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HOW TO CARE FOR THE INSANE
A MANUAL FOR NURSES
BY WILLIAM D. GRANGER, M.D.
PROPRIETOR-PHYSICIAN, VERNON HOUSE, MT. VERNON, N. Y.
FORMERLY FIRST ASSISTANT PHYSICIAN BUFFALO STATE
HOSPITAL, BUFFALO, N. Y. MEMBER AMERICAN ASSOCIATION
OF SUPERINTENDENTS OF HOSPITALS FOR THE INSANE. MEMBER
NEW YORK NEUROLOGICAL SOCIETY.
_SECOND EDITION. REVISED._
G. P. PUTNAM'S SONS
NEW YORK
27 WEST TWENTY-THIRD ST.
LONDON
27 KING WILLIAM ST., STRAND
The Knickerbocker Press
1891
COPYRIGHT
G. P. PUTNAM'S SONS
1886
Press of
G. P. PUTNAM'S SONS
New York
NOTE TO SECOND EDITION.
At the time of starting a training school, in 1883, the author was unaware
that like work was commencing at the McLean Asylum, Somerville, Mass., by
Dr. Campbell Clark and others in Scotland, and in New South Wales.
Each was independent, and each worked out the problem independently. Thus,
far separated efforts showed the time had come when attendants must be
evolved into trained nurses.
The most gratifying feature has been the unanimous approval by American
superintendents and the establishment of training schools in almost every
asylum in the land, often under the most difficult conditions and at a
great sacrifice of the precious time and strength of the medical staff.
The increasing number of these schools and pupils demands a second edition
of this little manual.
VERNON HOUSE, MT. VERNON, N. Y.,
March 21, 1891.
INTRODUCTION.
The writer began in October, 1883, at the Buffalo State Asylum for the
Insane, a course of instruction to the women attendants upon their duties
and how best to care for their patients. This has been regularly continued
till it has become a fixed part of the asylum life, and has developed into
a system of training, and now a class of attendants has nearly completed
its studies. Since July, 1885, instruction has been given to men
attendants.
In April, 1885, the Superintendent, Dr. J. B. Andrews, who had encouraged
the school from its conception, asked the Board of Managers to officially
recognize it. They adopted the recommendation and fixed the qualifications
for admission, the pay and privileges of its members, and provided for a
certificate as a trained nurse and an attendant upon the insane, to be
given to all, who at the end of two years successfully finished the full
course of instruction.
The writer believes that all attendants should be regularly instructed in
their duties, and the highest standard of care can be reached only when
this is done. He also believes that every person who is allowed to care
for the insane will be greatly benefited by such instruction, and will be
able to learn every thing taught, if the teacher uses simple methods and
is patient to instruct.
As a rule they enter upon the study with interest, and soon a skilled
corps is formed, who are competent to fill the responsible positions, and
control the unstable class that drift in and out of an asylum. Even the
dullest are awakened to new zeal, and are advanced to positions of trust
they could not otherwise have filled.
A brief outline of the course of instruction of the school may be of
interest.
The first year is spent in learning the routine of ward work and filling
minor positions. The attendants are changed from ward to ward, and have
the care of all classes of the insane.
They first receive instruction in the printed rules of the asylum. Every
rule relating to the duties of attendants is read and explained, and
special attention is called to the performance of the following duties:
_a._ Duties to officers.
_b._ Duties to each other.
_c._ Duties to patients.
_d._ Duties to the institution.
Thus the new attendants early get an outline of their duties in the
special care of the insane.
After this comes instruction in elementary anatomy and physiology. They
are taught of the bones, joints, muscles, and organs of the body, food and
digestion, the circulation and respiration, waste and repair, animal heat,
and the nervous system.
In order to be ready for advanced instruction the elements of physiology
must be thoroughly learned. The teaching must be adapted to the ability
and wants of those instructed. Having fixed the limit of duties required
of an attendant, it is easy to fix the limit of instruction. It is an
error to teach too much medicine, for then we begin to make physicians.
All that is needed is attendants who are able to do their work
intelligently, and, keeping this object in mind, lectures by a physician,
devoid of too much detail, but simple, direct, and plain, are better than
instruction from any of the text-books. With notes of the lectures
furnished, and with repeated recitations, any lesson is readily learned.
