,,how ,,to ,,care ,,for ,,the ,,insane ,a ,,manual ,,for ,,nurses ,,by ,,william ,d4 ,,granger1 ,m4,d4 ,,proprietor-,,physician1 ,,vernon ,,house1 ,,mt4 ,,vernon1 ,n4 ,y4 ,,formerly ,,first ,,assistant ,,physician ,,buffalo ,,state ,,hospital1 ,,buffalo1 ,n4 ,y4 ,,member ,,american ,,association ,,of ,,superintendents ,,of ,,hospitals ,,for ,,the ,,insane4 ,,member ,,new ,,york ,,neurological ,,society4 ,,second ,,edition4 ,,revised4 ,g4 ,p4 ,,putnam',s ,,sons ,,new ,,york #bg ,,west ,,twenty-,,third ,,st4 ,,london #bg ,,king ,,william ,,st41 ,,strand ,the ,knickerbocker ,press #ahia ,,copyright ,g4 ,p4 ,,putnam',s ,,sons #ahhf ,press of ,g4 ,p4 ,,putnam',s ,,sons ,new ,york ,,note ,,to ,,second ,,edition4 ,at the time of starting a training school1 in #ahhc1 the author was unaware that like work was commencing at the ,mc,lean ,asylum1 ,somerville1 ,mass41 by ,dr4 ,campbell ,clark and others in ,scotland1 and in ,new ,south ,wales4 ,each was independent1 and each worked out the problem independently4 ,thus1 far separated efforts showed the time had come when attendants must be evolved into trained nurses4 ,the most gratifying feature has been the unanimous approval by ,american superintendents and the establishment of training schools in almost every asylum in the land1 often under the most difficult conditions and at a great sacrifice of the precious time and strength of the medical staff4 ,the increasing number of these schools and pupils demands a second edition of this little manual4 ,,vernon ,,house1 ,,mt4 ,,vernon1 ,n4 ,y41 ,march #ba1 #ahia4 ,,introduction4 ,the writer began in ,october1 #ahhc1 at the ,buffalo ,state ,asylum for the ,insane1 a course of instruction to the women attendants upon their duties and how best to care for their patients4 ,this has been regularly continued till it has become a fixed part of the asylum life1 and has developed into a system of training1 and now a class of attendants has nearly completed its studies4 ,since ,july1 #ahhe1 instruction has been given to men attendants4 ,in ,april1 #ahhe1 the ,superintendent1 ,dr4 ,j4 ,b4 ,andrews1 who had encouraged the school from its conception1 asked the ,board of ,managers to officially recognize it4 ,they adopted the recommendation and fixed the qualifications for admission1 the pay and privileges of its members1 and provided for a certificate as a trained nurse and an attendant upon the insane1 to be given to all1 who at the end of two years successfully finished the full course of instruction4 ,the writer believes that all attendants should be regularly instructed in their duties1 and the highest standard of care can be reached only when this is done4 ,he also believes that every person who is allowed to care for the insane will be greatly benefited by such instruction1 and will be able to learn every thing taught1 if the teacher uses simple methods and is patient to instruct4 ,as a rule they enter upon the study with interest1 and soon a skilled corps is formed1 who are competent to fill the responsible positions1 and control the unstable class that drift in and out of an asylum4 ,even the dullest are awakened to new zeal1 and are advanced to positions of trust they could not otherwise have filled4 ,a brief outline of the course of instruction of the school may be of interest4 ,the first year is spent in learning the routine of ward work and filling minor positions4 ,the attendants are changed from ward to ward1 and have the care of all classes of the insane4 ,they first receive instruction in the printed rules of the asylum4 ,every rule relating to the duties of attendants is read and explained1 and special attention is called to the performance of the following duties3 a4 ,duties to officers4 b4 ,duties to each other4 c4 ,duties to patients4 d4 ,duties to the institution4 ,thus the new attendants early get an outline of their duties in the special care of the insane4 ,after this comes instruction in elementary anatomy and physiology4 ,they are taught of the bones1 joints1 muscles1 and organs of the body1 food and digestion1 the circulation and respiration1 waste and repair1 animal heat1 and the nervous system4 ,in order to be ready for advanced instruction the elements of physiology must be thoroughly learned4 ,the teaching must be adapted to the ability and wants of those instructed4 ,having fixed the limit of duties required