CHAPTER IX.

SOME OF THE COMMON ACCIDENTS AMONG THE INSANE, AND THE TREATMENT OF EMERGENCIES.

The insane, like others, may suffer from almost any accident. It is not intended to treat of all accidents, nor how to care for every emergency. This is so large a subject as to demand a separate text-book, and there are several excellent ones, that attendants would do well to read. But there are among the insane certain kinds of accidents that are likely to occur, certain classes who are liable to receive accidents, and certain emergencies that frequently have to be cared for by the attendant, and these will be described. Every injury received by a patient should be immediately reported to a physician.

Attendants, in the care of the insane should always remember the liability to accident and guard against it. The old, the feeble, the paralytic, and paretic need special care. They are weak, easily pushed over, or stumble and fall, and they cannot break the weight of their fall, or so defend themselves; they are irritable, childish, and often provokingly troublesome to the other patients, and their bones seem to be easily fractured. Some injuries are self-inflicted, some come to the patient in consequence of his own or others' violence, and some, as has been said, from the very weakness of the patient.

_Care of Fractured Bones._--Any of the bones may be fractured, and from slight cause. The bones most frequently fractured are: the collar bones, the ribs, the bones of the forearm just above the wrist, the bones of the lower leg and of the thigh. This last bone, the femur, is among old people most frequently broken at its neck, which is the constriction of the bone just below the rounded end that fits into the joint at the hip.

Fractures should, as much as possible, be let alone till the physician comes. The parts should be kept quiet so as not to cause unnecessary pain, and do further injury. By rough handling it is very easy to push a fragment of bone through the skin, thus making a simple fracture a compound one. When a rib is fractured a sharp end may pierce the skin or the lung; either complication is serious. If the lung is injured the sputa will be bloody, and the appearance of such a condition should be at once reported. Sometimes patients are violent after the injury and need to be firmly held, and sometimes they have to be carried to the ward from the outside, or placed upon a bed. Always carry the fractured limb as well as the patient.

If temporary splints are put on do not make them too tight, and loosen them from time to time as needed. The extremities sometimes swell rapidly after a fracture, and the splints may so stop the circulation that, in a few hours, gangrene may be caused by them. Besides, many patients cannot tell us if the part is swollen or painful.

_The Care of Wounds._--Bites. Insane patients often bite others and penetrate the skin. They may be very angry, their mouths foul and running with saliva, and this irritating substance introduced into the wound by the teeth may set up an ugly inflammation. The wound should be immediately and thoroughly washed. It should be well cleaned with a wet sponge or cloth, and soaked in warm water. A good after-dressing is powdered iodoform, sprinkled over the wound.

_Wounds of the Head._--These wounds are quite common. They should be thoroughly washed and cleaned from dirt and hair. Hemorrhage may be controlled by continued pressure upon the bones of the skull, and if an artery is cut, it can in this way be kept from bleeding till the physician arrives. Most wounds of the head, even though large, generally heal quickly, but the most trifling ones may assume serious proportions, and even prove fatal. If within two or three days heat, pain, redness, and swelling appear, pus is probably forming beneath the scalp, and this, within a few hours, may spread under a large surface and do serious injury, or erysipelas may be set up.

_Injuries from Blows on the Head._--Persons are sometimes stunned by blows on the head. They should be placed in bed with the head elevated, and kept perfectly quiet till the doctor comes. Efforts should not be made to arouse them, they should not be given liquor of any kind, but ice may be applied to the head. The danger to be feared is from the skull being fractured, or from bleeding vessels inside of the skull. Either of these conditions may, by pressure upon the brain, cause unconsciousness, paralysis, and death.

_The Care of a Cut Throat._--Patients may cut their throats from ear to ear and do really little injury, or they may make a small stabbing wound and divide a large blood-vessel and die almost immediately, or they may cut the windpipe and not cut the blood-vessels. The windpipe you can notice upon yourselves as a large, stiff tube, prominently situated in the middle and front of the neck; the blood-vessels are together on each side of the windpipe, and situated quite deep down among the muscles, and the carotid artery may be felt beating by the finger. Little can be done by the attendants to stop the flow of blood, even if the great blood-vessels are not cut. The head should be kept bent forward and the chin pressed against the chest.

