THE GENERAL CARE OF THE INSANE.
_The Reception of New Patients._--Attendants must at once study the
peculiarities, the physical condition, and the mental symptoms of a new
patient, so as to know the case thoroughly.
New patients should receive special attention; their fears quieted; they
should, if in a proper condition, be introduced to the other patients; the
effect of being in so large and strange a place, where the doors are
locked and the windows guarded should be noticed, and unpleasant
impressions overcome; they must be told they have come among friends and
will be kindly treated.
The necessary rules of the ward should be explained; they should be
invited to their meals, shown to their rooms and told at bedtime the night
watch will visit them, and they must be assured that no harm will come to
them.
The first impressions a new patient receives may be the lasting ones, and
influence their whole conduct in the asylum. If they resist what is
necessary to do for them, do not struggle and contend with them, and force
them to bed, or to the bath, but first seek advice from the supervisor, or
the physician.
Always search new patients, unless otherwise ordered, for money, jewelry,
weapons, medicine, and other like articles, or if in doubt what to do ask
for directions. The head, body, and clothing should be examined for
vermin, and the body for injuries and bruises. If what is wished to be
done in this particular is explained, patients will generally quietly
allow it.
_Work, Employment, and Occupation._--By this is meant whatever occupies
the patient's time and mind, in useful and pleasant ways.
Of all things idleness and loafing are the worst; even games, such as
billiards and cards, if indulged in to the exclusion of useful employment,
will degenerate a patient.
Some willing patients are kept in a tread-mill of daily work, their
monotonous life never broken by a diversion, an enjoyment, or a hope. It
is very questionable if it is beneficial to make a patient drudge through
such a daily routine.
Asylum life should be made as home-like, pleasant, and natural as
possible; as a rule every patient who is able should do some useful work
every day, and to this should be added the diversion, that comes from
amusements and the enjoyment of innocent pleasures.
Occupation then means a great deal more than work; it is the way a patient
spends his time. Unless encouraged and directed, patients may occupy
themselves in thinking of their delusions, in noise, violence, or
destructiveness, in idly walking up and down the wards, in the indulgence
of secret vices, in gossip, in spreading discontent, in prayer, or in
constant Bible reading. Some patients really work hard trying to do
nothing, and have no more ambition than to sit around on the ward, and
chew tobacco, and indulge in idleness.
Patients should be encouraged to do something for themselves, the women to
make and mend their own clothes, to keep their rooms in good order, and
assist about the ward. They should be made to feel that they can add to
their own comfortable surroundings by their own efforts.
For the men, ward work is not so natural or tasteful, but they will do
with interest much of this kind of work; to this may be added employment
in decorating their own rooms or the ward, and in caring for plants and
flowers.
The women can add to ward work, sewing, knitting, mending, embroidery,
artificial flower making, quilting, care of flowers in the ward, and it is
often a real enjoyment for patients to make some little present for their
outside friends. The laundry offers an inviting field for some patients,
but it is often too hard work, especially when they are sent twice a day
to the wash-tub, or kept in the hot ironing room. A half day is enough for
most patients, and many are not strong enough to go there.
Out-of-door work is well suited for the men. The farm, garden, lawn,
barns, and machine-shops offer much that can be made useful for the
patients' employment; the different mechanics and artisans about the
asylum should have patients working with them.
Thus it appears there are many directions for patients to work, and it is
also true that all patients are not suited to do the same work nor the
same amount of work. Whatever they do should be for their benefit alone,
otherwise we might take a contract for a given number of patients to work
a given number of hours every day, a good deal as has been done in prisons
and reformatories, but no one would believe such a course for the
interest, improvement, or recovery of the patients.
The only rule to go by is, that the work and occupation shall be for their
own good, and, that they shall not be made or encouraged to work for any
other purpose.
As a rule, patients should be allowed to employ themselves in ways that
most interest them, provided it is useful and seems to be beneficial.
Over-work is as bad as idleness; too much sewing will often give a
sleepless night.
Generally all patients may be allowed to engage in light work, without
special directions; new patients, however, should not be sent off the
ward, or given tools that may become weapons, unless by order of a
physician.
It is a bad habit for attendants to sit idly by, or stand around with
their hands in their pockets, and have patients do all the work. It may be
so necessary to watch the patients that the attendant cannot work
steadily, but he should have the appearance of doing something, and if
possible join with them in work.
A party of women sewing, should be laughing, talking, telling stories,
perhaps singing; they should be made to enjoy the time, and not to look
upon it as something irksome.
Some patients are too feeble in mind, and some too feeble in body to work;
many need rest, quiet, and nursing, and directions for the care and
occupation of such patients should come from the physician.
Many of these patients will do a little, others can be amused, or read to,
and their minds thus diverted from their troubles, and turned into
pleasant and cheerful directions of thought.
