It makes but little difference why patients refuse food, except that a knowledge of the reasons may enable us to overcome their disinclinations.

The thing to remember is that they must in some way be made to get enough.

_Care of Patients with Insanity, Accompanied by Exhaustion._--There is a condition a.s.sociated with acute mania or melancholia--though it is sometimes seen in connection with the more chronic forms of insanity,--of exhaustion so overpowering, that it may be rightly compared with the exhaustion of typhoid fever. It may last a few days or a month, or more, if it does not sooner terminate fatally. Instead of the quiet delirium of typhoid fever there is generally violent mania or frenzy. Neither mind nor body is quiet; sleep seems to have fled. The patient may be destructive, constantly out of bed, fighting care, refusing food, and wetting and dirtying himself. With these unfortunate conditions there generally is fever, often to a considerable degree, the heart is feeble, the pulse rapid, the tongue and lips dry and cracked, the teeth covered with sordes, and the body emaciated. Every case does not present all these symptoms, nor show such alarming exhaustion. There are many degrees of severity in this sickness.

Such patients must never be left alone and need constant nursing day and night. They must have food, even if it is given forcibly. They must, if possible, be kept in bed, and covered with clothing, and they must be kept clean. If wakeful, food must be administered during the night, and especially towards morning, which is the time of greatest weakness and physical depression.

Hot baths may be ordered for these patients, and stimulants and medicine to produce sleep left in the care of attendants. How to give the baths and medicine, what results are to be expected, and what dangers are to be feared, will be described later, in the chapter on the administration of medicine.

There are certain symptoms which should warn the attendant of danger, and which often precede death. When any of these are present they should be reported to the physician. They are: partial or complete unconsciousness, slow and labored, rapid, shallow, or irregular breathing, increased weakness and rapidity of heart or pulse, cold hands and feet. Picking at the bedclothes, or at imaginary objects in the air, or vacant staring, are bad symptoms.

_The Care of Patients in a Condition of Dementia._--It is to be remembered that dementia may be either, a condition of chronic insanity without recovery, or a less permanent state of mental enfeeblement following the acute attack, and from which recovery may be hoped. In the first of these conditions there is little to be done except to care for the patient. Many are able to do some work, and should be allowed, encouraged, and taught to do it. Others do not know enough to dress, feed, or care for themselves.

These must be kept neatly dressed, taken to the table and their food prepared, taken to the bath and closet, taken to walk, and put to bed. If not so attended to, they will degenerate into a ragged, dirty, and even filthy state, and the ward upon which they live will be offensive to the smell. They should be frequently examined for body vermin, as these pests are liable to breed and flourish among these patients. The condition of the demented affords the best evidence of the care given to the patients in an inst.i.tution. Attendants will often be gratified to see some of these apparently hopeless cases greatly improve and sometimes recover.

If attendants will watch their patients as they come out of acute mania or melancholia and become quiet, they will often notice that they gain in flesh and become demented. The dementia may be but partial, or so very complete that the patient knows nothing. From this they may gradually go on to improvement, or even recovery. They need all the care demanded by the confirmed dement, and, in addition, advantage must be taken of every means to promote recovery. They must be well fed, regularly taken out for exercise, and, as they are able, encouraged to employ themselves. Any symptoms of a return of their more violent condition, any failure to sleep, or change noticed in the health of the patient, should be at once reported.

_Care of the Convalescent Patients._--This is the period that precedes recovery from disease. With the insane it is often a critical time, and if not properly cared for they may fail to get well, and become chronic lunatics. The patients, and frequently their friends, think they are well and should be at home. It is the attendant's duty to encourage the patient, and to promote his confidence in the physician. They should not be told of their past conditions, or the disagreeable features of their sickness called to mind, and their last, as well as their first impressions of the asylum should be made pleasant. Sometimes there is a slight return of depression or mania, and the patient may suddenly begin to lose sleep. These conditions must be observed and reported, for it is very easy for patients who are recovering to become as disturbed as when they were first insane, and to suffer a relapse from which they may never recover. It is hardly necessary to remind the attendant that employment, amus.e.m.e.nt, and all the healthful means of occupation afforded by the asylum, should be judiciously allowed these patients.

Sometimes patients feel too well. They are too contented, happy, and indifferent, and are very active in body and mind. They want to work all day, from early in the morning until late at night. They sing as they work, and talk rather loud and fast. These patients need restriction; they should not be allowed to work too much, so as to overtax their strength.

