'■' ' '•'rt'S-'t' '-'' :'5*'>>'.-t'••."; -jy*-'-'* r» >. te -V?. . ■W«LW' •/'/■• ^W^m S.12 WITHDRAWN ■rue MEW YORK ACADEMY ™0EF MEDICINE LIBRARY NATIONAL LIBRARY OF MEDICINE Bethesda, Maryland Gift of The New York Academy of Medicine NURSING AND CARE OF THE NERVOUS AND THE INSANE BY CHARLES K. MILLS, M.D. PROFESSOR OF NEUROLOGY IN THE UNIVERSITY OF PENNSYLVANIA NEUROLOGIST TO THE PHILADELPHIA GENERAL HOSPITAL THIRD EDITION REVISED by the author, assisted by N. S. YAWGER, M.D. INSTRUCTOR IN NEUROLOGY IN THE UNIVERSITY OF PENNSYLVANIA ASSISTANT NEUROLOGIST TO THE PHILADELPHIA GENERAL HOSPITAL L COPYRIGHT, 1887, BY J. COPYRIGHT, 1904, BY J. COPYRIGHT, 1915, BY J. B. LIPPINCOTT COMPANY B. LIPPINCOTT COMPANY B. LIPPINCOTT COMPANY PRINTED BY J. B. LIPPINCOTT COMPANY AT THE WASHINGTON SQUARE PRESS PHILADELPHIA, XI. S. A. PREFACE TO THIRD EDITIOK In the present edition of this work the author, with the assistance of Dr. Yawger, has endeavored to bring it more nearly up to date. Such a book cannot be regarded as giving all the information necessary to be known by nurses concerning patients suffering from nervous and mental maladies. Useful anatomical and physiological data are to be found in the volumes upon anatomy prepared for nurses and in more general treatises. The book is chiefly intended to recall facts regarding nursing obtained by experience. Attention has been particularly directed to some new facts regard- ing epilepsy, fibrositis and insanity. New illustrations of the charts and the apparatus most useful in electrical practice have been added. The unusually fine motor- point plates from Dr. Toby Cohn's excellent work on "Electro-diagnosis and Electro-therapeutics" have been obtained through the courtesy of the author and his publishers. Instruction regarding hydrotherapy, not included in previous editions, has been incorpo- rated. The author trusts that the book in its revised form will be found more useful than previous editions. Philadelphia, July 24, 1914. PREFACE. The contents of this little book are the substance of a course of lectures delivered first at the Training School for Nurses of the Philadelphia Hospital, and subsequently at the Woman's Hospital Training School for Nurses, of Philadelphia. While books upon nursing are numerous, and a few valuable, no work devoted especially to the nervous and the insane had, so far as I know, appeared prior to the delivery of these lec- tures. Within the last few years, however, several books upon the care of the insane have appeared in England and in this country; but none on the nursing of patients suffering from either functional or organic nervous diseases, not forms of insanity. I have, there- fore, felt that this little book might fill a want and serve a purpose. In no class of cases is it more impor- tant for a nurse, care-taker, or companion to have good principles of action and clear notions of practice, thaD among patients suffering from nervous or mental affec- tions. Many of these unfortunates require prolonged and elaborate treatment, much of which necessarily must be carried out in the absence of the physician. I have frequently been asked by nurses where they could obtain, in compact form, some information as to the care of such patients, and also as to the use of 3 4 PREFACE. massage, electricity, bathing, etc., by nurses. Many books upon electricity and massage have been published, but these are either too voluminous, containing too much scientific or theoretical matter, or they are not adapted to the comprehension and purposes of nurses. They are nearly all, especially the works upon electricity, books for physicians. Some books upon nursing con- tain suggestions or directions as to apoplexy, drunken- ness, hysteria, epileptic seizures, etc.; but it will be found, on comparing these works with the present vol- ume, that considerable additions have been made. CONTENTS. CHAPTER I. PAGE Qualities and Qualifications of a Good Nurse for Nervous Patients—Social Service—General Management of Hys- teria—Hysterical Seizures—Epileptic Seizures—General Management of Epileptics—Diet for Epileptics—Forms of Insensibility—Cases of Chronic Organic Nervous Disease—Sleeplessness—Delirium—Diet —The Alcohol, Opium, or other Narcotic Habit............ 9 CHAPTER II. Massage—Movements................. 46 CHAPTER III. Hydrotherapy—Sponging—Hot and Cold Packs—Salt Rub— Continuous Bath.................. 65 CHAPTER IV. Forms of Electricity—Faradic Apparatus—The Mechanism, Management, and Care of Faradic Apparatus—Hints, Cautions, and Contraindications in Using Electricity— Electrodes—Conducting Cords—Methods of Applying Electricity—Motor Points............... 70 CHAPTER V. The Nursing and Care of the Insane........... 96 5 LIST OF ILLUSTRATIONS. FIG. PAGE 1. Continuous Bath................. 69 2. Faradic Battery................. 73 3. Dubois-Reymond Coil with Galvanic Apparatus ... 74 4. Faradic Apparatus for Office Table........ 77 6. Box of Electrodes................ 86 6. Method of Holding Electrodes in one Hand .... 87 7. Motor Points of Arm, Anterior Surface...... 90 8. Motor Points of Arm, Posterior Surface...... 90 9. Motor Points of Thigh, Anterior Surface..... 90 10. Motor Points of Thigh, Posterior Surface..... 90 11. Motor Points of Leg, Anterior Surface...... 90 12. Motor Points of Leg, Posterior Surface...... 90 7 THE NURSING AND CARE OF THE NERVOUS AND THE INSANE. CHAPTER I. Qualities and Qualifications of a Good Nurse for Nervous Patients—Social Service—General Management of Hys- teria,—Hysterical Seizures—Epileptic Seizures—General Man- agement of Epileptics—Diet for Epileptics—Forms of Insensibility—Cases of Chronic Organic Nervous Disease— Sleeplessness—Delirium—Diet—The Alcohol, Opium, or other Narcotic Habit. The nursing and care of the nervous and the insane call for special training in a high degree; and yet it is difficult to systematize and formally set forth instruc- tions and regulations for such nursing. In fever, sur- gical, obstetrical, and other forms of nursing, much of the training has reference to instruments, dressings, temperature records, etc., to things which can be seen, handled, and illustrated. In the training of those des- tined to care for the nervous and the insane, a certain amount of instruction as to machinery and manual pro- cedures must be given; but much of the teaching, from the very nature of the cases, must have reference to the 9 10 THE NURSING AND CARE OF conduct, habits, and characteristics both of nurses and patients. In order, in the four chapters of the present book, to cover in a practical way my entire subject, I will not be able to give much time to theoretical considerations, and I believe that it is best that this course should be followed. While it is an advantage, and sometimes an important one, for non-medical attendants upon the sick to have some acquaintanceship with anatomy and phys- iology, or other branches of medical science, the amount of knowledge of this description absolutely requisite is limited. The first chapter will be devoted to a consideration of some of the personal qualities and qualifications of nurses for nervous cases, and to certain miscellaneous matters in connection with nervous nursing; in the second, massage, movement, bathing, and certain in- struments will be treated of; the third will discuss electricity; and the fourth will be on the nursing and care of the insane. Diseases of the nervous system cover an enormous field and experience has taught me that while nurses who are called upon to care for the nervous and the insane may be needed to aid the doctor in almost any one of the long list of nervous and mental disorders, a rough attempt at arranging the different classes of cases in which they are most likely to be employed can be made, based upon the special qualifications which will be required, and the particular duties that will be imposed. First come the cases of functional nervous disorders, so THE NERVOUS AND THE INSANE. H called, under which head are included cases which fur- nish an important field for nurses thoroughly trained for their work,—patients suffering from hysteria in its manifold shapes; the neurasthenic or nervously ex- hausted ; neurotic people in general, some of them on the border-land between sanity and insanity ; the sleep- less, the neuralgic, and the choreic. In the second place, we find patients suffering from some forms of insensi- bility and from certain acute organic affections,—cases of apoplexy, of uraemia, of sunstroke, of cerebro-spinal fever, of acute meningitis, tetanus, etc. Thirdly, there are certain cases of chronic, organic nervous disease, some curable and some incurable,—patients afflicted with meningitis cerebral or spinal, the victims of tumor of the brain or spinal cord, the hemiplegic, the para- plegic, or sclerotic, and the sufferers from atrophic or wasting diseases. Under a fourth head are included all cases of insanity. At the outset let me speak briefly of some of the qualities and qualifications of a nurse for nervous pa- tients. My first remarks will apply more particularly to those who will have under their care the sufferers from hysteria, neurasthenia, and other functional ner- vous disorders. The care of these patients is in some respects one of the highest forms of nursing. They sometimes undergo a method of treatment which involves, among other things, more or less complete seclusion from all but physicians and attendants; and, confined to their rooms for weeks or months, almost isolated from the rest of the world, their care demands 12 THE NURSING AND CARE OF high qualities and qualifications in the companion and care-taker. Let me here quote the words of one1 whose wide ex- perience entitles him before all others to speak as to the trials and qualifications of those to whom fall the care of the nervously sick : " A life spent beside such a sick-bed is indeed a test alike of character and health. It requires a strong body and a fortunate balance of moral and intellectual qualities to escape from being made morbid by constant contact with such suffering; and intensely sympathetic people are surely hurt by it, and themselves grow mor- bidly sensitive. Where the unhappy invalid becomes exquisitely ill-tempered under the long pangs of illness, the constant nurse must endure a thousand petty trials of temper, and must know when to yield and when to resist the tiny and numberless oppressions of her sick tyrant; but incessant battle with one's self is exhaust- ing, and soon begins to show its results upon the health- iest nurse, cooped up in the sick-room. A pallid face, loss of energy, a certain passive obedience to routine duties are the sure consequences." While the fundamental qualifications for a good nurse for nervous patients are those for a good nurse of any description, it is important that she should have a few special qualities, and should be free from a few particular faults and foibles. It is in the highest degree impor- tant that she should possess the quality called tact, so i " Nurse and Patient," by S. Weir Mitchell, M.D., LL.D. THE NERVOUS AND THE INSANE. 13 often wanting in all walks of life. " Tact," says Dr. Anderson,1 " is a quality not easily defined; but if we go back to the original meaning we can construe a de- finition upon it. It means, literally, touch,—the touch of skill and experience. But it has a wider signifi- cance; it includes the mental touch, something more complete than the other; not a touch merely, but a grasp, —the grasp of the situation, the comprehension of a difficulty, the grasping of it on all sides so that it dis- appears in your hands." A domineering nurse will not succeed, while a decided one will have the best chance of success. Firmness should be combined with gentleness and fairness, and a genuine good temper is invaluable. Habits of close ob- servation should be particularly cultivated. The nurse should carefully note differences in the condition of the patient when the doctor is present and when he is absent; and any tendency to deceive or simulate symptoms should be quietly reported. She should be especially careful not to talk too much to the doctor about the patient before the latter. It is often best for her to retire from the room when the doctor is present, in order to give him an opportunity to talk to the patient in private. A good nurse will soon learn to discriminate as to when she should go and when she should stay, and when and how she should make her report. It often falls upon the nurse to carry out plans and 1U Lectures on Medical Nursing," by J. Wallace Anderson, M.D. 14 THE NURSING AND CARE OF invent expedients for amusing and occupying the pa- tients. She should, therefore, have intelligence and education to be able to interest her patient by either conversation, reading, or other measures. She may fail in this respect by attempting to do too much, or by having an erroneous notion of her own powers. A good reader may interest patients of a certain class; a bad one may torture them. Judgment in carrying out directions as to amusement and occupation will call for exercise of high qualities. If reading is permitted, the right books should be chosen; if cards are resorted to, they should not be made a source of excitement instead of relief; whatever the occupation or amusement, it should be such as is adapted to both the physical and mental conditions of the patients. In many cases the nurse can persuade the patient into usefully occupying moments which would otherwise be passed in intro- spection. " The nurse for these cases," says Mitchell,1 " ought to be a young, active, quick-witted woman, capable of firmly but gently controlling her patient. She ought to be intelligent, able to interest her patient, to read aloud, and to write letters. ... It is always to be borne in mind that most of these patients are over- refined, sensitive women, for whom the clumsiness or want of neatness or bad manners or immodesty of a nurse may be a sore and steadily-increasing trial. To be more or less isolated for two months, in a room with 1 "Fat and Blood: An Essay on the Treatment of Certain Formi of Neurasthenia and Hysteria," by S. Weir Mitchell, M.D., LL.D. THE NERVOUS AND THE INSANE. 15 one attendant, however good, is hard enough for any one to endure; and certain quite small faults or defects in a nurse may make her a serious impediment to the treatment, because no mere technical training will dis- pense in the nurse, any more than in the physician, with those finer natural qualifications which make their training available." "What is required," says Playfair,1 in a similar strain, " is a woman of kindly disposition and pleasant manners, and of sufficient intelligence and education not only to fully appreciate and second the object of the medical attendant, and to report to him the peculi- arities of each individual case, but also to form an agreeable companion to the patient during her long seclusion." A good nurse will always be loyal to the doctor; and indeed, to be loyal to him is always the best service to the patient. "Loyalty to the doctor," says Miss Weeks,2 very forcibly, " includes encouragement of the patient's faith in him, so long as he is in charge of the case. The imagination is so largely active in disease that to infuse a doubt and distrust into the patient's mind is often to destroy all hope of doing him good. The nurse is a connecting link between doctor and patient, responsible to the one, and for the other, and can do much to promote good feeling between them." These words apply with particular force to nervous patients. 1 " The Systematic Treatment of Nerve Prostration and Hys- teria," by W. S. Playfair, M.D., F.R.C.P. » " A Text-Book of Nursing." Compiled by Clara L. Weeks. 16 THE NURSING AND CARE OF Having detailed some of the qualities and qualifi- cations of a good nurse, let me picture some of the types of faulty nurses,—at least so far as the care of nervous patients is concerned; some of them faulty for any form of nursing. There is the nurse who talks too much. For some nervous patients, par- ticularly for those who are just commencing a long course of treatment by rest and seclusion, too much talking on the part of the nurse is a serious drawback. With the constitutionally talkative nurse it is worse than useless to attempt to correct the habit. She will talk in season and out of season, and is usually unable to curb this propensity even in the presence of the physician ; indeed, she sometimes seems to exhibit it as one of her greatest acquirements. On the other hand, I occasionally meet with a nurse who does not talk enough; or who never says anything when she does open her mouth; that is, an individual constitutionally wanting in conversational powers. Either of these extremes is bad. It is well that a nurse for nervous patients should talk sensibly, intelligently, and with judgment. An abomination of abominations is the habit which some nurses have of informing the doctor as to the ex- act nature of the patient's disease; telling him that the case is one of hysteria; whispering an opinion as to its treatment in a mysterious manner; or boasting of some wonderful discovery with reference to the patient. The too familiar nurse is also an abomination. Thr >wn closely in contact for weeks, and it may be for months, it is natural that a patient isolated from family THE NERVOUS AND THE INSANE 17 and friends should become attached to the nurse who is kind and sympathetic, and at the same time firm and just. Even some affection may at times grow between the patient and the nurse; but it is the duty of the nurse, while neither morose nor distant, to preserve a quiet dignity and reserve of demeanor. The typical, natural, heaven-sent nurse will know just what to do in mat- ters of this kind, but a few hints may be of value to some, who, although possessing many virtues, are not celestially endowed. While it is of the utmost importance that all nurses should pay proper attention to personal appearance, the nurse who is vain and devotes too much of her time to self-adornment is especially obnoxious to nervous pa- tients. She should not spend more time in preparing herself for exhibition than she does in attending to the interests of her patient. The conceited nurse is a sore burden, but the nurse who is too humble is almost as bad. The nurse has her rights and a certain position to sustain. It is for her, like the soldier, to serve willingly and well, but not meanly and with mock humility. The nurse who comes from a " good family" is some- times a very good nurse, but may nevertheless be a sore trial to patient and physician. On the whole, it is not a bad thing to have had respectable ancestors; it is not to be placed to one's discredit if one's progenitors have been men and women of distinction; but it is better that this fact should appear in good breeding and bear- ing rather than that it should be reiterated into the earn of all comers. 2 18 THE NURSING AND CARE OF The nurse who assures you that she is nursing sim- ply because she loves the business is particularly un- fitted for the care of nervous patients. Such an asser- tion generally means that the one making it either only half believes in, or is half ashamed of, her vocation. While nursing should not be regarded from a mer- cenary point of view, while those engaged in it should love it for its own sake as well as for what it brings, it is a business, and, at least, the effort should not be made to impress the outside world that an individual who is receiving twenty dollars or more a week is actu- ated wholly by philanthropic niotives. Such an effort will usually fail, particularly with those who settle the bills. The nurse who quarrels with the servants is often a nuisance; although I must say on her behalf, that in my experience the latter are most frequently the ag- gressors. In the rest treatment, and in some other lines of nursing, the nurse is required to look after some special matters of diet, sometimes at unseasonable times, or to otherwise disturb the normal equilibrium of house- keeping. Servants naturally dislike those who, while not in the same position as the family, are on a plane Higher than themselves. A nurse with tact and com- mon sense who starts right in a family—except in special instances where an angel from heaven could not get along with the cook or chambermaid—will usually be able to at least so steer her course as not to come in actual violent collision with the servants; but she who attempts to put on airs or to lord it over the denizens of the kitchen will usually be badly routed in the end. THE NERVOUS AND THE INSANE. 19 Before taking up special matters of nursing, let me say finally that I have noticed occasionally too great a disinclination on the part of the nurse who has been accustomed to a certain line of cases, to step out of that which she considers her particular sphere to take hold if patients of any other type. I regard it as a high (juality in a nurse to be willing to turn to any form of nursing in her general line in an emergency. Nurses are not to blame for wishing cases of a class to which they have been accustomed, or for which they have tried to especially prepare themselves; but the practice of some of refusing, sometimes in an offensive way, to take anything unless they can get exactly what they wish, usually shows weakness of character, which will interfere with full success in their vocation. Let me give here the views of a patient whom I asked, both because of her unusual intelligence and her experience with nurses as a patient, to give me her idea as to what should be said to a nurse just starting on her career. The physician has his point of view, the patient has his or hers, and by combining and comparing both the nurse will perhaps get a clear conception of what the world thinks and expects of her. " As the nurse is about to start out on her own re- sponsibility and merits, let her realize that she is now a business woman, and a part of a great profession, and she should never let herself drift from this reali- zation. She should take the very highest view of her work and stick to it through everything. She will then not only do a high grade of work, but will avoid 20 THE NURSING AND CARE OF many difficulties of which she knows nothing when starting out. And the highest view of her work is this, that she is to help fight disease. When she goes to a case it should make no difference to her whether the patient is a man, woman, or child; whether rich or poor, ignorant or educated. She should let no per- sonal consideration, aside from doing good work, creep into her ambition. When she is at work her patient's welfare comes first, and her ultimate recovery is the goal towards which all the nurse's efforts should be directed. No false idea of what is suitable to her position should stand in her way to mar her singleness of purpose. Whatever is for the patient's good is suitable for the nurse to do. " One of the best nurses I ever knew, and it is need- less to say a successful one, worked with her patient for weeks on a farm at every variety of farm-work. She became quite skilled in handling a spade, and many a night went to bed with an aching back after hours of weeding, and she did it all in a manner that inspired interest and pleasure in the work. This nurse was a strict observer of all forms of professional etiquette, but had a broad enough view of her work to be willing to hoe a row of corn as well as to adminis- ter a dose of the more usual kinds of medicine. " If her work becomes uninteresting or monotonous, the nurse may be sure that one of two things has taken place. Either she is tired and needs a rest and change, or she is not working intelligently. A Ger- man philosopher says that the world is a mirror, and if a donkey looks into it he cannot expect to see the THE NERVOUS AND THE INSANE. 21 face of a sage looking out of it; and this can always be applied to ourselves. One gets out of his work what he puts into it. " It is important never to deviate from a strictly professional relationship towards a patient and the household into which the nurse may enter. She can be the cause of much inconvenience and discomfort in a family, and herself be most unhappy, if she has a mistaken view of her own position. She is there for a definite purpose, which should occupy her whole attention, and she should not be concerned with any- thing outside of this." Within the last few years a new field has been opened up to the nurse: that of social service work. For this purpose the special training obtained by a few months' experience in a hospital for mental diseases is desirable. There are a number of obsessed persons, psychasthenic and neuropathic individuals who may be cared for at home. Under good hygiene in general and good men- tal hygiene in particular, such persons may be almost or quite self-supporting. In others who may be dis- charged from insane hospitals before completely recov- ered, but in whom further detention is undesirable, the " follow-up " plan is a most fruitful field for the nurse with this special training. I shall now briefly consider the management of hys- teria and epilepsy. These are two of the most important functional diseases of the nervous system, and their nursing and treatment call for the exercise of unusual skill and discrimination. First, before all, let me cau- tion the nurse not to make the diagnosis of hysteria. 22 THE NURSING AND CARE OF Even physicians of large experience sometimes find it difficult to make a correct diagnosis in alleged hysteria, and it is a source of either amusement or amazement to me to see the self-confident nurse glibly pronounce a patient that she has seen perhaps once or twice as hysterical, or as an hysterical fraud. On the whole, I would advise the nurse never to use the word hys- teria at all. To be hysterical is certainly not a disgrace; it is a condition into which the best of women, or, indeed, of men, may fall; but the idea which hysteria conveys to the common mind is too often that of sham- ming or fraud. Nine patients out of ten will feel that they are insulted if, in the midst of nervous suffering, they are called hysterical. It is a foolish thing in a nurse who has charge of a patient suffering with hysteria to give way to every whim and fancy of the patient; and yet, on the other hand, she cannot by denunciation or harsh measures get rid of the inconvenience and care which such patients inay give her. She should not do too much on her own responsibility in the way of severe treatment. The nurse may be called up three or four times during a night, or in some other way may be sorely tried, but all that she can do is to be watchful and careful, and if she finds that a patient is disposed to make things uncomfortable, by some mild but positive words or measures try to prevent her. She must not, as has been done in some cases, plunge the patient into a cold bath without direc- tions from a physician. The one to use threats and severe measures, if these are resorted to at all, is the physician. THE NERVOUS AND THE INSANE. 