THE CARE OF THE VIOLENT INSANE.
A careful study of each violent patient, of his habits, delusions, and
hallucinations, of his peculiar manner of showing violence, and a
knowledge of what is likely to provoke outbursts is necessary to properly
care for him. An attendant's ability to successfully manage a ward full of
patients will depend largely upon the study given to, and the thorough
understanding of, each case. Such study will soon teach him that every
violent patient has peculiar and pretty constant ways of showing and
exercising violence, and that the same rule of individuality holds good
among this, as it does among other classes of the insane.
Having learned what will cause violence, it can often be avoided by
removing the cause; having learned the symptoms that precede a patient's
outbursts of violence, they can sometimes be averted, or preparations made
to control them; having learned in what direction violence is shown, how
sudden, blind, or furious it may be, or how slow, deliberate, and planned,
the attendant is better able to meet, manage, and control it.
Few patients are so continuously and furiously violent as to need constant
repression, and the directions how to care for such patients can always be
given by the physician. Most violent patients are subject to the firm,
kind control of attendants, and can be kept sufficiently quiet and
orderly; they should never be left alone, and mops, pails, brooms,
chambers, and all other articles, that may become weapons should not be
left within reach. Strong comfortable clothing can generally be kept on
the most violent and destructive, with care and attention from attendants,
but not without.
Many violent patients will employ themselves and be the quieter for so
doing. Light out-of-door work is the best employment for this class, and
out-of-door walking and exercise should never be neglected. On the woman's
ward knitting, sewing, mending, and ward work are suitable for many, while
some will work at the laundry, and others will go quietly to church and
entertainment; books and illustrated papers should be furnished and will
be much read and enjoyed.
As a rule the more violent patients are restricted, kept continuously on
the ward, or in a small room, and given no work, amusements, walks, and
exercise, the more noisy and violent do they become.
Attendants must learn that mere noise, and much of maniacal activity, such
as running about, jumping, or pounding, is not in itself harmful, and that
unless such patients are doing themselves injury, or so disturbing the
ward and other patients as to require interference, it is better to
control than to repress and restrict them.
Many violent patients are subject to such paroxysms of great violence as
to require immediate care and often temporary control at the hands of
attendants. Generally these paroxysms spend themselves after a short
time, but if they do not, advice and help can be called for.
By careful watching, the approach of these paroxysms can be known and
often avoided. This may be done by removing the cause, which is often the
irritation of another patient or an attendant, by a word, a joke, by
simply letting the patient alone, or by a firm show of authority, or by
any other means experience has taught to be useful in the particular case.
If necessary to hold a patient, three persons should be able to care for
the most violent. This can be done by grasping each arm at the wrist and
elbow, and holding it out straight, the attendants standing behind while
another passes the arm about the neck and holds the chin, to prevent
biting and spitting; the patient may then be walked backward and seated in
a chair.
After the violence has subsided, though the patient should continue to
scold, swear, threaten, or cry, he should, as soon as possible, be left
alone, the attendants walking away, but remaining watchful. Do not, unless
it is necessary, interfere to stop the noise, for it is often a substitute
for the violence, and the attack wears itself out in this way.
If necessary to carry a violent patient, it can be done by four or six
attendants. The face should be turned downward, thereby lessening the
power to resist, and, to prevent dislocating the arms, the patient should
be carried by the shoulders and chest; the bands about the neck should be
loosened.
In using force in the care of violent patients, it should always be done
as gently as possible, and struggling should be avoided; he should never
be choked or kicked, receive a blow, or be knocked down; the arms should
never be twisted, nor a towel held over the mouth, but if the patient
persists in spitting it may be held in front of the face.
Care must always be used not to injure a patient while exercising
necessary control. In the violence of a patient innocent injuries are
sometimes received. The attendant is excusable if he can show that he used
necessary force only, without malice.
A violent patient should never be struggled with alone, and on a
well-managed ward help will always be within call. It may be necessary,
however, to break this rule in order to prevent homicide or suicide, or
serious injury to another patient, or setting the house on fire.
It is better not to visit the room of a violent patient alone, and if an
attack is feared, especially with a weapon, the door should be slowly
opened, and held so it can be quickly closed. The patient usually makes an
immediate attack, and, before he has recovered for a second, can generally
be disarmed and controlled.
Violence usually consists of noise, tearing the clothing, breaking glass
or furniture, biting, scratching, striking, hair pulling, kicking, or
attacking others with weapons. It is sometimes secretly and deliberately
planned and skilfully executed, though generally without reasoning or
direction, but blind and fierce.
