The persons who are under our care are always to be considered as patients, and it must be remembered that these sick people are sent away from their homes and given over to us, though strangers, because it is supposed that we can do better by them than their friends are able to do.

Their position is one of helplessness and dependence upon those who are placed in charge, and we are properly held responsible by the friends and the public, for a judicious exercise of the power and influence we possess over them.

Patients are not rightly influenced by the mere exercise of authority or by dictation or command; these they fear and obey, or resent and resist; but we should always appeal to the highest motives for obedience and correct conduct, and we should lead our patients to trust and not to fear us. In our dealings with them we should be truthful, straightforward, and strictly upright, and exercise over ourselves patience and self-control.

We can generally control our patients by the exercise of sympathy, kindness, and tact, joined with a reason for what is required, and where more is needed, a firm, kind authority and command will suffice.

The use of authority, restriction, and restraint is to be avoided, while on the other hand patients are to be allowed all the liberty and freedom they can safely enjoy, and taught to exercise all the self-control they are capable of.

The granting of more freedom and liberty of action than was formerly accorded the insane, does not imply a change in the character of the disease, but improved methods of care, and places more responsibility upon the attendants. The degree of liberty to be allowed must, in each case, be decided by the physician, and the attendants should closely observe the patient, and report any symptoms which makes the enlarged freedom dangerous to the patient or to others.

Patients being sick, are sent to the asylum that they may be kindly and judiciously cared for, and, if possible, cured. As many patients who may never fully recover may so improve as to be able to return to their homes, and, as it is impossible to say that any given patient will not recover, each case deserves and should receive our best care and efforts to this end.

Because our patients are sick they must be nursed, and nursing means tender care. And it is a nurse's duty to do all in his power to alleviate pain and promote bodily comfort. The insane are subject to all the ills that flesh is heir to, and there is always among our patients much sickness and bodily suffering. Many patients cannot tell when they are sick, nor when they suffer pain, but they show sickness and pain, and often appeal by their manner for that care and sympathy, we all feel in need of at such times.

These silent symptoms should be observed by the attendants, who should always see and know when their patients are sick. Some of these symptoms are, crying, moaning, weakness, going to bed, or lying down, cough, changes in respiration, signs of fever, a flushed face, quick pulse, or chills, a pale face, vomiting, or diarrhoea, and loss of appet.i.te.

Much insanity is a.s.sociated with great physical disturbances which require careful nursing. The old and feeble, the paralytic and bedridden also require special attention and care.

From this it appears that the care of the insane calls for the exercise of self-control, habits of close observation, the using of good judgment, the putting forth of enn.o.bling influences, and the tender care of the nurse.

CHAPTER V.

THE GENERAL CARE OF THE INSANE.

_The Reception of New Patients._--Attendants must at once study the peculiarities, the physical condition, and the mental symptoms of a new patient, so as to know the case thoroughly.

New patients should receive special attention; their fears quieted; they should, if in a proper condition, be introduced to the other patients; the effect of being in so large and strange a place, where the doors are locked and the windows guarded should be noticed, and unpleasant impressions overcome; they must be told they have come among friends and will be kindly treated.

The necessary rules of the ward should be explained; they should be invited to their meals, shown to their rooms and told at bedtime the night watch will visit them, and they must be a.s.sured that no harm will come to them.

The first impressions a new patient receives may be the lasting ones, and influence their whole conduct in the asylum. If they resist what is necessary to do for them, do not struggle and contend with them, and force them to bed, or to the bath, but first seek advice from the supervisor, or the physician.

Always search new patients, unless otherwise ordered, for money, jewelry, weapons, medicine, and other like articles, or if in doubt what to do ask for directions. The head, body, and clothing should be examined for vermin, and the body for injuries and bruises. If what is wished to be done in this particular is explained, patients will generally quietly allow it.

_Work, Employment, and Occupation._--By this is meant whatever occupies the patient's time and mind, in useful and pleasant ways.

Of all things idleness and loafing are the worst; even games, such as billiards and cards, if indulged in to the exclusion of useful employment, will degenerate a patient.

Some willing patients are kept in a tread-mill of daily work, their monotonous life never broken by a diversion, an enjoyment, or a hope. It is very questionable if it is beneficial to make a patient drudge through such a daily routine.

Asylum life should be made as home-like, pleasant, and natural as possible; as a rule every patient who is able should do some useful work every day, and to this should be added the diversion, that comes from amus.e.m.e.nts and the enjoyment of innocent pleasures.

Occupation then means a great deal more than work; it is the way a patient spends his time. Unless encouraged and directed, patients may occupy themselves in thinking of their delusions, in noise, violence, or destructiveness, in idly walking up and down the wards, in the indulgence of secret vices, in gossip, in spreading discontent, in prayer, or in constant Bible reading. Some patients really work hard trying to do nothing, and have no more ambition than to sit around on the ward, and chew tobacco, and indulge in idleness.

Patients should be encouraged to do something for themselves, the women to make and mend their own clothes, to keep their rooms in good order, and a.s.sist about the ward. They should be made to feel that they can add to their own comfortable surroundings by their own efforts.

For the men, ward work is not so natural or tasteful, but they will do with interest much of this kind of work; to this may be added employment in decorating their own rooms or the ward, and in caring for plants and flowers.