23 It may be a question sometimes whether a patient is suffering from a hysterical or from an epileptic fit, and this doubt is not always easy of solution, although usually the two affections can be separated. Hysterical seizures differ in character. Sometimes they are pur- posive or voluntary,—that is, they are completely under the control of the patient, by whom they are induced or feigned; at other times they are as completely be- yond the control of the will as are the convulsions of epilepsy. The simulated or foolish fits of hysteria can generally be recognized. The screaming, shouting, and violent movements of the patient, at the same time that, perhaps, she can be discovered closely watching others, will put the physician or nurse on guard. Some of the involuntary hysterical attacks, the par- oxysms of hystero-epilepsy so called, closely resemble true epilepsy. These attacks are in some respects grave, although they are not either as incurable or as tempo- rarily dangerous to life as genuine epilepsy. In the purposive or simulated hysterical fits consciousness is never lost. In the hystero-epileptic, or grave hysterical attack, however, it is not strictly true to say that loss of consciousness does not take place. It does occur, but there is a difference between the loss of conscious- ness in epilepsy and that in hystero-epilepsy. The question of consciousness is one of grade and degrees. A patient may be more or less unconscious. In epilepsy the unconsciousness is complete, profound, and per- sistent. In hystero-epilepsy consciousness is lost com- pletely during only a short phase of the attack. The hysterical or hystero-epileptic patient rarely bites the 24 THE NURSING AND CARE OF tongue, while this accident commonly happens in epi- lepsy. I have observed in hystero-epileptic cases that whether the patient is or is not responsive to ex- ternal impressions the countenance usually retains an unusual placidity. On one occasion, at the German Hospital in Philadelphia, I watched for more than two hours the frightful contortions of a typical hystero- epileptic ; and, although during this long period she got into almost every imaginable grotesque and extraordi- nary position, during all the time her countenance re- mained as placid as a summer morning. A nurse, or even a physician, sometimes makes a mistake with reference to the diagnosis between an epi- leptic and an hystero-epileptic seizure through igno- rance of the fact that sometimes the patient is the victim of both hysteria and epilepsy. A patient so afflicted is sometimes designated as a case of hystero-epilepsy, with separate crises. In the wards for diseases of the nervous system in the Philadelphia Hospital was a female patient who has had at long intervals well-mark ad epileptic seizures, accompanied by profound unconscious- ness with biting of the tongue. In addition, however, at more frequent intervals she had had violent hysterical outbreaks. In such a case as that the nurse who is not well informed about such matters might readily make a mistake. The nurse should have a clear idea of the character- istics of a genuine epileptic seizure. Usually such an attack comes on very suddenly, often preceded by a cry of pain or great fright. The patient falls suddenly with great force, sometimes in the most dangerous places. THE NERVOUS AND THE INSANE. 25 Convulsions then begin. Usually theyare at first what is termed tonic,—that is, the limbs and body become rigid and immovable in certain positions. Then the so-called clonio movements occur,—that is, the patient is violently twisted, contorted, and tossed about. Fre- quently these movements begin in one limb or part and extend rapidly until all portions of the body are in- volved, and the convulsion becomes general. The face, at first pale, changes to red, gray, or purple, or becomes absolutely livid ; or alternates between pallor, flushing, or lividity ; the pupils are dilated and fixed; the eyes are frequently turned upwards; the patient froths at the mouth, ejecting often a mixture of saliva and biood. The tongue is bitten generally early in the seizure. The breathing is irregular and sometimes stertorous. The attacks vary in length, always seeming longer than they are, usually not lasting more than a few minutes at most. As the convulsive movements cease the patient sometimes becomes semi-conscious, but continues much dazed, or more commonly falls into a profound stupor. Sometimes urine is passed unconsciously, or the bowels are involuntarily evacuated. The pulse shows great variations. When satisfied that a patient is suffering from an epi- leptic attack, it is important not to be too meddlesome. More harm may be done by unnecessary interference than by comparative neglect. It is important, however, that a person in an epileptic fit should be watched. If the clothing is binding anywhere, it should be loosened. The patient should be placed so as to have as little injury as possible result from the violent movement. 26 THE NURSING AND CARE OF It is better to have the head slightly elevated. If the room is close, fresh air should be allowed to enter it in abundance. It is not well to roughly seize and hold the patient, or to force open the clinched hands with great effort. It is not always best to make great efforts to open the mouth by means of a towel, or wedge, or bandage. The object of this would be to prevent the patient from biting the tongue, and as this commonly occurs early in the seizure, the mischief will usually have been done before the treatment can be applied. Here, as in so many other cases, no fixed rule applies; but good sense snd quick wit come into play. An epileptic attack cannot be aborted by brute force. Sometimes epileptics have, preceding the paroxysm, what is termed an aura,—that is, a peculiar feeling in some part of the body. It may be the sensation of a vapor passing up a limb, or a feeling of crawling, or a sharp pain. When it is known that such a sensation is felt at the extremity of a limb at each recurrence of the seizure, if the nurse is at hand the attack may sometimes be stopped by seizing and tightly holding the limb above the point where the aura begins. If with a patient known to be an epileptic, the nurse should see to it that the patient is never in any un- necessary danger; clothing should be worn a little loose, and the patient should be guarded from danger from fire or machinery. Independently of the management of the paroxysm, a number of important practical points in connection with the general care of patients suffering from epilepsy are worthy of consideration. Before or after couvul- THE NERVOUS AND THE INSANE. 27 sion, and sometimes in the place of such an attack, epileptics sometimes pass into peculiar abnormal mental states. These may vary from a state in which the patient is simply dazed, confused, or dull, to an attack of acute mauia. The nurse knowing this should be on the guard to prevent harm. Each patient should be carefully studied, and his or her peculiarities noted. Purposeless irritability and excitement, which are at- tributed sometimes by physicians and nurses to ill- temper, are really often the result of disease; and so likewise are states of suspicion and distrust. The diet in cases of epilepsy should be carefully attended to, as epileptics are likely to be large eaters. They seem sometimes to require large amounts of food ; but they can easily eat too much. The amount and character of food are of course to be directed by the physician in charge, but to the nurse or attendant the carrying out of these directions must necessarily be intrusted. Ob- servations made by some good authorities strongly favor a vegetable diet in epilepsy, and when such diet is ordered, the nurse should see that it is rigidly adhered to according to directions. What is known as the purin- free diet has proved in my experience one of the best in most cases of epilepsy. Dr. Wm. Aldren Turner in his work on epilepsy gives the following list of articles as the best out of which to get such a diet: Milk, eggs, butter, cheese, rice, macaroni, tapioca, white bread, cab- bage, lettuce, cauliflower, sugar, and fruit, both fresh and dried, and olive oil. (Turner, Wm. Aldren.—"Epi- lepsy. A Study of the Idiopathic Disease," p. 246.) Overloading of the stomach and prolonged constipation sometimes lead to the attacks; these should be prevented. 28 THE NURSING AND CARE OF Some epileptics show special features requiring par- ticular attention. One may have a recurrently dislocat- ing shoulder; others may have a tendency to run away. It is desirable that more extensive records be kept of these individuals, as the fit is but a small part of the epileptic's phenomena. Epileptics should never be allowed to bathe alone; they have been known to drown in a bath-tub with only a few inches of water. Since epileptic children are not allowed in the public schools excepting in special classes and but few of the adults are able to hold positions, they are best cared for on colony farms, but of course the well-to-do may be provided for at home. About 10 per cent, at times have insane periods and because of this they may require detention in insane hospitals. Epileptic insanities are precipitate and dangerous. The rules and regulations in force at the Craig Colony for Epileptics at Sonyea, N. Y., are in part given here: Duties of Nubses and Attendants. Nurses must hold diplomas showing them to be graduates from a recognized training school for nurses, and because of their superior advantages and training they will receive greater compensation than is paid to attendants, performing, at the same time, work and assuming responsibilities which attendants may not be qualified to perform or assume. Nurses should constantly set attendants worthy examples of industry, efficiency, neatness, punctuality and faithfulness, in the discharge of all duties to the sick. The first object of all nurses and attendants must be the wel- fare of the patients, and in all their intercourse with patients, they must treat them with respect and civility, address them mildly and kindly, and avoid rudeness and violence of any kind. Nurses and attendants are to avoid any exhibition of temper, THE NERVOUS AND THE INSANE. 29 and never scold, threaten or command authoritatively, but whenever they desire anything done by a patient, make the request in a respectful manner. In the care of epileptics kindness and tact must always take the place of force and display of authority. Epileptics can be governed by mild and kindly measures far better than by fear and force. A blow is never to be inflicted on a patient by an employee un- der any circumstances. Any violation of this rule will subject the offender to instant dismissal. Whenever a patient is excited, violent and destructive, as is so frequently the case with them just before, during, or after a seizure, and then it becomes necessary for a nurse or attendant to hold and restrain the patient to prevent him from injuring himself or others, they will be careful never to use undue force ; never to kneel on a patient's chest; never to grasp the patient by the neck or throat, but endeavor to exercise the needful restraint by grasping the patient about the body and holding his arms to his side, if possible, standing immediately behind the patient for the purpose. Nurses and attendants are cautioned against trying to restrain violent patients alone, and in every case possible, they must call some one to assist them. Nurses or attendants must never restrain or confine a patient in a room without direction of a medical officer. All persons employed in the care of patients are cautioned to be on their guard against acts of violence on the part of the patients, and must be careful to see that dangerous weapons are not carried by patients who are subject to violent outbreaks. Nurses and attendants must never allow patients to be laughed at, ridiculed or harshly spoken to on account of peculiarities of behavior. New patients must always receive special attention. The first effect of being in so novel a place, -where the restrictions are greater than at home, is to make many patients apprehensive of harm, and their fears should be quieted. The rules of the house should be explained; the patients should be invited to their meals, and be told at bed time that the night watch or nurse will visit them. Every effort should be made by the nurse or attendant to relieve anxiety and show kindly attention to the newcomer. One nurse or attendant or other responsible person must always be present with the patients in the house. Nurses and attendants must rise promptly at the signal for 30 THE NURSING AND CARE OF rising, and immediately commence the labors of the day. They will see that all patients are up; that all are properly dressed, washed and prepared for breakfast. All patients who are not taking their food or medicine, all cases of violence or blows, or of illness will be reported to the physician. Nurses, attendants or other employees are forbidden to use or wear articles belonging to patients. The first object of all employment of patients must be the bene- fit of the patient. Nurses and attendants must not grant any special or unusual privilege to any patient, except as authorized by a medical officer, and they will take care that clothing worn by patients is adapted to the season and the occasion. Under clothing is to be changed twice weekly when patients are bathed, and of tener when required. Soiled clothing is not to be left in a patient's room. When patients soil their clothing, it is to be immediately changed. All patients must be constantly and neatly clad, as far as re- sources permit. Attendants must be personally present at the bathing of the pa- tients; especially important is this in the case of the feeble. The at- tendant will see that the water of the bath has the proper tempera- ture. Bathroom doors are always to be kept locked when not in use. Not only shall nurses and attendants supervise the work of patients, but they shall, themselves, when necessary, take the initiative in all kinds of labor. Male patients are to be shaved twice weekly, or oftener if required. In shaving, great care is to be used to have the razor in good order. No patient shall be permitted to shave himself unless by order of a medical officer. Hair and nails must be cared for by the nurse when patient is unable to do so. When patients are unable to attend the dining room, the nurse or attendant must personally see that their food is properly served to them. Special diet should always be ordered by the physician and must always be given to the person for whom it is ordered. A nurse or attendant shall be in each dining room when patients are at meals. Patients who are in a low or critical condition shall always have someone in immediate attendance upon them, and must not be left alone. Such patients shall not be taken up for changing of cloth- ing or bathing without directions from a physician. THE NERVOUS AND THE INSANE. 31 Keys must be used by nurses or attendants. They are not to be left carelessly about, nor intrusted to patients. Patients must not be allowed to lie down on the cold, damp ground, nor walk on or near the railroad tracks, nor go bathing. Patients in Infirmaries who are able to walk, must, when the weather permits, be taken out of doors twice daily. Nurses and attendants will not receive visitors in the cottages, except by permission of a medical officer, nor shall they allow persons about the cottages who have not a right to be there. Nurses and attendants must avoid expressing opinions on the condition of patients to relatives and friends, referring all such inquiries to the physician. Nor shall they correspond with patients' relatives concerning the condition of patients, and when they get letters of inquiry about patients, they will refer such letters to the Superintendent. All night nurses and attendants shall wear noiseless shoes when on duty. In a few cases it may be important for the nurse to be able to diagnosticate the cause or nature of insensibility, of other forms than that seen in epilepsy. While diagno- sis is the duty of the physician, a little exact knowledge of a disease or condition may enable a nurse to so act in an emergency before the doctor arrives, or when he cannot come, as to give the patient a better chance of ultimate recovery, or possibly even to save life. The nurse should have some general idea how to distinguish not only as to whether a patient is either drunk or stricken with apo- plexy, but also whether he or she may be suffering from the effects of some narcotic poisoning; from what is termed uraemia, a condition in which the blood becomes surcharged with matters which should be excreted by the kidneys; or whether again those conditions which prevail in sunstroke, heat-exhaustion, or fainting are present. If we are able to recognize at once that a patient is suffering from an apoplexy, particularly what is termed 32 THE NURSING AND CARE OF a hemorrhagic apoplexy, in which blood from a broken vessel is poured out into the brain-substance, that pa- tient may be so handled as to give him a chance for life and approximate recovery. The treatment is chiefly a negative one, but this negative treatment is of great importance. If such a patient is jarred and moved about, is carried from pillar to post, is twisted and turned in order to remove clothing or for other pur- poses, the hemorrhage may be unnecessarily increased. In some cases of apoplexy, a comparatively small hemorrhage, from a small blood-vessel, will cause great shock and complete unconsciousness, and the bleeding in such a case may have a tendency to stop if the patient is kept absolutely quiet. Indirectly, tor), the danger is augmented by unnecessary movement ex- citing the heart and general circulation. Even when apoplexy is not of the hemorrhagic variety, quietness should be the rule. The stertorous or noisy breathing so often observed in cases of apoplexy, and in some forms of insensibility due to other causes, is some- times a sign of danger and is always a distressing symptom. An English physician named Bowles be- lieved that stertorous breathing is usually, if not always, due to mechanical causes, which may be re- lieved in whole or in part by attention to the position of the insensible patient. The tendency of a patient suffering from apoplexy is to lie on his back. In this position stertor is usually very marked. By turning the patient on his side, according to Bowles, and I have on a number of occasions confirmed his views, the stertor often disappears or is greatly relieved. If THE NERVOUS AND THE INSANE. 33 the patient is paralyzed, as is usually the case, when suffering from an apoplectic attack, he should by pref- erence be turned on or towards the paralyzed side. If the breathing is not at once relieved, some adjust- ment of the face and head may bring about this favor- able result. A completely unconscious patient will, as a rule, tend to gravitate again to the position on the back, and this can be prevented by carefully propping him with pillows, bolsters, or blankets. In turning the patient from the back to the side, the nurse or nurses should be careful to jar the patient as little as possible. If the patient is suffering from drunkenness, or is narcotized by opium or some other powerful drug, it may be all-important to promptly arouse and excite the dormant nervous system; and this is particularly true in cases of narcotic poisoning. It is for this reason that applications of electricity or even slapping or otherwise irritating the patient may be of service in cases of narcotism, but such treatment, as already stated, would be not only useless but dan- gerous in a case of apoplexy, in which the rule should be to keep the patient as quiet as possible, at least until the acute attack is over. It is by no means easy even for a physician well trained in his art to make a diagnosis in these cases, and therefore a nurse who should fail is not always to be held to rigid accountability. The nurse should, how- ever, be able to distinguish those cases in which the diagnosis is comparatively clear. The rarity of convul- sions without heart-failure; flushing of the face or more rarely pallor; stertorous breathing; slow and full pulse ; 3 34 THE NURSING AND CARE OF pupils fixed and one or both dilated; paralysis of one side; retention or involuntary passage of urine; tem- perature at first lowered, and, as a fatal issue approaches, rapidly rising, are some of the points usually given. These are good, and correct as far as they go, but some details as to the determination of these facts may be given, and a few points may be added. A nurse should know something of the methods of determining whether a patient is paralyzed upon one side. Glancing j carefully at the patient's face, usually, but not invari- ably, one-half of the face will seem to droop, or will i be twisted toward the other side; the angle of the mouth ' on the paralyzed side will perhaps be a little lower, and the lines and contours will be somewhat smoothed out. Lifting the arm, first to one side and then to the other, the paralyzed extremity will fall limp and flail-like, while the extremity of the unaffected side will usually convey a certain resistance to the examiner, even though the patient be totally unconscious. The same conditions can usually be determined by a cautious manipulation of the legs. The respiration is not only heavy and stertorous, but it is frequently also what is called " Cheyne-Stokes" in character,—that is, the breathing becomes less and less marked, descending until the pa- tient does not seem to breathe at all; then, after a few seconds, beginning again and gradually becoming more positive. It is an ascending and descending respiration, —a respiration with a break or gap. Another condi- 1 tion, called conjugate deviation of the eyes and head, very commonly present in cases of one-sided apoplexy, can be determined by simply looking at the patient THE NERVOUS AND THE INSANE. 35 The eyes constantly turn or tend to turn to one side, and the head also shows the same tendency. Usually, the direction is away from the side of the paralysis. If satisfied that the patient has had an apoplectic at- tack, or if in doubt about the matter, it is wise, as has been already intimated, to keep him as quiet as possible. The clothes should be loosened so that no undue press- ure will be exerted anywhere upon the blood-vessels or internal organs; but great caution should be exer- cised in the way in which the clothing is handled. It is sometimes far better to cut and destroy clothing than to move the patient unnecessarily in removing or loosen- ing it. Warmth, and even counter-irritation, may be safely applied to the extremities; cold to the head is usually indicated, but sometimes is better not employed, particularly when there is great general depression of temperature. As a rule, a nurse should not take the responsibility of administering medicines in such cases. Certainly emetics should not be given without orders. Probably the only medicine which a nurse would be j fully justified in administering on her own responsi- j bility would be a purgative, like one or two drops of croton oil in sweet oil. Some knowledge of the conditions present and the treatment called for in case of sunstroke or heat-pros- tration is essential. This affection may be caused not only by exposure to the sun, but by intense heat, par- ticularly with fatigue. The danger is usually very great. One of two conditions may arise : thermic fever, or heat exhaustion. The onset of thermic fever is usu- ally by headache, nausea and vomiting, a stuporous 36 THE NURSING AND CARE OF condition supervenes and the temperature may run to the extreme height of 110° F.; the face is flushed, the pulse is rapid and respiration is labored; the pupils are contracted. An abundance of fresh air should be supplied and the patient sponged with cold water or rubbed with ice. Ice water enemas may be given. If the condition be one of exhaustion, consciousness is retained, the skin is clammy, the pulse feeble, the respirations shallow and rapid. The patient should be covered and hot bottles applied. Stimulation is needed in the form of black coffee, whiskey, or aromatic spirit of ammonia, but these should not be used without medical advice. It is not always an easy matter to tell that a patient is dead drunk. A patient may smell of alcohol and , yet be suffering from an apoplectic attack. He may be * drunk and also have a " stroke." In the Philadelphia Hospital a fair percentage of the cases brought in during the apoplectic attack have been drinking, the excessive use of liquor acting as the exciting cause in an individual whose vessels are already diseased. What are some of the indications of genuine intoxication ? Con- sciousness may appear to be lost, but this loss of con- sciousness is not as absolute as in the majority of cases of apoplexy. The patient can generally be momen- tarily aroused from his stupor, if it is only to sink back again with a grunt. The face will be more commonly flushed than pale; the pupils will probably be equal, more frequently dilated; the breathing, although heavy, is not strictly speaking stertorous, nor is it likely to be of the Cheyne-Stokes variety. The temperature may THE NERVOUS AND THE INSANE. 37 be below the normal two or three degrees, but it does not show the peculiar variations which are commonly present in genuine apoplexy. In a case in which, in spite of examination and of studying the points here considered, the diagnosis still remains doubtful, it is better for a nurse to do nothing except quietly take care of the patient and prevent injury. Dr. Reginald Southey1 recommends the throwing up the rectum, by injection, of a pint and a half of cold water, with a tablespoonful of common salt dissolved in it. In a case of extreme drunkenness this brought the patient out at once. If carefully administered in a doubtful case, it would certainly be less likely to do harm than stomach-pumping, or galvanizing, a comatose person. In ursemic coma—that form of unconsciousness from the blood-poisoning which takes place because diseased kidneys cannot properly excrete effete matters from the eystem—a nurse will not usually be able or expected to determine the condition. In some cases of ursemic coma, however, certain evident physical conditions will enable almost any one to suspect the real state of affairs. Such a patient, for example, may have swelling of the limbs, or of the eyelids or face; a condition of wax- like pallor may be present; the breath may have a urinous or beef-tea odor; the pupils will generally be dilated; and, as a rule, but not without exceptions, one side of the body will not show paralysis more than the other. When a patient is known to be suffering frcm ursemic poisoning, active purgatives and measures to produce sweating, as warm baths, may do much good. 1 Lancet, December 4, 1880. 