It has been shown that work is not the only useful way that patients may
occupy their time, that nothing but work is as bad as no work, and that
they should have diversion, enjoyment, and entertainment.
For the entertainment and occupation of patients, there are furnished,
dances, concerts, theatricals, billiards, cards, pianos, books and papers,
schools, chapel services, walks, rides, and excursions, and they also
receive visits from friends, and write and receive letters.
Patients should be encouraged and sometimes made to take part in these
natural and pleasant amusements; of course every patient cannot play the
piano, or billiards, but among these many forms of recreation, all
patients can find ways of diversion and means of enjoyment.
Thus early in the study of the care of the insane, it is learned that the
life of patients is to be stripped, as much as possible, of restriction
and restraint; that self-control is to be taught; that useful work is to
be encouraged; that amusements and innocent pleasures are to be enjoyed;
in a word, attendants are to learn, that the characteristics of
institutional life are to be lessened, and those of a home life made
prominent.
_The Patients' Care of Themselves._--The general tendency of the insane is
to mental enfeeblement, to neglect of person, and to slovenly habits.
Patients should be encouraged as much as possible to care for themselves;
to be helpful towards others; to do such work as they are able; to seek
amusements, and to live as much as possible such a life as we ordinarily
are accustomed to outside the asylum.
Patients should be encouraged to keep themselves tidy, and nicely dressed,
to have the care of their clothing; if possible, they should be given a
room of their own, which they should take a pride in keeping in order, and
ornamenting with pictures and flowers; and should be allowed to do
whatever will help maintain their self-respect, self-care, and a feeling
of individuality.
There is great difference in patients as shown in their capacity for
self-help. Some seem to be able to do nothing, some everything. Nothing
can lighten the burdens of attendants so much as to make the helpless
self-helpful. Nothing benefits the patients more. Do not abandon effort
for any patient. Unexpected and gratifying results are the rewards of
earnest efforts.
_Out of Door Exercise--Walking._--If possible, patients should be out of
doors every day. In the summer much time can be spent in the fields, on
the lawn, either walking or sitting under the trees; in the winter time
shorter walks only can be taken, but on pleasant days, often an hour may
be spent out of doors. Warm clothing and good shoes must never be
neglected, and the person must be thoroughly protected, because the insane
are frequently "cold-blooded," that is, the circulation is poor, the hands
and feet congested, blue, and cold, they make animal warmth slowly and
with difficulty, and easily suffer from the cold.
Many patients go out to walk on parole. Those who are allowed this liberty
will be designated by the physicians; any change in the patient that
makes such liberty dangerous should at once be reported. Others go out in
large parties, with few attendants to care for them, while the old, sick,
and feeble, the homicidal and suicidal, the noisy and violent, require
special care and attention in their exercise and walks.
_Clothing of Patients._--In many asylums each patient has his own
clothing. Every article should be plainly marked with his own name, and
should be used only by the patient to whom it belongs, and never given to
any one else to wear. All clothing should be kept clean and well mended,
and should be properly put on and kept on during the day. There should
always be enough to keep the patient warm, and changed with the changes in
the weather, or the temperature of the ward, or the needs of the patient.
The sick, feeble, and old always need extra clothing; that worn next the
skin should be changed at least once a week, and all clothing should be
changed as often as soiled.
_Bathing of Patients._--Every patient should be bathed once a week and as
much oftener as is necessary. The tub should be cleaned and the water
changed for each patient; the temperature should be about ninety-five
degrees, or not hot to the hand, and the tub should be about two-thirds
full. The head, neck, and body should be washed with soap; each patient
should have a clean towel, be wiped dry, and given a change of clean
clothing.
Some patients object to bathing; they fear the tub, but will wash with
water and a sponge, and they should be allowed to do so. Others want to
bathe first; let them, if possible. Others will not bathe the day the rest
do; it is sometimes best to humor them.
Some patients have to be forcibly bathed. In such cases always wait, use
every art to induce them to bathe, and before acting send for advice.
Attendants are too prone to think that every thing should be done by rule,
and that all must be forced to obey the rule. Most will observe it without
trouble, and the object sought can generally be gained by patience, tact,
and kindness.
_Serving of Food._--The dining-tables should be neatly set and made
attractive; the food should be promptly served, and while hot; all
patients should be at meals, unless excused by the physicians. Economy
should be practised, and every thing should be used or saved. Each person
should have enough, but no one should be allowed to make a meal of a
delicacy, or take all of the best of a dish. Some patients would waste a
pound of butter or sugar at each meal; enough is sufficient for anybody.
The old and feeble should be served by attendants; those without teeth
should have their food prepared, and the meat should be cut very fine.
