found in the ear, and in this way the brain registers sounds, distinguishes their character, and determines the direction whence they come. The nature of the sounds varies with the volume of the sound-waves and the rapidity with which they succeed each other when striking upon the ear. The other The apparatus for taste, smell, and touch, is lenset! the same as the preceding in general design, but the construction of the end organ is simpler, and it can only be seen under the microscope. The senses of taste and smell resemble each other in much the same way as do the senses of hearing and sight. Impressions of hearing and sight are produced by waves of sound and light, impressions of taste and smell by invisi- ble particles touching the end organ. The smell of a drug, for example, is excited by a delicate vapor, the particles of which touch upon and stimulate the end organ of smell. The sense of touch is communicated from all parts of the body, and has end organs of special and simple construction in the skin. These have their corresponding nerves, which all con- verge to the brain and conduct messages thither. THE NERVOUS SYSTEM. 43 Each sense, then, has its own peculiar appa-The senses ratus and its respective function. Each is an Torie^ofThe observatory for the brain; and all combinedbrain' contribute the sum of knowledge necessary for the full development and the proper exercise of the mind. When their functions are disordered so as to affect the mind, a serious form of in- sanity appears, and you will be told of it in the chapter on mental diseases. But we may here Theheipiess- . , , , , .... ness of man consider how a mans mental condition is without affected not by disease, but by the absence of one or more senses. If a man is born blind, what can he know of color and expression ? if he is born deaf, what can he understand of sound or music? Without the senses, what can a man know or learn, or what communica- tion can he hold with other minds ? Yet there are surprising and gratifying in- The educa- . tion of re- Stances of the loss of one or two senses stimu- maining senses to lating the patient to the better exercise of make up for those which remain. The blind man finds a los^ or want- welcome compensation in the quickness of his ms' sense of touch, in the increasing acuteness of his sense of hearing, and in the new uses which he may find for the senses of taste and smell. One gateway of knowledge is closed; but he is no longer disconsolate, when he 44 THE BODY. How much learns how much more helpful the others are frTthfs wa"/ than they were before. In the wards of our Ayttendante. asylums there is no more encouraging feature in the experience of attendants than to see the idiot, born blind or deaf, increasing his knowl- edge, his pleasures and usefulness, and making the best of his small brain and few senses, under the painstaking care and judicious aid of those whose duty it is to lighten his burdens and brighten his existence. CHAPTER II. THE NURSING OF THE SICK. MOST asylums contain wards set apart for The care of the accommodation of patients in more than usually feeble bodily health. The sick and infirm persons in such wards naturally require more careful attention to their wants and symptoms than do those patients that enjoy comparatively good bodily health, and the wards and rooms in which they are placed also require to be kept even more than usually clean, orderly, and quiet. These wards must be looked on as most important, and the position of the attendants in charge of them is both difficult and honorable. All attendants should acquire, as soon as a knowledge n of sick-nurs- possible, some knowledge of sick-nursing, asj°f£^*2[ any one of them is liable to be called on to ant. perform this special and important duty. In this section of the handbook a few plain directions are given to aid attendants in carry- 45 46 SICK-NURSING. ing out the orders of the medical officers re- garding the sick. SICK-ROOMS. Special care must be taken to keep those rooms in which patients are confined to bed in proper order. Ventilation. A full supply of fresh air is specially neces- sary in sick-rooms ; for the sick, on the one hand, destroy the air more rapidly than do those in health, and, on the other hand, an abundant supply of pure air is necessary to aid The causes recovery in many cases. The breath from ^impure patients suffering from lung diseases, the dis- charges from sores, the unhealthy perspiration of the sick, and the odors arising, in spite of constant attention, from those of wet and dirty habits, all tend to make the air foul; while specially pure air has to be supplied to those whose powers of circulation and of respiration are feeble, who are unable to stimulate these functions by exercise, and whose lungs may be, through disease, only partially available for their proper functions. How to keep The purity of the air is to be secured, in the the air pure. firgt piace> by the prevention, as far as pos- sible, of the causes of bad smells, by strictly SICK-ROOMS. 47 attending to cleanliness, and the removing at once of all discharges, dressings, soiled linen, etc.; and, in the second place, by the admis- sion of fresh air in proper quantity, by atten- tion to windows, doors, chimneys, and any special apparatus for ventilation that may be provided. The windows may generally be kept partially The win. opened. A number of windows opened a little is more useful and less draughty than one or two opened widely, and care must be taken in the opening of windows that no patient is ex- posed to direct draught. When there is a fire in the grate, a chimney chimney- forms a very good ventilator, on account of the tutors.v constant draught of air ascending it, as this draws a corresponding quantity of fresh air into the room to supply its place. When there is no fire in the grate, the damper with which most grates are provided should always be kept open ; a little soot falling from time to time shows that the chimney requires sweep- ing, but is no reason why ventilation through this channel is to be prevented by closing the flue. When special ventilators are provided, they should be carefully attended to. An equable temperature, generally between 48 SICK-NURSING. Tempera- ij0 and 60 degrees, should be kept up in sick- rooms both by day and night. The thermome- ters on the walls should be frequently referred to, to ascertain that this is the case. In some diseases the keeping up of a special tempera- ture night and day is a matter of life or death to the patient. Light. in a sick-room the light should be subdued but cheerful. Sunshine should generally be allowed to enter freely, but not to stream on a patient's face and cause discomfort. The win- dow-blinds require constant attention, as the sun shifts its position. No more gas should be used than is required for proper s'pervis* ion and attention to the wants of patients. It is to be remembered that burning gas rapidly consumes the life-giving properties of the atmosphere, and its glare is apt to induce wakefulness. aeaniiness. The greatest cleanliness is necessary in every nook and corner of a sick-room. The floors, etc., should be frequently cleaned. This should be done, however, with the use of as small a quantity of water as possible in those rooms where patients are confined to bed, for a damp floor is dangerous to those lying in bed above it. All stools, discharges, GENERAL DIRECTIONS. 49 dressings, and soiled linen should be at once removed, and all plates, cups, medicine glasses, etc., kept clean and neatly arranged. It is not safe either for an attendant or for the sick to be dirty, the hands especially always being washed before and after dressing wounds, etc. Any one who has suffered from even so mild Quiet- an ailment as a slight headache can appreciate the necessity of quiet in a sick-room. Loud talking, the wearing of heavy boots, clattering of plates, banging of doors, etc., are to be avoided. Much may be done by a good attendant to Cheerful. make a sick-room and its occupants cheerful, by attention to the little wants of the patients, by providing them with books and work when these are allowed, by talking with those in- clined to conversation, and by attention to flowers, to the neat serving of food, orderly arrangement of bed-clothes, etc. GENERAL DIRECTIONS REGARDING THE CARE OF THE SICK. The meals of the sick should be carefully Food, etc. and neatly served. A capricious appetite may be tempted by a neat morsel, served at the 5° SICK-NURSING. Medical right time that might reject a half cold and sanction nee- -,-,.. » n t .1 essary for slovenly served dish. All extra diet must be tioenmofr0arti- strictly adhered to. No sick patient should be given anything to eat but what has medical sanction. In some diseases the life of a pa- tient may be seriously endangered by the administration of unsuitable food, given though it may be with a good-natured intention to humor or indulge him. Friends visiting the sick often bring in cakes, fruit, etc. Such articles should be at once taken in charge by the attendant, who should in no instance give them to the patient without permission. Sick persons, especially amongst the insane, are apt to refuse food, but, in many cases, by persuasion and patience, an attendant can suc- ceed in getting them to take it. Patients' tastes and fancies for or against various arti- cles of food should be observed and reported. Beds, All beds should be frequently aired, and should be as thoroughly made as possible every day, but no patient suffering from seri- ous bodily disease should be raised for this purpose without special medical sanction. The bed-clothes should be neatly arranged, and kept drawn up near the chin of the patient, GENERAL DIRECTIONS. 5 I who should be discouraged from keeping his arms out, and chest bare, unless these are protected by a flannel jacket or other extra covering. Many of the insane are constantly The Bed- throwing off the bed-clothes. These requirecc to be as frequently replaced. A patient lying half covered presents an appearance of neglect and slovenly management, besides being ex- posed to danger from risk of catching cold. Some margin may be allowed for the fancy of individual patients as regards the quantity of bed-clothing, but in no case is one to be al- lowed to become cold, an extra amount of bed- clothing being frequently required to keep the bodies of feeble sick persons properly warm. Cold feet are dangerous in all cases, and often cold Feet cause great restlessness and sleeplessness in old, feeble persons. When the feet are found to be cold, — and they should frequently be felt to ascertain this, — a properly protected hot- water vessel should be at once applied. The undersheet is to be kept perfectly The Under. smooth and scrupulously free from crumbs, etc. Wrinkles in the sheet, and crumbs lying on it, give rise to great discomfort, and frequently cause troublesome bed-sores. A piece of waterproof sheeting should be 52 SICK-NURSING. The Water- placed next the mattress of all wet and dirty proof Sheet. r . J cases, in order to keep it clean. These sheets require frequent washing, and the mattress should be at once removed if it absorbs any discharge through the displacement of the waterproof sheet. As a rule, the sheets should be changed as often as they become wet or dirty, no matter how often this may occur. In some cases of paralysis or great weakness, the stools and urine are passed almost continuously, and the condition of the patient renders the fatigue to him of frequent changing undesirable. In such cases, the drawsheet is of great service. The Draw- A drawsheet is a sheet folded several times sheet. lengthwise : one sheet, thus folded, is passed beneath the loins of the patient, and above the usual undersheet. As one portion be- comes soiled, a fresh portion is drawn gently beneath the patient, while the soiled portion is folded up at his side. One sheet may thus serve several occasions, but it should always be removed when it becomes so much soiled Urinals. as to be offensive. Various forms of urinals are used to receive the urine of patients passing it unconsciously. These should be kept constantly in position, and are to be GENERAL DIRECTIONS. 