So long, however, as they continue to gain, and sleep well, little is to be feared, and they generally become quieter and recover.

_The Care of the Epileptic Insane._--Not all epileptics are insane, but they are all liable to insanity. Generally the most hopeless and difficult to be cared for are brought to the asylum. Epileptics are liable to have fits at any time, but some patients have them at night only. The attack is generally sudden, though sometimes patients have feelings that warn them of their approach. This may precede the fit for a very short time, or the patient may know during the day that he will have a fit during the night.

Epileptic fits are accompanied by convulsions and unconsciousness, and are the type of all convulsions. The unconsciousness may be but momentary, or last an hour or longer, and even prolonged several days; the convulsions may be but the twitching of a few muscles, as of the face, or may consist of the most terrible writhings, and last for several minutes, and be often repeated. Sometimes the fits are ushered in by a scream.

The fit itself is not dangerous to life, but patients may at night turn their face downward and so smother; they may fall from high places, or down stairs, or into the water, or into the fire, and so injure themselves. There is little to do during an epileptic attack. Patients should not be held to prevent the convulsions, but so that they shall not injure themselves. A pillow should be placed under the head and the bands about the neck loosened. The nurse is sometimes given remedies which, if properly administered when the attack is felt to be coming on, may ward off the fit. Nitrite of amyl in small gla.s.s pearls is a common remedy. It is to be broken in a handkerchief and several strong breathfuls taken.

At their best, epileptics are cross, irritable, quick-tempered, unreasonable, and quarrelsome, and they will often give a blow at slight, or even for no provocation. After a fit they are frequently dangerous and always require guarded care and watching. As has been said, they may soon recover their natural condition, or remain in a more or less prolonged state of unconsciousness, or they may pa.s.s into a condition that appears natural, but in which they have but little or no appreciation of their situation or surroundings, or remember afterwards what they do. In these states they may, without warning, make violent a.s.saults, commit murder or suicide, or set things on fire. Sometimes they do outrageous acts, such as beating their own children to death against the wall, or mutilating them, or roasting them to death on the stove. Many often suffer from hallucinations or illusions of sight or hearing, and have delusions of impending harm or a.s.saults, and think they must defend themselves.

_Care of Patients with Paresis._--This is a form of insanity characterized by progressive dementia and increasing bodily enfeeblement and paralysis.

The paralysis is partial, not complete; the patient's walk is feeble, unsteady, and shuffling; the hands are tremulous, lose their fineness of touch and ability to do work and write; there is twitching in the muscles of the tongue and about the mouth, and the speech is thick and indistinct.

As the disease progresses the patient becomes helpless, bedridden, wet, and filthy. The result is always death. Convulsions like those of epilepsy are liable to occur, from which the patients may rally, or in which they may die or linger a few days. In the earlier stages the patients are often strong, and controlled by delusions and hallucinations that make them violent. Sometimes they are simply good-natured and easily managed. They generally have very exalted and extravagant delusions, and are without appreciation of their condition or surroundings, and are irritated at the control of the asylum, and on account of their unreasonableness they can rarely be allowed the liberty others enjoy.

Paretics often eat ravenously and rapidly, they stuff their mouths full of food and so choke themselves. Their condition of paralysis may render them unconscious of danger and powerless to help themselves. The care needed by bedridden, filthy paretics is practically the same demanded by helpless paralytics, the old, feeble, or demented cla.s.s, and all others who cannot care for themselves.

_Care of the Paralytic, Helpless, Bedridden, and Filthy Patients._--There are many patients in an asylum who are indifferent to all the wants of nature, who wet and dirty themselves. Some of these patients are bedridden; some are about the ward, but demented; some are violent and maniacal, and some from delusions make their persons and rooms as filthy as possible. Much can be done with many of these patients by regularly taking them to the closet, and their bad habits may in this way be broken up. Patients of this cla.s.s should be visited during the evening, attended to frequently by the night watch, and seen the first thing in the morning.

Patients, when dirty, should be thoroughly washed and carefully dried.

Their beds should be cleaned and changed, and during the day clean clothing should be given them as often as required.

The greatest danger that comes from not keeping patients clean is the formation of bed-sores.

