CHAPTER IV.

THE DUTIES OF AN ATTENDANT.

_What an Attendant Should First Learn._--The duties of an attendant upon the insane are varied, arduous, and exacting; they are associated with irritations, perplexities, and anxieties, bring grave responsibilities, and call for the exercise of tact, judgment, and self-control.

These many duties are not quickly nor easily learned, and the new attendant must be willing to fill, at first, a minor position, to begin at the beginning and learn gradually all the details of ward work; he must acquire habits of caution and watchfulness, and learn in a general way the care of the insane, before he can assume a position of authority over other attendants, the control of a ward, and the responsibility of the direct care of patients.

This last duty is the most difficult of all, because it brings the attendant into intimate relations with a class of persons, whose true appreciation of themselves, of their conditions and surroundings, is changed, whose thoughts and desires are unreasonable, whose conduct is unnatural, and who are largely controlled by insane delusions, hallucinations, and illusions.

It requires an intimate association with the insane, and a careful study of their manner of thought and conduct, to be able to successfully guide, direct, and control them.

_The Relation of Attendants to Patients._--The position of attendants is often a trying one; they are liable to misrepresentation when they have faithfully done their duty; they must learn to receive with calmness a blow or an insult, or even so great an indignity as being spit upon; they must bear with provocations that come day after day, and are seemingly as malicious as they are ingenious and designing; they must watch over the suicidal with tireless vigilance, control the violent, and keep the unclean clean.

To do all this requires the exercise of self-control and kindness; the putting a curb upon the temper; the education of judgment and tact; faithfulness in the performance of duty, and a knowledge of what to do and what to avoid.

These trials are, however, but a part of the experience of an attendant in caring for the insane, for there is associated in this care much that is satisfactory and pleasurable. It is a satisfaction to know that duty has been well done; to be able to care for the sick; to do something to alleviate suffering; to tenderly watch over and soothe the dying; it is a pleasure to see a patient improving, going on to recovery, and finally able to return home cured.

Many delightful friendships are formed between attendants and patients, some lasting for years within the asylum, and some for a lifetime, with those who have recovered. Most of the insane appreciate the services rendered them, and have a feeling of gratitude for those who care for them.

Attendants should always treat patients with politeness and respect; it is something that is never thrown away, and exerts a good influence, however rude and disrespectful a patient may behave.

Patients should not be ridiculed, their mental weakness and peculiarities made light of, nor should they be made a show to inquisitive visitors.

It is useless for attendants to try to argue patients out of a belief in their delusions, and to do so often results in fixing them more firmly in the mind. We should not however pretend to believe them, nor humor their belief, nor allow them to carry out their delusions in their dress, conduct, and general behavior.

_The Character of an Attendant._--The insane should always be treated with kindness, and nowhere is the golden rule "thou shalt love thy neighbor as thyself" more necessary of application than in caring for them; and it is well for attendants, when tempted, to stop and think how, under like circumstances, they would want their mother or sister or brother treated.

Keeping this noble teaching and this high motive for right-doing ever in mind, an attendant cannot go far astray.

It is a development of character to care for the insane, and instead of being brutalizing, as some ignorant people say, it is elevating and humanizing.

Attendants should never gossip, either among or about themselves, or of their patients. It is a mean and degrading habit to indulge in; it will undermine a good character, and often become overpowering and malicious.

On the other hand, never be afraid to speak the truth, and never let a lie, or the semblance of a lie, pass your lips, or remain for a moment in your heart. Of all things be truthful.

Attendants must acquire a spirit of willing obedience, of cheerful execution of all commands and directions, and of faithful performance of every duty that devolves upon them. Unless they have this spirit, they will be unable to successfully assume positions where obedience is to be exacted from others.

They should preserve their own self-respect; in all things set a good example; be neat and tidy in their dress, gentlemanly or ladylike in their conduct; considerate of the wants and feelings of other attendants; they should "cherish a high sense of moral obligation; cultivate an humble, self-denying spirit; seek to be useful; and maintain at all hazards their purity, truthfulness, economy, faithfulness, and honesty" (Utica Asylum Rules and Regulations).

In their relation to the institution, attendants should fulfil all their engagements with the same sense of right, that they expect will be observed towards them by those who employ them. It is a business contract that is assumed, and brings with it mutual legal responsibilities, rights, and obligations. Attendants should strive to so conduct themselves, that when they leave their employment they can go away with the respect of every one, and bear with them the reputation of a good character and of work well done.

_How and What to Observe in the Care of Patients._--It is important that attendants should early learn habits of close observation. The exercise of the habit increases the ability to observe, and one soon comes to see and know things he never saw, or thought of before. It is necessary to learn first the physical condition, mental symptoms, and habits of a patient, before we are able to observe and appreciate any change.

Observation, to be of value, should be systematically made, and only one thing at a time can be noticed, which must be understood before passing to another, otherwise every thing is confused.

The condition and appearance of a single part should be looked at to see what is natural, and what is evidence of disease.