38 THE NURSING AND CARE OF An attack of fainting is ordinarily not dangerous to life, although sometimes attacks which look like a simple faint are the result of serious disease of the heart or brain. The fainting person suddenly becomes pale, loses consciousness, and usually falls, the pulsa- tions of the heart and the movements of breathing becoming diminished. In a faint the brain is com- monly deprived temporarily of its proper supply of blood. The individual should be carefully placed on the back, and the clothes loosened. In some cases it is well to raise the body and limbs a little, above the level of the head. In this way the circulation will be given the best possible chance to right itself. Sprinkling cold water on the face and applying ammonia to the nostrils and heat to the extremities and the stomach will assist in bringing about reaction. In hospitals in which cases of chronic organic disease of the nervous system are treated, as, for example, in the Nervous Wards of the Philadelphia Hospital, where sometimes two hundred to three hundred patients, a majority of them suffering from structural affections of the brain or spinal cord, are to be found, it is im- portant that the nurse should have clear ideas as to the special care of those suffering from paralysis and other forms of extreme helplessness. Sometimes a paralytic case, and a ward in which paralytics are found in large numbers, are regarded as uninteresting, or possibly un- pleasant ; but to a faithful nurse, to one who has a just idea of her vocation, these helpless people should be interesting because of their suffering. Certainly, few cases of chronic diseases call for so much true sympathy; certainly, also, in few are the opportunities to comfort THE NERVOUS AND THE INSANE. 39 and relieve greater. These patients are sometimes lit- erally unable to move hand or foot, or, if the helpless- ness is not so extreme as this, they are paralyzed either upon one side or in the lower or upper half of the body, more commonly the former. Sometimes sensi- bility has departed from their limbs. Sometimes they suffer from contractures to such an extent that, as with one case now in the Philadelphia Hospital, they are literally tied into knots. When the condition is not so extreme as this, the limbs may be flexed upon each other and upon their bodies so as to prevent any move- ment except with great pain. Frequently paralysis of the bowels or bladder, or of the sphincter of the bowels or bladder, is present, causing involuntary evacuation or constant retention of fsecal matter or urine, and adding the dangers of overdistention and even rupture of the bladder. A quick-witted, efficient nurse will soon learn from observation and contact with helplessness how to be most helpful. In such matters as assisting a case of one-sided paralysis, or of ataxia, in walking, canes, crutches, wheel-chairs, and the like, can be resorted to, and it will be the duty of the nurse to see that they are used in the most advantageous manner. Certain little details of great importance, both with reference to the comfort and cleanliness of the patients and of the rooms, will need attention. When the patients suffer from paralysis of the bowels or bladder, the nurse should bear in mind the attendant evils; should pro- vide against emergencies, and should frequently examine to see that the patients are not in a filthy condition. 40 THE NURSING AND CARE OF Many cases of organic nervous disease suffer from in- flammation of the bladder, secondary to the paralysis of that organ so often present. It is often necessary that the bladder should be washed out, a work which will usually fall to the physician, and one which a nurse should not undertake without special and explicit directions. She should, however, know how either to wash out the bladder or to assist in doing this if called on by the doctor. Usually a double catheter or some par- ticularly-designed syringe is used in this operation. It may be done, however, by attaching to an ordinary catheter a long rubber tube. The catheter is passed in the usual manner, and then, by means of a funnel at- tached to the end of the tube, warm water or whatever liquid is directed can be gently poured into the tube, not more than about two fluidounces being poured in at one time. After this has been done, by simply low- ering the tube, the water will be discharged from the bladder and run off. This process can be repeated until the discharged liquid is perfectly clear. Bed-sores are among the most disagreeable and troublesome complications of chronic disease of the nervous system. Unless the greatest care is taken, and even sometimes in spite of close attention and proper pre- cautions, annoying and obstinate sores will form on those parts of the body subject to pressure or attrition, or to the action of irritating discharges. The nurse should, of course, be on the watch to prevent their occurrence; an ounce of prevention in such cases being emphatically worth a pound of cure. Among the most useful means THE NERVOUS AND THE INSANE. 41 of prophylaxis and cure, I need only mention the use of the water-bed and of air- and water-cushions. Small pillows may sometimes be used. When rub- ber air-cushions are employed they should be smoothly covered, and pins should not be used in the covers; preferably they should be sewed together. When a water-bed is used, it is well to put an old blanket or a cloth of some kind under it to keep it from sticking. The water which is used to fill it should be at a tem- perature of 70° F., and should be renewed every ten days or two weeks, or oftener. Charcot, the distinguished French physician, has pointed out the fact that occasionally, in cases of cere bral hemorrhage, a few days after the " stroke" an acuti bed-sore or eschar will form on the buttock of the par- alyzed side, long-continued pressure having nothing to do with its production. In rare instances the sore occurs on the sound side. In a case of this kind, usu- ally at first, an erysipelatous blush makes its appear- ance, in the centre of which a vesicle is soon seen, and this breaking down, a formidable sore rapidly results. Plans of treatment for bed-sores without number have been tried and recommended. Brown-Sequard strongly advocates the use of alternate hot and cold applications. For ten or fifteen minutes daily, sponges soaked in hot and cold water can be thus employed, or ice bladders alternating with hot poultices may be applied. The effect is to stimulate the circulation, and to promote the formation of granulations. The simple water dressing, the use of carbolized oil, and washes of carbolic acid and potassium permanganate, stimulation with solution 42 THE NURSING AND CARE OF of the nitrate of silver and sulphate of copper, packing with iodoform powder, the application of charcoal poul- tices and of various ointments, and powdering with oxide of zinc, and other methods used singly, or some of them in combination, are doubtless all more or less familiar to nurses who have had any experience. A good plan to prevent the development of bed-sorea is to use alcohol, or the fluid extract of hamamelis, as a wash. It is also important to watch and turn the patient from side to side. Some years ago I experimented in the Philadelphia Hospital with a method of treatment first suggested by Spencer Wells, of England. This I consider very valuable. It consists in taking a piece of fine silver plate and cutting it to the size of the bed-sore. A piece of zinc of the same size is taken, and the two are united by a wire. The zinc plate is laid a little above the sore, and the silver plate is laid on it, and the two are secured by adhesive strips. I have known sores, treated in this way, fill up with granulations in two or three days. A good nurse can do much to assist the physician in the treatment of sleeplessness from any cause. A fussy, a talkative, or a thoughtless nurse will be likely to make such a patient worse. The manner in which the even- ing is spent will often have much to do with the pro- duction of sleeplessness or the induction of sleep. Even when hypnotics are administered for the sake of causing sleep, the way in which this is done, and the course which is pursued subsequently, will have a decided bear- ing upon the results. Of what avail will be the drowsy THE NERVOUS AND THE INSANE. 43 syrup, or the soothing draught, if, after its administra- tion, the nurse becomes noisy and excites the patient? In delirium tremens, sleeplessness and suicidal im- pulses are common. The pulses may be very feeble and the nervous prostration and inability to take food ex- treme. Nourishing food must sometimes be given by force, and such patients must always be closely watched. In meningitis, in tetanus, in delirium tremens, as well as in fevers, and in some forms of insanity to be hereafter considered, the treatment of delirium will call for the intelligent help of the nurse. No matter to what the delirium is due, quiet and peace are always essential. Usually the room should be kept not only quiet but to some extent darkened. Care should be taken not to unnecessarily jar the bed. Loud talking, laughing, or any form of noise, should be interdicted. In brief, nothing should be done to startle or excite. In acute alcoholic delirium the mental condition of the patient is sometimes one which requires extreme care. Terrible anxiety with frightful hallucinations of sight and hearing are present. Sleeplessness is continuous. The patient must be vigilantly watched, must be soothed and comforted, and if necessary must be restrained. When delirium becomes so violent that it is absolutely necessary to use temporary physical restraint, the greatest possible care should be exercised. Physical restraint is indeed seldom necessary, and should always be avoided if possible. A patient can sometimes be wrapped in a sheet or blanket for a time. It is not within the scope of the present chapter to go into details as to food and its preparation. Such details 44 THE NURSING AND CARE OF belong more properly to a work on dietetics. I will only say that in the management of nervous patients of different classes attention to diet is often of the great- est importance. Sometimes, as in the so-called " rest treatment," a special milk diet is ordered, or a diet in which the patient is restricted to certain articles pre- pared in special ways. The orders given should be carried out explicitly. If the milk is to be peptonized, it should be exactly in the manner directed. If skim milk is ordered, skim milk should be given; and if raw-meat soup is directed after having been prepared in a certain manner, it should be prepared in this way and in no other. I wish to impress the importance of fulfilling every detail of treatment with care and exact- ness. The management of patients addicted to the opium or other narcotic habit requires peculiar qualities in a nurse. Firmness is here of the utmost importance, and vigilance cannot be too great. The victims of these unfortunate habits are weak in resolution beyond all other sick people. It may be laid down as a general rule that they can never be fully trusted. The majority of patients, says Kane, " express their willingness to be rid of their habit, and do endeavor up to a certain point to assist themselves, but at this period will-power, nat- urally weakened, gives way, and good resolves are thrown to the wind. It is at this time that every facility for full control of the patient is necessary, for without it the sufferer will invariably stop treatment, claiming that the suffering is beyond his strength, THE NERVOUS AND THE INSANE. 45 bemoan his sad fate, and return to the old habit with renewed force, exclaiming with Coleridge's son,— ' O woful impotence of weak resolve.' " Such patients must be ceaselessly watched. They must not be allowed to come in contact with servants and otners through whom they can buy the drug. Often they may have the narcotic concealed. The nurse is in these cases the physician's main-stay ; if faithless, treat- ment will invariably fail. In the course of the treatment of narcotic habits certain periods may arise in which it is important to exercise the utmost care in the management of the patient, and a nurse should be well informed with reference to this matter. In the method of treatment advocated by the German physician, Levenstein, for example,—that of rapidly reducing the amount of the narcotic taken,—a condition of collapse or semi-collapse is likely to come on about the time the drug is entirely removed, and when this occurs it is necessary that the patient should be closely watched and attended to by the nurse as well as the physician. 46 THE NURSING AND CARE OF CHAPTER II. Massage—Movements. A few years ago it was difficult, even in large cities, to get men or women who were capable of properly ad- ministering massage to patients ; indeed, the number of masseurs and masseuses, skdful and unskilful, was for a long time quite limited. The times have changed in this respect. Every large city now contains many who are, and others who claim to be, capable of giving this treatment. Often it is simply a claim. Not a few imagine that it is only necessary to have a little strength and more assurance to be able to treat a patient by the method of massage. In consequence much evil results; not only to the patients, but to the physician who rec- ommends the treatment, and to the cause of massage itself. It is not uncommon for nurses who have managed perhaps two or three patients, and while caring for them have watched a skilful masseur or masseuse operate, to believe themselves capable, with- out special training, of undertaking massage in all its forms. No one should set up as a practitioner of massage without having received special instruction. I have known an individual to undertake to administer mas- sage for pay after observing the operation on one or two occasions. Instruction should be received, and care THE NERVOUS AND THE INSANE. 47 should be taken that it is of the proper kind. A nurse to-day cannot be a masseur or masseuse to-morrow simply by thinking over the matter. Both teaching and preliminary practice are requisite to make a good operator. The amount of time required thoroughly to learn the art depends upon the intelligence, tact, and manual skill of the individual as well as upon the kind of teaching and the amount of practice. It is not absolutely necessary that masseurs should have a comprehensive knowledge of anatomy and physiology, but they should know something of these branches of medical science; they should know the names, positions, and modes of action of the principal muscles and groups of muscles of the body; they should know something of the size and shape or con- tour of these muscles in order that they may be better able to isolate and treat them; for quick reference some idea of the arrangement and distribution of the muscles may be obtained from illustrations 7, 8, 9, 10, 11 and 12. They should know something of the skin and its functions and powers. In my own practice, both hospital and private, I have made it a point to study the methods of operators, and I find that these differ very much. In Philadelphia, the majority of those who attempt mas- sage have methods which are, in some respects, wrong, although we have here a respectable minority of skilful operators. I have not only watched the procedure myself, whenever opportunity offered, but have also questioned my patients as to their own feelings and observations. To a majority of nervous patients, mas- 48 THE NURSING AND CARE OF sage is pleasant; some care but little for it; to a few it seems to be absolutely intolerable. When, however, a patient complains that she does not like or cannot en- lure the procedure, I always make it a point to observe the method pursued. I have had patients who were rendered more nervous by massage administered by one, speak of it as almost a luxury when they have received the treatment from the hands of another. One of my patients, an intelligent lady, had in succes- sion, although not by my orders, five different mas- seuses. Her rather amusing criticisms upon these individuals serve to point out some of the things to be avoided. She said that the first teased and tantalized her; the second wrung and twisted her; the third mauled and bruised her; the fourth was too dainty; and the fifth almost talked her to death. The patient may have been a little hard to please, but in the main her criticisms were just. Murrell1 says that the word massage is derived, ac- cording to some authorities, from a Greek word mean- ing to " rub," while others refer it to the Arabic word mass, to press softly. Dr. Benjamin Lee2 says that it comes to us from the Greek through the French, and means simply "kneading," the idea to be conveyed being that the operator works the flesh as the baker works his dough. He holds correctly that it is better to use the French word than to attempt to translate it into 1" Massage as a Mode of Treatment." *" Tracts on Massage." Translated from the German of Reib- mayr, with notes, Philadelphia, 1886. THE NERVOUS AND THE INSANE. 49 English, because the English equivalent is used to de- scribe one of the particular modes of massage, and also because the former has now a well-established position and definite signification in scientific medical literature all over the world. The same authority defines mas- sage as a communication of motion to the tissues of the living human body from an external source for thera- peutic purposes; but this definition does not define the term as it is commonly used,—that is, under it might be included Swedish movements and motion commu- nicated by means of steam, electricity, or special me- chanical agency. The latter forms of massage are sometimes spoken of as mediate,—that is, they are motions or movements communicated to the body through some contrivance or machine. It is to what is sometimes called immediate massage that the term is commonly restricted, and it is with reference to this form that my remarks in this connection apply. Mas- sage, then, in the sense in which I here employ the term, is the manipulation by a definite process of the tissues and organs of the human body by a living operator, for the purpose of promoting health or of relieving or curing disease. The subject has been unnecessarily confused and complicated by the multiplications of terms describing so-called methods of massage; thus, EstraderS, accord- ing to Lee, speaks of such a variety of procedures as stroking, friction, kneading, sawing, pulling, pinching, malaxation, percussion, chopping, clapping, pointed vibrations, and deep vibrations. These terms really represent only a few essential methods of procedure. 4 50 THE NURSING AND CARE OF The bast authorities, as Mezger, Berghman and Helle- day, Lee, Murrell, Jacoby, and others, describe four essential methods of procedure, namely, (1) stroking, or effleurage; (2) friction, massage a friction; (3) knead- ing, or petrissage; and (4) percussion, or tapotement Understanding these four methods practically, it wilL be found that the other so-called varieties are simply modifications of these, or are not strictly forms of mas- sage, but come more properly under the head of exercise or movements. My special purpose in this chapter is to give a few hints and suggestions as to proper and improper methods of performing massage. For details and de- scriptions of the procedure, the writings of Lee, Mur- rell, Jacoby, and others can be consulted. I will, however, for the sake of a clear understanding of what is said, quote the essential portions of the descriptions by Jacoby1 of the principal kinds of massage. " Stroking is nothing more than a very light centrip- etally-propelled pressure. It is executed in the fol- lowing manner: The volar surface of the ends of the fingers, or of the entire hand, having been applied to the part to be massaged, at a point situated more peripherally than the affected portion, is then pushed centripetal ly forward and a short distance beyond that part. When this hand has reached its destination, the other hand is placed at the starting-point and the same movement executed. Meanwhile the first hand has 1 "Journal of Nervous and Mental Disease," vol. xii., No. 4, October, 1886. THE NERVOUS AND THE INSANE. 51 been brought back, so that by the time the second one has fulfilled its purpose it is ready to begin again. This is then repeated with regularity. The time to be devoted to each stroke will vary very much, the strokes also following with more or less rapidity. The amount of pressure to be applied is not to exceed that of the dead weight of the hand. Effleurage of the extremities may also be executed in such a manner that the thumb and first finger are widely separated like a V, and the extremity grasped between them. Mosengeil advocates the use of a certain amount of pressure in this ma- noeuvre ; in fact, he recommends varying the pressure from moment to moment, so that it becomes undulating in form." " Massage a friction, or rubbing, is a forcible press- ure with a concomitant motion of the hand forward. This manipulation may be executed in various manners. The points of the fingers having been applied to the affected part, pressure is exercised, and they are moved in large or small circles, or simply to and fro, the press- ure being maintained. For this purpose the ends of one or more fingers may be employed. If a particu- larly great amount of force is desired, the first phalanx of the thumb of the left hand may be applied to the spot, and pressure exercised upon its dorsal surface with the thumb of the other hand, the rubbing then being executed with both together. By this means we are enabled to act. upon deeper-lying structure. Rubbing and stroking ought to be combined in such a manner that the operator simultaneously executes the one with his right hand and the other with his left." 52 THE NURSING AND CARE OF "Petrissage, a kneading in the true sense of the word, may be applied wheresoever soft, graspable tis- sues are present, and very intense effects may be at- tained by it. The part to be acted upon, generally a muscle, is grasped between the thumb and index finger, or between the thumb on the one side and the four fin- gers upon the other. It is then isolated as much as possible and lifted out of its bed, at the same time pressure being exerted upon a certain part. Then those parts more centrally located are taken, until the entire muscle has been acted upon. For this purpose either the points of the fingers or the pulps of the terminal phalanges may be used. If the points of the fingers are employed, the procedure is certainly rendered more energetic, but at the same time more fatiguing for the operator. " Petrissage may also be rendered more energetic, when acting upon large parts, by using both hands. " Tapotement is simply percussion of the affected part, either with the palm of the hand, the fist, the curved finger, a percussion hammer, or other instrument specially adapted for the purpose. Percussion without instruments is, as a rule, performed with the points of the fingers, these being semiflexed, and the movements of the percussing hand taking place at the wrist. It is this form which is most applicable over superficial nerves. When it is deemed desirable to act more en- ergetically upon deeper-lying structures, generally large muscular groups, the wrist-joint must be stiffened, the fingers held firmly extended, and motion allowed to take place at the elbow and partly at the shoulder-joint, THE NERVOUS AND THE INSANE. 53 the hand of the operator thus meeting the body of the patient at right angles." The terms which are used to designate those who follow massage as a business, and also the methods and processes of massage, are somewhat awkward for Eng- lish-speaking people, more particularly for nurses and operators who have not, as they cannot be expected to have, a French as well as an English education. The proper term for a male operator is masseur, for a female, masseuse, the plurals being masseurs and masseuses. The verb which expresses the performance of the pro- cedure is masser. It is therefore proper to speak of a patient as being masseed, or of masseeing a patient. I would not advise the use either of massageing or of " massacreing," although the former is sometimes used by good authority. The latter is certainly expressive in describing the violent performances of some of the untrained exponents of the art. It is common to speak of the process as " rubbing," " kneading," or " manip- ulating," and perhaps the use of one or the other of these expressions cannot always be avoided; but as they convey double meanings, or do not really express in English what is wished to be said, it is better to use the French terms until some more exact English equivalent is suggested. As in making electrical applications, so in using massage, attention should be paid to the position of the muscles and of the limbs. The muscles should not be tense; the limbs and trunk should be so placed, or so supported, as to be in a position of relaxation: usually this can be accomplished by having the limbs, as recom- 54 THE NURSING AND CARE OF mended by Graham, midway between flexion and ex- tension. A muscle which is tense and contracted cannot be thoroughly manipulated. A certain knack or tact is soon acquired by a good masseur or masseuse. In most cases wrist and hand movement should be employed. Just as it is important at the start for the young physician to obtain what is called the wrist movement in percussing patients, so it is essential that any one attempting massage should understand these wrist movements. Patients should not be mauled and twisted by movements which call into play the muscles of the arms and trunk, when the whole procedure can be better accomplished by the fore- arms and hands. Wherever it is possible, the operator should learn to use both hands at once. If the left hand, as in so many cases, is comparatively useless, efforts should be made to train it especially, using it in preference to the other hand until the two become equally skilful. To be ambidextrous or either-handed, is a great advantage in a masseur. Should the massage be dry, or should grease or lini- ments of some kind be used ? Differences of opinion about this practical matter prevail among those who have taught and written upon the subject. Mitchell, for example, advises, or at least permits, in some cases, the use of cocoa-oil or vaseline, but says that these make the work less efficient and more difficult. He does not order them unless it is considered advisable to rub into the system some oleaginous material. Busch and some other writers strongly recommend the em- THE NERVOUS AND THE INSANE. 