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 classes 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 class, 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 illustrated 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, amusements, 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 passes 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 substitute 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 glass 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 amusement 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 glass 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.

_The Use of the Covered Bed._--Like restraint it is never to be used except by the orders of a physician, nor is its use to be repeated without special orders; it is always to be considered a method of treatment and something the attendant has no interest in, except to know how best to use it when ordered to do so.

When in a covered bed the patient should be frequently visited; he should be taken up at least once in three hours, unless asleep; the bed and the patient should be kept perfectly clean. If used in the daytime an attendant should sit beside the patient for some hours and try to keep him quietly in bed, and the same should be done in the evening when the patient is put to bed. An attendant should be able to report how much the patient sleeps, how much quiet and rest is obtained, the effect of the treatment, and compare the condition of the patient when in the bed with what it is when not used.

_The Use of Seclusion._--Seclusion is shutting a patient alone in a room in the daytime. If allowed to be done without orders from the physician it should be immediately reported. If ordered to be continued the patient should be seen at least once in fifteen minutes, while many need to be seen once in five minutes, and an attendant should never be far from the door. The patient should be frequently taken to the closet. The effect and result of seclusion should be observed and reported.

Many physicians never use any form of restraint, while others make considerable use of it as a means of treatment. An attendant should be able to successfully care for any case, so as to meet the wishes and directions of the physician, and only as he is able to do this can he give the patient the highest standard of attention, care, and nursing.