After the physician has dressed the wound, constant watching day and night may be required to prevent the patient tearing off the bandages and reopening it. This same rule of watchfulness applies to the after-care needed to be given to many cases of fracture, and other serious injuries among the insane.

_Care of Wounds of the Extremities with Hemorrhage._--The hemorrhage from most simple wounds involving the cutting of skin and flesh or small arteries, can usually be controlled by direct and continued pressure. This may be done by a pad made of cloth, packed and pressed into the wound, or lint may be used in the same way. Water as hot as can be borne poured into the wound will frequently stop a hemorrhage when other means fail; cold applications and ice are also useful. If dirty, a wound should be thoroughly cleaned, being washed, and, if necessary, soaked in warm water. Iodoform sprinkled so as to cover wounds, is the best dressing for all attendants or nurses to apply, while awaiting directions from a physician. It keeps them clean, promotes healing, and lessens the danger of inflammation or the formation of pus.

When the arteries of the extremities are cut, pressure should be made on the large artery leading to the part. When the wound is high up on the arm, pressure is made by the fingers or a padded key upon the artery that lies back of the collar bone, and the attempt should be made to press it against the bone. This is a difficult thing to do, but nevertheless it should be attempted. When the wound is lower down, pressure is to be made by the fingers on the inner side of the upper arm, at about the middle point and against the bone. The artery runs downward, near the inner border of the biceps muscle, which is the large, bulging muscle of the upper arm, and can, with a little care, be felt beating by the fingers. Patients in breaking glass often cut one or both arteries at the wrist-joint where the pulse is felt. These are large and bleed rapidly, and when cut need the care just described.

When the artery in the leg is wounded, pressure is to be made on the inner side of the thigh, just below the groin. The position of these large arteries, and how to press against the bone, is best learned by instruction and demonstration from a physician, and with a little practice attendants will be able to easily and successfully do the act.

It is very tiresome to continue pressure with the fingers for a long time, and attendants should relieve one another till the physician comes.

_The Care of Sprains._--Sprains are a common accident and easily produced. The great end of treatment is to keep the sprained joint quiet. If the ankle or knee is sprained, the patient should be carried to bed. Perhaps the best early treatment, and the one that gives the greatest relief to pain, is to place the joint in a tub of water as hot as can be borne, and keep it hot by pouring in more. The part should be kept in the water until it is parboiled. The skin of some feeble or paralytic patients is easily scalded, and some cannot tell when it is too hot; the water therefore should never be uncomfortable to the hand of the attendant.

_Care of Patients Choking._--This is a frequent accident, and in order to know what to do when it occurs, it is necessary to have a knowledge of the air passages of the throat.

We breathe through the mouth and nose. They open into a common passage, the pharynx, which can be seen by looking into the mouth, lying back of the tonsils. Passing downward, it divides by branching into two tubes; one the windpipe, which is in front, behind it is the oesophagus or gullet.

The point of division is just beyond the tongue, and is almost within reach of the forefinger when crowded into the mouth.

The air we breathe passes through the mouth and nose to the pharynx, thence to the lungs by the windpipe. The food we eat passes from the mouth to the pharynx, and thence to the stomach by the oesophagus.

There is at the opening of the windpipe a cover, the epiglottis, which is generally open, but which closes when food is swallowed and helps to keep food from entering. When a substance touches the opening of the windpipe, we instantly cough to expel it.

A person may choke, when the mouth and the pharynx back of it are filled with food; or when a piece is lodged in the wind-pipe, or a large piece in the oesophagus at the point of division, and which crowds upon the windpipe, or covers the opening. Food gets into the windpipe, by being drawn in by a sudden and unexpected inspiration of air. This may happen while eating or in vomiting solid food. With this accidental exception all breathing stops during the act of swallowing.

Some patients, from paralysis, especially paretics, do not feel food when it is lodged in the throat; others, from great dementia, may not know when they are choking, and show no emotional signs of distress. Paretics are particularly liable to bolt their food, and cram the mouth and throat full.

The symptoms of choking are immediate, and if no relief is obtained, the sufferer will die in a few minutes. If the patient knows any thing, he will show immediate signs of distress, violent but ineffectual attempts to breathe, and the face quickly becomes a dark blue color, from the accumulation of carbonic acid in the blood.