The care of the violent insane involves the careful study of each case,
with constant watchfulness, and the exercise of a control that is kind,
but firm and unyielding, that does not repress except when necessary, nor
restrict without reason, that indulges whenever possible, that never
drives, scolds, or threatens, but influences, guides, and directs. The
greatest liberty possible should be allowed, and self-control encouraged,
and work, occupation, and amusement should be furnished. An attendant must
always remember that fear is the lowest motive to govern by, and that
kindness will often be appreciated and returned.
_Care of the Destructive Patients._--Besides the violently destructive
patients, there are some who are maliciously destructive, and who exercise
all their ingenuity to escape the watchfulness of the attendants; who
glory in their wrong-doing; who openly say they cannot be punished, and
exultantly tell the physician how they have outwitted the attendant, or
proclaim before him his shortcomings and neglect. Such patients will
destroy their own or others clothing, they will steal and hide, or throw
it out the window or down the water-closet, or erase the name by which it
is marked. They will destroy bedding, windows, crockery, pictures, or
furniture. With a pin, a nail, or a bit of glass or wood, they will mar
and deface their room or the ward, and often do damage that cannot be
repaired. The only way to meet such cases is by watchfulness. They should
be kept, if possible, at work, or at least with a company of workers, and
therefore under constant observation. When put to bed their clothing,
mouth, hair, and person should be thoroughly searched. Kindness often has
but little effect, but a threat is apt to make them more determined to
destroy.
_The Care of Patients by Mechanical Restraint and Seclusion._--All the
restriction of an asylum is restraint. The locking of bedroom doors at
night is very restricted restraint. Most patients in an asylum have a
feeling that they are under great compulsion and restraint, in being
deprived of their liberty. It has already been taught that patients are to
be given all the liberty possible, that restraint over their freedom is to
be exercised no more than is absolutely necessary, and that the greatest
good of the patients alone is to be thought of.
These teachings are equally true of special forms of restraint. If used at
all they are to be used for the good of the patient alone, and an
attendant should be able to care for any case without restraint.
Restraining apparatus should never be kept on the ward. An attendant
should never ask that it be used, nor say he cannot get along without it.
If ordered by the physician it is the attendant's duty to see that it is
so applied as to do no injury, that it does not bind or tie the patient
down, that it does not irritate and make the skin sore, nor restrict the
free movement of the limbs.
Patients who are restrained are not to be further confined to a chair
without specific order. Restraint used during the day is not, unless so
ordered, to be continued at night nor reapplied the next day. Patients are
to be taken frequently to the closet. Restraint should be taken off
several times a day, and kept off long enough to give relief to any
feeling of discomfort, and free movement should be allowed. When patients
are restrained they need unusual care and watching, and should never be
left alone.
The attendant should be informed why restraint is used, and what is hoped
to be gained by its use. He should closely observe the effect upon the
patient and compare his condition with what it is when not restrained. The
result of these observations should be reported.
Thus used, an attendant will soon learn that it is not the easiest way to
care for a patient, that its use involves increased watchfulness and care,
and greater discretion, and that it is strictly a form of medical
treatment. It is a harsh remedy at its best, and needs to be used with
kindness, intelligence, and judgment, and it is to be applied but for one
purpose, namely, that the patient may be benefited.
_The Use of the Covered Bed._--Like restraint it is never to be used
except by the orders of a physician, nor is its use to be repeated without
special orders; it is always to be considered a method of treatment and
something the attendant has no interest in, except to know how best to use
it when ordered to do so.
When in a covered bed the patient should be frequently visited; he should
be taken up at least once in three hours, unless asleep; the bed and the
patient should be kept perfectly clean. If used in the daytime an
attendant should sit beside the patient for some hours and try to keep him
quietly in bed, and the same should be done in the evening when the
patient is put to bed. An attendant should be able to report how much the
patient sleeps, how much quiet and rest is obtained, the effect of the
treatment, and compare the condition of the patient when in the bed with
what it is when not used.
_The Use of Seclusion._--Seclusion is shutting a patient alone in a room
in the daytime. If allowed to be done without orders from the physician
it should be immediately reported. If ordered to be continued the patient
should be seen at least once in fifteen minutes, while many need to be
seen once in five minutes, and an attendant should never be far from the
door. The patient should be frequently taken to the closet. The effect and
result of seclusion should be observed and reported.
Many physicians never use any form of restraint, while others make
considerable use of it as a means of treatment. An attendant should be
able to successfully care for any case, so as to meet the wishes and
directions of the physician, and only as he is able to do this can he give
the patient the highest standard of attention, care, and nursing.