55 ployment of oil, liniments, or ointments; Murrell as strongly favors the dry method, saying that the less ointment one uses the better, and that vaseline is never admissible. The only, or almost the only, excep- tion he makes is when the patient suffers from some form of specific disease, when the operator should use an antiseptic preparation, carbolic acid or oil of cloves and lard, for example, for his own safety and protection. My own view is that, as a rule, nothing in the form of oil, grease, or liniment should be employed. A skilful operator will usually do better without than with any- thing of this kind. Some attention must be paid to the direction in which massage is carried out,—that is, whether from the periphery towards the centre of the body, or from the centre towards the periphery. As a rule, the operation should be " from the extremities to the trunk, from the insertion to the origin of the muscles, and in the di- rection of the returning currents of the circulation" (Graham). The rule, however, is not invariable, but the masseur is not to be supposed to have sufficient knowl- edge of the subject to decide. The physician should decide; but when no special orders are given, it is proper to begin at the extremities—at the fingers or toes—and proceed up the limbs, finishing with the muscles of the back, chest, and abdomen. A peculiar twisting or wringing movement used by some operators should be especially avoided. In ma- nipulating the fingers, for instance, instead of support- ing the under surface of the finger and massSeing by causing the ball of the thumb to adhere to the muscle 56 THE NURSING AND CARE OF by downward pressure and then gently rotating, a twist- ing spiral movement is performed around the entire finger. In the same way the thumb or the hand is made to perform twisting or pulling or separating move- ments across the larger muscles, instead of pinching, kneading, or rolling them skilfully. Sometimes the process is simply a form of irregular friction of the skin instead of being true massage. It is of vital importance that those who follow mas- sage as a business should keep in good physical condi- tion. If the number of patients treated is small, a little extra exercise may be taken. On the other hand, too many patients should not be undertaken in a single day. Probably five or six patients are as many as can be done justice to by an operator in good physical condition ; but, of course, the exact number will depend in great measure upon individual skill and endurance. If too many patients are treated, those who come last will be likely to be slighted, and hardly anything will prove more injurious to the business of the operator than this. My experience is that patients pay close attention to the directions of the physician as to the length of time which is to be devoted each day to the procedure. In this, as in so many other matters, pa- tients wish to get the worth of their money. They soon learn whether some part of the body is not re- ceiving proper attention. It requires considerable strength and vigor to be a good masseur or masseuse; but better even than strength and vigor is the ability to use what strength the indi- vidual possesses to the best advantage; in other words, THE NERVOUS AND THE INSANE. 57 skill. The mistake is made by some operators of sup- posing that vigorous or even violent treatment is re- quired. I have heard the practitioners of massage of a certain city, which I will not name, spoken of as greasers and bruisers, and while I do not think this is deserved by them as a class, the practice of a few gave some reason for the derision. Patients should not be roughly handled. In some cases after the first few treatments, if the individual has had a delicate skin or some peculiar state of the circulation, some marks and bruises may be left upon the body, even when the oper- ation has been performed skilfully and not improperly; but patients should not appear after such an operation covered with bruises and blotches as if they had fallen down a precipice or had been to Donnybrook Fair. I have known patients comparatively strong complain bitterly of the severity of the treatment to which they have been subjected. On the other hand, it is possible for the treatment which is given to be too mild, or to be slighting in character. A patient should always be thoroughly treated, should be gone over systematically. One part of the body should not be treated with vigor and an other slighted. An operator who is not very strong, or who attempts to do too much work in one day, will sometimes start out vigorously enough, but before get- ting through will become fatigued, and in consequence the part of the body which receives attention last will also receive it least. The operator should so gauge time and strength as to be able to carry out the entire treat- menl uniformly. Treatment should, if anything, end 58 THE NURSING AND CARE OF with more vigorous movements than are employed at the start. 1 may be pardoned also for making a few remarks as to the mental requirements of masseurs. They should be discreet and judicious, and should have that persona] quality which is best expressed by the term " common sense." Inquisitiveness is to be avoided. They, like the doctor, may be called upon sometimes to penetrate the privacy of families, and they should first, before all, learn to mind their own business. Where more than one patient is in a house or hospital, it is well not to pry too much into matters relating to other patients than the one being treated. Talking too much should be avoided. Some practitioners of massage are as gar- rulous as the traditional barber, and are as much of a nuisance to their victims. It is not necessary, nor to be advised, that they should be taciturn or morose in the presence of patients. A little pleasant talk will do no harm, but they should avoid undue talkativeness; they should particularly avoid gossiping and boasting of their own powers. They should not set themselves up as " magnetic healers" or " professors," being partic- ularly careful not to impress either doctor or patient as to the amount of electricity they can convey by their manipulations. The masseur should refrain from talking much in the evening, so as not to charm away sleep. The lights should be turned away from the patient's eyes when the seance is in the evening. The patient should be in a well-ventilated room, say of 70°. The chest should be elevated somewhat, so as THE NERVOUS AND THE INSANE. 59 to promote free and easy respiration. Each limb should be covered after being treated, and the masseur should not unnecessarily expose any part of the patient. The masseur or masseuse should refrain from harassing the patient's mind by talking of his disease. The physician should in some cases inform the operator as to the pur- pose for which the massage is applied, as this will give the masseur more confidence and make more certain as to the thorough performance of his work. The treatment should be commenced very gently, gradually increasing in strength as the patient becomes more able to bear it. Care should be taken not to overdo the treatment on the first attempt. The mas- seur should exercise his judgment as to the amount of vitality and physical strength possessed by the patient, and upon this in part the treatment should be based. During the last few years we have been recognizing a condition in which massage has a distinctive use. This disorder is known as " fibrositis. " A number of articles have been published upon this subject.1 The !Yawger, N. S. "Indurative Headache (Schwielenkopf- schmerz) with Report of Three Cases " : Journal American Medical Association, April 24, 1909, p. 1316. "Chronic 'Rheumatic' Myositis (Muskelschwielen), with Cases Showing Some Common Errors in Diagnosis": The Lan- cet, London, July 31, 1909, p. 292. " Sciatica as Caused by ' Rheumatic' Myositis in the Gluteal Region; Its Diagnosis and Treatment": University of Pennsyl- vania Medical Bulletin, Sept. 10, 1910, p. 321. " ' Fibrositis' as a Cause of Chronic Hypertrophic Spondylitis, and Possibly with a Heretofore Undescribed Sign in Intestinal Auto-intoxication" : Boston Medical and Surgical Journal, July 15, 1911, p. 843. 60 THE NURSING AND CARE OF commonest example of this condition is the stiffness and soreness that some persons experience after expos- ure to a draft. It is familiarly known as muscular rheumatism. Another frequent cause is some poison- ous substance formed within the body of the patient and carried about by the circulation until it finds lodg- ment at some point where it sets up irritation, with the result that an area of fibrositis develops. Strictly speaking, the muscular tissue is not the seat of the dis- ease, it being mostly confined to the strands of white fibrous connective tissue and the fascia that run among the muscles and muscle fibres; hence the name, fibro- sitis. Since the fibrous connective tissue is found in most parts of the body, it is not surprising that fibro- sitis may develop almost anywhere. The particular disorders which it most frequently leads to are head- ache, backache, lumbago, neuralgia, sciatica, and painful feet. Massage should be supplemented by exercises to bring into play the muscles which are the seat of fibrositis. Movements, in the medical sense, are certain motions and operations performed for the purpose of helping the diseased human body. They are, as Taylor ex- presses it, motions of specific kinds, having specific effects, practised for specific purposes, and intended to secure definite results. Complicated apparatus is not required to carry out the movement treatment and my remarks will have reference chiefly to procedures which do not call for any special apparatus. By writers and teachers various divisions and sub- divisions of movements have been laid down. Efforts THE NERVOUS AND THE INSANE. 61 have been made by Ling and others to designate and classify both positions and movements; in other words, to establish a terminology for the movement cure. It is not my purpose, however, to go into this branch of the subject at present. Movements are sometimes spoken of as active and passive, or as single and duplicated. Active move- ments are those more or less under the control of the individual making or taking part in them, and they are performed by him under the advice or direction, and sometimes with the assistance, of another. They pro- ceed from within; they are willed. Passive movements come from without; they are performed on the patient, and independently of his will. He is subjected to pushings and pullings, to flexions and extensions, to swingings and rotations, which he can neither help nor hinder. The same movement may be active or passive according to circumstances. A man's biceps may be exercised through his will, against his will, or without reference to his will. Speaking medically, single move- ments are those not executed by the physician or attendant, but by the patient; they are, of course, active. Duplicated movements require more than one for their performance. Duplicated active movements are those to which I most commonly resort in the treatment of nervous disorders. In these the element of resistance plays an important part. The operator, with carefully- considered exertion, performs a movement which the patient is enjoined to resist; or the latter undertakes a certain motion or series of motions which the former, 62 THE NURSING AND CARE OF with measured force, resists. Skill and experience are here of great value, in order that both direet effort and resistance should be carefully regulated and properly modified to suit all the requirements of the case. By changing the position of the patient, or the manner of operating on him, from time to time, any muscle or groups of muscles may be brought into play. It is wonderful with what ease even some of the smallest muscles can be exercised by an expert ma- nipulator. To impress what is meant by duplicated active move- ments, I will illustrate them by supposing two cases, one, a case of partial paralysis of the muscles of one arm, the other a patient with hysterical paraplegia. In these cases muscular exertion can, to some extent, be called forth, the paralysis not being absolute. Sup- pose it is desired to bring into activity the biceps and brachialis anticus, the muscles particularly engaged in flexing the forearm. The arm being extended, with the palm of the hand upward, the manipulator takes hold about the wrist and directs the patient to draw the hand toward the shoulder. As the latter performs this movement, the former carefully resists, gradually, how- ever, allowing the hand to reach the shoulder, where the patient tries to keep it, while the operator now slowly brings the arm again to its extended position. To act upon the muscles of the trunk, the patient is seated upon a stool of the proper height, without back or arms, and is directed or caused to bend forward or backward or sidewise, or to semi-rotate the body, or to perform any other desirable movement, the operator THE NERVOUS AND THE INSANE. 63 antagonizing the patient and the patient the operator. The arms may or may not be made to take part in these movements, being, in the former case, elevated, flexed, extended, etc., in unison with the movements of the trunk. If it is wished to exercise any or all of the mus- cles of the lower limbs, the process is obvious. Begin- ning with the toes, these being flexed, while the patient endeavors to extend them the operator resists his efforts, or the procedure may be reversed, the patient offering the resistance. Similar methods are adopted for calling into play and developing the extensors, abductors, ad- ductors, etc., of both feet and legs. These duplicated active movements are designed to call out the latent power in the muscles of the indi- vidual. They are called duplicated active movements because the operator and the patient take part in them, and the important practical point is to see that both do take part. Great skill is acquired by some operators in this matter. The various movements of the trunk and limbs should be carefully studied, and the masseur should learn by practice the neatest and least awkward method of opposing the patient's movements or causing the patient to resist the force applied. As in massage, observation of two manipulators will reveal the greatest difference in this respect: one will be quick, easy, graceful, and encouraging; the other will be slow, stiff, awkward, and disheartening. The force which is used should be carefully graduated to the strength and par- ticular conditions of the patient. The movement which it is desired to bring out and improve should not be too forcibly resisted. Patients can be helped on to a cure 64 THE NURSING AND CARE OF much more rapidly by carefully coaxing out their latent energies. Deep breathings can often be combined advanta- geously with various forms of active movements. A favorite method of treatment with the writer, and one which often needs to be supervised by the nurse, is exercising the patient with light dumb-bells or with pulley-weights, accompanying the movements with deep breathings. The exercise should be very moder- ate at first, but should be gradually increased, and it is always best to give the treatment in a well-ventilated room. THE NERVOUS AND THE INSANE. 65 CHAPTER III. Hydrotherapy. In the care and treatment of nervous and insane patients, bathing, either general or local, is frequently employed. In text-books on general nursing and spe- cial works on hydro-therapeutics details of the different forms of baths and special procedures will be found. I may, however, say a few words about certain forms of bathing. In the treatment by rest, seclusion, massage, and electricity it is nearly always advisable that a sponge-bath should be given early every morning. It should be done quiokly and carefully. The spong- ing should be downward; the addition of a little alcohol to the water will sometimes make it pleasanter and more desirable where it is intended to get a cooling effect. The sponging should be cold or tepid, according to the directions of the physician ; usually tepid sponging is to be preferred, particularly in the early period of treat- ment. It is a well-known rule founded on physiolog- ical principles that baths should not be taken immedi- ately after meals. The sponge-bath, however, may be taken after a cup of milk, cocoa, or coffee in the morn- ing, or it may be given as other baths are administered between meals or at bedtime. Even the sponge-bath should not be given when the stomach is full of food. Dr. Mitchell says that for some reason the act of 6 66 THE NURSING AND CARE OF bathing, or even being bathed, is mysteriously fatiguing to certain invalids, and if so the general sponging should be done for a time but thrice a week. With reference to the matter of the temperature of the water to be used, either sponge or other bathing, the nurse should be observant, and should report the effects to the physician so that he may be guided in his direction. Other useful methods are the hot and cold pack, the salt rub, and the prolonged warm immersion bath. In the hot pack the bed is protected by a rubber sheet or blanket folded several times. Blankets are used and are wrung out of water several degrees higher than is desired for the pack. One blanket is placed under the patient and another over. Over the latter are spread heavy blankets or quilts. A cold compress is placed on the head. For the cold pack sheets are used and the arms may be wrapped in towels. If the sheet becomes too warm, cold water may be sprinkled over it. The average time for such a pack is from twenty to forty minutes. In administering these packs, the pulse must be care- fully watched, and any sign of weakness is cause for immediate interruption or cessation of the treatment. The salt rub may be given with the patient sitting, standing, or lying. Slightly moistened, medium-fine salt is applied over different areas of the body. This can be followed by a spray bath, after which the patient should be thoroughly dried. The prolonged warm immersion bath or the contin- uous bath has come greatly into favor in the manage- ment of delirious and maniacal patients. By a special THE NERVOUS AND THE INSANE. 67 arrangement the patient is gently but securely restrained in the bathtub, into which water is constantly running at a temperature of 98° or 100°F. (See Fig. 1.) In such a bath the motor restlessness is often promptly over- come and the insomnia greatly relieved. The filthy are kept clean and bedsores are prevented or, if present, they are benefited. Menstruation is no contraindication and there is no danger except in those with weak hearts, who of course should have special care. The patient may remain for days in the bath, eating and sleeping there. If it happens that there is a tendency to eczema, this may be overcome by anointing the part. When the intervals of immersion are for a few hours at a time, the bath becomes an intermittent one. During these baths, if the patient be insane, a nurse must be in constant attendance. In the treatment of some forms of delirium the wet pack is of great value, but should be used with care. In the treatment of some spinal disorders, as myelitis, and also in the treatment of neuritis, spinal irritation, and some other nervous affections, the alternate appli- cation of very hot and very cold water, or of hot water and of ice, is resorted to and must be given into the hands of the nurse. This treatment is carried out in one of two different ways. On^ method is to have a basin full of hot water, and another with ice-water and ice broken up in it. A sponge is dipped into the very hot water, squeezed out quickly, and rapidly passed up and down the spinal column or limbs; then another sponge is dipped into the cold water and the same procedure is used. In this way applica- 68 THE NURSING AND CARE OF tions first of the hot water and then of the cold are made, usually ten minutes or more, according to directions. Care should be taken in using these local baths not to expose unnecessarily, and not to have the water dripping or running all over the patient. As soon as the operation is completed the patient should be rapidly dried and made comfortable. If the opera- tion causes an undue amount of shock, that fact should be reported at once to the physician for further advice. In an article by Allan McLane Hamilton, M.D., on " The Use of Revulsives in Diseases of the Nervous System," published in the Philadelphia Medical Times for September 4, 1875, is described an ingenious instru- ment for the alternate application of dry heat and dry cold, a most valuable form of revulsion in spinal irrita- tion and other nervous maladies. It consists of two chambers of brass, three inches in diameter by one and a half inches deep. These have screw plugs inserted, so that they may be removed and the chambers filled, one with cold salt and water, the other with hot water. These chambers are fixed on a rod and separated by an insulating or non-conducting substance. The rod ter- minates in a handle. The flat surface, covered by thin flannel, is placed against the bare back, on either side of the spinous processes of the vertebra?, and the in- strument moved up and down rapidly. As the heated and cold surfaces constantly interchange, the effect is marked. as CO Fig. 1. INSANE PERSON IN WARM IMMERSION BATH. 70 THE NURSING AND (.'ARE OF CHAPTER IV. Forms of Electricity—Faradic Apparatus—The Mechanism, Management, and Care of Faradic Apparatus—Hints, Cau- tions, and Contraindications in Using Electricity—Electrodes —Conducting Cords—Methods of Applying Electricity— Motor Points. In the present chapter I shall call attention to the use of electricity by nurses; but while I believe nurses should sometimes be allowed to use this agent, I wish to have my position with reference to this matter clearly understood. Asa rule, only physicians, or others under the special direction of physicians, should use electricity for medical purposes. Nurses, therefore, should be per- mitted to make use of it only under special orders for particular objects. In order to employ electricity in all its forms, and for all or even many of its legitimate purposes, no one is qualified thoroughly unless he or she has received a regular medical training. Certain dangers, to which I shall recur later, attend the use of electricity in the treatment of disease ; and some of these dangers are of such a character that to avoid them pre- supposes a knowledge of the physiology of the nervous system and of the special senses. In brief, my view is that in a certain limited number of cases, under the direction of the doctor, the well-trained nurse may be entirely competent to use electricity. This is the view THE NERVOUS AND THE INSANE. 71 which is held by someof our best neurologists, who allow the nurses who have charge of certain of their patients to make electrical applications which do not involve any danger or require any unusual knowledge. It is well, therefore, that the nurse should know both what she can do and what she ought not to attempt. It is a serious mistake for any one not properly educated in medicine to set up as an electrician. I have known of one or two instances in which, after receiving a few directions from a physician, and after getting a few hints from a mechanical electrician, the nurse has im- agined that she had the whole science of electro-thera- peutics at command. Woe to the unfortunate patient who falls into the hands of such an electrician ! It is not necessary for the nurse to know much about the physics of electricity,—that is, about the nature of this wonderful force or about the principles involved in the construction and action of batteries; neither is it requisite that she should have a profound acquaintance- ship with the physiology of electricity,—that is, with the science which treats at length of the action of this force upon the animal tissues and organs. She should, how- ever, at least understand that she is dealing with an agent which is capable of doing harm as well as good, and which, therefore, requires great care in its management. Electric currents are used in medicine as a means of diagnosis and for treatment. The former is not within the province of the nurse but the latter, under the guidance of the physician, may be. It is therefore essential that she shall have some knowledge of the currents to be used, the apparatus delivering these cur- 72 THE NURSING AND CARE OF rents, and the parts of the body where the application is to be made. The forms of current in common use are the continuous, the interrupted, and the alternating. The continuous current flows constantly in one direc- tion. The interrupted current also flows in one direction but is broken at regular intervals. The alternating current flows at regular intervals first in one direction and then in the other. The current may be derived from two sources. One of these is the current used for lighting streets and houses, and the other is from the concealed cells of a portable battery. If the street current is used the con- struction of the apparatus will vary as to whether the current is continuous or alternating. If available the street current is preferable, since the cells of a portable battery may become exhausted at a most inopportune time. Static electricity is used by specialists to a limited extent in office practice. A nurse or attendant may be required occasionally to assist the physician in making applications of static electricity—to arrange the insulated stool, to revolve the plate, to assist in adjusting the condensers, or even in part, perhaps, to make the ap- plications. It is best not to use electricity of this kind except in the presence of a physician or under his direction. With faradism the nurse will probably have more to do than with any other form of electricity. A faradic battery, machine, or apparatus (Fig. 2) usually consists of a cell and a double coil. Some faradic machines are made with several coils, but most of them have but two, THE NERVOUS AND THE INSANE. Fig. 2. FARADIC BATTERY. a primary and a secondary. These coils are unfortu- nately not shown in this instrument; but one surrounds the other, the outer being called the secondary and the inner the primary. Both are shown in what is some- times called the Dubois-Reymond coil. (Fig. 3.) Much into which we cannot go is to be learned scien- tifically about a faradic instrument. Its current is not derived from a number of cells. No faradic battery needs more than one or at most two good cells. The faradic batteries are provided with a com- mutator or polarity-changer, and with a slow and rapid rheotome or current-interrupter, scales by which the primary and secondary currents may be 74 THE NURSING AND CARE OF DUBOIS-REYMOND COIL WITH GALVANIC APPARATUS. graduated to the utmost delicacy or greatest power, and with a special form of galvanic cell. The cells now commonly used are the so-called dry cells. They are much to be preferred, because there is no danger of damage being caused by acid liquids. They are put into action simply by bringing a switch in contact with a metallic knob. The wet cell is so made that when not in action the zinc is raised out of it altogether, and the aperture through which it passes covered with a piece of rubber called a hydrostat, making the cell fluid-tight, and saving both the zinc and fluid in transportation. THE NERVOUS AND THE INSANE. 