Immediate effects should be made to remove the obstruction, and continued until the physician arrives, who is to be sent for at once. Whatever is in the mouth and throat can be easily removed by the fingers; the forefinger should then be crowded down the throat to feel for other obstructions, care being taken not to push a piece of food into the windpipe. If any thing is felt, it can sometimes be pulled out by the fingers, or a hair-pin may be straightened and bent, or a piece of wire, and an effort made to fish it out. When in the gullet and beyond the fingers, it may be pushed into the stomach by a feeding-tube. Artificial respiration may be needed, but attendants must remember it is of no use until the obstruction to breathing is removed.

Marbles, coins, buttons, pieces of pencils, needles, pins, and fish-bones, are frequently swallowed. The physician should be informed at once.

_Directions how to Perform Artificial Respiration._--What is to be done must be done quickly; tight clothing about the neck and chest must be removed, and the mouth should be cleaned of dirt, water, or any obstruction to the flow of air. The body is then laid out flat on the back, covered, if possible, with light warm blankets, and some article should be folded and placed under the shoulders, so as to raise them three or four inches. The mouth must be kept open, and the tongue pulled well forward, as it is liable to fall backwards, and cover the opening of the wind-pipe. One person, kneeling behind the head, should grasp each arm at the elbow, and, draw them steadily around so that the arms will meet above the head. A strong pull should be made upon them, and they should be held a few seconds. These movements elevate the ribs and enlarge the chest and produce an inspiration.

The arms are then to be brought to the side, and pressed strongly against the lower ribs. This last movement drives the air out of the lungs, and makes an expiration. These manipulations should be repeated, slowly and regularly, about sixteen times a minute, and should, when there is the slightest hope of life, be continued at least thirty minutes. The heart should be listened to, in order to hear if it still beats. Warmth, by hot-water bags, bricks, and soapstones should be secured, care being taken not to burn the skin. The limbs may be gently rubbed with warm cloths, though it is not so important as some well-meaning people think. The rubbing should be towards the heart.

As the breathing begins, it should be still aided by the artificial means as long as necessary. When the patient can swallow, teaspoonful doses of brandy or whiskey, to two or three of water, may be given and repeated several times. As soon as possible the patient should be put in a warm bed, and milk and light food given.

_Care of Patients when First Burned._--When a patient's clothing is first on fire, dash water over him if near at hand, if not wrap him in a blanket or some heavy woollen garment, and smother the fire. Then unroll the patient and extinguish the smouldering pieces of clothing. The clothing must be cut and clipped off. Great care must be taken not to tear open the blisters. If any application is made, it may be by linen cloths soaked in sweet or castor oil, or equal parts of linseed oil and lime-water, or a layer of flour and molasses may be applied over the burned surface. These bland substances act largely by excluding the air, which, if blowing ever so quietly, is always painful and irritating, and they also protect the wound from the irritation of the bed and body clothing. Burns from scalding are practically treated in the same way as burns from fire.

_Care of Frost-bites._--Toes, fingers, ears, and noses are most frequently frozen. They will sometimes freeze in a few minutes on a very cold day. After a part is frozen there is no feeling of cold or pain, and it looks perfectly white, and is so stiff it may be broken.

Persons who are frost-bitten should not be taken into a warm room. They should be left in a cool room, and the frozen part rubbed with cold water, or ice, or snow. As these last melt they melt the frozen flesh. If the parts are thawed too quickly gangrene is liable to follow.

_Care of Patients in States of Unconsciousness._--This is not an accident, but a frequent emergency. The medical word for unconsciousness is _coma_. It may be partial or complete, may come on suddenly or slowly, or may be accompanied by convulsions or paralysis. The more frequent causes of coma, are epilepsy, the convulsions of paresis, blows on the head, hemorrhage in the brain or apoplexy, some diseases of the brain, sunstroke, and some poisons.

When coma comes on, attendants should observe, if it is slow or sudden; if the patient complains of pain in the head; if the respirations are changed, and how; the condition of the pupils, whether large, contracted, uneven, or changeable; if the mouth and face are drawn to one side; if there is any paralysis of the arms or legs; if there are any convulsions, or twitching of muscles; if the patient can be aroused, and from time to time observe and count the pulse.