of an attendant1 it is easy to fix the limit of instruction4 ,it is an error to teach too much medicine1 for then we begin to make physicians4 ,all that is needed is attendants who are able to do their work intelligently1 and1 keeping this object in mind1 lectures by a physician1 devoid of too much detail1 but simple1 direct1 and plain1 are better than instruction from any of the text-books4 ,with notes of the lectures furnished1 and with repeated recitations1 any lesson is readily learned4 ,this way of instructing1 by lectures1 notes1 and recitations1 is continued throughout the entire two years4 ,a course in hygiene follows the lectures in physiology4 ,instruction in these three studies occupies the first year4 ,an attendant who1 at the end of this time1 successfully passes an examination in them1 and who has been faithful in his duties1 is ready to receive the advanced instruction of the second year4 ,this includes the nursing of the sick1 the management of emergencies1 and finally the special work of caring for the insane4 ,the wits of an attendant upon the insane have to be sharpened in many directions not required of a general nurse4 ,the text-books on nursing may properly be followed by another1 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 asylum4 ,to furnish this is the object of this manual4 ,a brief review of the physiology of the nervous system is introduced for the aid of students1 in reading the chapters on the mind and insanity4 ,to teach any thing metaphysical or pathological may seem questionable4 ,the class1 however1 has not only been interested in the simple study of the phenomena of the mind1 but has been able to comprehend and profit by the lectures on this subject4 ,the lectures on the care of the insane were given to the class almost as they appear in these pages4 ,the suggestion was made that if they were printed they would find a place in the hands of attendants in other asylums4 ,this is the reason of their publication4 ,to my colleague1 ,dr4 ,a4 ,w4 ,hurd1 ,i wish to tender my thanks for the valuable assistance he has given me in the preparation of this manual4 ,i am greatly indebted to ,dr4 ,andrews for his ever kind but critical advice4 ,but for his encouragement and help neither the work of instruction nor the preparation of these pages would have been begun1 nor success1 if success be gained1 achieved4 ,,contents4 ,,page ,,introduction v ,,chapter ,i4 ,,the ,,nervous ,,system ,,and ,,some ,,of ,,its ,,more ,,important ,,functions #a ,nerve ,centres4--,brain and ,spinal ,cord4--,the ,nerves4--,nerve ,cells and ,fibres4--,motor and ,sensory ,nerves4--,the ,five ,organs of ,special ,sense4--,nerve ,impulses4--,the ,brain and ,nervous ,system ,always ,busy4--,need of ,rest4 ,,chapter ,,ii4 ,,the ,,mind ,,and ,,some ,,of ,,its ,,faculties #g ,mind and ,matter4--,life4--,relation of ,mind and ,brain4-- ,faculties of the ,mind4--,intellectual ,faculties4--,will4-- ,emotions4--,instincts4--,moral ,faculties4 ,,chapter ,,iii4 ,,insanity2 ,,or1 ,,disease ,,of ,,the ,,mind #ac ,insanity a ,change4--,involves ,disease of the ,brain4-- ,delusions4--,hallucinations4--,illusion s4--,incoherence4-- ,mental ,states4--,mania4--,melancholia4--,demen tia4-- ,monomania4--,emotional ,insanity4--,dipsomania4--,moral ,insanity4 ,,chapter ,,iv4 ,,the ,,duties ,,of ,,an ,,attendant #bb ,what an ,attendant ,should ,first ,learn4--,the ,relation of ,attendants to ,patients4--,the ,character of an ,attendant4-- ,relation to the ,institution4--,how and ,what to ,observe4-- ,systematized ,plan of ,observation4--,control and ,influence of ,attendants over ,patients4--,care and ,study of the ,individual4--,liberty to be ,allowed ,patients4--,self-,control of ,patients to be ,encouraged4 ,,chapter ,v4 ,,general ,,care ,,of ,,the ,,insane #cc ,reception of ,new ,patients4--,work and ,employment4--,patients' ,care of ,themselves4--,walking4--,clothing4--,ba thing4--,serving of ,food4--,bed and ,rising ,time4--,night ,care4 ,,chapter ,,vi4 ,,care ,,of ,,the ,,violent ,,insane #de ,need of ,studying ,each ,case4--,constant ,attention and ,oversight4--,value of ,employment and ,out-,door ,exercise4-- ,restriction and ,idleness4--,paroxysms of ,violence2 ,how ,cared ,for4--,how to ,hold or ,carry a ,patient4--,danger of ,injury4-- ,struggles to be ,avoided4--,care of ,destructive ,patients4-- ,use of ,restraint1 ,seclusion1 and ,covered ,bed4 ,,chapter ,,vii4 ,,care ,,of ,,the ,,homicidal ,,and ,,suicidal ,,insane1 ,,and ,,of ,,those ,,inclined ,,to ,,acts ,,of ,,violence #ec ,delusions of ,suspicion4--,homicidal ,patients4--,suicidal ,patients4--,self-,mutilation4--,incendi ary ,patients4 ,,chapter ,,viii4 ,,care ,,of ,,some ,,of ,,the ,,common ,,mental ,,states ,,and ,,the ,,accompanying ,,bodily ,,conditions #fj ,care in the ,earlier ,stages4--,insanity with ,exhaustion4-- ,symptoms of ,danger4--,care of ,dementia1 ,early ,dementia1 ,chronic or ,terminal ,dementia4--,convalescence4--,relapse4-- ,epilepsy4--,paresis4--,care of ,paralytics1 the ,helpless1 the ,bed-ridden4--,bed-,sores4 ,,chapter ,,ix4 ,,some ,,of ,,the ,,common ,,accidents ,,among ,,the ,,insane1 ,,and ,,the ,,treatment ,,of ,,emergencies #ga ,certain ,classes of ,insane ,liable to ,injury4--,fractures4-- ,wounds4--,bites4--,blows on the ,head--,cut ,throat4--,wounds of the ,extremities with ,hemorrhage4--,sprains4--,choking4-- ,artificial ,respiration4--,burns4--,frost-bites4--, states of ,unconsciousness4--,apoplexy4--,sunstrok e4--,poisoning4--,eating ,glass4--,injury with ,needles4 ,,chapter ,x4 ,,some ,,services ,,frequently ,,demanded ,,of ,,attendants ,,and ,,how ,,to ,,do ,,them #he ,administration and ,effects of ,medicine4--,opium1 ,chloral1 ,hyoscine1 and ,hyoscyamine2 ,doses1 ,effects1 ,poisoning1 ,treatment4--,stimulants4--,applications of ,heat and ,cold4-- ,baths and ,wet ,packing4--,hypodermic ,injections4--,forcible ,feeding with ,stomach-,tube4--,nutritive ,enemata4 ,,how ,,to ,,care ,,for ,,the ,,insane4 ,,chapter ,i4 ,,the ,,nervous ,,system ,,and ,,some ,,of ,,its ,,more ,,important ,,functions4 ,the nervous system is made up of a nerve centre and nerves4 ,the great nerve centre is the ,brain and ,spinal ,cord4 ,the brain is a body weighing about forty ounces1 and fills a cavity in the upper part of the skull4 ,the spinal cord1 commonly called spinal marrow1 is directly connected with the brain4 ,the skull rests upon the spinal column1 or backbone1 and there is a cavity inside the whole length of this column1 which contains the cord4 ,there is an opening through the base of the skull where it rests upon the spinal column1 and it is through this opening that the fibres of the cord go1 to pass into and become a part of the brain4 ,these most important parts are carefully protected by a strong bony covering4 ,many nerves are given off from the brain and cord and go practically everywhere1 so that every part of the body is supplied with them4 ,these nerves are white cords of different sizes2 the largest nerve of the body1 the one that goes to the leg1 called the sciatic1 is as large as the little finger4 ,there are really two brains and two cords1 as along the central line of the body there is a division of the brain and cord1 making two halves exactly alike4 ,these halves are connected together1 the division not being complete4 ,nerves are given off in pairs2 for example1 from either side of the brain arises a nerve that goes to each eye4 ,so two nerves exactly alike spring from the two sides of the spinal cord1 going to each arm4 ,a nerve is composed of a bundle of fibres1 microscopic in size4 ,as a nerve passes to the extremities it divides by branching much as does an artery1 and thus a bundle of fibres is distributed to a muscle1 or a part of the skin1 or to an organ1 and every part of the body has a direct nerve supply1 much as you saw in the microscope it was supplied with blood by means of the capillaries4 ,we cannot prick our finger with the finest needle but nerve1 fibres are irritated1 and we feel it1 and capillaries are injured and we get a drop of blood4 ,most of the nerves that go to the arms1 legs1 and organs of the chest and abdomen1 arise in and proceed from the spinal cord1 but some of the fibres begin in the brain and are continued down the cord1 where1 joining with fibres that originate in the cord itself1 both go to make up the nerve1 thus connecting all parts of the body with the great centre4 ,the brain and cord are made up of blood-vessels1 nerve cells1 nerve fibres1 and1 holding them all together1 connective tissue4 ,the cells are very small1 being microscopic in size2 there are an immense number of them1 and they make up most of the gray matter or outside of the brain1 but in the spinal cord the gray matter