This way of instructing, by lectures, notes, and recitations, is continued
throughout the entire two years.
A course in hygiene follows the lectures in physiology.
Instruction in these three studies occupies the first year. An attendant
who, at the end of this time, successfully passes an examination in them,
and who has been faithful in his duties, is ready to receive the advanced
instruction of the second year. This includes the nursing of the sick, the
management of emergencies, and finally the special work of caring for the
insane. The wits of an attendant upon the insane have to be sharpened in
many directions not required of a general nurse. The text-books on nursing
may properly be followed by another, which shall aid one skilled as a
nurse to perform the varied and difficult duties incident to the care of
the insane and the wards of an asylum. To furnish this is the object of
this manual.
A brief review of the physiology of the nervous system is introduced for
the aid of students, in reading the chapters on the mind and insanity.
To teach any thing metaphysical or pathological may seem questionable. The
class, however, has not only been interested in the simple study of the
phenomena of the mind, but has been able to comprehend and profit by the
lectures on this subject.
The lectures on the care of the insane were given to the class almost as
they appear in these pages. The suggestion was made that if they were
printed they would find a place in the hands of attendants in other
asylums. This is the reason of their publication.
To my colleague, Dr. A. W. Hurd, I wish to tender my thanks for the
valuable assistance he has given me in the preparation of this manual. I
am greatly indebted to Dr. Andrews for his ever kind but critical advice.
But for his encouragement and help neither the work of instruction nor the
preparation of these pages would have been begun, nor success, if success
be gained, achieved.
CONTENTS.
PAGE
INTRODUCTION v
CHAPTER I.
THE NERVOUS SYSTEM AND SOME OF ITS MORE IMPORTANT FUNCTIONS 1
Nerve Centres.--Brain and Spinal Cord.--The Nerves.--Nerve
Cells and Fibres.--Motor and Sensory Nerves.--The Five
Organs of Special Sense.--Nerve Impulses.--The Brain and
Nervous System Always Busy.--Need of Rest.
CHAPTER II.
THE MIND AND SOME OF ITS FACULTIES 7
Mind and Matter.--Life.--Relation of Mind and Brain.--
Faculties of the Mind.--Intellectual Faculties.--Will.--
Emotions.--Instincts.--Moral Faculties.
CHAPTER III.
INSANITY; OR, DISEASE OF THE MIND 13
Insanity a Change.--Involves Disease of the Brain.--
Delusions.--Hallucinations.--Illusions.--Incoherence.--
Mental States.--Mania.--Melancholia.--Dementia.--
Monomania.--Emotional Insanity.--Dipsomania.--Moral
Insanity.
CHAPTER IV.
THE DUTIES OF AN ATTENDANT 22
What an Attendant Should First Learn.--The Relation of
Attendants to Patients.--The Character of an Attendant.--
Relation to the Institution.--How and What to Observe.--
Systematized Plan of Observation.--Control and Influence
of Attendants over Patients.--Care and Study of the
Individual.--Liberty to be Allowed Patients.--Self-Control
of Patients to be Encouraged.
CHAPTER V.
GENERAL CARE OF THE INSANE 33
Reception of New Patients.--Work and Employment.--Patients'
Care of Themselves.--Walking.--Clothing.--Bathing.--Serving
of Food.--Bed and Rising Time.--Night Care.
CHAPTER VI.
CARE OF THE VIOLENT INSANE 45
Need of Studying Each Case.--Constant Attention and
Oversight.--Value of Employment and Out-Door Exercise.--
Restriction and Idleness.--Paroxysms of Violence; How Cared
For.--How to Hold or Carry a Patient.--Danger of Injury.--
Struggles to be Avoided.--Care of Destructive Patients.--
Use of Restraint, Seclusion, and Covered Bed.
CHAPTER VII.
CARE OF THE HOMICIDAL AND SUICIDAL INSANE, AND OF THOSE
INCLINED TO ACTS OF VIOLENCE 53
Delusions of Suspicion.--Homicidal Patients.--Suicidal
Patients.--Self-Mutilation.--Incendiary Patients.