53 frequently emptied, and kept scrupulously clean. Waterbeds are frequently used. They should be filled with water somewhat below the tem- perature of the human body, as ascertained by thermometer, say 90 degrees. No patient may be taken out of bed and Cleansing of sick patients. placed in a bath without special orders. When a bath is given to a sick patient, great care must be taken that he is warmly clad while going to and from it, that he is not exposed to draughts, and that all linen, etc., is ready, aired, and warmed, so that no time may be lost in covering him again. Much may be done to keep the persons of patients lying in Spongingtha bed clean, by careful sponging. One limb should be sponged at a time, then the front of the body, and then the back. Each part thus sponged should be carefully dried before a fresh part is commenced with. Great care must be taken that the bed-linen does not be- come damp in the process. The face may in all cases when there is no special disease of that part, such as erysipelas, be kept clean by tepid sponging. The eyelids require special attention to remove the matter that so fre- quently accumulates about them. In serious 54 SICK-NURSING. cases, the lips and mouth become dry and crusted. These crusts should be partly re- moved with a small stick covered at one end with soft lint and dipped in water. Special attention requires to be paid to keeping clean the private parts of paralytic patients. The hair of the sick is very liable to become in- fested by lice, and requires increased attention. The nails also grow fast, and require frequent cutting. The use of An attendant cannot be too careful about ants?e " disinfectants, and should carry out the instruc- tions of the medical officers regarding their use to the very letter. They are frequently ordered in cases of infectious disease, and a neglect of their use cannot but cause danger to the attendants themselves as well as to all others in the institution. Keeping of In many cases of disease, charts are kept, Charts and , . , ,. . , , Records. showing the condition of the temperature, pulse, and respirations at certain times, and attendants should learn to fill in these accu- rately and neatly. Other papers also are kept in some cases, on which are recorded the tem- perature of the room at stated intervals, the amount of food, drink, and stimulants taken, and at what hours, the amount of sleep ob- GENERAL DIRECTIONS. 55 tained, the frequency of stools, of fits, of paroxysms of coughing, etc. All entries on charts or records should be made at once, for experience shows that the best memory is not to be trusted on these points. Attendants in charge of the sick will find it Noting of #° . Symptoms. useful to keep a private note-book in which to enter, between medical visits, any symp- toms or matters of interest occurring in the patients that do not require to be immediately reported. Such a book, carefully kept, will prevent the danger of any symptom being for- gotten, and in it may also conveniently be entered any fresh instructions regarding medi- cines, etc., given by the medical officers at each visit. Attendants should be able to report intelli- gently regarding the symptoms of the sick under their charge to the medical officers at their visits. Among the principal subjects on which in- formation may be asked, are the following : — Appetite. The amount of food taken. The mode of chewing and of swallowing. Bowels. How often moved, and at what times. Whether the stools are full or scanty, natural, costive, relaxed, watery, painful, bloody, 56 SICK-NURSING. or of peculiar color or smell. Whether they contain foreign bodies sometimes swallowed by the insane, such as pebbles, buttons, etc.; or contain worms, and of what kind the worms are, whether threadworms, roundworms, or tapeworms. Whether the patient is attentive to the calls of nature, or wholly or partially neglectful in this respect. Examination Urine. How often passed, and in what of Unne. . r quantity. Whether it is natural in color, or unusually pale or dark. Whether it is clear or turbid, or contains blood, or matter, or gravel. Whether it remains clear, or deposits a sediment on standing, and the color and quantity of this sediment. Whether it is passed easily, or with difficulty, or pain. Great attention should be paid to paralytic patients, and indeed to all who are seriously ill, and to those recently admitted, and it should be at once reported if they do not pass water for some length of time, appear wishful but unable to pass it, or pass it constantly in a feeble trickle; all these conditions showing that there is something very serious amiss. Women Conditions peculiar to women. These condi- Patients. tions are to be the subject of frequent report by the nurses. GENERAL DIRECTIONS. 57 Cough and Expectoration. The frequency of E*P.ectora" the cough, and its character, whether slight or severe, dry, or accompanied by spit, etc. The character of the spit, whether clear or opaque, tinged with blood, or dark-colored. The spit, and all unnatural motions and dis- charges, should be preserved for inspection at each medical visit. Other important symptoms are vomiting, at- other im- tacks of shivering, bleeding at the nose, fits, Symptoms. attacks of faintness, etc. All these must be reported. Pain. Any complaint of pain on the part of a patient should be noticed and reported, and, also, if a patient appears to shrink or complains of pain on any portion of the body being touched. All pressure on or interference with painful parts is to be avoided. Complaints of pain or peculiar sensations must also be reported. Sleep. How long, and at what times, whether sleep. peaceful or disturbed, whether light or pro- found. Unusually deep sleep with heavy breathing and a difficulty in arousing the patient may indicate a dangerous condition. Effect of medicines and stimulants. When medicines are given, the effect should be 5» SICK-NURSING. watched, especially in cases where sleeping- draughts have been administered. When stim- ulants are given, it should be noted whether they appear to soothe or excite, to increase or diminish strength, to cause drowsiness or wake- fulness, or be followed by flushing of the face. External appearances. All bruises, eruptions, sores, swellings, distortion of limbs, or other unusual external appearances, are to be re- ported, every opportunity being taken while patients are changing their clothes to see that all is right in these respects. SPECIAL DUTIES. ^rat1?Tem* ^e normal temp£rature of the human body is 98.4 degrees. The temperature of a patient is usually taken by placing a thermometer in the armpit. The index of the thermometer should be gently shaken down to 95 degrees before each observation. It should then be placed close to the skin, with its bulb in the centre of the armpit, and the arm brought close to the side of the body. Care must be taken that the skin is dried, and that there is no clothing between it and the bulb. Ten minutes is usually long enough to leave the thermometer in, if the patient has been well covered up SPECIAL DUTIES. 59 beforehand. If not, he should be well clothed up to the chin for ten or fifteen minutes before it is inserted. Temperatures are sometimes taken in the mouth, but attendants should never attempt to do this in the case of insane patients. The average rate of the pulse is 70 to 75 Feeling the beats a minute. Feeling the pulse is per- formed by placing the first three fingers of the right hand on the patient's wrist, on its inner margin, just a little above the thumb. The pulse may be slow or fast, strong or feeble, regular or irregular, or intermittent. An at- tendant should be able to count the number of beats a minute of a pulse, and be prepared to report roughly on its character, but a proper appreciation of its character can only be made by a medical man. As a rule an adult breathes about 17 times Counting Respira- a minute. The respirations are counted by tions. watching the movements of the chest — each rise and fall making together one respiration. This can generally be done without moving the patient's clothes. While counting it may be noted whether the breathing be regular or irregular, light or heavy, easy or painful, etc. Cold dressings are applied to wounds or 6o SICK-NURSING. Cold Dress- sores, and are usually lotions or ointments, or of plain water. They should be changed regularly, and should always be replaced or renewed when removed or destroyed by a restless patient. The old dressing should never be taken off until the new one is ready to be put on. Dressings are to be removed gently, from both sides of the wound or sore at once, drawing them off towards the centre. The edges of the wounds and sores should be gent- ly cleansed, but the surface should never be touched except with such applications as may be specially ordered. Any alterations in the appearance of the sores should be noted when the dressings are changed. Everything re- quired for a dressing must be in readiness before the operation is commenced. The old dressing should be removed at once from the sick-room and burned. Wet compresses. These consist of a roll of flannel or calico wrung out of cold water, ap- plied to the part, and covered with waterproof. Wet compresses should be allowed to remain on continuously, and should not be renewed unless they become dry. Poultices. Poultices may be of bread, linseed meal, mustard, etc. Mustard poultices, though so SPECIAL DUTIES. 