In practice, written notes taken at the time, are extremely valuable in teaching close and accurate observation, and cultivating an ability to clearly express to others the result.

For the purpose of suggestion and guidance, the following system for observation is given:

Observe the effect of medicine.

The face.--Observe if it is pale, and if the pallor is sudden, temporary or permanent; if flushed, if congested, if blue with venous blood, if there are any eruptions, bruises, or scars. Observe the expression of the face.

The tongue.--Observe if it is coated, and if so, if white, brown, red, black, glazed, dry, or cracked; if it is tremulous, or drawn to one side, or protruded with difficulty.

The lips.--Observe if pale, blue, dry and cracked, if there is tremulousness about the corners of the mouth; the teeth, if covered with sordes; the gums, if bleeding.

The breath.--Observe if sweet, sour, foul, or offensive.

The respiration.--Observe if slow or fast, quiet and natural, or loud, labored, and difficult, if puffing, wheezing, shallow, or irregular.

The eyes.--Observe if congested, the color, if any blindness; the pupils, if contracted, dilated, irregular, unequal, or if they respond readily to light.

If there is cough, observe if moist or dry, if croupy, if with pain, or if prolonged.

If any expectoration, observe if it is bloody or streaked with blood, if thin and frothy, thick and purulent, or if it sticks to the cup.

The pulse.--Observe if it is slow or rapid, full, weak and thin, if irregular or intermitting. Count it.

The temperature.--Observe by the hand or thermometer.

The body.--Observe for eruptions of the skin, for sores, bruises, or deformities, or if there is any paralysis.

The appetite.--Observe if it is poor, changeable, if food is relished or disliked; if refused, if it is constantly or occasionally, and if from delusions or indifference; if there is overeating and gluttony, if food is bolted, or chewed, or if the patient has teeth to eat with.

The digestion.--Observe if natural, or painful, and if so, whether upon taking food, or if the pain is delayed; if gas is discharged from the mouth, if the stomach is sour, if the food is heavy and distressing; also observe what kinds of food give dyspepsia, and what seem to be well borne.

Of vomiting.--Observe if occasional or constant, if immediately after food, or delayed, if sour or bitter, if preceded by pain or nausea, if it contains any undigested food.

Of diarrhoea.--Observe how frequent the discharges, if with pain, and where it is situated, the color, the consistency, if there is any blood or mucus, if it alternates with constipation.

Of constipation.--Observe if alternating with diarrhoea, if habitual, the effect of medicine and food; if there are any piles.

The menses.--The quantity, if there is any pain, its cessation and reappearance, if any effect upon the mental condition.

Of pain.--Observe the character and severity, its location, and any evidence of a cause.

Of dropsy.--Observe if it is general or local, if in the chest, face, abdomen, arms, or legs; if there are any varicose veins.

Of sleep.--Observe the length of time, if quiet and natural, if restless, if deep or light, if there is great drowsiness or continued wakefulness, and the effects of medicine.

Of unconsciousness.--Observe if it comes on slowly or suddenly, if partial or complete, if the patient can be aroused.

Of convulsions.--Observe if slight or severe, if of short or long duration, if continued or interrupted, if general or of one side, or of an arm or a leg, or the face, or of a few muscles only.

Of the mental condition.--Observe if fixed or changeable, the nature of delusions, illusions, or hallucinations; dangerous attempts or threats toward himself or others; any change in the mental state.

Of habits.--Observe if fixed or changeable, how formed or how corrected.

Of the general conduct.--Observe the dress, if neat and tidy, or otherwise, private habits, care of personal wants, improvement in conduct, the influence of attendants and other patients, or the influence the patient himself exerts on others.

This by no means includes all that it is necessary to observe, but it contains much that is important, and the system, if studied and used practically, will suggest to the observer whatever may require attention.

_The Control and Influence of Attendants over Patients._--By a "smart attendant" is meant one who sees little to do beyond having a control of the ward by a rule that is close and exacting, who maintains a strict discipline, and who has a love for cleanliness, order, work, and scrubbing. But a "useful attendant" is one who tempers these mentioned traits, by striving to gain the confidence of his patients, by exerting over them a beneficial influence, who is able to bring the individual patient into accord with his surroundings in the asylum, so as to help his improvement or recovery, meet his wants, and increase his comfort and enjoyment. In order to do this it is necessary that the attendant should give careful study and attention to each patient. Such a study will soon demonstrate to, and teach the attendant the fact, that the insane are very individual in their habits, and while no two are alike, there are resemblances that in an asylum are made the basis of classification by wards: there is the convalescent, the suicidal, the demented, the sick and feeble, and the noisy or violent wards.

Attendants must first learn that patients are not to be treated merely as a ward full of people to be kept in order, to be clothed, fed, and put to bed, but that the peculiarities of each patient are to be studied, and that it is their duty to know thoroughly the wants, and condition of each case, and how best to care for and control it. The better knowledge an attendant has of the individual, the better he can care for a ward full of individuals.

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 appetite.

Much insanity is associated 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 ennobling influences, and the tender care of the nurse.