How To Care For The Insane Part 5

Some patients object to bathing; they fear the tub, but will wash with water and a sponge, and they should be allowed to do so. Others want to bathe first; let them, if possible. Others will not bathe the day the rest do; it is sometimes best to humor them.

Some patients have to be forcibly bathed. In such cases always wait, use every art to induce them to bathe, and before acting send for advice.

Attendants are too p.r.o.ne to think that every thing should be done by rule, and that all must be forced to obey the rule. Most will observe it without trouble, and the object sought can generally be gained by patience, tact, and kindness.

_Serving of Food._--The dining-tables should be neatly set and made attractive; the food should be promptly served, and while hot; all patients should be at meals, unless excused by the physicians. Economy should be practised, and every thing should be used or saved. Each person should have enough, but no one should be allowed to make a meal of a delicacy, or take all of the best of a dish. Some patients would waste a pound of b.u.t.ter or sugar at each meal; enough is sufficient for anybody.

The old and feeble should be served by attendants; those without teeth should have their food prepared, and the meat should be cut very fine.

Those who will not eat must be kept in the dining-room and fed; the attendants may use force by holding the hands, and placing food in or to the mouth; but it is dangerous to do more, and holding the nose is something that is never allowable. If these efforts to get them to take food do not succeed, report to the physician. Some patients from delusions will eat certain kinds of food, and either not get enough or not a sufficient variety.

A mixed diet is the best, and patients should if possible be made to eat bread, b.u.t.ter, meat, vegetables, and drink milk and plenty of water. No patient should be allowed to lose in flesh and strength on account of failure to take sufficient, or proper food; before these things happen it should be reported to the physician. Some patients will only eat enough if they are allowed to eat it in their own way; they will eat it perhaps standing, or after the others have finished, or alone, or in their room, or they may steal it, if given the opportunity. Such peculiarities often have to be indulged.

Some patients will take nothing but milk, then about three quarts a day are needed; eggs may be added and are often readily taken, and some may be got to eat bread and milk, which is a very nutritious diet.

The food of the sick should be nicely and invitingly served, and efforts should be made to meet their whims and fancies.

Patients who are so profane, violent, or noisy, that they are not allowed to come to the dining-room, must always be fed by, and in the presence of an attendant, and meals should not be pa.s.sed into a patient's room and left there.

Knives and forks should always be counted by an attendant before and after each meal; care should be used that they are not lost, secreted, or carried out of the dining-room by patients. No one but an attendant should ever handle the carving knife and fork, or the bread knife.

_Care of Patients when Going to Bed, or Rising._--The beds should be daily aired, and always clean and nicely made up; for a filthy patient a straw bed, that can be changed, alone is clean.

All patients do not need to go to bed at the same time, and while some are able to care for themselves, most need care, attention, and watching. The helpless should be dressed and undressed, and put to bed first: the violent and homicidal need to be watched, and should be put to bed early, while the suicidal should be kept under supervision, and put to bed at the most convenient time. After a patient is in bed, an attendant should go into the room, with a lantern, so as to see that every thing is in order and safe, and, with a cheerful "good-night" close the door. Patients who need care should be visited during the evening, and left clean and in good condition to be cared for by the night watch.

In the morning patients need attention before any thing else is done.

First, the suicidal, sick and feeble, the violent, and those likely to be filthy should be visited, and every patient should be washed and dressed before breakfast; or, if for any reason they do not come to this meal, their faces and hands should be washed, the bed put in order, and the room made clean and aired.

After these things have been attended to, the ward work should be done, though generally the two can go on together.

_Care of Patients during the Night._--After the patients have gone to bed the ward should be quiet, doors should be quietly closed, voices lowered, and loud calls and laughter not indulged in, squeaking boots should not be worn, and heavy walking avoided. Many patients go to sleep early, but are easily awakened, and may remain sleepless till morning, or at least a part of the night.

The night watchers have responsible, arduous, and trying duties.

Attendants should always, during the night, quickly respond whenever a demand is made upon them for a.s.sistance, though an unnecessary call should never be made. The night watchers should be informed of any changes that have occurred during the day, that will require their attention during the night; they should see new patients and be made acquainted with their peculiarities; they should visit the wards during the evening before they come to the medical office to receive instructions from the physicians.