61 named, are rather of the nature of a blister, and care must be taken not to let them re- main on too long, for a nasty sore may be the result. Other poultices proper should be ap- plied as warm as can be borne, and should be frequently changed. A poultice applied all round the chest is called a jacket poultice. Jacket poultices require frequent changing, the skin being gently wiped dry before each fresh one is put on. A cold jacket poultice is worse than useless, from the chill it may cause about the diseased organs. Fomentations are made by wringing flannels Fomenta- out of water as hot as can be borne. They should be applied to the skin at the part di- rected, and covered with waterproof to keep the heat from being lost by evaporation. They should not be allowed to get cold, but be renewed frequently during the time their application is directed. A material called spongio-piline is frequently used for fomenta- tions. It is a thick woollen material, with a waterproof coating on one side. The hot water should be applied to the woollen side. Stupes are fomentations with some external stupes. remedy, such as spirits of turpentine, poured on the surface that is to be placed next the skin. 62 SICK-NURSING. Enemas. When an enema is given, of whatever kind, whether of food, medicine, or purgative mix- tures, etc., the amount ordered must be strictly adhered to. When a warm enema is admin- istered, care must be taken that it is not too hot, not more than 90 degrees. The tube is to be oiled, and passed gently in a backward direction for two or three inches into the bowel with the right hand, while the patient lies on the left side, with the knees drawn up. The injection should be very slowly and most gently administered, and its flow should be stopped at once if the patient shows any sign of distress. When the required quantity has been injected, the tube is to be gradually and gently withdrawn, and the buttocks pressed together for a few minutes. Air must not be injected, and for this reason the syringe should be filled before the introduction of the nozzle. Great care must be taken in using all warm applications, whether poultices, fomentations, or stupes, that they are not too hot, and the same caution is necessary in the case of enemas, and of food, etc., given by the mouth. Supp°si- Suppositories should be gently passed up the bowel with the forefinger of the right hand SPECIAL DUTIES. _ 63 for a distance of two inches, while the patient lies on the left side, with the knees drawn up. A little sweet oil on the suppository and on the finger facilitates the operation. Care should be taken to ascertain that a supposi- tory is retained in the bowel. Great difficulty is frequently experienced in Gargles. teaching patients to gargle properly. An at- tendant may learn to do it himself, and thus teach them by gargling in their presence, and explaining how it is done. A patient should always sit fairly up in bed before being allowed to gargle. When steaming is ordered, care is necessary steaming .... and Inhal to see that the steam constantly strikes on the tions. nose and mouth of the patient, and that the steam is not too hot at that point. The moist- ure gathering on the face should be wiped off from time to time, and the pillow and upper part of the body and bed-clothes protected from the moisture by waterproof sheeting. When steaming is ordered, it must be con- stantly kept up for the time directed; other- wise it may do more harm than good. Hot, tepid, and cold baths may be ordered Baths- medicinally. The temperature ordered must be strictly maintained during the whole time 64 SICK-NURSING. the patient is in the bath. To ascertain this, a thermometer should be in constant use. Should any symptom of faintness come on while a patient is in a bath, he should be at once removed and placed in bed. The Wet Packing in the wet sheet is thus performed : — The patient is to be stripped, and the whole of his body wrapped in a sheet wrung out of water, which may be hot, tepid, or cold, ac- cording as may be ordered. He is then en- veloped in a blanket, and laid on his side, in bed, on several thicknesses of blanket. A number of blankets are then placed over him, and carefully tucked in all round him and up to his chin. A patient in the wet pack is not to be left on any account, but must be care- fully watched during the time he is in it. When the time ordered has expired, the wet sheet is to be removed, and the patient's body rapidly sponged with tepid water and dried. He is then to be placed in a well warmed bed, and carefully covered up. Sponging. Cold or tepid sponging is sometimes ordered in cases of fever, etc. It is to be done while a patient is in bed protected by waterproof sheeting. As the cooling effect is desired in such cases, the body of the patient should be SPECIAL DUTIES. 65 exposed during the time the sponging is or- dered to be continued. Should any symptom of faintness come on, the patient should be at once dried, and removed to a warm bed. All medicines must be given regularly at the Administra- . . . . . , I tion of Med- times and in the quantities ordered. It iscines. well to shake all mixture-bottles before pour- ing out the required dose, even if this direc- tion is not specially given on the label. The label of directions must be read each time be- fore the medicine is given, and the quantity ordered carefully measured into a clean glass. In giving pills care must be taken to see that they are really swallowed by a patient. Should any patient refuse medicine, this fact should be carefully reported. When a patient refuses food, much may be Forcible done by attendants by means of gentle persua- sion with some, and by a firm but kind man- ner with others. Beyond this, an attendant should never go. No apparatus for forcible feeding may be employed by any other than a medical officer under any pretext whatever. Great care is necessary in feeding para- lytics, delirious patients, and those who are unconscious or dying. The quantity given at a time should be very small, and it must be 66 SICK-NURSING. ascertained that one spoonful has been swal- lowed before another is placed in the mouth. No paralytic or epileptic patient should eat alone. Bandaging. Of bandaging, little can be learned from a book. In bandaging a limb, the bandage should be carried with a gradually decreasing pressure from below upwards. Any complaint or appearance of a bandage being too tight should be at once attended to, and the band- age loosened without loss of time. EMERGENCIES. In any case of faintness, the patient should at once be placed on his back, the clothing about the neck should be loosened and the chest bared, while fresh air is freely admitted. The face and chest should then be flicked with the end of a towel dipped in cold water, while warmth is applied to the feet and limbs by means of hot-water vessels and heated flan- nels. When a patient takes a fit, he should be laid on his back on a bed or sofa, or, if nei- ther of these is at hand, on a clear space on the floor. A pillow is to be placed under his head, and the clothing about the neck and Fainting. Epileptic EMERGENCIES. 67 chest loosened. In violent convulsions the movements may be gently restrained, care being taken that the patient does not in- jure himself by dashing his head or limbs against the floor, the walls, or the furniture. Some patients show warning signs of an ap- proaching fit of epilepsy ; and when these oc- cur, he should be induced to lie down as soon as possible, and remain lying until the fit is over. In nearly all cases of epilepsy, a period of rest in the recumbent position after the fit, to encourage sleep, is desirable, and may ward off the excitement that frequently follows. The character and duration of a fit should be ob- served, and notice taken which parts of the body are most affected by convulsions. If a fit occur in a patient not known to be epileptic, and, in the case of those subject to fits, if the attack be unusually long or severe, medical aid should be summoned. Should apoplexy, or any other form of loss Apoplexy. of consciousness by a patient, occur, the cloth- ing about the neck and chest is to be loosened, the patient placed in bed, and a medical officer sent for without delay. Should choking occur, medical aid must be Choking. Instantly summoned, as every moment is of the 68 SICK-NURSING. greatest value. Paralytics, epileptics, dying persons, and those of the insane addicted to " bolting " their food, as also suicidal patients, who sometimes seek self-destruction by this means, require to be specially watched and guarded against choking. Until aid comes, all food should be removed from the mouth, the body of the patient in- clined forwards, and his back be sharply clapped with the back of the hand. Hemorrhage Any considerable loss of blood is at once to be reported, the color of the blood and the quantity lost being carefully noted. In the case of bleeding from wounds and incisions, the flow of blood may be controlled somewhat until medical aid arrives, by pressure on the spot with the finger or a pad of linen, and by the application of cold water allowed to drip on the part from a sponge. The part from which the blood comes should be raised as much as possible above the rest of the body. In bleeding from the nose, the head should be kept erect, and the hands raised above it. Labor. No nurse that has not received special in- struction in midwifery should attempt to inter- fere with a patient in labor, but should place her in bed, and at once report the case. At- EMERGENCIES. 69 tendants on the insane must, however, care- fully watch patients that are pregnant, as the insane in this condition frequently give no warning of the onset of labor by expressing their sufferings, or even by showing signs of discomfort. One of the most common modes of suicide Attempted Suicide. attempted by insane patients is hanging or strangulation. In some of these cases, the life of the patient may be saved by prompt and timely action on the part of an attendant. The moment such a case is discovered, the ligature should be at once cut and removed Hanging or 0 . . Strangula- from the neck. If the patient is unconscious, tion. what means are to be taken to restore him by the ° application of cold water as in cases of faint- ing; and if the breathing has ceased or is feeble, artificial respiration is to be instantly commenced, and continued until medical aid arrives. Artificial respiration is performed thus : The Artificial patient is laid on his back, and the operator, How it is ac- r . comphshed. standing at his head, grasps the patients arms, just above the elbows, draws them gradually upwards till they meet above the head, and keeps them in that position for two seconds; then, bringing the arms down again, 70 SICK-NURSING. he presses them gently but firmly against the sides of the chest for two seconds more. These acts are to be steadily repeated alternately, and the process of artificial respiration by this means continued until medical aid arrives. Hints in case When poisons have been taken, vomiting of poisoning. x ' ° may be encouraged by tickling the throat, and by the administration of warm water with a little mustard added to it. BED-SORES. Nothing is a surer test that careful attention is given by the attendants to the sick-nursing in an asylum than the absence of bed-sores in those patients liable to them, and the success- ful management of such sores, when, in spite of every precaution, they do unfortunately oc- cur. The patients most liable to bed-sores are those known in asylums as general paralytics, those suffering from other forms of paralysis, and those that, confined to bed for a length- ened period, have become extremely feeble and emaciated. Such cases require very special attention to the state of their skin and the bedding on which they lie. The undersheet should be kept smooth, free from crumbs, and EMERGENCIES. 71 as dry and clean as possible, and the position in which the patient lies should be frequently altered. The back should be examined daily and carefully cleaned, and a liniment, when such is provided for the purpose, regularly applied. When bed-sores occur, they are to be man- aged as are other such wounds, but with an extra amount of care as to cleanliness, and with frequent change of dressings, which, from their situation, are apt soon to become foul. LAYING OUT THE DEAD. When a patient dies, the eyelids are to be The Dead. closed by gentle pressure with the fingers, and a bandage applied under the lower jaw to support it. The limbs are to be straightened out, the arms placed by the sides, and the lower extremities kept in position by a bandage round the ankles, and by one connecting the great toes. The clothing is then to be re- moved, the body thoroughly washed, and re- clothed in a clean bed-gown. The corpse is then to be completely wrapped in a clean sheet. CHAPTER III. MIND AND ITS DISORDERS. Brain the A s already shown in a former section of the organ of f_\ J Mind. ±\_ Manual, the brain is the centre of the nervous system. In it all the nerves of the body converge ; and through them it regulates the movement, sensations, and nourishment of every part of the body. But the brain has still another function — it is the organ of mind. A healthy mind requires a healthy brain ; and all disordered mental manifestations have their origin in derangements of the brain. Healthy The mind is complex in its constitution : and Mind. .