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.