CHAPTER VIII.

THE CARE OF SOME COMMON MENTAL STATES, AND ACCOMPANYING BODILY DISORDERS.

_Care of Patients in the Earlier Stages of Insanity._--Patients in the earlier stages of insanity act differently, one from the other, when first brought to the asylum and placed under care and restriction. Sometimes patients accept the situation and fit into asylum life without any friction. They may even come willingly, knowing they need care and treatment, or from confidence in their friends or their physician's advice.

To some patients the restrictions of an asylum are irksome and misunderstood; the quiet, regularity, and routine of the life on the ward does not at first affect them; they may, and often do, become fretful, are irritated by their confinement, sleep poorly, eat little, and may make violent efforts to escape.

These conditions, if nothing is done to occupy the patient's time and mind, and so relieve them, will often be sufficient to provoke violence. These patients should be carefully watched and their condition studied; they should be brought under the kind control and influence of attendants, induced to take part in the regular order of the ward, and, if strong enough, should be furnished with proper work and occupation.

Patients, when first brought to the asylum, frequently have much anxiety about their homes, their families, or their business affairs. This is particularly true in recent cases of insanity, because such patients often have cares and responsibilities, or they have tried to continue to assume them, up to the time of coming to the asylum. Special care should be taken to quiet fears in these directions; they should be assured that they are groundless, told they will be allowed to communicate with their friends, that they will be visited by their family, and that all their interests will be cared for.

It is impossible to speak of the varied causes of insanity, or of the equally varied manifestations of the disease and conduct of the patient at its onset, but there are a few conditions which, being present, give a character to a particular case, and suggest the care required.

Sometimes, as has been said, the patient partly realizes his condition, and is willing to come to the asylum, and in every way to conduct himself in accordance with the rules and requirements.

Sometimes the onset is slow and the symptoms so obscure as to attract little attention. Following this, more decided symptoms may appear; the patient may become violent, noisy, destructive, or sleepless, or he may try to commit suicide or homicide, or do some other act of violence; or the great restlessness, moaning, crying, and sleeplessness of melancholia may come on, or the patient may refuse, for several days, all food. The reason for bringing such patients to the asylum is that they can no longer be kept at home.

Following the treatment that has been described, these patients will frequently in a short time become more quiet, self-controlled, and more easily influenced and cared for.

The earlier stages of insanity are frequently accompanied by considerable disturbance of bodily health. The appetite is poor, the digestion disordered, the bowels constipated, the breath foul, the secretions of the skin changed and often offensive, the temperature a little elevated, the pulse rapid, and the heart weak. Sometimes, on the other hand, the temperature is normal, or a little below, while the hands are cold and clammy. In addition, nutrition is frequently impaired, so that the food taken by patients does not seem to properly nourish and strengthen. All of these symptoms are not present in a given case; sometimes most of them may be, and again but few are to be noticed.

The important lesson to learn in the care of these cases is that such patients may rapidly pass into a more serious condition, in which there is great exhaustion, which is always alarming, and may even result fatally.

Recent cases, such as have been spoken of, need our best care, closest attention, and kindest nursing. The patient should daily take sufficient food, which, if necessary, should be enforced, and the opportunity for sleep promoted. A few days, or a day, without food and sleep may bring on alarming symptoms.

For these patients, milk is the best article of diet; it is most easily given and readily taken; it should be given by the glassful, or if not able to do this by the spoonful. Some patients, for reasons not always known, will refuse food one hour and take it freely the next; it should, therefore, be frequently offered. With milk as a basis, we may add to it, as we are able. Raw egg, gruel, boiled rice, oatmeal, custard, and bread are adjuncts that are nutritious and easily given.

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 associated 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 institution. 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, amusement, 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 glass 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 pass 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 assaults, 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 assaults, 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 class, 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 class 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.