75 The Dubois-Reymond coil is provided with slow and rapid interruptions, with a switch for making con- nections with the primary and secondary currents, and with a screw for regulating the tension of the currents. Most faradic batteries are modifications of the old. Let me now give somewhat explicit and detailed directions as to the methods of using a faradic machine. To some these directions may seem almost too detailed and particular, but they are important matters which belong to the province of the nurse. To start a faradic current is a simple matter, and yet I have seen it bother a nurse or untrained doctor. Bat- teries by different manufacturers are started in somewhat different ways, but all are on the same general principle. Understanding the method of starting one, the nurse will probably have no trouble with another. The cell must be in good working order. The apparatus shown in Fig. 2 is supplied with a series of switches. One of these is used to complete the circuit through the coils and cells, and also as a commutator or pole-changer. This switch if swung to the right strikes one post, if to the left another; it must be in contact with one or the other. On the faradic apparatus for office-table (Fig. 4) I will explain what is necessary about the rheotome or current-interrupter and some other matters. The old batteries had only one form of interrupter, a spring lever with one contact screw. This spring gave only rapid interruptions. Some new instruments are made in this way, but this is a mistake. A good battery should have either two rheotomes or a double rheotome, as has 76 THE NURSING AND CARE OF the apparatus shown in Fig. 4 one for slow and the other for rapid interruptions. The rapid interruptions are made by an ordinary vibrating spring lever; the slow by a long lever swung horizontally and adjustable by an inclining ring, which regulates the lever's range of vibration. The contact screw is the same for both levers, which are at right angles to each other. It is mounted so as to move horizontally across the angle be- tween the two springs, and can be rapidly swung fiom one to the other by a simple movement. The method of changing from slow to rapid interruptions is worth knowing. If the contact post is moved carelessly it is apt to scratch the spring. The operator should learn to make this change with one hand, holding down the two springs with two fingers and moving the bar with an- other or the thumb. If a very rapid interruption is desired, the contact post is brought over the elastic spring (rapid rheotome, Fig. 4) and then gently screwed down until it gets to the finest point at which can be had any interruption at all. If it is screwed down too far, the circuit is com- pleted so as not to allow any interruption. If a mod- erately rapid interruption is required, the screw is with- drawn to a more and more remote point until it is no longer possible for any current to pass. If a slowly- interrupted current is required, the post is swung to the long lever (slow rheotome, Fig. 4). The ring surround- ing this lever may be placed at any angle. When placed at a right angle, the result is that the lever swings through the largest possible arc, and the slowest THE NERVOUS AND THE INSANE. 77 possible interruption is obtained. If the ring is ad- justed at a somewhat acute angle, the lever is no longer able to move in a large arc, and the rapidity of the in- terruptions is increased. In this way can be obtained Fig. 4. Switch to repiilnte 'nr ent-stivnirth Cylinder regulator of currant for primary coil. strength. FARADIC APPARATUS FOR OFFICE TABLE. interruptions from one per second up to hundreds in the same time. Batteries are not all made like the one here shown. In one battery tne lever moves horizontally and has a somewhat different arrangement; in another 78 THE NURSING AND CARE OF an inverted cone within a fork constitutes the slow in- terrupter. They are all on the same principle,—that is, that of the vibration of a lever in a greater or smaller arc. The rheotome or interrupter sometimes gets out of order. The elasticity of the spring is sometimes impaired by bad usage, or an accumulation of dust on the spring will tend to make an irregular current. Sometimes the point of the contact screw is worn off and needs replacing. How to " regulate"—that is, how to increase or de- crease the current strength—is a most important matter. Machines from different manufacturers have apparently different methods of regulating the current, but they are all on similar principles. The simplest current- modifier consists of a copper tube sliding over, or cov- ering to any desirable length, the soft-iron core inside the primary coil. It acts under the theory that when a current traverses the primary coil and magnetism is induced in the soft-iron core, a current is also induced at the same time in the copper tube, which, being a closed body and under the influence of the current, acts as a closed coil. When, therefore, the entire length of the copper tube covers the iron core, the current induced in the copper tube counteracts and neutralizes to a certain extent that elicited in the primary coil; and because the secondary coil depends on the inductive force of the primary, also the secondary cur- rent. The current is, therefore, weakest when the cop- per tube covers the entire core, because it checks, by induction in the opposite direction, the primary current. THE NERVOUS AND THE INSANE. 79 The more the tube is withdrawn the larger is the part of the coil that is made free, the current becoming stronger and stronger until the coil is freed entirely from the con- trainduction of the tube. This mode of regulating the current, however, is not entirely satisfactory for the demands of a good faradic coil for therapeutic purposes, since the current, even with the tube-modifier in all the way, is often found too strong for application to sensi- tive nerves. To meet such cases, the entire coil is divided up into sections, or tapped at different lengths. First-class batteries, such as Flemniing's, are provided with switch arrangements, by means of which any one section or any number of sections may be used at pleasure, thus opening currents hardly perceptible by switching into the circuit a small portion of the coil, or increasing the strength by adding coils. Another mode of regulating the current-strength is found in the DuBois-Reymond induction coil, which, in the absence of a copper tube, is acted upon in this regard by its own secondary coil. The primary coil with the iron core is stationary, while the secondary coil is made to slide over it. When the secondary coil covers the entire length of the primary, the primary is weakest, since both wire-ends of the secondary coil are metallically connected together, this coil becoming one closed body, and behaving precisely like the copper tube enclosing the iron core, counteracting induction. By withdrawing the secondary coil, thus releasing a larger area of the primary coil, the current increases. The reverse action takes place in using the secondary cur- 80 THE NURSING AND CARE OF rent. The wire connecting the two coil-ends is re- moved, and the more the secondary coil is pushed in over the primary the more inductive surface is brought to bear, and the secondary current increases in propor- tion. Another contrivance for diminishing coarse currents is the so-called water-rheostat,—a glass tube with me- tallic bottom and top-cap in which is a movable rod. When the tube is filled with water and one terminal post of the battery is joined to the metallic bottom, and the top and the other terminal of the battery connected with the electrodes, the current is forced through the column of water, and increases in strength by gradu- ally pushing the movable rod downwards towards the bottom. In some older forms of batteries, the iron core is made movable and is used as a modifier; in these bat- teries the current is weakest with the core out, and by gradually feeding the core in, thus putting more of its iron mass under the influence of induction, the current becomes stronger. It the battery is a good one, ihe operator can begin with the weakest possible current and increase to the strength necessary without danger. This should be done by using the two methods of regulating the strength of the current, in an apparatus in which the tube and switch methods are both possible. Suppose with a cer- tain patient it is necessary to be very careful about the use of the battery. The patient may be timid. Some patients imagine that when the battery is applied they are THE NERVOUS AND THE INSANE. 81 going to have a thunderbolt hurled at them. The best way to begin in such a case is to increase the current by the use of the hollow cylinder. This is pulled out slowly, and, when a certain strength of current is reached, it is left at that point. If necessary to with- draw the cylinder further in order to get sufficient strength, it is well after drawing it out a certain distance to return it and push the switch up one point. The cylinder can then again be withdrawn if necessary ; and later, if it is desired, the cylinder can be once more re- turned and the switch moved to another knob. Let me now give a hint or two about handling and taking care of a faradic battery. One that is well cared for should not often get out of order. The nurse should be able, when the battery is not working properly, to tell whether the defect is in the apparatus, in the current-carriers, or in the electrodes. All that she needs to do is to moisten the fingers and place them at the points where the rheophores are con- nected with the instrument. If the battery is all right the current will be felt passing through the fingers. The trouble must then be in the cords or in the elec- trodes. The difficulty is frequently to be found in the cords. When the apparatus is not being used the switches should be set back to the lowest possible strength,—the first knob of the semicircles. This is an important rule, and one which, I am sorry to say, is frequently violated in hospitals and elsewhere. Remember not only to put the switches back, but also to push in the cylinder-reg« 6 82 THE NURSING AND CARE OF ulator. Keep the apparatus clean in every respect. Re- move all dirt. If anything forms through corrosion it should be removed. Harm may be done with the faradic battery, chiefly by the use of currents of too great strength. Without going into scientific details with reference to this point, it is sufficient to say that while nerve and muscle can both be strengthened and restored to usefulness through the help of a faradic current, on the other hand, if such current is used of too great strength or for too long a time at one sitting, nerve and muscle may be exhausted by the enforced overwork, and in some cases wasting or other serious trouble may result. It is, therefore, the duty of a nurse to carefully and explicitly attend to the directions which are given to her with reference to the strength of the current and length of the application. The temptation with one not thoroughly posted is to rather overdo than underdo the application ; and patients themselves sometimes assist in bringing about this re- sult by their natural desire to get the most out of the agent that is being used for their relief or cure. Neither singlu muscles, grouns of muscles, nor the limbs should be subjected to ourrents which are sufficient to twist and contort them so that they are beyond voluntary control. If a faradic current is applied to the head, before it is of sufficient strength to do harm the pain produced will be so great that, as a rule, patients, if able to indicate their wishes at all, will not allow its further use. Owing to mismanagement of the battery or of the cords or electrodes, however, a very strong cur- rent, possibly the full force of a coil, may accidentally be THE NERVOUS AND THE INSANE. 83 applied to a patient's head or neck, or other part of the body, and cause a serious jar, contortion, or other dis- turbance. Patients who are unfamiliar with electricity should always be handled with gentleness, and if strong applications are required these should be gradually led up to by the careful use of the graduators or regulators. Many persons have a deep-seated dislike, or even fear, of electrical applications, and this is not best overcome by beginning their treatment with a strong shock. The abdomen, next to the head and neck, is perhaps the most susceptible part of the body in making faradic or other applications, and it is often well to moderate the strength of the current in passing from applications to the pos- terior part of the trunk or limbs to the abdominal muscles. The galvanic current may be a very dangerous one, and its use by the nurse is most limited and then only under the guidance and direction of the physician. Bearing this in mind the current may be used to advantage in some cases of neuralgia, neuritis, torti- collis, in the occupation neuroses and sometimes in paralysis. Care should be taken that the current is measured by the galvanometer. It is important to dis- tinguish between the anode or positive pole (+) and the cathode or negative pole (—). This may be done by placing the two ends of the conducting wires about an inch apart in water when, with the current turned on, quite a quantity of bubbles will appear at the end of the wire known as the negative pole. Another method is to bring the ends of the charged wires in contact with wet blue litmus paper and the positive pole will turn the blue color red. 84 THE NURSING AND CARE OF The term electrode or pole is given to the instru- ment with which electricity is applied to the patient. The term rheophore or current-carrier is sometimes used to indicate the same appliance, but it is more prop- erly employed to designate the flexible conductors or cords which go from the binding post of the battery to the electrodes or handles. I shall here confine myself to a few practical general remarks about electrodes and rheophores, but may say more about them when I come a little later to speak of the methods of applying elec- tricity to different portions of the body. Electrodes are large or small; they are of different shapes, and are designed for making application to various organs and parts,—to the skin, muscles, nerves, joints, internal or- gans, etc. As a rule nurses will not be called upon to use the more special forms of electrodes for internal ap- plications, as to the throat, bladder, urethra, or uterus. It is beyond their province to make such applications; therefore, it is not worth while to study the forms of elec- trodes used for these purposes. They will be concerned only with the use of the commoner forms of electrodes. These are usually disks of metal or carbon connected by a screw with wooden, vulcanite, or other insulating handles. They are also, of course, joined to the con- ducting cords which run to the battery. The nurse should know how to select the best form of electrode for accomplishing certain purposes under the direction of the physician. When, for instance, an application is to be made beneath a patient's clothing, a good form of electrode is one in which the disk is in the same plane as the handle. In most electrodes the plane of THE NERVOUS AND THE INSANE. 85 the disk is at right angles to that of the handle, and this makes it inconvenient to slip beneath the clothing. Never use a sponge or moistened electrode of any kind which is not clean. It ought to be unnecessary to say this, but it is a rule that is sometimes violated. If the nurse is making a series of applications to the same patient, it may not be objectionable to use the same Fig. 5. BOX OF ELECTRODES. electrodes continuously; but even in such a case the coverings should be cleaned after each appl ication. They should be washed thoroughly in warm water, or with some form of corrosive sublimate or carbolic soap, or other good cleansing material. After a time elec- trodes may become incrusted from being dipped into salt solutions, or certain chemical deposits may take place on them. These deposits on the surface of the 86 THE NURSING AND CARE OF electrodes may cause local electrical actions, and render the application unnecessarily painful. A clean, polished electrode is, therefore, less painful than any other. A neat method of covering an electrode, suggested by Dr. G. B. Massey, of Philadelphia, is to employ absorbent cotton instead of chamois skin or sponge. Take a piece of clean absorbent cotton, fold and twist it over the disk of the electrode, and wet it. It will cling to the disk, and after the application it may be thrown away and a fresh piece used every time. Physicians and nurses should learn to hold the elec- trodes in an easy and advantageous manner; if possi- ble, both should be held in one hand. This is important for various reasons. It leaves the other hand free to regulate the strength of the current and for other pur- poses. In direct muscular applications, and in all others in which it is possible to hold electrodes in one hand, this should be done in a certain way. They should be held, pointing backwards, the handle of one electrode between the index and middle finger, and that of the other between the ring and little finger, as shown in Fig. 6. Held in this way, the disks can be brought very close together, or can be separated several inches. Almost the entire length of the forearm or upper arm can be included between the electrodes thus held in one hand, or by shifting one of them between the thumb and index finger. The nurse should practise employing one hand wherever it is possible. It is not unimportant to know something about the connecting cords which are used in making electric THE NERVOUS AND THE INSANE. 87 applications. A good conducting cord should have cer- tain qualities. It should be flexible, not easily broken, and capable of being easily repaired. The operator should know how to detect any break or defect in the cord. Most conducting cords are made either of tinsel or of more or less flexible copper wire. If it is found that the current is not being conveyed properly, thecords should be looked at, particularly at the points where the Fig. 6. METHOD OF HOLDING ELECTRODES IN ONE HAND. wires are attached to the terminal pins. The best cord is, I think, a somewhat flexible twisted copper wire, insulated and attached to the pins in a peculiar manner by double eyelets. The practical thing to do is to have two sets of cords,—one of insulated flexible wire, the other several yards of " cable wire." I generally have three or four yards of this " cable wire" in the drawer of the battery box, and then I am not at a loss if the cords should break. This cable wire is copper wire about No. 16 or 17, covered with gutta-percha. If it breaks, all that ii is necessary to do is to scrape off the gutta- 88 THE NURSING AND CARE OF percha and repair it. To shorten it, it can be broken at any point. In taking up the methods of applying electricity I shall restrict myself to those which are in most common use,—those which should alone be employed by the nurse under competent direction. I shall discuss appli- cations to the muscles, nerves, skin, joints, and limbs, and in addition to these certain general methods of treatment. Nurses will chiefly have to deal with neuro-muscular applications,—applications to nerves and muscles. To make a deep-seated application to a muscle or nerve the electrode should be moistened or wet. It was discovered by Duchenne—although it seems so small a matter that it can hardly be spoken of now as a dis- covery—that an application can be restricted or limited to the skin by the dry method, and that by the wet method the skin can be almost entirely neglected and the deeper- seated parts reached. In making applications to muscles or to nerves sup- plying muscles, in cases of paralysis, two different meth- ods, known as the direct and the indirect methods, or direct muscular electrization and indirect muscular elec- trization, are commonly used. In direct applications the electrodes are applied as directly as possible to the muscles. In the indirect method the muscle is caused to contract through the nerve or nerves which supply it. In order to understand the indirect method it is necessary to know something about motor points. These are points where the nerves which supply the muscles are most readily reached by the electrodes. THE NERVOUS AND THE INSANE. 89 They are points where the nerve bends round the mus- cle, or dips beneath it, or passes into it, or comes out of it. To a certain extent motor points can be studied readily by any one. Placing one electrode at any con- venient place, as on the sternum or along the spine, and then gliding over any selected muscle, a point is found where it contracts most readily. This is the motor point for this muscle. No difficulty should be experi- enced in this matter after consulting illustrations 7, 8, 9, 10, 11, and 12. Suppose we have a case of so- called wrist-drop; the hands hanging limp from want of power in some of the muscles of the forearm. The elec- trodeis placed atone point and the hand movedinwards ; at another it moves outwards, but the movement desired is upward, and finally a point is found where extension or lifting of the hand is produced. Certain movements belong to the foot,—upward or downward flexion or ex- tension, and certain combinations of directions, as out- wards and upwards, inwards and upwards, inwards and downwards, etc. It is necessary to know in a general way where the muscles producing these movements are situated ; then, if a certain form of paralysis is to be treated, the operator will soon learn to what points the electrodes should be applied in order to do the most good. Something should also be known of the muscles producing thegeneralmovementsof the limbs and trunk. I will give a few hints and cautions about muscular applications. In the first place, the operator should be satisfied to make a moderate application, and thus avoid one of the mistakes often made by the nurse, and some- times by the physician. If the contraction is distinctly 90 THE NURSING AND CARE OF visible, it is sufficient. The patient will often urge the nurse or physician to use more, on the principle that if a little will do good a larger quantity will do more good. The limbs should not be violently contorted, nor should the applications be continued too long. General faradization, to be described later, if done skil- fully, either by the lying or the sitting method, can be completed in from twenty to forty minutes. The nurse simply passes rapidly from one muscle to another, or one muscular group to another, producing contractions for a few seconds. If the application is continued too long, or made too severe, it may cause exhaustion and even wasting. Although these patients may improve for a time, the benefit will not be lasting. One reason why electricity is often unsuccessful is be- cause doctors and nurses are slipshod in its use. It is not always an interesting matter to apply electricity, but any one who does not intend to do it properly should not attempt it at all. Electricity should never be used soon after meals, for electrical applications may interfere with digestion. The preferable time is midway between meals, or as far away from meals as possible. Another practical point is that electricity should never be applied to a limb or muscle which is in a tense condition. The muscles should always be relaxed, but the opposite of this is frequently the case. The patient will stretch the arm to its full length, or will stand while electricity is applied to the back of the leg and calf. This is improper. If the patient is standing at all, the application should be made to one leg while the / '/ Xn *«-. Fig. 7. tn. triceps (common point) m. pronator teres abductor dig. V, MOTOR POINTS AXD MUSCULATURE OF ARM; ANTERIOR SURFACE. Fig. 8. m. deltoideus (post port.) m. deltoideus (mid- dle port.) m triceps (median and lateral head) brachioradialis m. extensor carpi rad. long. in extens. poll. long. adductor pollicis MOTOR POINTS AND MUSCULATURE OF ARM; POSTERIOR SURFACE. Fig. 9. *. tensor fasc. lat. JV. femoralis m. pectineus m. sartonus tn. quadriceps (common point tor 7*i. rectus et vast. lat.) t. vastus lateralis N- obturatorius tn. adduct. long. m. gracilis . rectus femoris . adduct magn vastus medialis MOTOR POINTS AND MUSCULATURE OF THIGH; ANTERIOR SURFACE. . glutaeus med. glutaeus max. MOTOR POINTS AND MUSCULATURE OF THIGH; POSTERIOR SURFACE. ) m* gastrocnemius m. peroneus longus m. tibialis anterior m. extensor halluc. brevis MOTOR POINTS AND MUSCULATURE OF LEG; ANTERIOR SURFACE. Fig. 12. K. tibialis m. flexor dlgitor. long. m. flexor halluc. long. MOTOR POINTS AND MUSCULATURE OF LEG; POSTERIOR SURFACE. THE NERVOUS AND THE INSANE. 91 weight is borne on the other; it is better to have the patient lying down. So in the arm it is well to have the arm raised half-way, so that the muscles shall be relaxed. The affected arm may be supported by the well hand. Faradic electricity will do for muscular applications in most cases; it will do in all cases of paralysis due to a central lesion; it will answer in all cases where the muscles respond readily to it. If the affection is due to rheumatism, injury, lead-poisoning, or other so-called peripheral cause, producing what the doctor calls a pe- ripheral paralysis, it will be difficult or impossible to get a response with faradism, and galvanism will have to be used. In making applications of electricity to the muscles of the face it is important to proceed with great care. The current which is applied should not be too strong, and its strength should be very slowly and cautiously increased. In such application it is necessary to use small motor-point electrodes, as it is impossible to reach the individual muscles unless the electrodes are small. One pole is placed upon an indifferent part, or as near as possible to the point where the nerve emerges from the skull. Nurses should never make these applications except by explicit orders and under observation. In making an application to the skin, a rapidly-inter- rupted faradic current is usually preferred by the phy- sician, although a galvanic current may sometimes be usea. A metal'ic electrode should always be used,— unless other directions are received,—a brush, or one of the uncovered disks already shown. One of the elec- 92 THE NURSING AND CARE OF trodes is to be moistened and the other may be a wire brush. The moistened electrode is to be placed at an indifferent spot, as on the sternum, at the lower part of the spinal column, over the knee-pan, or at the upper part of the thigh. The important electrode is the dry one. The surface to be treated with the metallic brush or disk should be gone over rapidly. A large brush elec- trode should be used where a large extent of the skin is to be treated. Another way of making applications to the skin, particularly to the skin of the face and head, is by the hand; and this is the only sort of application that the nurse should be allowed to make to the head. One electrode is put into the hand of the patient and the other taken in the hand of the operator, and the free hand of the latter, dry, is then passed over the skin of the face, neck, and head. The back or front of the hand may be used. If it is desired to make an application to a joint, this may be done in two ways. One is to take two broad, wet electrodes, or one large and one small electrode, and, placing one on one side of the joint and the other on the opposite side, allow the current to pass through the part. Another method, which is useful in apply- ing electricity to the joints of the foot, is to take a basin of warm water to which a little salt has been added, and place the electrode in the water. The foot is immersed in the water and the other electrode applied to some portion of the limb. Nurses may be called upon to make applications to all, or nearly all, parts of the body. This so-called gen- THE NERVOUS AND THE INSANE. 