CHAPTER VIII.
CARE OF SOME OF THE COMMON MENTAL STATES AND THE ACCOMPANYING
BODILY CONDITIONS 60
Care in the Earlier Stages.--Insanity with Exhaustion.--
Symptoms of Danger.--Care of Dementia, Early Dementia,
Chronic or Terminal Dementia.--Convalescence.--Relapse.--
Epilepsy.--Paresis.--Care of Paralytics, the Helpless, the
Bed-ridden.--Bed-Sores.
CHAPTER IX.
SOME OF THE COMMON ACCIDENTS AMONG THE INSANE, AND THE
TREATMENT OF EMERGENCIES 71
Certain Classes of Insane Liable to Injury.--Fractures.--
Wounds.--Bites.--Blows on the Head--Cut Throat.--Wounds of
the Extremities with Hemorrhage.--Sprains.--Choking.--
Artificial Respiration.--Burns.--Frost-bites.--States of
Unconsciousness.--Apoplexy.--Sunstroke.--Poisoning.--Eating
Glass.--Injury with Needles.
CHAPTER X.
SOME SERVICES FREQUENTLY DEMANDED OF ATTENDANTS AND HOW TO
DO THEM 85
Administration and Effects of Medicine.--Opium, Chloral,
Hyoscine, and Hyoscyamine; Doses, Effects, Poisoning,
Treatment.--Stimulants.--Applications of Heat and Cold.--
Baths and Wet Packing.--Hypodermic Injections.--Forcible
Feeding with Stomach-Tube.--Nutritive Enemata.
HOW TO CARE FOR THE INSANE.
CHAPTER I.
THE NERVOUS SYSTEM AND SOME OF ITS MORE IMPORTANT FUNCTIONS.
The nervous system is made up of a nerve centre and nerves.
The great nerve centre is the _Brain_ and _Spinal Cord_.
The brain is a body weighing about forty ounces, and fills a cavity in the
upper part of the skull. The spinal cord, commonly called spinal marrow,
is directly connected with the brain. The skull rests upon the spinal
column, or backbone, and there is a cavity inside the whole length of this
column, which contains the cord. There is an opening through the base of
the skull where it rests upon the spinal column, and it is through this
opening that the fibres of the cord go, to pass into and become a part of
the brain. These most important parts are carefully protected by a strong
bony covering.
Many nerves are given off from the brain and cord and go practically
everywhere, so that every part of the body is supplied with them. These
nerves are white cords of different sizes; the largest nerve of the body,
the one that goes to the leg, called the sciatic, is as large as the
little finger.
There are really two brains and two cords, as along the central line of
the body there is a division of the brain and cord, making two halves
exactly alike. These halves are connected together, the division not being
complete.
Nerves are given off in pairs; for example, from either side of the brain
arises a nerve that goes to each eye. So two nerves exactly alike spring
from the two sides of the spinal cord, going to each arm.
A nerve is composed of a bundle of fibres, microscopic in size. As a nerve
passes to the extremities it divides by branching much as does an artery,
and thus a bundle of fibres is distributed to a muscle, or a part of the
skin, or to an organ, and every part of the body has a direct nerve
supply, much as you saw in the microscope it was supplied with blood by
means of the capillaries. We cannot prick our finger with the finest
needle but nerve, fibres are irritated, and we feel it, and capillaries
are injured and we get a drop of blood.
Most of the nerves that go to the arms, legs, and organs of the chest and
abdomen, arise in and proceed from the spinal cord, but some of the fibres
begin in the brain and are continued down the cord, where, joining with
fibres that originate in the cord itself, both go to make up the nerve,
thus connecting all parts of the body with the great centre.
The brain and cord are made up of blood-vessels, nerve cells, nerve
fibres, and, holding them all together, connective tissue. The cells are
very small, being microscopic in size; there are an immense number of
them, and they make up most of the gray matter or outside of the brain,
but in the spinal cord the gray matter is in the centre. The fibres that
go to make up the nerves begin and spring from the cells, and they also
unite them together.