is in the centre4 ,the fibres that go to make up the nerves begin and spring from the cells1 and they also unite them together4 ,the cells are gathered into groups1 which have each a separate function to perform4 ,there is a group from which the nerve of the eye proceeds2 another for the nerve that goes to the ear2 another for the nerve that goes to the arm2 and another for the nerve of the heart4 ,there is a group that presides over speech1 and other groups that preside over mental action1 while all of these are connected together by fibres4 ,thus it appears that the brain is a true centre1 and the nerves but the means of connection between different parts of the body and the brain1 and also between different parts of the brain4 ,nerves have two special functions3 one to carry impressions made upon the fibres1 that end in the different parts and organs of the body1 to the brain2 another to carry from the nerve cells so-called nerve impulses1 to the different parts and organs of the body4 ,some nerves have in themselves these two functions1 as the nerves that go to the arm or leg2 others have but one1 as the optic or eye nerve1 which can only carry the sensation of sight from the eye to the brain4 ,the nerves that carry sensations to the brain are called ,sensory ,nerves4 ,the nerves that carry motor impulses from the brain are called ,motor ,nerves4 ,there are five special organs of sense1 each receiving different impressions1 and sending by its sensory nerve or nerves a different character of sensation to the brain1 namely3 ,the eye1 giving sensations of light and color4 ,the ear1 giving sensations of sound4 ,the nose1 giving sensations of smell4 ,the mouth1 giving sensations of taste4 ,the skin1 giving sensations of touch1 with ideas of roughness1 smoothness1 hardness1 softness1 heat1 and cold4 ,there must be1 in every case1 a direct nerve connection from the organ of special sense to the special group of cells in the brain to which the nerve goes4 ,if the connection is broken at any point1 the impression made upon the fibres in the organ of sense cannot reach the brain4 ,only after the impression reaches the brain and the cells are affected1 do we become conscious of a sensation4 ,we then say1 as the case may be1 ,i see1 or hear1 or smell1 or taste1 or feel something4 ,it thus appears that these organs of sense simply receive the impressions made upon them to transmit to the brain1 and it is really the brain that sees1 hears1 smells1 tastes1 and feels4 ,by the action of the organs and nerves of special sense we get all our knowledge of the external world1 and1 probably1 if we had no organs of sense1 we would have no consciousness of our existence4 ,pain is due to abnormal action of sensory nerves1 caused by disease1 injury1 or pressure1 and the irritation made1 being carried to the brain makes us conscious of the peculiar sensation we call pain4 ,so the want of food or water makes an impression upon nerves1 which being carried to the brain causes a peculiar sensation1 and we say we feel hungry or thirsty4 ,the ,motor ,nerves arise in the cells of the brain and cord4 ,those which go to the voluntary muscles cause them to contract1 and are under the control of the will4 ,if the cells are diseased1 if they do not get enough arterial blood1 or are poisoned by carbonic acid1 or if the nerves are diseased1 injured1 or cut1 so that nerve impulses cannot be sent from the brain to the muscles1 we have paralysis of a muscle or a group of muscles1 according to the extent of the injury4 ,now we can appreciate the force of this teaching in the physiology of the muscular system1 that paralysis is a loss of power1 either partial or complete1 to contract muscles1 due to disease of the nerves4 ,by the ready action of our mind1 the quick working of our will1 we direct and control the action of our muscles1 so as to perform with the utmost skill and ease the varied and innumerable movements of our body4 ,it seems very easy to do this1 but watch a child learning to walk2 it is educating its mind and will to control the muscles1 and it is a slow and difficult education4 ,but all motor impulses and bodily activities are not under the control of the will4 ,the heart is supplied with motor nerves1 but we cannot by our will stop its beating or control its action4 ,the taking of food makes a mental impression1 and without the will