Those who will not eat must be kept in the dining-room and fed; the
attendants may use force by holding the hands, and placing food in or to
the mouth; but it is dangerous to do more, and holding the nose is
something that is never allowable. If these efforts to get them to take
food do not succeed, report to the physician. Some patients from delusions
will eat certain kinds of food, and either not get enough or not a
sufficient variety.
A mixed diet is the best, and patients should if possible be made to eat
bread, butter, meat, vegetables, and drink milk and plenty of water. No
patient should be allowed to lose in flesh and strength on account of
failure to take sufficient, or proper food; before these things happen it
should be reported to the physician. Some patients will only eat enough if
they are allowed to eat it in their own way; they will eat it perhaps
standing, or after the others have finished, or alone, or in their room,
or they may steal it, if given the opportunity. Such peculiarities often
have to be indulged.
Some patients will take nothing but milk, then about three quarts a day
are needed; eggs may be added and are often readily taken, and some may be
got to eat bread and milk, which is a very nutritious diet.
The food of the sick should be nicely and invitingly served, and efforts
should be made to meet their whims and fancies.
Patients who are so profane, violent, or noisy, that they are not allowed
to come to the dining-room, must always be fed by, and in the presence of
an attendant, and meals should not be passed into a patient's room and
left there.
Knives and forks should always be counted by an attendant before and after
each meal; care should be used that they are not lost, secreted, or
carried out of the dining-room by patients. No one but an attendant should
ever handle the carving knife and fork, or the bread knife.
_Care of Patients when Going to Bed, or Rising._--The beds should be daily
aired, and always clean and nicely made up; for a filthy patient a straw
bed, that can be changed, alone is clean.
All patients do not need to go to bed at the same time, and while some are
able to care for themselves, most need care, attention, and watching. The
helpless should be dressed and undressed, and put to bed first: the
violent and homicidal need to be watched, and should be put to bed early,
while the suicidal should be kept under supervision, and put to bed at the
most convenient time. After a patient is in bed, an attendant should go
into the room, with a lantern, so as to see that every thing is in order
and safe, and, with a cheerful "good-night" close the door. Patients who
need care should be visited during the evening, and left clean and in good
condition to be cared for by the night watch.
In the morning patients need attention before any thing else is done.
First, the suicidal, sick and feeble, the violent, and those likely to be
filthy should be visited, and every patient should be washed and dressed
before breakfast; or, if for any reason they do not come to this meal,
their faces and hands should be washed, the bed put in order, and the room
made clean and aired.
After these things have been attended to, the ward work should be done,
though generally the two can go on together.
_Care of Patients during the Night._--After the patients have gone to bed
the ward should be quiet, doors should be quietly closed, voices lowered,
and loud calls and laughter not indulged in, squeaking boots should not be
worn, and heavy walking avoided. Many patients go to sleep early, but are
easily awakened, and may remain sleepless till morning, or at least a part
of the night.
The night watchers have responsible, arduous, and trying duties.
Attendants should always, during the night, quickly respond whenever a
demand is made upon them for assistance, though an unnecessary call
should never be made. The night watchers should be informed of any changes
that have occurred during the day, that will require their attention
during the night; they should see new patients and be made acquainted with
their peculiarities; they should visit the wards during the evening before
they come to the medical office to receive instructions from the
physicians.
It is the duty of a night watch to visit regularly all the wards under his
charge; to see and know the condition of the sick, the helpless, feeble,
the suicidal, and the epileptic; to attend to, by taking up, those who are
inclined to be filthy, and wash those who need it, and make them, their
beds, and rooms perfectly clean. He should observe the conduct of new
patients, be watchful of the violent, know how much wakeful patients
sleep, visit all associated dormitories, wait upon all those who need
attention, and guard against fire and accident. The night watch should
place each day on the medical office table, a detailed account of every
patient that needed care or attention, who was disturbed, or did not sleep
during the previous night.
Patients should be left clean for the night watch, who should leave them
in as good condition in the morning, for the day attendants, and any
neglect in these directions should be reported by either party. Sick
patients frequently have to receive special night service, to be watched,
and given food and medicine. When this cannot be done by the night watch,
it devolves upon the day attendants, and is a duty that should be
cheerfully rendered.
During the night, any accident, attempt at suicide or to escape, or
unusual violence, persistent sleeplessness, or being out of bed, a serious
sickness or change for the worse, or the approach of death, should be
reported to the physician. It is, in many institutions, the duty of the
night watch to report any neglect or misconduct on the part of an
attendant or employe, and it is something that should be faithfully and
impartially done.
Having briefly sketched the general duties of an attendant, it seems best
to again remind them, that an asylum is built and maintained for no other
purpose than for caring for the insane; that each patient is entitled to
the best our means can afford; that while the attendants are not
responsible for the medical treatment, they are for that kind and
intelligent care it is within their province to give; and they are also
reminded that, so far as it can be done, such personal attention is to be
given to each patient as will assist in recovery or improvement, or
promote his well-being.