„ / r ' we are still very far from having a complete understanding of it, or an accurate knowledge of its working. But for our purpose it is suffi- cient to regard it as being made up of (i) the intellectual faculties, (2) the will, and (3) the emotions or feelings. intellectual The intellectual faculties are the reasoning Powers.°mng powers, those powers by which we observe or perceive, judge of and compare, and reason 72 DEPRESSION. 73 regarding our surroundings or anything put before us, and in them we include also memory, the power of recalling to our mind former events or impressions. It is these faculties which we appraise roughly when we speak, in ordinary language, of a person as being of good intelligence or the reverse ; and in health they are not only up to the normal standard in power, but are also always more or less actively in use. The will is the faculty by which we direct The wm, ' J Feelings a and control our actions. Certain desires and instincts. susceptibilities are, as observation shows us, implanted in every person independently of the reasoning powers, such as the love of life, the love of offspring, the capacity for joy and grief, etc.; and these are termed the emotions or feelings. In addition to the purely mental faculties, we also have various " organic" or bodily appetites or desires, such as the appetite for food and drink, and the sexual instinct; and these are called the organic appetites or instincts. Bv insanity is meant " disease or unsound- Unsound 3 J Mind. ness of mind " ; and this unsoundness shows itself in a derangement or alteration of one or more of the mental faculties, feelings, or in- 74 THE MIND. stincts. Thus the intellectual or reasoning powers may be more or less impaired in their working, or may be so perverted that the Affections of person forms notions which are altogether the reason- . ing powers, wrong and constitute delusions; or the will the will, the , r ,. . , rr , feelings and and power of self-control may be affected ; or petites. ^ the feelings and organic appetites are dis- ordered. The outcome of this mental derange- ment is seen in the patient's conversation and general conduct. For instance, when a person who is naturally bright, active, and cheerful, becomes dull, stupid, and unable to do his work properly, or says that he is Jesus Christ, or feels intensely miserable without due reason, or shows by his conduct that he is acting from motives which are not usually recognized as natural and reasonable, we say that he is insane. The mental condition of every person varies from time to time under different circum- Uuheaithy stances ; but such variations are not regarded variations in ° the Mental as unhealthy so long as they do not pass be- Condition. / ,. . ° J r yond certain limits. But when the variations are such as to render the person unable to take proper care of himself, or to behave rationally towards his fellow-creatures, they are regarded as morbid, and the mental condi- tion is considered unsound. DEPRESSION. 75 A person's mental state is judged of by (i) Mental his conversation, and (2) his conduct; and in judged by , . conversation estimating these we compare him with the and conduct. generality of his fellow-men. We also compare him with himself as he was before becoming insane. Even before speaking to him, we may learn much regarding him by noting his expression, posture, etc. We see whether he is bright, lively, restless, and energetic, or dull, stupid, and listless, or suspicious of those around him. Then in conversation we find if he has a proper understanding of what is said to him, if he answers correctly and intelli- gently, if his memory is good or bad, and if he has any delusions. And by more prolonged observation of his general conduct, we judge if he shows any evidences of insanity in his actions or habits. In the great bulk of our cases, the intellect- insanity ual faculties, the will, and the feelings and affects the ., . rc . Mind as organic appetites, are all more or less affected a whole. together; and it is rare to find one of them deranged without the others being also in- volved. Therefore, in shortly reviewing the symptoms of insanity, we take, first, conditions of disturbance of the mind as a whole. In con- sidering these, the changes in the intellectual 76 THE MIND. faculties are the most striking, and call for most notice, though the will and the feelings are also affected. Some further reference will then be made to the condition of the will, to the more common changes in the feelings and instincts, and to various insane acts and habits shown by our patients in consequence of their mental derangement. Our arrangement then is the following: — (A.) States of General Mental Disturbance. 1. Depression of Mind. 2. Exaltation of Mind. 3. Enfeeblement of Mind. 4. Perversion of Mind. (B.) Condition of the Will. (C.) Changes in the Feelings and Instincts. (D.) Insane Habits and Peculiarities. (A.) States of General Mental Disturbance. Mental De- (1) Depression of Mind. In this condition there is a morbid feeling of distress or unhappi- ness. This feeling varies much in degree in different cases, being sometimes slight, at other times very intense and all-absorbing; and it may also vary in the same case at different times. It may exist without any impairment of the intelligence — the patient may be able to converse rationally and acutely on the vari- Arrange- ment of Symptoms. DEPRESSION. 77 ous subjects put before him, and show no evident mental weakness apart from the mor- bid feeling of wretchedness. But far more commonly the feeling of distress is more or less constant, and is so marked as to occupy the patient's thoughts more or less persistently, and interfere with the healthy play of the intellectual powers ; or there is very frequently great perversion of the intelligence, and delu- sions are developed. These delusions are of Distressing r Delusions. a more or less distressing nature, such as that poison is put in the food, that everybody is conspiring to kill the patient, etc. Often they have reference to the religious sentiment, such as that the patient has been cast off by God, and is doomed to eternal misery; or to the bodily health, as when the patient says that his bowels are closed up, or that his stomach cannot digest the food he puts into it. In this state of mental depression, the pa- tient is sometimes very quiet, sitting quite still in his own place, disinclined to talk, or refusing to say even a single word, showing no interest in the persons and things around him, moody and self-absorbed, and brooding constantly over his morbid fancies. In other cases there is more or less restlessness, with talkativeness, 78 THE MIND. crying and moaning, wringing of the hands, frequent complainings, and the other outward signs of mental distress. The mental depres- sion leads often to refusal of food, and to suicidal and homicidal acts by the patient. Mental (2) Exaltation of Mind. The intellectual powers, while not weakened in themselves, may be working at too high pressure, and the balance between them and the power of self- control be disturbed. The thinking centres in the brain are morbidly active, ideas pass through the mind with excessive rapidity, and the patient is more or less " excited" in his conversation and conduct. The power of self- control being now insufficient, the patient is absurd and extravagant in his behavior, talking too much, or chattering incessantly, wandering from one subject to another without apparent connection, and being restless, noisy, interfer- ing, impulsive, mischievous, destructive, or vio- lent. The degree of this disturbance varies very much in different cases. In acute delirious mania, for example, the brain excitement is so great that the patient is quite oblivious to ordinary external impressions, and he then remembers nothing of what happens during his illness. Or, without being delirious, he PERVERSION. 79 may evidently understand what is said to him, but be so excited that he cannot pay any steady heed to it (ordinary acute mania). Or, in the less severe forms of mania, he may understand and answer questions readily and smartly, but still show the mental exaltation in being excessively talkative and restless and interfering. The feelings and appetites are altered, and often exaggerated. (3) Enfeeblement of Mind. The whole men- Mental . 1 , .... Enfeeble- tal power may be more or less impaired orment. destroyed. Intellectually, this is shown in stupidity, impairment or loss of memory, in- coherence, want of energy, want of attention, etc. The will power is weak; and the feelings and instincts are usually much dulled. It is well seen in the condition of mental enfeeble- ment which often supervenes when the acute or severe symptoms of an attack of insanity pass off without recovery taking place. In degree it may vary from slight enfeeblement, indicated by some silliness or childishness in conversation or conduct, up to deep dementia, when the patient even cannot tell his own name. (4) Perversion of Mind. The intellectual Mental Per- faculties, with or without marked depression, De7usion.r 8o THE MIND. exaltation, or enfeeblement, may be so twisted in their action that the patient forms a wrong conception regarding himself or his surround- ings ; and he is then said to show delusion. A delusion is a " false belief arising from diseased mental action." Frequently the be- lief is on the face of it preposterous and ab- surd, as when a person says that he is God Almighty and can move the world. At other times the patient's statement is not absurd in itself, as when he says that he has lost all his money, or that he is about to die ; and in such a case we have to ascertain that the belief is not founded on fact, or is not justified by the patient's circumstances, before regarding it as a delusion. Haiiucina- When the false belief refers to any of the special senses, of seeing, hearing, taste, smell, and touch, it is usually spoken of as a halluci- nation ; while those false beliefs which are not connected with any of the special senses, but are simply false intellectual ideas, are delu- sions proper. Examples of For example, a patient may say that at tions? " night, when everything is quiet, he hears peo- ple in the next room or outside the house call- ing him by abusive names, and telling him to PERVERSION. Si do things which he ought not to do; he is then suffering from hallucination of hearing. In such a case there may be either no sound at all to set up the sensation of hearing; or there may be some sound, such as the noise of the wind, which the patient hears, but mis- interprets and twists into some diseased no- Examples of tion. Similarly with hallucinations of sight: tions. a patient may say that he sees certain people in his room, when there is no one there at all; or, seeing certain persons there, his sight per- ceptions regarding them are disordered, and he takes them to be other than what they really are. An example of hallucination of taste is when a patient says that he tastes the poison or filth which is maliciously mixed with his food; of hallucination of smell, when he complains of sulphur being burnt under his nose, or of bad smelling gases being led into his room ; and of hallucination of touch, when he imagines that insects are creeping all over him.