CHAPTER VII.

THE CARE OF THE HOMICIDAL, SUICIDAL, AND THOSE INCLINED TO ACTS OF VIOLENCE.

Patients with Delusions of Suspicion demand special care, and are properly classed with those inclined to commit acts of violence, because they are frequently fully under the control of delusions, which make them dangerous and difficult to manage.

Many patients have ideas that make them suspicious of those about them; these may relate to the patients, but more frequently to the attendants and physicians, and they may arise from delusions, hallucinations or illusions. This class of patients is apt to be morose, cross, and irritable; they sit brooding over their fancied wrongs; repulse advances and friendly intercourse; they refuse to employ themselves, and do not respond willingly to the requirements of the attendants.

Our most trifling and unmeaning acts may give rise to the most intense suspicions and hatred. A look, a shrug of the shoulder, the manner of shaking the head, a cough, the squeaking of our boots, are frequently enough to arouse, these feelings.

Suspicious patients often think they are the subjects of ridicule; that their thoughts are read and proclaimed to the ward; that their virtue, truth, or honor is called in question, and the accusations openly told to others, or that they are called vile and insulting names. They often have delusions of conspiracy to do them or their families harm, and connect the attendants and physicians with them, thinking, as they keep them locked in the asylum, they are associated in the conspiracy. Sometimes these patients think themselves some great persons, perhaps that they are a member of the Deity, or a ruler, or prophet, or that they have some great mission to perform, and that they are deprived of their rights, or their work interfered with, by being kept in the asylum, and that those in authority are imprisoning and persecuting them. Such persons may be, on account of their fancied wrongs, very suspicious, and even violent towards those who care for them.

Other patients have suspicions and fears of bodily harm. They may think they are to be tortured, that they are to be burned alive, or that some one is trying to kill them. To-day, as I wrote these lines, a patient told me she did not sleep last night for fear the night-watch would kill her--saying that God told her the watch was armed with a knife for that purpose, and she threatened homicidal violence in defending herself.

Many patients mistake ordinary sensations of pain and bodily discomfort, and have delusions that they are being injured. The feelings of dyspepsia may make patients think they have been poisoned; ordinary pains or aches, that they have been shot, stabbed, or pounded; women may, for some such causes, think they have been violated or are pregnant. Peculiar sensations of various kinds may make patients think some one is affecting them by electricity or mesmerizing them.

It is very easy to trace from such ideas of persecution and suspicion, the origin of homicidal, suicidal, incendiary and other violent tendencies and acts.

_Homicidal Patients._--Patients are sometimes both homicidal and suicidal, and sometimes they are inclined to only one of these forms of violence. Homicides are not of frequent occurrence in an asylum. The better the care the less is the liability to homicide. But there are always a great many homicidal patients, and many more who have delusions and ideas that may cause such tendencies to arise.

Many patients are homicidal merely from violence and frenzy, and without any settled plan, any fixed delusion, or intense suspicion. They may attack others suddenly and furiously; they may commit the act while trying to escape, or it may be the result of the violence of acute mania. Other patients become homicidal under the desire to protect themselves from supposed assaults. They may think a person who is approaching them is coming to kill or torture them. Others are homicidal from any of the ideas of persecution and suspicion that have just been spoken of. Sometimes patients hear voices telling them to commit the act, perhaps it is God's voice commanding a father to offer up his only son as a sacrifice, or a mother to kill her little children to save their souls, or keep them from some misery or crime that awaits them. Patients may think themselves God, or a king, or ruler, and therefore have a right to take life. Homicidal patients are often among the quietest, and are found in the quiet wards. They frequently lay careful plans, are secretive, and only try to commit the act when they feel sure it will succeed.

Patients who are homicidal should be especially watched. They should, if possible, be kept employed, but never given tools that may become weapons. They should sleep in a room by themselves. All persons against whom they have delusions should be warned. Patients against whom they harbor suspicious or homicidal ideas should be separated from them.

Attendants should remember that a mop, a pail, or a chair, may become a dangerous weapon, or that a knife, scissors, or a sharpened piece of iron or tin, may make a fatal wound.