It is the duty of a night watch to visit regularly all the wards under his charge; to see and know the condition of the sick, the helpless, feeble, the suicidal, and the epileptic; to attend to, by taking up, those who are inclined to be filthy, and wash those who need it, and make them, their beds, and rooms perfectly clean. He should observe the conduct of new patients, be watchful of the violent, know how much wakeful patients sleep, visit all a.s.sociated dormitories, wait upon all those who need attention, and guard against fire and accident. The night watch should place each day on the medical office table, a detailed account of every patient that needed care or attention, who was disturbed, or did not sleep during the previous night.

Patients should be left clean for the night watch, who should leave them in as good condition in the morning, for the day attendants, and any neglect in these directions should be reported by either party. Sick patients frequently have to receive special night service, to be watched, and given food and medicine. When this cannot be done by the night watch, it devolves upon the day attendants, and is a duty that should be cheerfully rendered.

During the night, any accident, attempt at suicide or to escape, or unusual violence, persistent sleeplessness, or being out of bed, a serious sickness or change for the worse, or the approach of death, should be reported to the physician. It is, in many inst.i.tutions, the duty of the night watch to report any neglect or misconduct on the part of an attendant or employe, and it is something that should be faithfully and impartially done.

Having briefly sketched the general duties of an attendant, it seems best to again remind them, that an asylum is built and maintained for no other purpose than for caring for the insane; that each patient is ent.i.tled to the best our means can afford; that while the attendants are not responsible for the medical treatment, they are for that kind and intelligent care it is within their province to give; and they are also reminded that, so far as it can be done, such personal attention is to be given to each patient as will a.s.sist in recovery or improvement, or promote his well-being.

CHAPTER VI.

THE CARE OF THE VIOLENT INSANE.

A careful study of each violent patient, of his habits, delusions, and hallucinations, of his peculiar manner of showing violence, and a knowledge of what is likely to provoke outbursts is necessary to properly care for him. An attendant's ability to successfully manage a ward full of patients will depend largely upon the study given to, and the thorough understanding of, each case. Such study will soon teach him that every violent patient has peculiar and pretty constant ways of showing and exercising violence, and that the same rule of individuality holds good among this, as it does among other cla.s.ses of the insane.

Having learned what will cause violence, it can often be avoided by removing the cause; having learned the symptoms that precede a patient's outbursts of violence, they can sometimes be averted, or preparations made to control them; having learned in what direction violence is shown, how sudden, blind, or furious it may be, or how slow, deliberate, and planned, the attendant is better able to meet, manage, and control it.

Few patients are so continuously and furiously violent as to need constant repression, and the directions how to care for such patients can always be given by the physician. Most violent patients are subject to the firm, kind control of attendants, and can be kept sufficiently quiet and orderly; they should never be left alone, and mops, pails, brooms, chambers, and all other articles, that may become weapons should not be left within reach. Strong comfortable clothing can generally be kept on the most violent and destructive, with care and attention from attendants, but not without.

Many violent patients will employ themselves and be the quieter for so doing. Light out-of-door work is the best employment for this cla.s.s, and out-of-door walking and exercise should never be neglected. On the woman's ward knitting, sewing, mending, and ward work are suitable for many, while some will work at the laundry, and others will go quietly to church and entertainment; books and ill.u.s.trated papers should be furnished and will be much read and enjoyed.

As a rule the more violent patients are restricted, kept continuously on the ward, or in a small room, and given no work, amus.e.m.e.nts, walks, and exercise, the more noisy and violent do they become.

Attendants must learn that mere noise, and much of maniacal activity, such as running about, jumping, or pounding, is not in itself harmful, and that unless such patients are doing themselves injury, or so disturbing the ward and other patients as to require interference, it is better to control than to repress and restrict them.

Many violent patients are subject to such paroxysms of great violence as to require immediate care and often temporary control at the hands of attendants. Generally these paroxysms spend themselves after a short time, but if they do not, advice and help can be called for.

By careful watching, the approach of these paroxysms can be known and often avoided. This may be done by removing the cause, which is often the irritation of another patient or an attendant, by a word, a joke, by simply letting the patient alone, or by a firm show of authority, or by any other means experience has taught to be useful in the particular case.

If necessary to hold a patient, three persons should be able to care for the most violent. This can be done by grasping each arm at the wrist and elbow, and holding it out straight, the attendants standing behind while another pa.s.ses the arm about the neck and holds the chin, to prevent biting and spitting; the patient may then be walked backward and seated in a chair.

After the violence has subsided, though the patient should continue to scold, swear, threaten, or cry, he should, as soon as possible, be left alone, the attendants walking away, but remaining watchful. Do not, unless it is necessary, interfere to stop the noise, for it is often a subst.i.tute for the violence, and the attack wears itself out in this way.