* * When the false perception arises from something external, which really exists, but is misinterpreted, the term illusion is sometimes applied to it. The term hal- lucination would then be restricted to that graver form of derangement in which there is a false sense-percep- tion with nothing external to account for it. A person 82 THE MIND. Allied to the hallucinations of special sense are the cases of misinterpretation of those sensations which are perceived by us as aris- ing in one or other of the organs in the body. For instance, a person after a severe drinking bout may misinterpret the pain felt in the stomach, and may think that rats are gnawing inside him. Similarly some patients say that their " inwards" are being constantly dragged on and twisted. importance Hallucinations are a very important symp- ofHallucina- . ; tions. torn in insanity. All the different forms may occur in cases of acute and recent insanity; but the most frequent are those of hearing and hearing the noise of the wind, and taking it to be a voice, would be said to have an illusion of hearing; while if he heard a voice when there was no sound at all, it would be a hallucination. A sane person may have illusions and hallucinations. Some people, for example, see the figures of animals, such as a cat, in the room, when there is really no ani- mal present. But the reasoning powers are brought into play to correct the false impression; the person knows from other observations that there is no ani- mal in the room, and understands that it is simply his sight which is playing him false. When the false sense-perception is not corrected by the reasoning powers, but is accepted as true, it becomes a " false belief " and is delusional. DELUSIONS. 83 sight. Often the hallucinations persist for a time, and then gradually pass away as the pa- tient progresses towards recovery. It is usu- ally an unfavorable sign if the hallucinations persist without change for more than five or six months, and often means that the patient will not recover. In the chronic forms of in- sanity the hallucinations most frequently found are those of hearing; and every asylum shows cases in which the hallucinations of hearing constitute the most striking feature, and in which the patient's conduct is largely guided by what the " voices " tell him. Hallucinations of sight are common in the insanity associated with epilepsy. Occasionally hallucinations have their origin in some local disease of the organ of the affected sense ; and this ought to be kept in mind, for then the local disease should be corrected if possible. Delusions proper. These are found in very Delusions • 1 r 1 j. proper: th many cases of insanity, and are ot the most Variety. varied character. Thus, in the depressed cases, the delusions are, as already mentioned, usually of a more or less distressing character, such as having committed unpardonable sin, being lost eternally, being repulsive to every- body, causing infection, and bringing evil on 84 THE MIND. relatives, and having lost all property. In states of mental exaltation the patient may say that he is possessed of great wealth, that he is Jesus Christ, or Napoleon Buonaparte, or some person other than himself (delusion of iden- tity), that his legs are made of glass, etc., etc. These delusional ideas may be constantly changing ; or they may persist for some time and then disappear as the patient improves in his mental state; or they may become perma- nent. Limited or In some cases we find that the patient labors fixed Delu- . sions. under delusions on one subject, or one set of subjects only, while apart from these particu- lar delusions he appears to be rational and in- telligent and can behave himself very well. This is the class known as monomania or par- tial insanity ; and here the delusion is more or less permanent or " fixed." In it we find the following three types of delusion: First, the monomania of grandeur or pride, as when the patient believes himself to be an emperor or king, the heir to the throne, or to be pos- sessed of great wealth or of the whole place round him. Second, some patients are mor- bidly suspicious, saying that they are the ob- jects of persecution, that they are constantly DELUSIONS. 85 being insulted, and that every little thing that is done is intended to annoy them : they at- tribute their supposed injuries to the people around them, and often bring unfounded com- plaints against the attendants and other pa- tients. These are the cases of monomania of suspicion. Third, another class carry these suspicious ideas to a still further extreme, and imagine that they are worked upon by elec- tricity, or mesmerism, or gases, but refer their persecution not to the real persons around them but to some imaginary, supernatural, and unseen power. This is termed the monomania of unseen agency. Delusions of different characters may be Varying ... . ™, . , . Delusion; shown by the same patient. Ihus delusions the same of grandeur and of suspicion may be associ- ated, as when a person says he is the rightful owner of certain property, but is unjustly kept out of it by the plots of his enemies. And de- lusions of a depressed character are sometimes found existing along with those of an exalted nature. It is of great importance to ascertain the particular delusions and hallucinations of each patient, as in them we often find the ex- planation of the patient's general conduct; and from their character we are enabled to 86 THE MIND. judge better of the patient's mental condition and of his propensities. For instance, a pa- tient may think that he hears a voice from heaven telling him to do away with himself; and in such a case we must be prepared to guard against a suicidal attempt, especially if we see that the patient is very strongly under the influence of the hallucination. As with hallucinations, so with delusions proper : it is a bad omen when the false belief becomes fixed, while we are more hopeful as long as the delusions are of a changing nature. (P.) Condition of the Will. Condition of In health the will and the power of self-con- insanity; trol regulate our general conduct, and keep pulses. m"our natural impulses within normal bounds. The strength of this self-controlling power varies greatly in different individuals, and is much influenced by the education and training which the person has received. Some persons seem to be naturally deficient in it — they are of "weak will," flighty and irregular in their conduct, and largely under the sway of their impulses. Or, on the other hand, the will may not be weak in itself; but the impulses or de- sires may, either from vicious indulgence or from disease, be greatly intensified until they DELUSIONS. 87 become overmastering in their strength, and the controlling power is now insufficient to regulate them. For example, persistent ex- cessive indulgence in alcohol begets a con- stant craving for stimulants, and at the same time weakens the will power which ought to enable one to control the craving; and the person, from vicious indulgence of the habit, becomes a slave to drunkenness. But some- times drunkenness is a real disease (dipso- mania), not a vice ; the person is free from the craving for long periods together, but at certain times the desire for alcohol assails him with such terrible force as to be quite uncon- trollable, and he will then do anything in order to gratify the diseased appetite. Such diseased and overmastering impulses some- times hurry the patient on to deeds that he would naturally shrink from and abhor. In insanity the will and the power of self-The insane J are not fully control are often impaired to a greater or less responsible , for their ac- extent; and there are frequently great irrita-tions. bility and impulsiveness. Then the insane often act under the influence of delusions, of ideas which are mistaken but which are never- theless very real to the patient; and conduct which would be regarded as quite unnatural in 88 THE MIND. a sane person, may in an insane person be the very natural outcome of his diseased mental condition. Hence we should always bear in mind that the insane are not fully responsible for their actions, and sometimes are quite ir- responsible. Alterations (C.) Changes in the Feelings and Instincts. andTn-nss Any of the natural feelings, emotions, or ampies! e* appetites may be exaggerated, impaired or de- stroyed, or perverted. A few examples will best show what is here meant. There is natu- rally in every man the love of life, with a de- sire to preserve it. In some forms of insanity this natural feeling is destroyed — the patient has no wish to live, or may even loathe life and try to kill himself. In the mental de- rangement which sometimes follows child- birth, the natural affection of the mother for her child is often lost, or replaced by a feeling of intense hatred, and she may attempt to de- stroy the child. The appetite for food may be lost, and the patient refuse his food; or it may be perverted, as when the patient eats filth and other repulsive substances. The sexual instinct may be lost, or it may be exaggerated and perverted, and then the patient gratifies his desires in an immode- CHANGES IN THE FEELINGS. 89 rate or unnatural way, and shows indecent practices. There is in health a feeling of bodily well- being or pleasure, which is often not appreci- ated during health, but the want of which is at once indicated when we say that we " feel unwell." This is often impaired in insanity, as when a melancholic patient says that he feels utterly miserable or wretched. Patients sometimes say that they have " no natural feeling." Or, on the other hand, the feeling may be exaggerated. In general paralysis the patient often says that he is thoroughly well and strong and in the very best of health, when in reality he is so paralyzed that he can hardly move or speak. (D.) Insane Habits and Peculiarities. insane Acts v ' . and Habits; The various insane acts and habits of our examples. patients have their explanation in one or other of the forms of mental disturbance which we have just considered. Some of these acts have been already incidentally men- tioned. Wet and dirty habits, when not due to bodily paralysis, may arise from carelessness or wilful design, as in some cases of mania, or may be an indication of general mental en- feeblement, showing that the patient is too 90 THE MIND. stupid to take care of himself. Destructive propensities, such as tearing clothes, are very common among the insane, and may be the result of a paroxysm of acute excitement, of Examples of mischievous intent, or of delusion. Fantastic Insane Acts , .... and Habits, dressing, such as wearing a tinsel crown, is usually due to some delusion of grandeur. Theft is a frequent practice—the patient sometimes thinking that everything he sees is properly his, while at other times he is not able to control his morbid desire to get pos- session of whatever takes his fancy, even though he knows it does not belong to him. Under the delusion that stones, pieces of glass, etc., are articles of great value, patients may hoard up all sorts of useless rubbish, as often seen in general paralysis. Or they may squan- der their property recklessly, under the idea that their wealth is inexhaustible. Refusal of food may be due to loss of the natural appe- tite for it, or may be the result of a melan- cholic delusion such as that the food is poisoned, or that it cannot be paid for; or of an exalted delusion, as when the patient imagines he is a deity and needs no food. Talking to himself, especially in a loud scolding tone, usually means that the pa- SUICIDE AND HOMICIDE. 