CHAPTER X.

SOME SERVICES FREQUENTLY DEMANDED OF ATTENDANTS, AND HOW TO DO THEM.

_The Administration and Effect of Medicine._--The only proper way of giving medicine is by using standard weights and measures. Dropping medicine, or using spoons or cups, is not sufficiently accurate. A drop may be half a minim, or as large as two or even three. The modern teaspoon holds ninety or more minims, and a tablespoon more than half an ounce.

Medicines are introduced into the system through the stomach, the lungs, the rectum, the skin, or by being injected into the tissues, under the skin. They are either local or general in their effects. A blister or a poultice is a local remedy, so is an emetic, that acts by irritating the walls of the stomach. General medicines are absorbed into the blood, and carried to different parts of the body.

The following are a few of the reasons for which medicine is given: to relieve pain, to give sleep, to produce vomiting, to check vomiting, to move the bowels, to check diarrhoea, to assist digestion, to produce a greater or diminished flow of urine, to increase the perspiration, to increase the red blood corpuscles, to check hemorrhage, to regulate the action of the heart, to overcome the effects of poison, to increase or diminish the amount of blood in the brain, to control spasm, to diminish the temperature in fever.

In some cases the effect desired and expected from a medicine given to a patient is told to the attendant, who should closely observe and be able to report the result. Sometimes medicines are left in the hand of the attendant, to give in repeated doses, at stated intervals, till a desired effect is produced. The attendant is also instructed to watch for certain symptoms which show that the medicine is doing harm, when it is to be discontinued. An attendant, who has studied and learned, "how and what to observe" in his patient, will be able to give intelligently any medicine ordered by a physician.

Sometimes medicines, given in large or long-continued doses, cause symptoms that an attendant should notice and report to the physician; some of these are, eruptions on the face and body, puffiness about the eyes, irritation and running of the eyes, a metallic taste in the mouth, bleeding of the gums or soreness of the teeth and profuse flow of saliva, nausea, vomiting, diarrhoea, constipation, indigestion, ringing of the ears, feeling of fulness in the head, headache, dizziness, drowsiness, coma, convulsions, or convulsive movements of muscles.

In asylums, medicines are mostly sent to the wards in single doses, each cup or bottle being marked with the name of the patient for whom it is intended. The tray in which they are carried should never be set down and left, for a mischievous or suicidal patient may poison himself by taking every thing he can get hold of.

No patient, unless ordered by the physician, should be allowed to keep his cup and take his medicine at his leisure. Suicidal patients often ask to do this, and then save the medicine, until they have enough to poison themselves. Others will throw the medicine away. The way to administer medicine to the insane is to give it personally to the patient, and also see that it is swallowed. It is a frequent custom of many patients to retain the medicine in the mouth, and, when the attendant has left, to spit it out.

It is often very important that patients should take the medicine ordered, and every effort should be made to induce them to take it. Such patients should be designated by the physician. Night medicines, or those given about bedtime, are usually of great importance. All patients who refuse to take their medicine should be reported to the physician.

The reasons for refusing medicines are various; some say they are perfectly well and need no medical treatment, others think the medicine injures them, that it turns their skin black, or poisons them, or that it is wrong to take it, or displeasing to God; ideas much like those that we learned were the causes for the refusal of food. Attendants are to use every effort to get patients to take medicine, and may employ as much force as they were instructed to use in giving food, but no more.

Patients should not be deceived about medicines, nor told by attendants that it is nothing, that it is only a little water, or some nice drink that is sent to them, nor should an attempt be made to give them, by trying to disguise them in food or drink, except by the permission of a physician. Patients should, on the other hand, be told that it is medicine, that the doctor ordered it for them, that it is for their good to take it, that it is given to help them get well.

The giving of medicine and food is among the most important and frequent duty that an attendant is called upon to perform, or assist others in doing. Attendants must remember that many medicines are injurious or even poisonous, if not properly given, or if mixed with other medicines, or if given to the wrong patient; they should therefore, never make a mistake, or, if by carelessness they commit one, should immediately report it.

_Opium and Some of its Preparations._--Opium is a medicine that is very frequently given to patients in an asylum. The ordinary dose is one grain. _Tincture of opium, or laudanum_, is opium dissolved in alcohol. Ten minims equal one grain of opium. _Camphorated tincture of opium, or Paregoric_, is a weaker alcoholic solution, with some camphor, and flavored with a pleasant aromatic. One half a fluid ounce equals a grain of opium. _Morphine_ is a white powder extracted from opium. An eighth of a grain about equals a grain of opium.

Opium, in some of its forms, is a common household remedy. To an adult, not more than one grain should be given; it should not be repeated more than once, nor less than six hours after the first dose. It would be better if never given, except by a physician's order. Under no circumstances should any one but a physician give it to a weak or old person, or to a young child.

Opium, is given in ordinary doses to relieve pain, to check diarrhoea, to relax spasm of muscles, and to produce sleep. The sleep from opium is generally quiet and refreshing, and one from which the patient can be easily aroused.