_Suicidal Patients._--Patients with this tendency will generally talk freely of their suicidal ideas, tell why they wish to commit it, what provokes the idea, and how they would do the act. They are frequently grateful for the care bestowed to help them resist the impulse, and will sometimes tell the attendants when they feel the suicidal ideas coming on, that they may be the more surely watched.

Melancholic patients are most inclined to suicide, but any insane person, whatever the mental state, may commit the act. Delusions of depression generally cause the suicidal ideas, but hallucinations sometimes play an important part. Some persons are simply tired of life, and see no hope in living; some think they are a burden to their friends, and that they are taking food away from their children; others wish to die to escape from their misery, which is generally a mental, and not a physical suffering; others that by so doing they may get forgiveness of their sins; others because they think they will save their children from a fate like theirs; sometimes it is the result of hallucination, as a direct command from God, telling them to commit the act.

But few patients are constantly determined to commit suicide. The opportunity offered, as a bath-room door left open, a rope, a knife, often prompts the desire and allows the accomplishment of the deed.

Attendants must remember that it takes but a few minutes to commit suicide, by drowning or hanging--but a moment to cut the throat; that persons can drown themselves in a pail of water, hang themselves by the hem of the sheets, cut their throat with a piece of glass or tin. Sometimes patients slyly save their medicine until they get enough to poison themselves.

About dusk in the evening, or at early morning, is the time when patients are most inclined to commit suicide. When patients are rising, going to bed, or to their meals, when going to chapel, amusements, or to walk, when all is busy and astir on the ward, are the times that offer the most favorable opportunities for the act.

Often patients have a certain way by which they will commit suicide, and they will do it in no other; one wishes to drown himself, another to hang, and another to take poison. Sometimes patients will appear cheerful to avoid suspicion and so find their opportunity, while others may suddenly and while convalescent commit the act.

The only way to care for patients who are suicidal, is by constant watchfulness day and night. During the day they should be employed and kept with other patients, they should be especially looked after at those times when opportunities for suicide are increased. At night it is better to have them sleep in an associated dormitory with some one to watch them. If a patient is found hanging he should at once be cut down, all restriction about the neck removed and artificial respiration set up, or if drowning, the mouth and lungs should be first emptied of water; if there is hemorrhage compression should be made upon the artery, or if this is not possible, then directly upon the wound. How to control hemorrhage and do artificial respiration will be described in the chapter on emergencies.

_Patients Who Have Tendencies to Self-Mutilation._--Some patients horribly mutilate themselves. They may gouge out an eye, cut off a hand, pull out their tongue, or even disembowel or dreadfully burn themselves. Some patients persistently beat their heads against the wall or floor, others scratch the skin, making large sores. Such patients frequently think certain passages from the Scriptures apply to them, and they must obey the application and command. They quote in justification of the acts, "An eye for an eye," "And if thy right eye offend thee, pluck it out," "And if thy right hand offend thee, cut it off." Talk of this kind should make an attendant very careful and watchful of the patient.

The origin of the ideas that lead to the attempts at self-mutilation is to be found in delusions, and arise in the same way as do ideas of suicide and homicide. These patients are all of the same class and need the same character of care, attention, and watching.

_Patients with Tendencies to Setting Things on Fire._--Patients with these tendencies generally desire to commit incendiary acts under the influence of delusions or hallucinations; added to these there are frequently suspicions and feelings of wrong treatment, and the patient takes this way of showing revenge, or, as he may say, of repaying the wrong. Sometimes patients are so feeble in mind that they light a fire because they think it is a pretty sight to see it burn. There are some conditions accompanying epilepsy where patients are liable to commit any of the class of violent acts described in this chapter. The special care demanded by these patients will be fully spoken of hereafter.

There are some patients whose minds are so distorted by disease that they seem to take a pleasure in wrong-doing, and are much inclined to do great mischief, and sometimes to commit acts against life or property.

The care demanded by patients who are inclined to acts of violence is practically the same for all. The attendant should thoroughly know the habits, peculiarities, and delusions of each person under his care; he should exercise constant watchfulness, and remember that a moment of thoughtless inattention may give the opportunity for a patient to commit some violent act, that will cause him lasting regret. The mind of a faithful attendant will, when upon duty, always be full of anxiety, and there should be in the care of very troublesome patients of this class frequent relief.