91 tient hears or sees imaginary persons whom he is addressing. Other acts which may be evidence of in- sanity are stripping naked ; indecent exposure of the person; sexual malpractices; eating ravenously or like an animal, or eating strange articles ; and various other less frequent ec- centricities of conduct. But two propensities — the suicidal and the homicidal — require to be considered in more detail. A very large proportion of the insane are prone to injure themselves or others, and we have constantly to take measures for preventing suicidal and homicidal acts. Suicidal Acts. The suicidal desire may be Suicid* due to simple misery or weariness of life. Such patients converse quite intelligently, be- tray no delusion, but say just that they are wretched and that life is a burden to them. These are cases which require most careful watching, for suicide is often attempted by them, and their mental acuteness makes them more able to elude the care of their guardians. More frequently, however, the suicidal pro- pensity springs from a delusion, as when the patient thinks that he is hunted by his ene- mies, or has some other distressing idea, and 92 THE MIND. The quiet cases are often the worst for suicide. Modes of suicide. tries to escape from his misery by killing him- self ; or when he hears a voice from heaven commanding him to destroy himself. Or, without delusion and without any feeling of wretchedness, there is sometimes an ungov- ernable impulse to self-destruction. Occasion- ally patients kill themselves accidentally, as when in a burst of wild excitement they try to escape from the house by jumping from the window, but such cases are not suicidal in the same sense as the others, for here there was not the intent to destroy life. The quiet cases that say nothing about their suicidal inclination or intention are in reality far more dangerous, and more likely to make a determined effort at self-destruction, than those who speak much about it. Hence we should be very vigilant with these quiet cases. Again, it must not be thought that a patient will not kill himself because he is afraid of being killed by others. On the contrary, this is one of the most common delusions of suicidal patients, and one that is very apt to throw the relatives off their guard. The most frequent modes of suicide are drowning, hanging, starvation, cutting, poison, using firearms, and precipitation. Sometimes SUICIDE AND HOMICIDE. 93 the mere sight of the means of destruction, such as a sharp knife, rouses the suicidal im- pulse in the patient's mind. Similar to suicide is the propensity to self- mutilation, as when the patient tears out his tongue, puts out an eye, or chops off a finger. This is almost always delusional in its origin. Homicidal Acts. Under these we include Homicide. also the less severe forms of assault upon others. Such assaults may be made by a patient when trying to escape from restraint, or they may occur in a paroxysm of acute insanity; in the wild excitement of acute mania, the patient may assault any one near him, without showing the reason that prompts his attack. More frequently it arises from hallucination of hearing, or other delusion, as when the patient thinks the assaulted person has been calling him abusive names or is his enemy. Or it may spring from the mere impulse to kill. In the insanity associated with epilepsy there is often intense irrita- bility; and these patients frequently make assaults, which may even be murderous, upon those near them, on the very slightest provo- cation. 94 THE MIND. Various Varieties of Insanity. The following names forms of .. r r . insanity. are given to the more common forms of insan- ity:— i. Congenital Imbecility and Idiocy. Mental feebleness or defect which has existed from birth or from infancy, — the mind never having reached its proper standard of devel- opment. The term imbecility is applied to the slighter degrees, and the term idiocy to the more marked degrees, of this congenital defect. 2. Melancholia. States of mental distress or suffering, the patient being always more or less wretched or unhappy (mental depression). There may be just the simple feeling of depression or dulness to a greater or less degree; or delusions may be developed, which are of a more or less distressing character, and aggravate the condition. 3. Mania. There is here exaltation or mor- bid activity of the mental powers, shown in excited conduct and speech, usually with delusions, but without any feeling of mental distress. The term monomania is often ap- plied to those cases in which the insanity shows itself mainly in fixed delusions limited to one subject or one set of subjects. SUICIDE AND HOMICIDE. 95 4. Dementia. Mental feebleness similar to imbecility, but coming on in a person whose mental powers have previously been of a healthy standard. 5. General Paralysis. This form of insanity General Pai results from degeneration and wasting of cer-symptoms. tain portions of the brain, and is marked by a combination of mental and bodily symptoms. The disease tends to increase more or less steadily, and is always fatal, the patient usually dying in from two to three years. Mentally there is a gradually increasing enfeeblement, which in the last stage of the disease is very pro- found ; often with periods of more or less acute excitement, delusions of great power and wealth, restlessness, and propensity to steal and hoard rubbish. This delusional condition often prompts the patient to engage in struggles and feats of strength which are beyond his power, and therefore attended with risk of injury. The bodily affection consists in a paralysis, which usually affects in the first place the lips and speech, and gradually extends over the whole body, until the patient becomes utterly helpless. The power of swallowing is more or less im- paired, and there is thus risk of choking when food is being taken. The patient becomes 96 THE MIND. wet and dirty in his habits, from loss of power over the bladder and bowels. The nutrition of the body is affected ; the bones become soft, and are then liable to be fractured by very slight violence. Convulsive seizures, similar to epileptic fits, often occur in general paraly- sis ; and there is also a liability to attacks of congestion of the brain, in which the patient lies unconscious as if in an apoplectic seizure. In the last stage of the disease there is great loss of flesh, bed-sores form, and the patient is in a very miserable plight. Epileptic in- 6. Epileptic Insanity. Associated with epi- lepsy we frequently find attacks of excitement. This excitement may come on before the fits, or after the fits, or may occasionally take the place of the fits ; and it is often of the wildest and most furious character. Delusions are common, and also hallucinations of sight and hearing. There is frequently great suspicious- ness ; and often the soreness and muscular pains which are felt after the convulsive seizure are attributed by the patient to rough usage by those near him at the time of the fit. As already mentioned, there is often intense irri- tability and quarrelsomeness, with great impul- siveness and deficient self-control, leading to SUICIDE AND HOMICIDE. 97 violent and homicidal acts. Sometimes in A marked these violent acts the patient is quite uncon- violence. scious of what he is doing. When epileptic fits recur frequently over a long period, there usually results more or less marked enfeeble- ment of mind. CHAPTER IV. THE CARE OF THE INSANE. THE duties of an attendant on the insane are of a very responsible kind, and he is concerned in looking after both the bodily and the mental welfare of the patients under his charge. Importance Management of the Bodily Condition. Among of attending ° J y ° carefully to the insane, just as among the sane, the mental the bodily ' J & ' health. condition is very largely affected by the state of the body, by its well-being and comfort or by its derangement and discomfort; and every- thing that tends to promote the bodily welfare has a direct and beneficial influence in pro- moting the mental health. Hence in all cases, and more especially in those in which the mental condition is such that the patient can- not take proper care of himself, everything possible should be done by the attendant or nurse, under the direction of the doctor, to preserve the bodily health, — to improve it if necessary, and to keep it up to a proper stand- 98 MANAGEMENT OF MENTAL STATE. 99 ard. In studying the bodily functions (first section of the handbook) we saw the necessity of good ventilation, cleanliness, warmth, suffi- cient clothing, good and sufficient food, regular open-air exercise, undisturbed sleep, etc., for the proper discharge of these functions; and it is necessary to attend to all these matters in the interest of our patients. The attendant Management 1 of the Bod- should keep the day-rooms and the sleeping- iiy condition -i j °* l rooms scrupulously clean, tidy, well ventilated, sane. and sufficiently warm; he should have the bed- clothing thoroughly aired at proper times, and kept clean and dry; and he should see that the patient wears clothing suitable and suffi- cient for the season of the year. Cleanliness, both of person and of clothing, is absolutely essential. The attendant should be very par- ticular in seeing that the instructions of the doctor as to the amount of exercise or work to be done by the patient, the taking of medi- cines, and any other details of treatment, are accurately and punctually carried out. Suffi- cient time should be allowed for the taking of food; there should be no undue haste in re- moving the dishes; and the attendant should see that each patient takes his food in sufficient quantity and in a proper way, duly masticating IOO THE CARE OF THE INSANE. it. Attention to the bowels is necessary ; and this is especially important in cases of epilepsy and general paralysis, for in them derangement of the bowels is often the cause of an increase in the number and severity of the fits, or brings on the " congestive " attacks. During the night all noise or other source of disturb- ance should, as far as possible, be prevented in the sleeping-rooms. All the in- The various conditions which bear upon the sane are _ patients. bodily health have been already fully indicated in previous pages of the handbook; and it is therefore unnecessary to enlarge further upon them here. In the second section of the hand- book instructions are given for special nursing in the cases of more pronounced bodily illness. A good attendant should consider that all the persons under his charge, even when they are not in the hospital ward of the asylum, axe pa- tients in the truest sense of the term, and require special care and management; and many of the general instructions given in the second section are directly applicable in the treatment of all insane persons. Note and re- It is also the attendant's duty to take note changTsyin of any symptoms of bodily derangement or symptoms, failing health, such as cough, breathlessness, MANAGEMENT OF MENTAL STATE. IOI loss of appetite, irregularity of the bowels, wasting of body, increasing feebleness in walking, etc., and to report them without delay to the medical officer, so that any treat- ment which is called for may be begun at once. It is likewise a good rule to examine the patient's person carefully every time he is being dressed or undressed or bathed, and to observe if there are any abnormal appearances, such as bruises, marks of injury, redness, swelling, eruptions on the skin, commencing bed-sores, etc. When found, these should be reported to the doctor at once. Patients of wet and dirty habits should be frequently attended to, and kept as dry and clean as possible ; and any medical directions given to prevent scald- ing of the skin should be carefully carried out. In some cases, especially in the advanced stage of general paralysis and in the stupor which follows a succession of epileptic fits, there is risk of choking, from paralysis of the power of swallowing; and then all food should be given in a soft form, such as minced meat, milk, custards, and the soft part of bread, while hard food, such as crusts, should be avoided. Management of the Mental Condition. The Management ° J of the mental arrangements of an asylum, its discipline and state. 