An attendant will frequently be told when the medicine is given and directed to note and report its effect.

_Opium Poisoning._--The taking of opium is a frequent way of committing suicide by persons outside of asylums. Sometimes patients manage to save their doses, or they steal it from the tray, or, if there is some sent to the ward for repeated doses, they secure it through the carelessness of an attendant, or occasionally it is secretly sent to patients by officious outside friends,--thus poisoning by opium sometimes occurs among asylum patients.

The full symptoms of poisoning are profound coma, pupils contracted to pin-points, and which do not respond to light; very slow respiration, often not more than four or six times a minute, but heavy and labored. Sometimes the effect of the drug is but partial, the patient can be aroused for a moment, but falls to sleep again, or the symptoms may be even less pronounced.

The treatment of opium poisoning, before the physician comes, consists in giving _very_ strong coffee, or tea, an emetic, and in trying to keep the patient awake by walking him about, or, if this is not possible, to keep him from falling into deeper coma, by shaking, calling loudly in the ear, and striking and slapping the body with wet towels.

_Chloral._--This is a white crystal, with a pungent, burning taste. It is always dispensed, dissolved in water, and should be further diluted when given to a patient. The dose is from ten to thirty grains. It is too powerful a drug to be given, except upon the order of a physician. Chloral is given to produce sleep, which is usually quiet and natural. The effect lasts about four or six hours.

The symptoms of poisoning are not so marked as to make it easy to know that they are caused by chloral. There is generally a weak heart and pulse, and feeble respiration, and the patient is in a deep sleep, from which he may be aroused; or the coma may be profound, and continue uninterrupted till death.

The treatment consists in giving an emetic, stimulants, coffee, and, if necessary, performing artificial respiration.

_Hyoscyamine and Hyoscine._--These are extracts, from the leaves and seeds, of the plant hyoscyamus.

These are very powerful medicines, and are never given except on the order of a physician. They are always given in solution.

The action of both is practically the same. In ordinary doses they quiet restlessness, produce muscular weakness, flushing of the face, dryness of the tongue, wide dilatation of the pupils, and frequently cause sleep. These effects should be noticed and reported. These medicines are mostly given to patients who are continually restless, violent, and sleepless, and the object is to bring quiet, repose, and sleep. Large doses may produce coma, very heavy breathing, and great muscular weakness; the pulse however is full and strong, but if it should fail, the physician should be at once sent for.

_Alcohol and Stimulants._--It is the alcohol in liquors that intoxicate, and it is that part, also, of liquor that stimulates when given as a medicine. Whiskey, brandy, and gin are about one half alcohol. The dose is a tablespoonful, in water, and not repeated oftener than two or three times. Wines are about one fifth alcohol, beers and cider about one twentieth.

Liquors containing alcohol are never to be given to patients as a beverage, but always as a medicine, and, except in emergencies, never without a physician's order. Do not give them in emergencies, without a good reason for so doing, and not simply because you feel you must do something, for in some emergencies they may do a great deal of harm, and perhaps, a fatal injury.

Alcohol is mostly given to stimulate the action of the heart. A stimulant is something "that arouses or excites to action." It is given (in the doses just mentioned) in accidents, when the heart is very weak, the pulse almost or quite imperceptible, the face pale and pinched, and the extremities cold.

In continued sickness, with exhaustion, stimulants are sometimes left with the attendant to give, with directions about the size of the dose and its frequency. If it quiet the patient, strengthen the heart and pulse, it is doing good; but if restlessness comes on, the face becomes flushed, or if the pulse is made more rapid and feeble, it is probably doing harm, and should be discontinued, and the physician informed.

_Dry and Moist Heat._--In applying heat, either dry or moist, to the insane, care must always be used to protect the skin from being blistered. This happens very easily when it is applied directly to old, feeble, paralyzed, or paretic patients, and also to those who are too demented to complain if they are being burned. Burns are very serious accidents among this class of patients, and may, if they extend over a large surface, even though not deep, heal with difficulty, and even prove fatal.

Dry heat is applied by means of rubber bags filled with hot water, hot-sand bags, bricks, or soapstones, and by the lamp bath. Moist heat by hot baths, fomentations, turpentine stupes, and poultices.

_Hot Baths and Wet Packing._--Hot baths are sometimes prescribed for patients. The water should be about 100 degrees F., and, if ordered, slowly increased to 110 deg. The patient is to be left in as long as directed, which may be but a few minutes, or half an hour, or even longer. Sometimes a blanket is ordered thrown over the tub, the head only being uncovered.

When the bath is being given, the pulse should be counted; if it become weak and rapid, if the face become flushed, and the patient complains of dizziness, or if the lips show venous congestion, the patient should be at once removed, and, unless there is immediate recovery from these evil effects, the physician should be informed.

In giving a wet pack, the patient is wrapped in a sheet, without any clothing, wet either in cold or warm water, as ordered, and then rolled in a blanket, put to bed, and left in it as long as directed.