If necessary to carry a violent patient, it can be done by four or six attendants. The face should be turned downward, thereby lessening the power to resist, and, to prevent dislocating the arms, the patient should be carried by the shoulders and chest; the bands about the neck should be loosened.

In using force in the care of violent patients, it should always be done as gently as possible, and struggling should be avoided; he should never be choked or kicked, receive a blow, or be knocked down; the arms should never be twisted, nor a towel held over the mouth, but if the patient persists in spitting it may be held in front of the face.

Care must always be used not to injure a patient while exercising necessary control. In the violence of a patient innocent injuries are sometimes received. The attendant is excusable if he can show that he used necessary force only, without malice.

A violent patient should never be struggled with alone, and on a well-managed ward help will always be within call. It may be necessary, however, to break this rule in order to prevent homicide or suicide, or serious injury to another patient, or setting the house on fire.

It is better not to visit the room of a violent patient alone, and if an attack is feared, especially with a weapon, the door should be slowly opened, and held so it can be quickly closed. The patient usually makes an immediate attack, and, before he has recovered for a second, can generally be disarmed and controlled.

Violence usually consists of noise, tearing the clothing, breaking gla.s.s or furniture, biting, scratching, striking, hair pulling, kicking, or attacking others with weapons. It is sometimes secretly and deliberately planned and skilfully executed, though generally without reasoning or direction, but blind and fierce.

The care of the violent insane involves the careful study of each case, with constant watchfulness, and the exercise of a control that is kind, but firm and unyielding, that does not repress except when necessary, nor restrict without reason, that indulges whenever possible, that never drives, scolds, or threatens, but influences, guides, and directs. The greatest liberty possible should be allowed, and self-control encouraged, and work, occupation, and amus.e.m.e.nt should be furnished. An attendant must always remember that fear is the lowest motive to govern by, and that kindness will often be appreciated and returned.

_Care of the Destructive Patients._--Besides the violently destructive patients, there are some who are maliciously destructive, and who exercise all their ingenuity to escape the watchfulness of the attendants; who glory in their wrong-doing; who openly say they cannot be punished, and exultantly tell the physician how they have outwitted the attendant, or proclaim before him his shortcomings and neglect. Such patients will destroy their own or others clothing, they will steal and hide, or throw it out the window or down the water-closet, or erase the name by which it is marked. They will destroy bedding, windows, crockery, pictures, or furniture. With a pin, a nail, or a bit of gla.s.s or wood, they will mar and deface their room or the ward, and often do damage that cannot be repaired. The only way to meet such cases is by watchfulness. They should be kept, if possible, at work, or at least with a company of workers, and therefore under constant observation. When put to bed their clothing, mouth, hair, and person should be thoroughly searched. Kindness often has but little effect, but a threat is apt to make them more determined to destroy.

_The Care of Patients by Mechanical Restraint and Seclusion._--All the restriction of an asylum is restraint. The locking of bedroom doors at night is very restricted restraint. Most patients in an asylum have a feeling that they are under great compulsion and restraint, in being deprived of their liberty. It has already been taught that patients are to be given all the liberty possible, that restraint over their freedom is to be exercised no more than is absolutely necessary, and that the greatest good of the patients alone is to be thought of.

These teachings are equally true of special forms of restraint. If used at all they are to be used for the good of the patient alone, and an attendant should be able to care for any case without restraint.

Restraining apparatus should never be kept on the ward. An attendant should never ask that it be used, nor say he cannot get along without it.

If ordered by the physician it is the attendant's duty to see that it is so applied as to do no injury, that it does not bind or tie the patient down, that it does not irritate and make the skin sore, nor restrict the free movement of the limbs.

Patients who are restrained are not to be further confined to a chair without specific order. Restraint used during the day is not, unless so ordered, to be continued at night nor reapplied the next day. Patients are to be taken frequently to the closet. Restraint should be taken off several times a day, and kept off long enough to give relief to any feeling of discomfort, and free movement should be allowed. When patients are restrained they need unusual care and watching, and should never be left alone.

The attendant should be informed why restraint is used, and what is hoped to be gained by its use. He should closely observe the effect upon the patient and compare his condition with what it is when not restrained. The result of these observations should be reported.

Thus used, an attendant will soon learn that it is not the easiest way to care for a patient, that its use involves increased watchfulness and care, and greater discretion, and that it is strictly a form of medical treatment. It is a harsh remedy at its best, and needs to be used with kindness, intelligence, and judgment, and it is to be applied but for one purpose, namely, that the patient may be benefited.