102 THE CARE OF THE INSANE. daily routine, are intended (i) to promote re- covery when that is possible; (2) to secure that the patients shall be kept under due ob- servation ; and (3), in cases where recovery does not take place, to make the surroundings of the patients as favorable, healthy, and com- fortable for them as is possible, consistent with their safety and proper custody. It is therefore the duty of the attendant to make himself familiar with the arrangements and regulations of the institution in which he is serving, and to carry them out in a loyal and conscientious manner. In most asylums the attendant, on beginning duty, receives a copy of the rules applicable to his work; and he should carefully study these rules, and act up to them. For example, in. one or more of the wards the patients may, by direction of the medical officer, receive a very considerable amount of liberty, because it adds to their contentment; certain doors may be left open; and the at- tendants are expected to supervise the patients without the aid of locked doors; while in other wards, where the cases are not so trust- worthy, the doors are kept constantly locked, to prevent the patients passing away from di- MANAGEMENT OF MENTAL STATE. 103 rect observation. In these latter wards the doors should never by any negligence of the attendant be left unsecured at any time. And equally in the former wards the doors should be kept open at the stated times ; and the at- tendant has no right,- unless instructed by one of the upper officers, to lock a door which is meant to be open, simply to save himself some extra bother in looking after a troublesome case. In the same way all the other arrangements importance J ° of the routine of the asylum, which are intended to secure work. the safety or promote the comfort of the pa- tients, should be intelligently carried out ; and the instructions for the routine work, such as raising the patients, the serving of meals, the bathing of patients, and their supervision when at work or taking walking exercise, should be carefully followed. The windows are usually " checked," so that they cannot open wide enough to let a person pass through ; and the shutters in the sleeping-rooms can, when necessary, be securely fastened. In the treatment of individual cases we try Treatment of , , . , . 111 tne different to lead the mind into a more healthy groove mental states of action, to repress morbid acts or habits, and to train the patient to more healthy and 104 THE CARE OF THE INSANE. correct habits. We endeavor to cheer the de- pressed by kindly, sympathetic conversation and conduct towards them, and to divert their thoughts from their distressing fancies by get- ting them to take an interest in the things around them, and by inducing them to engage in active work and amusement when their bodily health permits it. The noisy, turbulent cases should as far as possible be soothed by persuasion and judicious management, and kept from annoying their fellow patients. When the excitement is severe and long-con- tinued, we try to provide a healthy outlet for it in active muscular work or active open-air exercise. With the demented patients the at- tendant has more or less to think for them in everything. He has to see to their being diessed and undressed, to their getting their food prop- erly and going out for exercise, to their being protected from exposure to cold or other dan- ger, and to all the other routine of their daily life. Those patients who are impulsive and way. ward in their conduct should be encouraged to habits of better self-control. Do not With regard to delusions, these should never ridicule deh> be made a subject of thoughtless ridicule or ill-timed jesting. Neither argument, nor ridi GENERAL MANAGEMENT. 105 cule, nor flat contradiction will convince 3 pa- tient of his error; and he may be needlessly annoyed and hurt thereby. It is much better, then, just to ignore the delusions as far as possible. The attendant should avoid bring- ing them up in conversation, or doing anything which leads the patient to think about or ex- press them, and he should try to get the pa- tient to act as if the delusion had no exist- ence. Insane persons do not by any means always follow out their delusions to their logi- cal conclusion. A patient may think he isThew'se kindly and a king or the owner of the whole place, but temperate . ......... treatment of still sees nothing incongruous in helping like patients with , 1 r 1 delusions. any ordinary person in the work of the house, or in taking his orders from the asylum officers; and it is wise to encourage him in this habit, and thus quietly to ignore his delusion. If the patient speaks about his delusions of his own accord, we should just say firmly but temperately that we think he is wrong there, and then try to lead him away from the subject. Nicknames should never Dn any account be given to patients from their delusions, for doing so is just one way of keeping the idea constantly present to their mind. 106 THE CARE OF THE INSANE. All those acts and habits which spring from the diseased mental condition, and which are therefore morbid and unnatural, should be re- pressed as far as possible, and correct habits inculcated in their place. Thus destructive- ness and all other mischievous propensities should be checked. Slovenliness in dress and disorderliness in eating should be corrected, and the patients encouraged to be neat, tidy, and orderly. When food is refused, much may be done by tact in persuading the patient to take it. Sometimes patients, while refusing all food offered directly to them, will yet take readily anything they can steal or pick up un- observed; and advantage may be taken of this peculiarity in getting them to take food. When forcible feeding is required, it should of course be done only under the immediate di- rection of the doctor. The eating of leaves, cloth, and other improper things, should be prevented, for the patient may thereby injure himself seriously. Some general paralytics are especially apt to eat ravenously, stealing the food from the plates of other patients, and cramming it in great pieces into their mouths, at the risk of choking themselves ; and this propensity should be guarded against. Dress- GENERAL MANAGEMENT. 107 ing fantastically in obedience to a delusion should not be permitted. When wet and dirty habits are due to the mental condition, not to bodily paralysis, much may be done by assidu- ous attention from the attendant, and by train- ing the patient to attend to the calls of nature at certain regular times, to get him into more correct habits. This training to proper healthy habits not Promote only promotes the comfort of the patient, but s° has a very direct effect in improving the men- tal state. And the attendant's exertions repay themselves well in the end, for the time and trouble bestowed on the patient at first save still more time and still more trouble with him afterwards, as well as prevent the discredit at- tached to his being found in an unsatisfactory state. The daily routine of the asylum is meant to help in carrying out these various indications for the treatment of the insane. The regular hours for rising, taking food, work, exercise, amusement, and retiring to bed, are beneficial not only to the bodily health, but also to the mental state, in making the patient lead a regu- lar life, and educating him in good habits. Occupation is a most important means in the 108 THE CARE OF THE INSANE. importance treatment of our patients. It is not the of regular ■* occupation, amount and value of the work done that is here considered — it is that suitable occupa- tion, however simple in itself, by exercising alike the bodily and the mental powers, has a most salutary effect on both the body and the mind. It diverts the patient from his morbid fancies, and leads his thoughts into a healthy channel. Hence, whenever the bodily strength allows of it, we should try to get the patient to occupy his time usefully and engage in some work that is suitable and congenial to him. Such occupation is found in housework, in the garden or workshops, on the farm, in needle- work, in the laundry, in drawing, writing, or any other work which the patient is able for. It is not enough for the attendant to take the patient out with the working party, and then let him lounge about idly: he ought rather to make diligent efforts to get every patient to engage in some steady work, however simple that may be. The willing must not be over- tasked ; and the idle are to be induced to work. Amuse- Suitable amusements, such as dancing and ments. r . . games, are of value in introducing variety and interest into the life of the patients; and as GENERAL MANAGEMENT. 