93 eral faradization may be used upon the patient either in bed or sitting up. In what is commonly termed the " rest treatment"—the treatment by seclusion, rest, massage, and electricity—the electricity is applied to all parts of the body in succession, the patient remaining in bed. Well-wetted electrodes are used, either sponges or absorbent cotton, which are dipped in warm water to which in some cases a little salt may be added. The patients for whom the rest treatment is appropriate usually have no changes in the nerves and muscles which would call for any particular selection of the galvanic or faradic current; in other words, the nerves and muscles commonly respond readily. For this reason the faradic current which is most readily managed and applied is most resorted to in these cases. Beginning with the limbs, preferably the lower extremities, the electrodes are applied either directly over the muscles or to the motor points. Care must be taken to include as far as possible every muscle and group of muscles in the application. Contraction is first caused in the muscles which move the toes and foot; next the operator passes to the legs and thighs, taking in each set of muscles in turn,—the posterior, anterior, outer, and inner. Having completed the application to the lower extremities, the upper limbs are next faradized, beginning with the fin- gers and hands and ascending to the shoulders. The muscles of the back, chest, and abdomen are treated last. Sometimes it is advised to treat the muscles of the back, loins, and abdomen before the upper extrem- :ties. Perhaps it makes but little difference as to this 94 THE NURSING AND CARE OF matter, but on the whole I believe it is most convenient usually to leave these until the last. The strength of current should be just sufficient to produce visible movement of the muscles. Violent contorting of the muscles should be carefully avoided. From time to time the electrodes should be re-moistened, care being taken always to squeeze out the water thoroughly in order not to have it trickle over the patient. Applica- tions are not made to either the head or the neck unless they are especially directed. In making applications to the shoulders and chest, care should be taken not to place the electrodes carelessly over the side and front of the neck. The second method of general faradization—that used upon the patient in a sitting position—is a method often employed by physicians in their offices, and may some- times be used by nurses under direction. Drs. Beard and Rockwell were among the first to make this method popular. According to them, the use of a faradic cur- rent for half an hour or less daily has a decidedly tonic effect upon the nervous system. Other observers believe this observation to be correct, hence electricity is fre- quently used in this way. The special mode of treat- ment differs a little according to choice or convenience. One method is to place in the hand of the patient one of the well-wetted electrodes; the other is at first held by the operator, who with his free hand makes appli- cation to the head, face, and neck. A weak rapidly- interrupted primary current is usually employed. A fter this careful application to the head, face, and neck has been made, the patient still keeping the electrode in the THE NERVOUS AND THE INSANE. 95 hand, the operator passes down the back and arm with the other electrode. The patient then shifts the elec- trode to the opposite hand and the operator passes down the arm of this side. Both electrodes can be taken into the hand of the operator and rapidly passed or glided over the arms and trunk. The lower extremities are treated last. A good plan is to have first one foot and then the other placed upon a flat electrode, or both feet can be placed upon a large metallic electrode covered with moistened cloth or chamois skin; with the other electrode the operator passes carefully over all accessible portions on the lower extremities. Instead of this method it is sometimes more convenient to keep one electrode upon the lower portion of the back, while the other, passed under the clothing from below, is applied to muscles and muscular groups in succession from the feet to the hips. At certain positions, as under the knee, the large nerve-trunks are more accessible than else- where, and by occasionally applying the electrode in these positions any muscles which may have been omitted in the direct application can be reached more or less thoroughly, according to the current's strength, by way of the nerve supply. Unnecessary exposure should be carefully avoided. A little ingenuity and forethought will often enable the operator to make his entire application with comparatively little exposure. 96 THE NURSING AND CARE OF CHAPTER V. The Nursing and Care of the Insane. With reference to many matters that are sometimes included in the published or oral instructions which are given to nurses and attendants upon the insane, it is not my purpose to deal in the present chapter. In other works upon nursing—surgical and medical treatises in particular—specific directions are given with refer- ence to many things necessary to be known by those who are in attendance upon the injured or sick, whether sane or insane; such as dislocations and fractures; sprains, wounds, and hemorrhages; artificial respiration; the use of compresses, poultices, stupes, and fomentations ; the treatment of bed-sores and ulcers. Very little has been published with reference to the nursing and care of the insane, except what may be found under the head of treatment in the general text- books on insanity. Two small books have appeared within a few years, one in Great Britain and one in this country. The first, entitled " A Hand-Book for the Instruction of the Attendants on the Insane," was prepared by a sub-committee of the British Medico- Psychological Association, appointed at a branch meet- THE NERVOUS AND THE INSANE. 97 ing held in Glasgow on February 21, 1884, and has been published in this country by Cupples, Upham & Co., of Boston. It contains much useful information and valuable instruction, but too much attention is de- voted to the consideration of elementary anatomy and physiology. A more valuable work is entitled " How to Care for the Insane. A Manual for Attendants in Insane Asylums," by W. D. Granger, M.D., First Assistant Physician in the Buffalo State Asylum for the Insane, and published by G. P. Putnam's Sons, New York and London. I have obtained from both of these books some valuable facts, hints, and suggestions; but most of my remarks will be based upon observation and experience, and upon information obtained directly from specialists, and from the medical officers and at- tendants of insane hospitals with which I have been connected as consultant. While a knowledge of such subjects as the anatomy and physiology of the nervous system and the nature of the different forms of insanity may be of value to nurses and attendants, it is not strictly necessary that they should be fully informed about such matters. There is, indeed, a certain danger that if too much at- tention is paid in the instruction of nurses and attend- ants to subjects which belong in strictness to a true medical education, they may make the mistake—a not infrequent one among them—of supposing that they are the doctors. The information absolutely necessary for nurses to have about the structure and functions of the nervous system can be compressed into a very small compass. It is necessary that they should know that 7 98 THE NURSING AND CARE OF the brain—with the details of the treatment of whose diseases they are sometimes intrusted—is an organ which, although deeply seated within a thick and strong bony chamber, is subject, through the multitude of nerves which put it into communication with the outside world, to impressions which soothe, annoy, comfort, distress, or irritate. It is well that nurses and attendants upon the insane should have some knowledge as to the forms of insanity and the special symptoms exhibited by certain patients; but, as already intimated, this knowledge need not be very extensive nor profound, though it should be exact as far as it goes. When it is remembered that even edu- cated physicians, unless they have spent some time in the special study of insanity, have considerable diffi- culty in separating the different forms of insanity, it is easy to be seen that it would be folly for an individual who is not medically educated to try in a little brief instruction to obtain such information. The superficial features of a case will not enable an opinion to be reached as to its nature. Thus in melancholia, which is a form of mental disease, the essential feature of which is emotional depression, a patient sometimes has the violent outbreaks of agitation or excitement which are really the result of depression; and, conversely, a patient suffering from true mania may, for brief inter- vals, be in a state of great moodiness and depression. We might illustrate by references to other well-known forms. What a nurse should know is that there are certain great divisions of diseases of the mind which give special symptoms, and that patients must be THE NERVOUS AND THE INSANE. 99 cared fbr in this way or in that according as they suffer from one or the other of these forms. The doctor having once, in the presence of the nurse or attendant, clearly made the diagnosis of the form of mental trouble, the latter, knowing this, should bear certain facts in mind: should remember, for instance, that a case of melancholia is likely to be suicidal or to starve to death; that one of mania is not infrequently homicidal or destructive ; that one of monomania may exercise duplicity and may suppress for a time his de- lusions ; that a dement is likely to be filthy and not to take care of himself in any way; that an insane epileptic may one minute be peaceful and serene and the next may be in a most dangerous motor or maniacal parox- ysm; that the hysterical insane may make false or pseudo-attempts at suicide. To illustrate still further, the nurse or attendant should know that, for various reasons, accidents are likely to occur among cases of paretic dementia,—the " general paretics," as they are commonly termed in the hospital. These patients, al- though often exceedingly weak and frail physically, owing to their peculiar mental condition, to their delu- sions of strength and grandeur, are likely to be de- monstrative and pugnacious. Frequently they have weak hearts, or degenerated livers or kidneys; often, as in locomotor ataxia,—a disease closely allied in pa- thology and often merging into it,—their bones are very brittle; not infrequently they have lung troubles. If such patients are handled as roughly as a case of ordi- nary acute mania, the consequences may be serious. Collapse has been known to come on almost instantly 100 THE NURSING AND CARE OF after a struggle with a patient of this kind, and in badly- regulated asylums bones are frequently broken; these accidents occurring even when no cruelty or unusual violence was intended or attempted. Attendants should remember that, as a rule, these patients are not as strong as their demonstrations would make them ap- pear. A serious accident, resulting in the death of the patient and the subsequent trial of the attendant on a charge of manslaughter, occurred not long ago in one of our large hospitals, the patient being a general par- etic with pugnacious and aggressive symptoms, but with advanced mental and physical degeneration. It Ls in just such matters as flow out of considerations of this kind that attendants require to be informed; they need that kind of knowledge of mental disease which will enable them to discriminate in their management of patients of different classes. What is known as hEema- toma auris, or the "insane ear," is not infrequently present in general paretics, and is another evidence of degeneration. The external ear becomes enormously swollen, as the the result either of transudations or ex- travasations. Some have thought that all cases of this kind were due to injury, to falls, or to blows. The truth probably is that neither cases of haematoma auris, or the frequently-occurring fractured ribs among the insane, are always or often due to cruel treatment; but that, in handling such patients without due care or con- sideration, slight injuries produce these affections to which the patients are predisposed, and which might have occurred spontaneously if the injuries had not been inflicted. THE NERVOUS AND THE INSANE. 101 It is sometimes said that attendants should be encour- aged to take a scientific interest in their patients. Properly understood, this assertion is true. I do not think that it will be of any service to the unfortunate patient for the attendant to become a sciolist in psychi- atry,—that is, to have a smattering of knowledge of anatomy, physiology, and pathology of insanity to pa- rade on occasions or make use of improperly in behalf of the patient; but the kind of scientific knowledge which attendants should have in order to manage the insane for their best interests is that which comes from a study of the mental, physical, and other qualities of their patients, and of the details of the best methods of handling them mentally, physically, and otherwise. They should study their patients; they should learn what gives them pleasure; what, in cases of melancholia, will best serve to draw them out of the mental shell into which they have retired ; in cases of mania what will best answer to soothe and calm their stormy minds; what, in cases of fixed and limited delusions, will best divert them from the unhealthy channels into which their thoughts are directed. Nurses and attendants should have sufficient knowl- edge of what is meant by delusions, hallucinations, illusions, etc., to enable them to understand the mental condition of the patient, for certain practical purposes which come within their own province. Not a few in- sane have delusions which they for a time or altogether suppress, or which are not freely or openly expressed. The existence of such delusions in most cases is, in- deed must be, known to the physician who has the 102 THE NURSING AND CARE OF patient in charge, and the nurse or attendant should be promptly informed, in order not only to guard against special dangers which may arise out of the delusions, but also to be better able to manage the unfortunate patient without offence or injury. Thus, an attendant who knows that the patient has delusions which may lead to mutilation, will be on guard against the occur- rence of mutilation. In one case under my care the patient's delusions sometimes took the form that it was his duty to destroy his eyes because they had offended, and he almost succeeded in accomplishing this insane purpose before a new attendant had become properly informed as to the delusion. Under the influence of peculiar delusions mutilations of a most extraordinary character are sometimes per- formed, and attendants should always be upon the alert. To no one as much as to the insane does the old saying so fully apply, that it is the unexpected that always happens. After seemingly almost every avenue for the commission of suicide or self-mutilation has been closed, some new device will be put in action, and perhaps successfully. I recall one instance of a patient in a large hospital who was noticed speaking in a mum- bling manner. He was at first passed by, but on second thought, was questioned, and on refusing to open his mouth it was opened forcibly, and it was found that he had tied his tongue with a cord, which had caused it to be much swollen, and would probably in a short time have brought about sloughing and possibly fatal hemorrhage. In this case the act was performed in all probability under the influence of a delusion that THE NERVOUS AND THE INSANE. 103 his tongue was an unruly member. Although not under my charge at the time of the occurrence, this man had been a patient of mine, and one of his delusions was with reference to his tongue or speech. The tendency of some patients to secrete and swallow foreign bodies should be guarded against. It is well that attendants should know not only that the sane sometimes simulate insanity, but that the in- sane also may simulate insanity, giving a curious combination of a real and a feigned disease which is sufficient to baffle a skilful expert. It is well that nurses and attendants should appreciate this, be- cause it has happened to me, as well as to other physi- cians who are concerned with the care and treatment of the insane, that attendants, otherwise faithful and suit- able for the work, become disturbed as to the existence of insanity in the patients whom they discover to be shamming in some particulars. TLey discover some deception, and with their little knowledge begin to think that they have solved the problem of the case better than the doctor himself. Still another similar point, which it is well, perhaps, that attendants should know, is that among the really insane hysteria in some form is often present. We have not only a form of insanity which is called hysterical, but hysteria in many forms manifests itself among the insane of different classes. I am led to remarks like these for practical reasons which have grown out of experience. I have had a faithful nurse come to me and say that a patient was hysterical, and only wished to create a sensation; that she did not believe that the 104 THE NURSING AND CARE OF patient would hurt herself; and such statements may have had some foundation in truth: but in just such a case as this, also, I have known, within twenty-four hours of the time at which the statement was made, the patient nearly to succeed in committing suicide in a way that left no doubt for a moment even in the mind of the skeptical nurse. A nurse should not have ar opinion which she puts in practice to the possible danger or detriment of patient or physician. In the long run, she will be safest to refer all doubts to the physician, rather than to act upon them herself. Later I shall speak of the importance of cleanliness on the part of attendants, and also of the close at- tention which they should pay to cleanliness on the part of patients. Not only should cleanliness of body be attended to as a matter of great importance, but cleanness of speech and of heart are essentials for nurses and attendants upon the insane. A vulgar, profane, or immoral person has no right to be in charge of an insane patient. Opportunities for evil and for injury are great and should be guarded against by carefully selecting attendants of high moral tone. If I were to be asked who make the best attendants, [ should say young men or women, not necessarily overlearned in medicine, but bright, intelligent, sym- pathetic, and sensible persons. At one of the large asylums, in answer to my inquiries, I was told that on the women's side young, healthy Irish girls, on the whole,, made their best attendants, for the reason that, as a rule, they were strong, had good animal spirits, were quick, and at the same time were kind-hearted. THE NERVOUS AND THE INSANE. 105 One defect serious in character, however, was a tendency not always to adhere to the truth in their statements. A good nurse or attendant for the insane should be firm and yet forbearing, quick and yet not hasty, courageous and yet not aggressive, should have tact and yet not be deceitful. It has often been observed in large institutions for the insane that the coming of a new nurse or set of nurses will change for a time the conduct and character of a whole ward. Order will give place to confusion and quietness to discord. A nurse who is fussy and too demonstrative is, above all, a nuisance, particularly in public institu- tions. Nurses should avoid deceiving or lying to the patients under their charge. Just as in the examination of the insane an occasion may arise when a doctor will be justified in resorting to stratagem or even to deception, so it is possible that a nurse or attendant in some grave emergency or peculiar position may be justified in tem- porarily deceiving the patient. Such occasions are, however, exceedingly rare, and deception should never be practised when it is in any way possible to avoid it. Most insane patients, unless they be dements, are capa- ble of recognizing deceit and dissimulation in others. The tendency of the insane mind itself is often to deceit and dissimulation, and a part of the moral or psychical treatment of the insane should be the enforcement by ex- ample of physicians and nurses of good moral principle. Promises which cannot be kept should not be made. The duties of a faithful nurse or attendant upon the insane are, as a rule, arduous and wearing. Sometimes a nurse may be put in charge of a private case, one of 106 THE NURSING AND CARE OF dementia or mild melancholia for instance, which will give comparatively little trouble; but, on the whole, cases of insanity require great care and attention, and to be in charge of them is not to hold a sinecure. In one of the large state hospitals, with which I was formerly connected as consultant, the best and strongest attendants, after a year of faithful service, usually showed marked signs of physical and mental wear. The amount of service required by the regulations of some of the large asylums is, I think, too great, while. as a rule, the compensation is far too small. The nursing and care of the insane in private practice is a matter of grave importance and one which requires some special points of consideration. If sufficient means are at hand, some forms of insanity can be as well or even better treated at their own homes or in private houses than in hospitals or asylums, either private or public. Patients suffering from some forms of mental disorder are comparatively easy to manage at their own homes. Most of them, however, present peculiar diffi- culties, which call for particular mention and attention. Among the cases most likely to be treated with success at home with ultimate chances of recovery are mild melan- cholia, common acute mania, when not too severe in char- acter, and some forms of hysterical insanity. Some other forms of insanity, such as senile and secondary de- mentia, idiocy, and imbecility of various grades, may be cared for at home, as a rule, without danger, although in such cases nothing is to be hoped for so far as cure is concerned. The effort should never be made to treat patients at home or in private houses if such patients THE NERVOUS AND THE INSANE. 107 require constant watching, unless the friends or rela- tives of the patient are fully able to employ faithful attendants. The physician is often asked whether such and such members of a family cannot, as well as not, look after the patient. As a rule, but not one without exceptions, it is running considerable risk to allow a patient who is dangerous to himself or others to be attended solely by members of his family. It certainly cannot be done without great risk if those who are. supposed to have charge of the patient have other duties which claim their attention. When the patients are so situated financially that attendants cannot be hired, or that members of the family or friends cannot give them exclusive attention, it is far better to resort to hospital or asylum care. It will frequently happen in the private or home care of the insane that two attendants are put in charge of a patient; occasionally the number will even be greater. Unless the case is such that one attendant is required to be in charge absolutely for a certain number of hours and the other for a like time, the physician finds it desirable to have one in chief authority. He puts one nurse in charge, making him or her especially responsible, and requiring the other, when necessary, to aot under instructions. Occasions frequently arise, particularly in the care of the violent or suicidal insane, when there is necessity for prompt and decided action,—such action as can be taken and directed by one clear head. In such a case it should be understood that the re- quests or even directions of the ohief nurse shall be 108 THE NURSING AND CARE OF coincided with or obeyed by the other. I have known a patient to be injured, so far as efforts to control him were concerned, by the petty jealousies which have arisen between the nurses in attendance. It has seemed to me —possibly I may be mistaken with reference to this— that these are more likely to arise among women than among men. No appearance of discord or disagree- ment between attendants should ever be shown before a patient. Such an exhibition may be destructive of all efforts to control a patient for his or her own good. Much of the instruction which is given to resident physicians, nurses, or attendants in charge of the insane must necessarily have reference to the habits, conduct, and peculiarities both of patients and those in charge; and it is for this reason that I am compelled to devote so much space to the consideration of ques- tions of this kind. Attendants should never foolishly ridicule patients. While sometimes harmless amusement may be derived from listening to the vagaries of the insane whose de- lusions or notions are of a pleasant or joyous type, on the other hand patients should never either be encour- aged in their delusions, or ridiculed because of them or of anything else which is the result of their impaired mental condition. In institutions, nurses and attendants should be care- ful not to indulge in favoritism, and not to single out any patients for special antipathy. Probably nowhere in the world can so many annoying and gener- ally disagreeable individuals be found together as THE NERVOUS AND THE INSANE. 