The women can add to ward work, sewing, knitting, mending, embroidery, artificial flower making, quilting, care of flowers in the ward, and it is often a real enjoyment for patients to make some little present for their outside friends. The laundry offers an inviting field for some patients, but it is often too hard work, especially when they are sent twice a day to the wash-tub, or kept in the hot ironing room. A half day is enough for most patients, and many are not strong enough to go there.

Out-of-door work is well suited for the men. The farm, garden, lawn, barns, and machine-shops offer much that can be made useful for the patients' employment; the different mechanics and artisans about the asylum should have patients working with them.

Thus it appears there are many directions for patients to work, and it is also true that all patients are not suited to do the same work nor the same amount of work. Whatever they do should be for their benefit alone, otherwise we might take a contract for a given number of patients to work a given number of hours every day, a good deal as has been done in prisons and reformatories, but no one would believe such a course for the interest, improvement, or recovery of the patients.

The only rule to go by is, that the work and occupation shall be for their own good, and, that they shall not be made or encouraged to work for any other purpose.

As a rule, patients should be allowed to employ themselves in ways that most interest them, provided it is useful and seems to be beneficial.

Over-work is as bad as idleness; too much sewing will often give a sleepless night.

Generally all patients may be allowed to engage in light work, without special directions; new patients, however, should not be sent off the ward, or given tools that may become weapons, unless by order of a physician.

It is a bad habit for attendants to sit idly by, or stand around with their hands in their pockets, and have patients do all the work. It may be so necessary to watch the patients that the attendant cannot work steadily, but he should have the appearance of doing something, and if possible join with them in work.

A party of women sewing, should be laughing, talking, telling stories, perhaps singing; they should be made to enjoy the time, and not to look upon it as something irksome.

Some patients are too feeble in mind, and some too feeble in body to work; many need rest, quiet, and nursing, and directions for the care and occupation of such patients should come from the physician.

Many of these patients will do a little, others can be amused, or read to, and their minds thus diverted from their troubles, and turned into pleasant and cheerful directions of thought.

It has been shown that work is not the only useful way that patients may occupy their time, that nothing but work is as bad as no work, and that they should have diversion, enjoyment, and entertainment.

For the entertainment and occupation of patients, there are furnished, dances, concerts, theatricals, billiards, cards, pianos, books and papers, schools, chapel services, walks, rides, and excursions, and they also receive visits from friends, and write and receive letters.

Patients should be encouraged and sometimes made to take part in these natural and pleasant amus.e.m.e.nts; of course every patient cannot play the piano, or billiards, but among these many forms of recreation, all patients can find ways of diversion and means of enjoyment.

Thus early in the study of the care of the insane, it is learned that the life of patients is to be stripped, as much as possible, of restriction and restraint; that self-control is to be taught; that useful work is to be encouraged; that amus.e.m.e.nts and innocent pleasures are to be enjoyed; in a word, attendants are to learn, that the characteristics of inst.i.tutional life are to be lessened, and those of a home life made prominent.

_The Patients' Care of Themselves._--The general tendency of the insane is to mental enfeeblement, to neglect of person, and to slovenly habits.

Patients should be encouraged as much as possible to care for themselves; to be helpful towards others; to do such work as they are able; to seek amus.e.m.e.nts, and to live as much as possible such a life as we ordinarily are accustomed to outside the asylum.

Patients should be encouraged to keep themselves tidy, and nicely dressed, to have the care of their clothing; if possible, they should be given a room of their own, which they should take a pride in keeping in order, and ornamenting with pictures and flowers; and should be allowed to do whatever will help maintain their self-respect, self-care, and a feeling of individuality.

There is great difference in patients as shown in their capacity for self-help. Some seem to be able to do nothing, some everything. Nothing can lighten the burdens of attendants so much as to make the helpless self-helpful. Nothing benefits the patients more. Do not abandon effort for any patient. Unexpected and gratifying results are the rewards of earnest efforts.

_Out of Door Exercise--Walking._--If possible, patients should be out of doors every day. In the summer much time can be spent in the fields, on the lawn, either walking or sitting under the trees; in the winter time shorter walks only can be taken, but on pleasant days, often an hour may be spent out of doors. Warm clothing and good shoes must never be neglected, and the person must be thoroughly protected, because the insane are frequently "cold-blooded," that is, the circulation is poor, the hands and feet congested, blue, and cold, they make animal warmth slowly and with difficulty, and easily suffer from the cold.

Many patients go out to walk on parole. Those who are allowed this liberty will be designated by the physicians; any change in the patient that makes such liberty dangerous should at once be reported. Others go out in large parties, with few attendants to care for them, while the old, sick, and feeble, the homicidal and suicidal, the noisy and violent, require special care and attention in their exercise and walks.

_Clothing of Patients._--In many asylums each patient has his own clothing. Every article should be plainly marked with his own name, and should be used only by the patient to whom it belongs, and never given to any one else to wear. All clothing should be kept clean and well mended, and should be properly put on and kept on during the day. There should always be enough to keep the patient warm, and changed with the changes in the weather, or the temperature of the ward, or the needs of the patient.

The sick, feeble, and old always need extra clothing; that worn next the skin should be changed at least once a week, and all clothing should be changed as often as soiled.

_Bathing of Patients._--Every patient should be bathed once a week and as much oftener as is necessary. The tub should be cleaned and the water changed for each patient; the temperature should be about ninety-five degrees, or not hot to the hand, and the tub should be about two-thirds full. The head, neck, and body should be washed with soap; each patient should have a clean towel, be wiped dry, and given a change of clean clothing.