109 many of the patients as possible should be en- couraged to join in them. The amount of liberty allowed to each patient Liberty, - 111,. . r guard again: is ot course regulated by the instructions of escapes. the doctor. Escape should as far as possible be prevented by watchfulness on the part of the attendants. Certain patients show them- selves more prone to escape than others ; and they of course require to be specially looked after. General paralytics, in the early restless stage of their disease, often make numerous attempts to escape in a foolish, aimless way. When an attendant takes a number of patients out for work or walking, he should know ex- actly how many are with him, and should on his return see that all have come back with him. It is a good practice also to go over the patients when they are at table, and at bed- time, and to see from the unoccupied chairs and beds if any are missing. The risks of suicide and homicide must be Precautions guarded against. When the suicidal propen-luidde. sity is known or suspected, the doctor usually gives instructions for the patient to be placed under special observation — that is, to be kept under the direct and constant supervision of one or other of the attendants. When this IIO THE CARE OF THE INSANE. Precautions order is eriven, the attendant should carry it against ° Suicide. out faithfully. There should be no negligence, no allowing the patient to wander away from the room and get out of sight for a longer or shorter time, and no relaxing of the watchful- ness without direct permission from the doctor, for there is no knowing when or how a suicidal patient will attempt to carry out his intention. In passing him from the charge of one to another, the first attendant should, before relinquishing duty, see that the second attend- ant has duly taken him under his care. Such articles as scissors, razors, knives, etc., which may be used for suicidal purposes, should be carefully kept out of the patient's way. It is well to have these articles safely locked up when not in use. They should be counted when given out for use, and again when taken back, so as to ensure that none are left out. All medicines should be kept in a place of safety. It may be necessary to examine the patient's pockets and clothing at frequent times, to see that he has not succeeded in secreting anything that may be used hurtfully. Melancholic patients are often at their worst in the early morning, just after waking a.id before food has been taken ; while after break- GENERAL MANAGEMENT. Ill fast, and as the day wears on, they get less wretched, and the suicidal desire is less marked. It is necessary, then, to see that the supervision is kept up carefully in the early morning, just as at other times ; and it is often advisable to give the patient some food, such as a cup of milk or warm coffee, immediately on his waking. Homicidal assaults may best be guarded Precautions . . against against during the day by having the patient Homicide. suitably occupied, by judicious supervision, and by having a sufficient number of attend- ants to be able to control the patient thor- oughly if required; while at night the patient may be made to sleep in a room by himself. When a dangerous patient has a special dislike to any attendant or patient in the same ward, it should be reported to the doctor, who will separate them by removing one or other to another ward. The irritability after epileptic fits is often best treated by persuading the patient to lie down in bed and rest quietly away from his fellow-patients. Struggles with patients should always be Avoid ._,...- struggles. avoided if possible. This is, for reasons already indicated, particularly important in the case of epileptics and general paralytics, 112 THE CARE OF THE INSANE. Never use When it is necessary to use force, the attend- force single- 1,1 i • 1 handed. ant should not, unless there is no help for it, attempt single-handed to struggle with the patient. It is far better to summon assistance and get several attendants together, when the patient, seeing that resistance is useless, will often submit quietly; or, if a struggle is still necessary, the patient can now be mastered thoroughly and with sufficient ease, so that the risk of his receiving any injury during the struggle is lessened as much as possible. In- experienced attendants often think it a weak thing to get assistance, and pride themselves on managing a troublesome patient without aid from others. This is a grave mistake. It leads to personal struggles with patients, which ought never to occur; and these struggles are often dangerous to both parties, and are always injurious by the bad feeling they create. In certain circumstances, indeed, it behooves the attendant simply to leave the patient and get out of his way; and there is not only no cow- ardice, but there is real wisdom, in such a course, if the patient, while morbidly irritable and quarrelsome, can be safely left alone. Struggles with patients ought to be immedi- ately reported to the doctor. GENERAL MANAGEMENT. 113 Other exigencies in particular cases call for other # appropriate management. Thus, with newexlgene patients it is well to keep them under more particular observation for a time at first, until their propensities can be known, and a trust- worthy idea formed regarding their mental state. In the insanity of old age there is often great restlessness, along with great bodily frailty. This increases the risk ot accidental injury ; and sometimes the restless- ness is so incessant as in itself to exhaust the patient's strength. These dangers must be guarded against, and the patient got to rest as much as possible. Epileptics should be pre- vented from engaging in work or getting into situations (such as going too near an unguarded fire or being left alone in the bath) which would be dangerous if a fit were to occur. Treatment which benefits the fits has usually a correspondingly good effect on the mental state; and any medical directions given with this view should be carefully carried out. When par- alysis is present, it is necessary to guard the patient more carefully from risk of injury; the bodily health has to be specially looked after; and the danger of choking, of scalding from the wet habits, etc., has to be kept in mind. 114 THE CARE OF THE INSANE. Report As with the bodily, so with the mental state, changes in . , . , . the mental the attendant should endeavor to notice any state. , , changes or new symptoms, such as greater restlessness, greater dulness, any delusions expressed, attempts to escape, or other pecu- liarities of conduct, etc., and should report them to the doctor at his next visit. Attendants In their personal intercourse with the pa- outtheir tients, the attendants should remember that firmness, example is better than precept. They should constant'self-themselves, therefore, be examples of neatness, tact.r°' a" punctuality, and orderly conduct; and should always bear themselves with courtesy and respect towards both their fellow-attendants and the patients. Few persons can exercise control over others, especially if they are weak, without tending to abuse it; and the position of authority in which attendants are placed is specially apt to be abused by coarse and unfeeling persons. This must be guarded against, and attendants should bear in mind that the power over their unfortunate fellow- creatures entrusted to them is to be exercised always justly and considerately, never for the purpose of gratifying any personal wish for retaliation, or the mere vain-glorious desire of lording it over others, but always with a single GENERAL CONDUCT OF ATTENDANTS. 115 eve to the welfare of the patient. They should The insane 1 , , • r 11 not fully re" remember that the insane are not fully respon- sponsible. sible for their actions, and should therefore not resent rude language or rough conduct from them, but show constant self-control and kindliness as well as firmness towards them. It is most difficult to distinguish the annoying speech and conduct of many insane pa- tients from the bad conduct of sane people, which would deserve punishment. For such insane conduct attendants must never, on any account, resort to punishment. They should report it fully to the doctor, and he will adopt the proper means for checking it in a medical way, which will have far more effect than the summary treatment of an attendant, just as society is far better governed by a magistrate dealing with offenders than by each man taking the law into his own hands. Attend- ants should not make a promise to a patient unless it is to be fulfilled. They should try to Sympathetic . . and consider- win the confidence of the patients by sympathy, ate treat- kindness, and due consideration for their feel- ings. They should not hold themselves aloof from their charges, or be content with super- vising them, but should join heartily in their occupations and amusements, and work both Il6 THE CARE OF THE INSANE. Personal m- with and for the patients. Much may be done fluence. . . by personal influence ; and a patient will otten be docile and quiet with one attendant who guides him in the right way, when under another attendant he would be very trouble- some. When it is necessary to refuse requests by patients, or to enforce control over them, attendants should constantly refer to their "rules" as their reason for doing so, rather than their own will, for thus there is much less feeling of irritation roused in the patient. Above all things, remember that " a soft answer turneth away wrath." No maxim is of more value in dealing with the insane, or will save an attendant more trouble in the end. These duties call for the exercise of much tact, that knack of knowing how best to manage a patient, which cannot be taught on paper, but which can be acquired when there is forgetfulness of self and an earnest desire to do the best for the patient. ATTENDANCE ON THE INSANE IN PRIVATE HOUSES. Home The attendance on those suffering from Treatment. it • i • mental disease in their own homes, or in lodgings, is now one of the recognized IN PRIVATE HOUSES. II7 branches of nursing. Few patients in the higher classes are sent to asylums without home treatment having been tried in the earlier stages of the disease. A good attend- ant is of incalculable value in the home treat- ment of a case of insanity. Through such services, attacks may be cut short, infinite anxiety and risks saved to patient and rela- tives, accidents avoided, suicides averted, and valuable lives restored to reason. The chief differences between treating a Differences , , . . 1 <• i between case at home and in an institution are the fol- Home and . . Institution lOWing :--- Treatment (1) Less help can be got either from fel- low-attendants or doctors, and therefore more forethought and observation of the patient's symptoms more resource and self-command, are needed. (2) The risks are far greater from stairs, open windows, razors, knives, etc.; and therefore the first thing an attendant in charge of a patient at home must do, is care- fully to obviate such risks, by taking posses- sion of keys, removing bolts from inside of water-closets, checking windows, arranging for rooms on the ground floor, and putting away knives and razors. (3) The difficulties of getting the patient to take food, medicines, Il8 THE CARE OF THE INSANE. Differences and exercise, are much greater; therefore, i{ Home and these things can't be done by tact and persua Treatment, sion, the patient will probably have to do with less of them than he needs. A patient will usually be found to be much worse to control in his own house than anywhere else, and more apt to resist interference with his liberty. (4) The relatives of the patients will often be suspicious, or lose their heads from fear, or be fussy or positively obstructive ; therefore an attendant must be patient but firm with the relatives and friends, and above all things get- ting the doctor in attendance to give explicit orders for the course adopted, and to take the responsibility of the instructions required. It is in many cases better if the doctor will sug- gest that the patient should be left with his at- tendant without relatives coming in to inter- fere too much. (5) The labor is more ex- hausting, being often night and day work. An attendant should tell before his own strength and nerve are giving way and ask for assistance. (6) A good attendant can help the doctor in attendance greatly, by keeping a daily written note of : (a) the food taken, (b) the amount of sleep, (c) the length of time in the open air, (d) the patient's tempera- IN PRIVATE HOUSES. 119 ture, (