The cells are gathered into groups, which have each a separate function to
perform. There is a group from which the nerve of the eye proceeds;
another for the nerve that goes to the ear; another for the nerve that
goes to the arm; and another for the nerve of the heart. There is a group
that presides over speech, and other groups that preside over mental
action, while all of these are connected together by fibres. Thus it
appears that the brain is a true "centre," and the nerves but the means of
connection between different parts of the body and the brain, and also
between different parts of the brain.
Nerves have two special functions: one to carry impressions made upon the
fibres, that end in the different parts and organs of the body, to the
brain; another to carry from the nerve cells so-called "nerve impulses,"
to the different parts and organs of the body. Some nerves have in
themselves these two functions, as the nerves that go to the arm or leg;
others have but one, as the optic or eye nerve, which can only carry the
sensation of sight from the eye to the brain.
The nerves that carry sensations to the brain are called _Sensory Nerves_.
The nerves that carry motor impulses from the brain are called _Motor
Nerves_.
There are five special organs of sense, each receiving different
impressions, and sending by its sensory nerve or nerves a different
character of sensation to the brain, namely:
The eye, giving sensations of light and color.
The ear, giving sensations of sound.
The nose, giving sensations of smell.
The mouth, giving sensations of taste.
The skin, giving sensations of touch, with ideas of roughness,
smoothness, hardness, softness, heat, and cold.
There must be, in every case, a direct nerve connection from the organ of
special sense to the special group of cells in the brain to which the
nerve goes. If the connection is broken at any point, the impression made
upon the fibres in the organ of sense cannot reach the brain. Only after
the impression reaches the brain and the cells are affected, do we become
conscious of a sensation. We then say, as the case may be, I see, or hear,
or smell, or taste, or feel something.
It thus appears that these organs of sense simply receive the impressions
made upon them to transmit to the brain, and it is really the brain that
sees, hears, smells, tastes, and feels. By the action of the organs and
nerves of special sense we get all our knowledge of the external world,
and, probably, if we had no organs of sense, we would have no
consciousness of our existence.
Pain is due to abnormal action of sensory nerves, caused by disease,
injury, or pressure, and the irritation made, being carried to the brain
makes us conscious of the peculiar sensation we call pain. So the want of
food or water makes an impression upon nerves, which being carried to the
brain causes a peculiar sensation, and we say we feel hungry or thirsty.
The _Motor Nerves_ arise in the cells of the brain and cord. Those which
go to the voluntary muscles cause them to contract, and are under the
control of the will. If the cells are diseased, if they do not get enough
arterial blood, or are poisoned by carbonic acid, or if the nerves are
diseased, injured, or cut, so that nerve impulses cannot be sent from the
brain to the muscles, we have paralysis of a muscle or a group of muscles,
according to the extent of the injury. Now we can appreciate the force of
this teaching in the physiology of the muscular system, that "paralysis is
a loss of power, either partial or complete, to contract muscles, due to
disease of the nerves."
By the ready action of our mind, the quick working of our will, we direct
and control the action of our muscles, so as to perform with the utmost
skill and ease the varied and innumerable movements of our body.
It seems very easy to do this, but watch a child learning to walk; it is
educating its mind and will to control the muscles, and it is a slow and
difficult education.
But all motor impulses and bodily activities are not under the control of
the will. The heart is supplied with motor nerves, but we cannot by our
will stop its beating or control its action. The taking of food makes a
mental impression, and without the will being involved, impulses are sent
to the glands of the mouth, setting them actively at work, and saliva
flows. So the stomach begins to churn food when it is introduced, and the
liver is kept at work making bile and sugar, and we breathe when we are
asleep.
All the organs of the body are supplied with motor nerves, that regulate
their action and give them the power to do their function or work, but
with the exception of the muscles, this power is sent without the action
of the will.
Our brains are very busy. While we are awake we are constantly receiving
sensations, we are thinking, remembering, willing, and sending many
messages every minute, and directing power to all parts of the body. The
brain works and gets tired, just as the rest of the body gets tired, and,
if abused, injured, or overworked, may become diseased as may any part.
Its tissues wear out, are burned up, and require the same supply of
material to repair them that any other part of the body requires. It needs
then rest, good food, good blood, and plenty of oxygen.
No wonder some brains give out, and fail to do their work properly, and so
cause insanity.