_Bed-Sores._--Bed-sores occur in patients long confined to bed, and who suffer from exhaustive diseases. Paralytics and paretics are particularly liable to them, the diseased condition of the nerves allowing the tissues to break down easily. Sometimes the fingers or toes of a paretic become gangrenous or large surfaces of the skin die, and sometimes deeper tissues slough away rapidly. These conditions may come on in a day or a night.

Patients who are wet and dirty are more liable to have bed-sores. They will always appear in a bedridden paretic in a few days if not kept perfectly clean. They most frequently occur over bony projections where the weight comes in lying, as upon the hips, back, or shoulders.

Such patients, should, if possible, be made to sit up several hours every day, or placed first on one side, then on the back, and then on the other side. If it can be done, they should, as they lie in bed, rest their hips on an inflated rubber ring, and if the skin is red the part should be bathed in diluted alcohol. After being bathed and dried the skin about the hips should be dusted with some dry powder. Powdered oxide of zinc is perhaps the best, but ordinary corn-starch flour is valuable and serves a good purpose. Insane patients frequently will resist all care and every effort to prevent bed-sores, tearing off the bandages and dressings and picking and irritating the sores.

Bed-sores should never be allowed to come because of want of attention or cleanliness, but there are conditions in which they will appear in spite of every preventive.

Bed-sores once formed should be treated as ulcers and according to the direction of the physician.

CHAPTER IX.

SOME OF THE COMMON ACCIDENTS AMONG THE INSANE, AND THE TREATMENT OF EMERGENCIES.

The insane, like others, may suffer from almost any accident. It is not intended to treat of all accidents, nor how to care for every emergency.

This is so large a subject as to demand a separate text-book, and there are several excellent ones, that attendants would do well to read. But there are among the insane certain kinds of accidents that are likely to occur, certain cla.s.ses who are liable to receive accidents, and certain emergencies that frequently have to be cared for by the attendant, and these will be described. Every injury received by a patient should be immediately reported to a physician.

Attendants, in the care of the insane should always remember the liability to accident and guard against it. The old, the feeble, the paralytic, and paretic need special care. They are weak, easily pushed over, or stumble and fall, and they cannot break the weight of their fall, or so defend themselves; they are irritable, childish, and often provokingly troublesome to the other patients, and their bones seem to be easily fractured. Some injuries are self-inflicted, some come to the patient in consequence of his own or others' violence, and some, as has been said, from the very weakness of the patient.

_Care of Fractured Bones._--Any of the bones may be fractured, and from slight cause. The bones most frequently fractured are: the collar bones, the ribs, the bones of the forearm just above the wrist, the bones of the lower leg and of the thigh. This last bone, the femur, is among old people most frequently broken at its neck, which is the constriction of the bone just below the rounded end that fits into the joint at the hip.

Fractures should, as much as possible, be let alone till the physician comes. The parts should be kept quiet so as not to cause unnecessary pain, and do further injury. By rough handling it is very easy to push a fragment of bone through the skin, thus making a simple fracture a compound one. When a rib is fractured a sharp end may pierce the skin or the lung; either complication is serious. If the lung is injured the sputa will be b.l.o.o.d.y, and the appearance of such a condition should be at once reported. Sometimes patients are violent after the injury and need to be firmly held, and sometimes they have to be carried to the ward from the outside, or placed upon a bed. Always carry the fractured limb as well as the patient.

If temporary splints are put on do not make them too tight, and loosen them from time to time as needed. The extremities sometimes swell rapidly after a fracture, and the splints may so stop the circulation that, in a few hours, gangrene may be caused by them. Besides, many patients cannot tell us if the part is swollen or painful.

_The Care of Wounds._--Bites. Insane patients often bite others and penetrate the skin. They may be very angry, their mouths foul and running with saliva, and this irritating substance introduced into the wound by the teeth may set up an ugly inflammation. The wound should be immediately and thoroughly washed. It should be well cleaned with a wet sponge or cloth, and soaked in warm water. A good after-dressing is powdered iodoform, sprinkled over the wound.

_Wounds of the Head._--These wounds are quite common. They should be thoroughly washed and cleaned from dirt and hair. Hemorrhage may be controlled by continued pressure upon the bones of the skull, and if an artery is cut, it can in this way be kept from bleeding till the physician arrives. Most wounds of the head, even though large, generally heal quickly, but the most trifling ones may a.s.sume serious proportions, and even prove fatal. If within two or three days heat, pain, redness, and swelling appear, pus is probably forming beneath the scalp, and this, within a few hours, may spread under a large surface and do serious injury, or erysipelas may be set up.