109 in a large insane hospital. It follows as a matter of course from their mental condition that this should be so; but the highest type of nurse or attendant is one who, appreciating all this, is able to pursue a straight-forward, honorable course in caring for every patient. All disputes and differences of opinion should be referred to the physician. Forbearance under temp- tation, the ability to suppress envy, jealousy, or self in any way, the willingness to do all things and forego all things for the sake of the patient, are among the most needed qualities of a good attendant. The nurse who is given chief authority in the care of a private patient should not be officious or exacting, but should make it her special aim to see that the directions of the physi- cian are implicitly carried out; should report to the physician in charge everything disagreeable, and all derelictions. In most cases it is well for the chief nurse to keep a careful record of the details of treatment and also of the meals, amount of sleep, exercise, kind of occupation or amusement, and in particular instances the individ- ual peculiarities of certain patients. A systematic method of recording the time of administration of medicines, and so on, is advisable. Printed blanks are used in some institutions, and if carefully prepared may be of great service. Attendants upon the insane should not become to any extent routinists. They should not become so fa- miliar with their patients as to forget many of the little things that they may need. The insane often suffer for 110 THE NURSING AND CARE OF want of little things,—for things of which they need not be deprived and of which no one cares to de- prive them, but which they often do not get because of carelessness or thoughtlessness. They often suf- fer, for example, for water. I have been told by an intelligent lady that she drank her own urine, not because of a delusion, but because of absolutely un- controllable thirst which was not properly gratified. Acts of this kind are most frequently, no doubt, due to delusions. Sometimes the insane do not receive sufficient food. In some forms of insanity, owing to the tremendous waste of tissue which takes place in consequence of the wearing mental disorder, large quantities of food are called for. Of course, arranging the amount of food is a matter for the physician, but nurses should see to it that the food is given as directed. As a rule, insane patients eat too much rather than too little, and this, of course, must also be guarded against. The protection of the insane from the commission of suicide is a most important duty upon the part of an attendant. It is strange in how many ways and with how much shrewdness the insane will accomplish this dire purpose if intelligent vigilance is not exercised. Suicides by the insane, like suicides by the sane, are of the most diverse character, as far as method of performance is concerned. The attempt to hang is common. An insane patient has been known to hang herself by a shoe-string or an apron-string to the door- knob of a room, or the bed cords, the sheets, clothing, etc., have been employed. To drown themselves, pa- THE NERVOUS AND THE INSANE. \\\ tients do not require rivers nor even bath-tubs. They have been known successfully to accomplish this pur- pose by thrusting the head into a pail or even into a basin of water. Sometimes objects are thrust by the patients into their own mouths to choke themselves or strangle themselves to death. Sometimes they cut them- selves with glass which has obtained by breaking win- dows. Knives, scissors, razors, and all forms of cutting instruments should be carefully kept out of the way of patients who are likely to injure themselves by such means. The greatest possible care should be taken by nurses or attendants with reference to the custody of medicines administered to the patients. Here, again, it is advisable that they should have some little prac- tical instruction as to the strength and danger of the most potent remedies which are intrusted to their care for administration. They cannot be expected to have exact and profound knowledge as to the physiological properties, sources, etc., of morphia, conium, hydrobro- mate of hyoscine, atropia, duboisia, digitalis, chloral, bromides, cannabis indica, and the long list of powerful medical implements which are put into their hands; but they should know that these drugs are dangerous and deadly poison in more than a proper dose. They should keep them out of the reach of patients in inter- vals between the times of giving the particular doses ordered; where possible, they should be kept in an adjoining room, and always under lock and key and entirely out of reach. While, however, in the case of patients suicidally inclined the means of suicide should 112 THE NURSING AND CARE OF be kept or put out of reach, this should not be done in a fussy or demonstrative way. Such things should, as far as possible, not attract the attention of patients. Comparatively little restraint of a mechanical kind is now used in the care of the insane. In some cases, however, rare though they be, it may be absolutely necessary to protect patients from mutilation or suicide. Mechanical restraint should not be applied by a nurse or attendant except by the direction of the physician ; and, if it is used, care should be taken that no evil consequences result. Not long since, in a large hospital for the insane, a patient who had been restrained by straps in a bed, and was supposed by the attendant to be sleeping, so dragged himself down over the side of the bed as actually to cause his death by means of the Btraps with which he was supposed to be restrained and protected. When it becomes absolutely necessary for a nurse or attendant to take hold of an insane patient, care should be exercised as to the manner in which this is done. Usually patients requiring to be taken hold of are vio- lent,—cases of mania, homicidal monomania, of agi- tated melancholia, and the like. When two attendants are present it is well, while one secures the attention of the patient by demonstrations in front, for the other to get behind him and either throw the arms around him or seize both arms carefully but firmly above the elbows. Whatever plan of seizing patients is adopted, care should be taken not to inflict injury. It is only in self-defence, that is, in defence of life or limb in an emergency, that an attendant is ever justified in THE NERVOUS AND THE INSANE. 113 striking or roughly handling a patient. A patient, of course, may kick backwards when seized from behind; but the attendant by slipping his feet and legs as far as possible to one side can usually avoid being injured in this way. When applications of heat or cold are made to the insane, special attention should be paid to them. In some forms of insanity insensibility of the skin is present, and patients would in these cases allow blisters or mustard-plasters or stupes, or fomenta- tions or any form of hot or counter-irritating appli- cations to remain until serious blistering occurred. On the other hand, the insane are sometimes more im- patient of such applications than the sane ; in any case, special attention should be given to the matter by the attendant. The same remarks apply to the use of cold water or ice. All physicians who are engaged in the care and treat- ment of the insane now recognize the importance of occupation, amusement, and educational training as therapeutic resources. To attendants, the carrying out of plans of occupation, amusement, and teaching must be largely intrusted. In institutions, of course, methods and measures for the promotion of these objects will be carefully planned and regulated, if the institutions are up to the times in their management. The curse of many hospitals and asylums for the insane has been idleness. It is not within my design in the present chapter to go into a consideration of the methods and forms of employment, amusement, and instruction, but simply to give a few hints and suggestions as to the 114 THE NURSING AND CARE OF manner of carrying out the details, so far as such de- tails are intrusted to nurses and attendants. In the first place, patients should be encouraged, and in some cases be compelled, to do that work which is called for in their own personal care. They can be encouraged, or made, to take care of themselves, so far as cleanliness is concerned. Female patients should be made, when possible, to care for their own rooms, beds, etc. Attention should be paid, of course, particularly in private practice, to the question of the usual customs and habits of the patient. No matter what may be the work at which an insane patient is engaged, whether sewing, knitting, quilting, ironing, or book-keeping; or, if men, gardening, ploughing, brush-making, chair-making, or printing, a duty that will be incumbent upon the attend- ant more often than upon the physician will be to see that the patient does not overwork himself. While the tendency will be to do too little, in some cases insane patients will certainly try to do too much. This is particularly true in some forms of insanity attended with excitement, some varieties of mania, for instance, in which the patient tends to do everything to excess. Again, a patient may overwork as the result of some special delusion. Thus, Dr. Massey1 speaks of the case of a lady in good circumstances who, having been left with a family to support, resorted to dress-making, but became insane and was sent to an asylum, where she was induced to go to work in the sewing-room. The result Penn Monthly, November, 1879 THE NERVOUS AND THE INSANE. 115 was the production of a new delusion: she believed she was in charge of the sewing-room with large wages, and made great exertions in consequence. Becoming troublesome, she was transferred to the laundry, where the same thing was re-enacted; this resulting at last in complete exhaustion and confinement to bed. Exercise is of the utmost importance to many insane patients. In suitable weather, out-of-door exercise should be provided for; and here, again, the careful attendant will guard against under-exercising on the one hand, or over-exercising on the other. Torpor of the bowels and obstinate constipation are of such frequent occurrence among the insane that both resident physicians and attendants should have their attention particularly directed to these conditions. In melancholia, the bowels may remain constipated for days and even weeks if the patients are neglected. A large number of insane patients in asylums, par- ticularly many of the cases of dementia, are troubled with involuntary evacuations from thebowels or bladder, particularly at night In private patients the same difficulty may be encountered, and it is well for physi- cians and nurses to have some plan of meeting the difficulty. In one large hospital the plan adopted is a very sensible one. The physician in charge has a list of all patients who are troubled in this way, and in the evening before retiring injections of warm water are given; the lower bowel is thus emptied, and the proba- bility is that the patients will not soil their beds. In some cases, in addition to emptying the bowels, the bladder may have to be relieved by the catheter. 116 THE NURSING AND CARE OF Cleanliness on the part of a nurse or attendant upon the insane is of the utmost importance. It is impor- tant not only for itself, but for the example which it sets to the patient. The insane may be made less cleanly than their mental affliction would lead them to be by the example of others; on the other hand, they may become cleanly in habit simply from an example steadily set. The bathing of insane patients is a matter of im- portance, both from the point of view of cleanliness and as a therapeutic agent, and attendants should be thoroughly instructed in reference to this matter. They should also have a lively appreciation of the dangers which may attend bathing. A terrible acci- dent recently occurred in one of the larger asylums of a neighboring state, the patient having been liter- ally parboiled by an attendant. As many insane pa- tients make a great fuss and offer much resistance to bathing at all times, a careless or impatient attendant might fail to listen or assure himself of the conditions. Rigid rules are prescribed in all well-regulated public institutions. The rules for bathing which are in force at the State Hospital for the Insane, Norristown, Penn- sylvania, so fully express what should be said with reference to this matter that I will quote the most im- portant of them: The ward captains will personally supervise the bathing of pa- tients, which shall not be conducted during their absence without permission. Every patient .a to be bathed immediately after admission, and once a week afterwards, unless excused by medical order. Should THE NERVOUS AND THE INSANE. 117 there be the least doubt as to the advisability of bathing any pa- tient, owing to sickness, feebleness, or excitement, the matter should be immediately reported to the general officer. To provide against catching cold, the captains will see that the bath- and dressing-rooms are sufficiently warmed at bathing times, otherwise to postpone bathing until the rooms are heated. Any marks, bruises, wounds, sores, pain, or evidence of dis ease complained of by the patient, or noticed during any of the bathing operations, must be immediately reported to the physician. During the use of the bath, the room is never to be left by the attendant, except by special permission of the resident physician. When the room is not in use the door must be kept locked. Before putting the patient into the bath observe that the water is of proper temperature. It should not be less than 88° nor above 98°. Never turn on the hot water when the patient is in the tub. In the bath the body of the patient is to be well cleansed with soap; and in washing the hair be careful that no soap gets into the patient's eyes. After leaving the water, especial care must be taken to thoroughly dry the patients, and clothe them as rapidly as possible. A separate towel must be provided for every one. Under no pretence whatever is a patient's head to be put under water. An attendant must not attempt under any circumstances to bathe a struggling patient alone. Cold baths must never be given. Neither before nor after the bath will patients be allowed to stand about unclothed. The keys are never to be left on the bath-taps, nor are they to be used by the patients. I will next speak briefly of the methods of feeding patients forcibly. I do this because this book is intended for the instruction of resident physicians, as well as of nurses and attendants. I do not believe that nurses or attendants should be allowed to have the feeding of patients in this manner under their own 118 THE NURSING AND CARE OF charge; but, as it is necessary for them to assist in performing this work, they should receive instruction as to the whole process in order that they may be better able to render assistance to the physician. In some institutions head nurses have been allowed to admin- ister food in this way; but it is contrary to the regu- lations of all the institutions for the insane of which I have knowledge to allow this to be done. Not a few cases of insanity require, at times, to be fed by force. The cases in which such treatment is called for differ somewhat. In melancholia patients will allow themselves to run down rapidly in health, or even starve to death, if the food is not promptly admin- istered by artificial means. Sometimes cases of mania will refuse to take food, either because of their general excitement and combativeness or because of delusions. Paranoiacs or monomaniacs refuse food, if at all, because of some fixed delusion. A patient suffering from chronic alcoholic insanity, or even in rare instances a paretic de- ment, may refuse food because of a delusion, for instance, that food is being poisoned by physicians, attendants, or others, or that it is a means resorted to to accomplish some purpose on the part of a persecutor. The refusal of food by a patient with hysterical insanity, like the ap- parent attempts at suicide, is usually simply resorted to for the purpose of exciting sympathy. In most cases these patients will obtain food on the sly if pos- sible, but sometimes they will carry on the deception sufficiently long to injure themselves, if the attendants do not resort to active interference. Various plans of feeding patients by force have been THE NERVOUS AND THE INSANE. 119 recommended at different times; two of these are now almost universally employed, and one of the two, namely, nasal feeding, is now coming more and more into general use. The three methods in more or less common use will be described. The first plan is that of holding the nos- trils closed and opening the mouth, or thus compelling it to be opened, while the food is quickly poured into the mouth, and the patient is forced to swallow it in- stantaneously. A certain amount of danger accompa- nies this plan, which, by the way, is the one often re- sorted to in the case of recalcitrant children. If any one should make the experiment of trying to swallow liquids or solids while the nose is tightly held, so that no air can enter through it, he will find that it is a very difficult or almost impossible thing to accom- plish. The fact that the reason an individual, whose nose is held, opens the mouth in order to breathe shows the source of possible danger, which is that the glottis being open in order to receive air into the lungs at the same moment that food is hastily thrust into the mouth, some of the food is very likely to find its way into the windpipe and thus choke or strangle, or partially choke or strangle, the patient. This method of feeding is now not much employed. Dr. D. Anderson Moxey1 was among the first to call attention to the administration of food and medicine by the nose when they could not be given by the mouth. He resorted to this method in cases of insanity, in in- 1 The Lancet. 120 THE NURSING AND CARE OF flamed and ulcerated sore throat, in glossitis, in deep intoxication, and in infancy, where nothing could be administered by the mouth or retained by the rectum. In cases of insanity he fed his patients without the use of a tube by simply holding a small wedgewood funnel in one of the nostrils, and pouring through it the liquid or semi-solid nourishment. He describes his method with insane patients as follows : After first trying to induce the patient to take the nourishment quietly and in the ordinary way, he summoned three attendants at least (four or five, if they could be had), and laid the patient down on his back as quietly as possible on a low couch in the middle of the room. If there were only three attendants, one controlled the legs and the other two the arms; if a fourth was present, he attended only to the head, which was held between his knees as the attendant sat on a low stool at the top of the couch. If a fifth was present, he assisted in holding down the legs. In this way the patient was completely controlled, and sometimes would yield and swallow in the usual way. Then introducing the end of the funnel gently into one of the nostrils, he poured the liquid slowly into it, pausing now and then to allow the patient to take a deep inspiration, and not allowing the food to accumulate in the funnel. A determined patient would generally be able to sputter a little of il out of his mouth; when such was the case he poured the contents of the jug faster into the funnel, and some- times obstructed the other nostril. In troublesome cases a medical man ought, he insisted, invariably to administer the draught as he alone could properly THE NERVOUS AND THE INSANE. 121 judge of the extent to which it was necessary to in- terrupt nasal respiration. Dr. Moxey never found any serious results from this method of feeding. I have referred to these observations of Dr. Moxey to show the perfect feasibility of nasal feeding, and one of the methods of holding the patient by which it can even be accomplished without the aid of a tube, although un- doubtedly the use of the tube is the neater and better method. A good tube for feeding by the nose can be made by attaching a soft Nelaton catheter to a long piece of drainage-tube of a calibre which will just allow the catheter to tightly fit into it. To the extremity of the drainage-tube a funnel of large size should be attached. In nasal feeding some of the difficulties and dangers which are met with should be borne in mind. The number of patients who cannot be fed by the nose is very small; occasionally, however, a patient is found whom it seems impossible to feed in this way, owing to the choking and strangling produced. This may be because of some peculiar anatomical conformation, or some special idiosyncrasy on the part of the patient. Such a patient will choke or strangle with nasal feed- ing when he will not when the stomach-tube is resorted to. If, when the attempt is made to pass the well- oiled tube through the nostril, resistance is encountered, and if, after a few trials, the tube cannot be made to pass, great force should not be employed by the oper- ator, but the tube should be at once withdrawn and the effort should be made to pass it through the other nostril. In nearly all cases where special resistance is 122 THE NURSING AND CARE OF offered on one side the tube will pass with ease upon the other, and this, in most instances, is because, if hypertrophies or projections exist upon one side, there will be upon the other corresponding or compensating depressions and enlargements. Sometimes, but rarely, the mucous membrane is exceedingly irritable. After the nasal tube has passed through the nostrils it seems to have the peculiar tendency in some cases to drop into the glottis, the patient struggling and attempting to scream meanwhile. Some patients will spit or force the tube out into the mouth, and attendants can some- times, through the mouth, keep the tube, which has been passed through the nose, in position. Occasionally the nose is made sore by the use of the tube, but this is not likely to occur if the tube is always perfectly clean and well oiled. If it is of the proper kind,— that is, a soft tube,—there will be no danger of injur- ing the parts by breaking or perforating the mucous membrane. Indeed, one of the advantages of the nasal tube over the form of stomach-tube or oesophageal- tube which is commonly employed is that the danger of injury by perforation or abrasion is much less. The stomach-tube must be a little larger and of firmer make, and it is likely, after a little usage, particularly if not looked after with care, to become stiff and hard. I know of one instance in which the oesophagus was pierced by a stomach-tube in the hands of an unskilful attendant. In using the nasal tube, care should al- ways be exercised to see that at least fifteen to sixteen inches of the tube has been passed before beginning the feeding. This will make it certain that the entrance THE NERVOUS AND THE INSANE. 123 to the windpipe has been passed. Of course, care should be taken to observe that the tube has not doubled on itself. Dr. Spitzka speaks of the method of feeding by force as follows : " Whether fed with the funnel or the stomach-pump, the patient should sit up ; and if he is very obstructive, a restraining-chair will save the patient much needless muscular exertion, the physician much trouble, and diminish the chances of doing an injury. In case the oesophageal tube is passed along the floor of the nasal cavity, it is apt to encounter a resistance and be deflected forward by a prominence which is sometimes very marked on the posterior pharyngeal wall, and which corresponds to the bodies of the cervical vertebrae. Dr. Tuke advises throwing the head of the patient back at the moment when the sound approaches the posterior nares, the tube having previously been bent a little so as to facilitate its downward passage; then at the mo- ment when it is about to glide down into the oesophagus, when there is a risk of its passing into the larynx, he advises the head to be brought forward and downward so as to send the point against the posterior wall of the pharynx. After passing the upper end of the oesoph- agus, the tube is usually swallowed, as it were, and glides down without any further difficulty into the stomach through the action of the constrictor muscles."1 Whenever a patient is fed forcibly, care should be taken to have ample force to restrain him without '"Insanity, Its Classification, Diagnosis, and Treatment." By E. C. Spitzka, M.D. 124 THE NURSING AND CARE OF a violent struggle. The sight of overwhelming force will have a good moral or psychical influence over the patient. Three persons can feed a patient successfully, no matter how great the inclination to resist, if these persons are skilful and have sufficient strength. With less than three persons the difficulty will be very great, and in some cases it will be impossible successfully to accomplish the purpose. One attendant should always be charged with the task of firmly holding the head in position; another can hold the arms and hands, with the body thrown over the limbs of the patient, who be- fore this is attempted should be well enveloped in a blanket or sheet. It is much better, however, to have two attendants hold the arms and legs. After a patient has been fed, the tube should be always promptly cleansed. Hot water cannot be used because of the melting of the india-rubber, but the tube should be washed by allowing cold water to run through and over it. Negligent attendants are likely to neglect this matter. Whether fed by the mouth and oesophagus or through the nose, patients in rare instances learn to vomit or regurgitate the food. If this occurs, it is a matter for a physician rather than for a nurse or at- tendant. It has been found that the administra- tion of morphia and hyoscyamine prior to the time of feeding will sometimes prevent the patient from ex- ercising this power. Two doses, say of sulphate of morphia gr. \ and hyoscyamine gr. fa to fa, may be given, the first three or four hours, and the second THE NERVOUS AND THE INSANE. 