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 assured 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 amusements 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 assist 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 amusements; 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 amusements and innocent pleasures are to be enjoyed; in a word, attendants are to learn, that the characteristics of institutional 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 amusements, 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.

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 prone 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 butter 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, butter, 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 passed 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 assistance, 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 associated 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 institutions, 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 entitled 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 assist in recovery or improvement, or promote his well-being.