_Injuries from Blows on the Head._--Persons are sometimes stunned by blows on the head. They should be placed in bed with the head elevated, and kept perfectly quiet till the doctor comes. Efforts should not be made to arouse them, they should not be given liquor of any kind, but ice may be applied to the head. The danger to be feared is from the skull being fractured, or from bleeding vessels inside of the skull. Either of these conditions may, by pressure upon the brain, cause unconsciousness, paralysis, and death.

_The Care of a Cut Throat._--Patients may cut their throats from ear to ear and do really little injury, or they may make a small stabbing wound and divide a large blood-vessel and die almost immediately, or they may cut the windpipe and not cut the blood-vessels. The windpipe you can notice upon yourselves as a large, stiff tube, prominently situated in the middle and front of the neck; the blood-vessels are together on each side of the windpipe, and situated quite deep down among the muscles, and the carotid artery may be felt beating by the finger. Little can be done by the attendants to stop the flow of blood, even if the great blood-vessels are not cut. The head should be kept bent forward and the chin pressed against the chest.

After the physician has dressed the wound, constant watching day and night may be required to prevent the patient tearing off the bandages and reopening it. This same rule of watchfulness applies to the after-care needed to be given to many cases of fracture, and other serious injuries among the insane.

_Care of Wounds of the Extremities with Hemorrhage._--The hemorrhage from most simple wounds involving the cutting of skin and flesh or small arteries, can usually be controlled by direct and continued pressure. This may be done by a pad made of cloth, packed and pressed into the wound, or lint may be used in the same way. Water as hot as can be borne poured into the wound will frequently stop a hemorrhage when other means fail; cold applications and ice are also useful. If dirty, a wound should be thoroughly cleaned, being washed, and, if necessary, soaked in warm water.

Iodoform sprinkled so as to cover wounds, is the best dressing for all attendants or nurses to apply, while awaiting directions from a physician. It keeps them clean, promotes healing, and lessens the danger of inflammation or the formation of pus.

When the arteries of the extremities are cut, pressure should be made on the large artery leading to the part. When the wound is high up on the arm, pressure is made by the fingers or a padded key upon the artery that lies back of the collar bone, and the attempt should be made to press it against the bone. This is a difficult thing to do, but nevertheless it should be attempted. When the wound is lower down, pressure is to be made by the fingers on the inner side of the upper arm, at about the middle point and against the bone. The artery runs downward, near the inner border of the biceps muscle, which is the large, bulging muscle of the upper arm, and can, with a little care, be felt beating by the fingers.

Patients in breaking gla.s.s often cut one or both arteries at the wrist-joint where the pulse is felt. These are large and bleed rapidly, and when cut need the care just described.

When the artery in the leg is wounded, pressure is to be made on the inner side of the thigh, just below the groin. The position of these large arteries, and how to press against the bone, is best learned by instruction and demonstration from a physician, and with a little practice attendants will be able to easily and successfully do the act.

It is very tiresome to continue pressure with the fingers for a long time, and attendants should relieve one another till the physician comes.

_The Care of Sprains._--Sprains are a common accident and easily produced.

The great end of treatment is to keep the sprained joint quiet. If the ankle or knee is sprained, the patient should be carried to bed. Perhaps the best early treatment, and the one that gives the greatest relief to pain, is to place the joint in a tub of water as hot as can be borne, and keep it hot by pouring in more. The part should be kept in the water until it is parboiled. The skin of some feeble or paralytic patients is easily scalded, and some cannot tell when it is too hot; the water therefore should never be uncomfortable to the hand of the attendant.

_Care of Patients Choking._--This is a frequent accident, and in order to know what to do when it occurs, it is necessary to have a knowledge of the air pa.s.sages of the throat.

We breathe through the mouth and nose. They open into a common pa.s.sage, the pharynx, which can be seen by looking into the mouth, lying back of the tonsils. Pa.s.sing downward, it divides by branching into two tubes; one the windpipe, which is in front, behind it is the oesophagus or gullet.

The point of division is just beyond the tongue, and is almost within reach of the forefinger when crowded into the mouth.