125 one hour or less before the times for administering the food. If the nasal mucous membrane or the mucous mem- brane of the throat should be unusually irritable, resort may be had to a weak solution of the hydrochlorate of cocaine, which can be painted over them. The administration of such remedies as morphia, hyoscyamine, and the bromides will also, of course, in cases of insanity, as in other cases, tend to diminish the pharyngeal reflex and thus allow of the use of forcible mechanical feeding with less trouble; but prescribing medicines is the duty of the physician, and therefore little is said here about such matters. One advantage in using the stomach-tube through the mouth is that when the latter is kept well opened by means of a bandage or a screw-wedge, the finger of the physician or attendant can be used to guide the tube past the epiglottis into the oesophagus, and thus pre- vent any danger no matter how much the patient may struggle or use his breathing apparatus. No matter how a patient is fed, whether by the nose or through the mouth, care should be taken to have everything ready before the operation begins. It is one of those processes which cannot be done properly if it is only half prepared for or attended to indifferently. The proper appliances should be on hand and within easy reach. The food and medicines that may become necessary, if they have been previously ordered, should be ready for the doctor. Care should be taken in the preparation of the food, which is administered ar- 126 THE NURSING AND CARE OF tificially, if it is anything more than milk or some single substance of a fluid kind. If gruel or any form of semi-solid food, care should be taken to have it of the exact consistence, which is best administered through a tube. When medicines are ordered to be given with the food, as for instance bromide of potassium in milk, only just as much as is required should be mixed at one time. Even when patients are not fed by force, it is of im- portance that their eating should be carefully watched and attended to by those in charge. In some forms of insanity the tendency is to bolt the food with great rapidity and in enormous quantity. So little control have some demented patients over matters of this kind that they will choke and strangle themselves, or fill themselves to more than repletion. Such patients should, by kind but firm measures, be trained to eat more slowly and carefully. It is sometimes desirable that the temperature of the insane should be taken, and when this is the case spe- cial precautions should be used. It would, for instance, ordinarily, be foolish to attempt to take the temperature of an insane patient in the mouth. In many cases the thermometer would either be broken in the struggle which would take place, or it might be bitten off by the patient, and the glass swallowed with fatal results. Only when the exact mental status of the patient is so well known that the physician, feeling that no danger can arise by taking the temperature by the mouth, directs it to be done, should this plan be followed. The temperature of the insane should therefore usually be THE NERVOUS AND THE INSANE. 127 taken in the axilla, and when taken in this way the in- strument should not be left so that the patient can take hold of it himself. The nurse should stay by the side of the patient, and by preference in most cases should hold the thermometer in position the whole time of the deter- mination. Occasionally, when specially directed so to do, the temperature may be taken in the rectum, but here, as in the mouth, great caution is usually neces- sary,and it is often advisable not to resort to this method. Artificial respiration may have to be resorted to at any moment in the care of suicidal cases. Aside from self-inflicted wounds the methods most commonly resorted to are hanging, drowning, and the inhalation of illuminating gas. The prone pressure method of artificial respiration introduced by E. A. Schaferl is now frequently used instead of the methods of Sylvester and Marshall Hall. This method, in the distinguished physiologist's own words, is as follows: " The subject, whether a drowned person or not, is allowed to lie prone, i.e., face downwards, no prelimi- nary manipulation of the tongue being required. The operator kneels or squats either across or on one side of the subject, facing the head, and places his hands close together flat upon the back of the subject over the loins, the fingers extending over the lowest ribs. By now leaning forwards upon the hands, keeping the elbows extended, the weight of the operator's body is 1 Schafer, Prof. E. A.—"Artificial Respiration in Man." The Harvey Lectures, Delivered under the Auspices of The Harvey Society of New York, 1907-8. J. B. Lippincott Company, 1909. 128 THE NURSING AND CARE OF brought to bear upon the subject, and this not only compresses the lower part of the thorax but also the abdomen against the ground, the pressure being fairly equally distributed. The result of this is that not only is the thorax diminished in extent from before back, but, owing to the pressure which is communicated to the abdomen, the viscera are compressed and tend to force the diaphragm up, so that the thorax is diminished in capacity from above down. This is no doubt the reason why the pressure method when applied in the prone position is more effective than when applied, as by Howard, in the supine position. The pressure is applied not violently, but gradually, during about three seconds, and is then released by the operator swinging his body back, but without removing his hands. The elasticity of the chest and abdomen causes these to re- sume their original dimensions and air passes in through the trachea. After two seconds the process is again commenced and is continued in the same way, the oper- ator swinging his body forwards and backwards once every five seconds or about twelve times a minute, without any violent effort and with the least possible exertion. This last condition, viz., the absence of mus- cular exertion other than that involved in swinging forwards and backwards, renders it possible to continue the process without fatigue for an indefinite time. It can further be carried out unaided, by a woman almost as well as by a man, by children upon children; it hardly requires to be taught—a simple demonstration sufficiently teaches it to a large audience. Its advantages in drowning cases over any method which involves the THE NERVOUS AND THE INSANE. 129 supine position are sufficiently obvious—for with it there is no risk of obstruction by water or mucus or the contents of the stomach, which cannot accumulate in the throat but must come away by the mouth; and the tongue, in place of falling back, as in the supine position, falls forwards, and is unable to produce obstruction." The pulmotor has come into use recently, and, if avail- able, should be employed. It is easily manipulated and works automatically. The following are some of the most important rules enforced in the female and in the male departments of the Philadelphia Hospital for the Insane: All attendants, excepting probationers, must wear complete uniform while on duty. Male attendants must not wear their caps in the wards. Attendants shall be neat and tidy in appearance, and shall keep their rooms in neat and attractive order. They shall show kindness, civility and respect to all patients and visitors, and to each other. They shall see that patients are properly fed, and that the food is neatly and properly served. They shall not administer medicines without a written order from the physician. They shall not administer food or medicine, if refused, except by the direction and in the presence of a physician. They shall not employ mechanical restraint except by the direction of a physician. In every case in which force is necessary to control violence two or more attendants shall be summoned. Force is justifiable to pre- vent violence, but no more than is necessary to control a patient. Attendants shall not abuse patients by striking, pulling hair, laying on of violent hands, tripping or pushing. The use of pro- fane, low or violent language is prohibited, also scolding and loud calling from one part of the ward to another. 130 THE NURSING AND CARE OF Attendants shall examine immediately all patients as soon as they are admitted to their respective wards, and shall note all marks, bruises and injuries, and report them in writing to the Chief Resident Physician. They shall report immediately in writing any accident that may occur to a patient, the character and extent of the injury, and how incurred. The escape of any patient shall be reported immediately, and the manner of escape stated in writing. Attendants shall report immediately to the physician any marked physical or mental change in a patient. They shall separate any patients seen to be quarrelling among themselves. They shall not permit patients to have matches or lighted papers, or to come in contact with lighted gas. They shall not permit patients to use sharp knives or other instruments which might be used for the purpose of doing injury to themselves or others. Attendants shall not leave the wards or duties assigned them without permission from the Supervisor. Attendants shall not leave the Hospital without a pass fur- nished by the Chief Resident Physician, and shall return at the date or time specified on the pass, and report their return at such place as may be designated by the Chief Resident Physician. Attendants shall not wear part or parts of clothing or other material belonging to the Hospital, or use any material, instru- ments or apparatus of the Hospital for their personal needs with- out a written order from the Chief Resident Physician. They shall see that the wards are kept clean, and that there is a full supply of materials on hand. They shall report imme- diately to the Supervisor any insufficiency of material or any damage to the ward or its contents. They Bhall be held responsible for all articles of furniture, bedding, ward supplies and clothing in their respective wards, and if any article is missing the fact must he reported immedi- ately to the Supervisor. All Head Attendants shall keep a correct laundry list, and see that the full number of articles is returned; that all goods re- turned from the laundry are clean, and that any damages are repaired before the articles are used again. A written laundry THE NERVOUS AND THE INSANE. 131 report from each ward shall be sent each week to the Chief Resi- dent Physician. No attendant shall leave the gas burning in a room or ward that is not occupied at the time. Attendants shall observe economy in the use of all supplies. They shall count all knives, forks and spoons after each meal or service, and then place them in a suitable receptacle, properly protected from the patients. They shall not allow the Hospital keys out of their possession, and when a key is missing they shall report the loss immediately to the Supervisor. Attendants in charge of wards shall see that all general clean- ing of the wards is stopped while the physician is making rounds. At the time of the morning rounds they shall bring in line for inspection all patients who are not in bed and not employed out- side of the ward, unless excused by the Chief Resident Physician. The Head Attendant shall accompany the physician on his rounds, or any visitor or officer who may have occasion to visit the ward. All the attendants shall remain standing during the presence of a physician or officer in the ward or yard. Attendants shall not permit visitors to give the patients food, money or other articles without permission from the Chief Resident Physician. They shall not permit visitors to talk to patients other than the patient visited. They shall not gossip with visitors, or give them any information concerning the condition of any patient. The attendants shall observe strictly the rules governing vis- itors, and see that these rules are enforced. No attendant shall sell anything to a patient, or for any reason accept money or other valuables from a patient. Attendants shall not allow patients to carry any article other than a handkerchief about their clothing, unless by special per- mission from the Chief Resident Physician. They shall deliver any valuable found on a patient to the Chief Resident Physician. They shall send, unsealed, to the office of the Chief Resident Physician, all letters, writings and drawings of patients. No attendant, employee or visitor shall mail any letter or doc- ument of a patient without permission from the Chief Resident Physician. 132 THE NURSING AND CARE OF All attendants shall respond promptly to fire drill, and in case of fire each attendant shall be on duty at the ward and place which is assigned to him or her. At fire drill, and in case of fire, the Head Attendant shall be the last to leave the ward, and shall be sure that no patient is left in the ward. Attendants shall count the patients as soon there- after as possible. No attendant shall have any communication, verbal, written, or otherwise, with employees of the opposite sex, except such as might occur in fulfilling their respective duties. This rule shall apply within the Institution and within the immediate vicinity thereof. They shall comply with all the general rules and regulations of the Institution. They must bear in mind that they are subject not only to these rules, but to the state laws governing the care of the insane, and that violation of the rules or laws may furnish cause for reprimand, suspension, dismissal or arrest, according to the rule or law broken. The head night attendants shall be held responsible for the condition of patients, wards and supplies during the night, and report to the head day attendants the condition of patients, wards and supplies when going off duty at 7 a.m. The head day attendants shall, in turn, make a similar report to the head night attendants when going off duty at 7 p.m. The head day attendants and the head night attendants shall carefully read said reports and see that they are thoroughly understood before assuming charge. Any attendant found sleeping on duty shall be disciplined. The night attendants shall carry out all instructions relative to medicine, treatment and reports as requested by the supervis- ing nurse. They shall pay special attention to those patients who are critically ill and who require special care. All suicidal and homicidal cases shall be closely watched both during the day and night. The attendants shall see that ice-picks, drugs and instruments are not kept in the wards, except in the infirmaries, and there they shall be kept under lock and key. Attendants shall also see that the scissors used for the general care of the patients are kept under lock and key. THE NERVOUS AND THE INSANE. 133 Night attendants shall report every hour to the night patrol. They shall also see that the lights are turned down after 3.30 p.m., and that there is no talking or noise. Attendants shall not accept any remuneration or gifts of any kind from the patients or their relatives. Attendants shall submit a correct statement as to the number of patients, diets, restraints and special reports to the office of the supervising nurse not later than 8.30 a.m. No head attendant shall leave the ward without permission, and then not until relieved by a capable person, who is to assume charge. In case of death the attendant shall report at once to the super- vising nurse and await further instructions. Attendants shall see that bodies are prepared for the morgue —namely, that the body is bathed with a weak solution of car- bolic acid, 6 per cent.; the finger nails and toe nails trimmed and cleaned ; the hair properly prepared; wounds and ulcers properly dressed ; a napkin properly applied and fastened with safety pins; the body covered with a shroud, and a mortuary sheet folded neatly around it. Head attendants shall be held responsible for the attendants and patients under their charge, and they shall also be held responsible for the enforcement of all rules and regulations relative thereto. Attendants shall see that hot-water bottles and cans are cov- ered before they are applied to the patients. Attendants, after arising, shall see that the bed-covers are thrown over the foot of the beds and the windows raised. Visitors. General visiting will be allowed on Tuesday and Thursday afternoons, between 1 and 4 p.m., and at no other time except by special appointment with the Chief Resident Physician. Visitors who cannot come week days will be admitted Sundays between 9 and 11 a.m. on special passes countersigned by the Chief Resident Physician and the Superintendent. Such passes will be issued only to near relatives and friends. No patient will be allowed to see more than two visitors at a time or during a single week, except by special permission from the Chief Resident Physician. 134 THE NURSING AND CARE OF Visitora will not be permitted to remain with a patient longer than fifteen (15) minutes, except by special permission from the Chief Resident Physician. Visitors will not be permitted to visit a patient who has been in the Hospital less than one (1) week, unless special permission be obtained from the Chief Resident Physician. Disturbed patients and patients in the acute and infirm wards shall not be visited oftener than once each week, or as the Chief Resident Physician may designate. Patients critically ill may be visited as frequently and for as long a time as the Chief Resident Physician or Assistant Physi- cian may direct. Visitors shall not give personally any food, candy, ice cream, tobacco, matches, paper, medicine, or articles of any kind directly or indirectly to a patient. Visitors shall not bring or send to patients any food or article (other than fruit, flowers) or select reading matter (other than re- ligious reading); and all packages must be left in the office of the Chief Resident Physician, with the patient's name on the package. Visitors shall not converse with attendants. All information concerning patients must be obtained from the Chief Resident Physician or Assistant Physicians. Visitors shall not secure the signature of a patient to any doc- ument or paper except by the permission and in the presence of the Chief Resident Physician. Visitors shall not speak to any patient other than the patient visited. Visitors shall not mail letters to patients, or take away from the department any message written by patients. All written communications to patients shall pass through the office of the Chief Resident Physician. Complaint regarding any neglect, incivility or inattention on the part of employees shall be made to the Chief Resident Phy- sician as soon as possible. No loud talking, scolding, violence, or intoxication on the part of visitors will be permitted. Visitors may see the Chief Resident Physician or Assistant Physicians at the prescribed visiting hours. " The members of families of patients, their personal friends, agents, or attorneys, shall be permitted to visit them not less THE NERVOUS AND THE INSANE. 135 than once in two weeks, unless the medical officer consider the visit likely to be injurious to such patient, or otherwise inexpe- dient, in which case he shall so state in writing, if requested, giving his reasons therefor, and a copy of such writing shall be given to every visitor, if requested, who is refused a personal interview with the patient."—Rules and Regulations of the Committee on Lunacy of the Board of Public Charities, State of Pennsylvania. I will conclude this chapter by quoting in full the quaint description of the " Good Attendant," by Dr. Ray*: " The good attendant never shirketh his appointed work, and it is not in him to be satisfied with just that measure of performance which will enable him to keep his place. He elevateth his employment by the manner in which he performeth its duties. Though offensive to the senses, or trying to the temper, or exhaustive of patience, as many of them are, yet he meeteth them all faithfully and promptly. Like every true man and true woman, he findeth that dignity inherent in every good work, that ennobles even the meanest service. As the good artisan rejoiceth over some choice specimen of his craft, wrought by his own hand, so doth the good at- tendant rejoice when, after much toil and trial, he seeth the mind of his patient coming out from under the cloud. To hasten this blessed consummation, he spareth neither time nor trouble, rendering every attention needful for the bodily comfort, and by unceasing arts of kindness soothing the troubled spirit. The good at- 1 " Ideal Characters of the Officers of a Hospital for the In- sane." By I. Ray, M.D. 136 THE NURSING AND CARE OF tendant is ever gentle in his words and ways, and under no provocation will he return a blow or an abusive word. Unlike the people of former times, who be- lieved that the insane must first be made to feel that they have a master in their keeper, and for this purpose resorted to threats and blows, he seeketh to obtain the desirable control by gaining the patient's respect, and this he well knoweth will not follow angry words, or harsh measures, or any form of intimidation. " The good attendant never attempteth to reason his patient out of his false beliefs, and, as far as practica- ble, he preventeth him from conversing about them. He knoweth that argument giveth them additional strength, besides exciting and souring the temper. He refraineth from joking on the notions or circumstances of his patient, for he hath learned that the disordered mind is impervious to a joke, but rather construes one into an insult. He is careful to obey every change, bodily or mental, for better or worse, and maketh due report thereof to the physicians. His constant pres- ence with the patients giveth him opportunity to see and hear much that may escape the attention of the officers in their casual visits, and his eyes and ears are ever open for this purpose. Especially doth he en- deavor to inspire his charge with confidence in the physicians, always holding them up as his friends and protectors, who will never see him wronged or injured. When abroad, he refraineth from entertaining company with the fancies or conduct of his patients, nor is he swift to pour into itching ears the gossip of the house. The rules made for the government of attendants he THE NERVOUS AND THE INSANE. 137 faithfully follows, bound thereto by a sense of respect for himself and of fair dealing with his employers. " The good attendant avoideth all vulgar ways in language, dress, or demeanor, as well as all familiarities which he would never venture upon outside of the hospital. He beareth in mind that the people who have fallen to his charge, however perverted or de- graded by disease, were once as good as himself, if not better, and have done nothing to forfeit their claims to his respect and protection. For deficiencies of culture and of good breeding, he more than maketh up by gentle words, acts of kindness, and little attentions. Especially is the female attendant not to add fresh poignancy to the sorrows of her charge by coarse ex- pressions, untidy ways, and manners utterly devoid of refinement." IND] Air cushions, 41. Alternate hot and cold applica- tions, 67. Amusement of the insane, 113. Anderson on tact in nurses, 13. Apoplexy, Bowles's recommenda- tion as to position in, 32. general management of, 33. hemorrhagic, 32. position in, 33. signs and symptoms of, 32. what to do in case of, 35. Applications of heat and cold to the insane, 113. Artificial respiration, 127. Attendants, scientific interest of, in the patients, 101. tests of good, 109. the best, 104. Bath, continuous, 66. intermittent, 67. Bathing, 65. dangers of, among the insane, 116. of the insane, 116. rules for, 116. Beard and Rockwell's method of general faradization, 94 Bed-sores, 40. acute, 41. plans of treatment for, 41. prevention of, 42. treatment with galvanic plates, 42. Bladder, washing out of, 40. Breathing, stertorous, 32. Cases, different classes uf nervous and insane, 11. of chronic organic nervous dis- ease, 38. X. Cerebral hemorrhage, acute bed- sores in, 41. Cheyne-Stokes breathing, 34. Cleanliness of nurses of attendants upon the insane, 116. Cleansing of feeding-tube, 124. Conducting cords, 86. Conjugate deviation of the eyes and head, 34. Consciousness, loss of, in epilepsy and in hystero-epilepsy, 23. Constipation among the insane, 115. Continuous bath, 66. Cotton, use of absorbent, 86. Current-carrier, 84. regulators or modifiers, 78. Defects in nurses and attendants, 110. Delirium, treatment of, 43. Delirium tremens, 43. Delusions, 101. suppression of, by patients, 101. which lead to mutilation, 102. Diet, purin-free, 27. Drunkenness, diagnosis of, 36. management of, 33. signs and symptoms of, 36. Dubois-Reymond coil, 74. Eating, watchfulness of, among the insane, 126. Educational training of the insane, 113. Electrical apparatus, importance of keeping clean, 82. applications, deep-seated, 88. direct and indirect methods of, 88. to the face, 91. to the joints, 92. to the skin, 92. to timid patients, 80. 139 140 INDEX. Electricity after meals, 90. forma of, used in medicine, 72. how far it should be used by nurses, 70. methods of applying, 90. position of limbs and muscles in using, 90. what a nurse should know about, 71. Electrodes, 84. for application beneath a pa- tient's clothing, 84. how to hold, 87. method of covering, 86. methods of cleaning, 85. Epilepsy, general care of patients Buffering from, 25. Epileptic seizure, aura preceding, 26. description of, 24. management of, 25. Epileptics, amount and character of food for, 27. peculiar abnormal mental states of, 27. rules for management of, 28. Eschars, acute, 41. Estradere1 on the varieties of mas- sage, 49. Exercise for the insane, 115. Exhaustion, heat, 35. Exhaustion produced by electrical applications, 90. Expedients for amusing and occupy- ing patients, 14. Fainting, 38. Faradic apparatus for office table, 77. battery, description of, 72. harm done with, 82. hints about handling and caring for, 81. current, how to start a, 75. machine, other names for, 72. Faradism, when to use, 91. Faradization, general, 93, 94. Favoritism of nurses and attend- ants, 108. Fibrositis, 59. Food, directions as to its prepara- tion, 44. insufficient or too much, among the insane, 110. preparation of, for forcible feed- ing, 126. Forcible feeding of the insane, 117. three methods of, 119. Galvanic current, 83. Grease or liniments in massage, 54. Haematoma-auris, 100. Hallucinations, 101. Hamilton, Allen McLane, on the use of revulsives, 68. Heat prostration, 36. Helplessness, how to be useful in cases of, 39. Hydrotherapy, 65. Hysteria, 21. among the insane, 103. Hysterical attacks, involuntary, 23. simulated, 23. cases, general management of, 22. seizures, different forms of, 22. Hystero-epilepsy, 23. with separate crises, 24. Illusions, 101. Insane, attention to little things among the, 109. ear, 100. hysteria among the, 103. nursing and care of, in private practice, 106. patients, methods of seizing or holding, 112. ridicule of the, 108. Insanity, practical hints as to dif- ferent forms of, 98. simulation of, by the sane, 103. of sanity by the insane, 103. what a nurse should know about, 98. INDE Insensibility, cause and nature of, in various affections, 31. Intermittent bath, 67. Involuntary evacuations among the insane, 115. Jacoby on the methods of massage, 50, 51, 52, 53. Kneading, 52. Lee, Dr. Benjamin, on derivation of word massage, 48. Levenstein's treatment of narcotic habit, 45. Loyalty of nurse to the doctor, 15. Manuals for attendants on the in- sane, 96, 97. Massages, friction, 51. chapter on, 46. complaint of patients as to, 48. definitions of, 49. derivation of word, 48. direction of, 55. grease or liniment in, 54. immediate, 49. mediate, 49. number of patients to be treated in one day, 56. position of muscles and limbs in, 53. rough handling of patients in, 57. so-called methods of, 49. special instruction in, 46. temperature and ventilation of room in, 58. terms to describe the process of, 49. the four essential methods of, 50. the use of both hands in, 54. twisting or wringing movements in, 55. wrist movements in, 54. Masseur, 53. Masseurs, mental requirements of, 58. knowledge of anatomy and . physiology by, 47. ?