Apoplexy is a term that is much used, and is a condition of coma, caused by pressure on the brain. This organ is in a tight, rigid box, the skull. If the fluid of the brain is much increased, or blood-vessels ruptured, pressure is the result, and the soft tissues yield, rather than the bony covering. This pressure may destroy or injure the cells and fibres, and so interfere with the function of the part. Another way that apoplexy occurs is by plugging of an artery of the brain, so that it cannot deliver blood to the part to which it goes, and consequently the part loses its ability to perform its function. The plugging is most frequently due to a small clot floating in the blood, and which is usually formed in the heart.

Paralysis and apoplexy are often, through ignorance, used synonymously, but they really mean very different conditions. Paralysis is a loss of power of contracting a muscle, due to disease or injury of the nervous system; it frequently follows or is associated with apoplexy.

In the case of apoplexy, and most conditions of coma, there is generally little for the attendant to do. The patient should be put to bed, with light coverings, and the head raised on pillows. Do not annoy the patient by trying to rouse him, and do not give stimulants.

_Care of Sunstroke._--A sunstroke is a very serious condition, and when it occurs, requires immediate efforts to save the life of the one suffering from it. It generally comes on suddenly, the patient first complaining of the head; he soon becomes unconscious, the skin hot and dry, and the pulse full and bounding. The treatment consists of taking the patient to a cool, shaded place, removing all unnecessary clothing, applying ice or cold water to the head, and bathing or sponging the body in cold water. If the patient recovers, the temperature will fall under this treatment. If the heart begins to fail, or the pulse becomes weak or fluttering, small doses of whiskey and water may be given and repeated.

Patients should not be taken out in the fields nor exposed places on very hot days, except as ordered by the physicians; they should wear light clothing and a straw hat; if permitted to go out, they should not overwork, and should be allowed frequently to rest in the shade. Patients are easily injured by working in the sun; headache caused, recovery retarded, and bad symptoms brought back, without having the alarming conditions of sunstroke.

_Unconsciousness from Poisoning._--Opium and its preparations, including morphine, chloral, and the two extracts of hyoscyamus, now so much employed in asylums, namely, hyoscine and hyoscyamine, are medicines frequently given, that poison in over-doses and produce coma.

These medicines and their effects will be described in the next chapter, and at the same time the symptoms of poisoning by them, and the treatment.

_Poisoning._--Poisonous drugs are not kept upon the wards. Attendants frequently have strong ammonia in their rooms to clean their clothing, and a patient may get it and drink it. It is a strong alkali, and burns the throat and mouth. Vinegar is the best ready antidote, but should be given immediately or not at all. Soft soap is a strong alkali, and if eaten becomes an irritating poison. Again vinegar is the best antidote.

The best antidotes for acids are soda, lime-water, soap-suds, and chalk; for alkalies, weak acids, such as lemons, oranges, vinegar, or cider. Olive oil, eggs, and mucilaginous drinks are the most bland and soothing remedies to give. To vomit a person who has taken poison, give a pint or a quart of lukewarm water; to it may be added one or two teaspoonfuls of mustard. Syrup of ipecac is a common remedy, the dose is a teaspoonful, and repeated in ten minutes if necessary. It assists vomiting to tickle the throat with a finger or a feather. If after poisoning there is depression or approaching coma, very strong tea or coffee is the best stimulant, and it is as well an antidote to many poisons. If the heart and pulse are very weak, whiskey diluted with water may be given and repeated.

_Injury from Eating Glass._--Patients sometimes eat glass. This injures by the edges cutting and inflaming the walls of the stomach and intestines. This may be so severe as to cause death. In the treatment do not give an emetic or a cathartic. Such food as has a tendency to constipate the bowels, and such as will also enclose the glass and coat its sharp edges, is to be given. Potatoes, especially sweet, oatmeal, or thick indian-meal pudding, are appropriate. Cotton, which is generally at hand, will, if swallowed, engage the glass in its fibres, and so protect from injury.

_Injury with Needles._--This is a self-injury, but it may be severe and require immediate attention. Patients may open a vein or an artery with a needle, or plunge it into the eye. But the more common way is for a patient to stick many needles under the skin, sometimes to the number of several hundred. Sometimes patients introduce them near the heart or lungs, and as a needle will often "travel" when in the flesh, it may work its way into a deeper part, and so a number get into the lungs or the heart, causing death. Within a few weeks I saw two needles taken from a man's heart, who died in consequence of their presence there. An attempt or desire to so injure one's self should be guarded against by the attendants, and if accomplished should be at once reported to the physician, that efforts may be made to extract the needle.