These methods of treatment are frequently ordered by physicians for patients who are restless, violent, and sleepless, with a view of giving quiet and sleep. The attendant should observe and report the result.

_Application of Cold._--The attendants are frequently ordered to apply ice to some part of the body, for the purpose of producing local cold. The ice should be broken into small pieces and put into a bladder, or rubber bag, partly filling it. It remains sufficiently cold until all the ice is melted.

Another way is to put a piece of ice in a sponge and bathe the part. When cold cloths or compresses are applied, the heat of the body soon warms them, when they become warm applications and act as a poultice; they should therefore be frequently changed. In applying moist dressings care must be used not to have any leaking nor wetting of the bed or clothing.

_Hypodermic Injections._--Morphine, hyoscyamine, or hyoscine, in solution, are frequently injected under the skin. The direction to do this, and the quantity to be given, will, in every case, be ordered by the physician. A fold of the skin is held between the finger and thumb, while the needle held in the other hand is quickly pushed straight under the skin to the depth of about half an inch. Care should be used to inject no air, and not to inject the contents of the syringe, into a vein.

_Forcible Feeding with the Stomach-Tube._--Attendants are frequently called upon to assist in the forcible feeding of patients, and in some cases may themselves be directed to do it. The dangers of feeding are that the pharynx may be filled with fluid, and the patient choke, or it may be drawn into the lungs, that the wedge with which the mouth is held open may be so loosely held that in the struggle of the patient the soft parts of the mouth may be injured, and occasionally it happens that the mere pressure of the tube causes choking.

Attendants should watch the process of feeding, and particularly the face, for symptoms of venous congestion, and report to the physician any thing they see that denotes danger.

In preparing for feeding, attendants must see that the food is properly made ready. If any thing is to be mixed with milk, it should be mixed so as to be perfectly smooth, without lumps, and so it will run easily through the tube. If some concentrated food is used, it is better to put it in a small quantity of milk, just enough to make it liquid, that it may be given first. Medicines ordered for feeding are not to be mixed with a large quantity of milk, but saved, that they may be given directly from the dispensing bottle whenever the physician desires to do so.

Every thing should be got ready for feeding before the physician arrives. Upon a tray should be all the feeding apparatus--the food and medicine, several spoons, and cups, and a pitcher. Near at hand should be plenty of water, soap, and towels, and a tin basin. It is very provoking to have to wait for many things to be brought after the patient has been got ready.

Many patients are easily fed. Some like it, but some violently and furiously resist. Such patients should be restrained to a chair fixed to the floor, and the more securely this is done the more easily can they be fed, and with less fatigue and danger of their being injured.

The patient's clothing should be well protected from being soiled, by towels about the neck, and a basin should always be held under the chin to catch falling liquids and any thing vomited. The holding the head and wedge is an important matter, and is some thing that belongs to the attendant to do. The attendant stands behind the patient, and holds the chin by the right hand, and with the left firmly grasps the wedge, which is inserted straight into the mouth, between the back teeth, about two or three inches. The wedge should be grasped with the palm upwards, and the little finger and side of the hand should be pressed firmly against the chin. If held in this way there is little danger that in violent struggles, the wedge can be suddenly driven backward and wound and tear the soft parts of the mouth. If the throat fills with fluid, the attendant who holds the head should bend it far forward, that it may, if possible, run out of the mouth.

After feeding, patients' faces should be washed. They should be watched for some time to see that they do not vomit, or, as is often the case, that they do not make themselves vomit.

There is no special difference in caring for a patient fed with a nasal tube, except that the wedge is not used.

If attendants are allowed to feed, they must remember all the dangers, and guard against them. In introducing the tube, the forefinger of the right hand is to be introduced at the same time, and, as the tube passes over the tongue it is to be turned downward by the finger and _gently_ pushed into the oesophagus. If there seem to be unusual difficulty in so doing, severe and unusual struggling, or the slightest symptom of danger, cease the effort to feed, and report to the physician.

Of course no attendant would undertake to feed any patient unless ordered to do so by the physician, which order would be given, if at all, only after careful training and in cases easily fed.

_Nutritive Enemata._--It is often necessary to feed patients by the rectum. This is done by injecting food, to the amount of four or six ounces. Care should be used to inject no air. The nozzle of the syringe well oiled is to be gently introduced, and the fluid slowly forced into the bowel. The patient should lie on the left side, near the edge of the bed, with the knees well drawn up. If the patient resist, he must be placed upon the back, the legs separated and firmly held. This may require four or six attendants, but enough should always be at hand to thoroughly and easily overcome the patient. Before giving the first injection of food the bowels should be moved by an injection of soap and water. Sometimes the injected food escapes from the rectum. The patient should be watched to see if this happens. In such a case a long tube can be introduced into the rectum, about four or six inches, and the food injected through it. The tube should be well oiled, and introduced slowly and with gentle force.

Patients often thrive upon this way of feeding. The character of the food will be ordered by the physician.

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End of Project Gutenberg's How to Care for the Insane, by William D. Granger