being involved1 impulses are sent to the glands of the mouth1 setting them actively at work1 and saliva flows4 ,so the stomach begins to churn food when it is introduced1 and the liver is kept at work making bile and sugar1 and we breathe when we are asleep4 ,all the organs of the body are supplied with motor nerves1 that regulate their action and give them the power to do their function or work1 but with the exception of the muscles1 this power is sent without the action of the will4 ,our brains are very busy4 ,while we are awake we are constantly receiving sensations1 we are thinking1 remembering1 willing1 and sending many messages every minute1 and directing power to all parts of the body4 ,the brain works and gets tired1 just as the rest of the body gets tired1 and1 if abused1 injured1 or overworked1 may become diseased as may any part4 ,its tissues wear out1 are burned up1 and require the same supply of material to repair them that any other part of the body requires4 ,it needs then rest1 good food1 good blood1 and plenty of oxygen4 ,no wonder some brains give out1 and fail to do their work properly1 and so cause insanity4 ,,chapter ,,ii4 ,,the ,,mind ,,and ,,some ,,of ,,its ,,faculties4 ,we know there is something we call mind1 because we know something of its way of working1 or its faculties4 ,what mind is we do not know1 but we know it is not matter1 because matter is something that occupies space1 and has qualities that do not belong to mind4 ,we say of mind1 it reasons1 remembers1 or wills2 of matter1 that it is hard or soft1 or cold or elastic1 or that it has color2 speaking always of the faculties of mind or what it does1 and of the qualities of matter1 or what it is4 ,we do not know what matter is1 only how it appears to us2 we know it is not mind because mind is something spiritual1 and possessed of faculties or powers that do not belong to matter4 ,mind and ,matter are the only forms of existence of which we have any knowledge4 ,we speak of matter as inorganic--that is1 without life1 as iron1 water1 oxygen2 and as organic1 or matter plus something we call life4 ,life appears in two forms1 namely1 vegetable and animal4 ,the lowest forms of animal life have no nervous system1 but as we ascend in the scale the nervous system appears1 and becomes more and more complete4 ,man possesses the most perfect nervous system1 has the most perfect brain1 and also an intelligence far above that of any other animal1 and is endowed with some mental faculties that belong to him alone4 ,the brain may be said to be the organ of the mind1 but we do not know what is the true relation between them2 that is1 how the brain is acted upon by the mind1 or how the action of the mind affects the brain4 ,brain is matter1 and very solid matter as well1 mind is immaterial1 or spiritual1 and the exact connection between something material and something spiritual has never been made out and never will be4 ,some say the brain makes mind a good deal as liver makes bile1 or the glands of the mouth make saliva1 or the cells of the brain make motor impulses1 and if the brain does not act there is no mind made2 so much cell action1 so much memory1 reason1 or will produced4 ,but how1 it is immediately asked1 is something material to make something immaterial8 ,others say that mind is something1 and has an existence of its own1 and1 though spiritual1 acts upon its organ1 the brain1 and by so doing1 we are conscious that we see1 reason1 remember1 and will4 ,but how1 it is immediately asked1 does something immaterial act upon something material8 ,we do not know1 and we probably never shall know4 ,this intimate connection between mind and matter exists during life only2 it begins with life and ends with life4 ,we must then come back to the starting-point--there are two forms of existence1 mind and matter4 ,we do not know what either really is1 but only the faculties or working of our minds1 and the qualities or appearance of matter4 ,mind thinks or remembers1 reasons or wills1 but these are faculties of the mind2 it is what the mind does1 not mind itself4 ,gold is yellow1 but yellow is not gold2 gold is hard1 but hardness is not gold2 these are qualities of gold1 and not gold itself4 ,in the study of physiology you found the body divided into many parts1 and that these parts had each a separate function or duty to perform4 ,in the study of the mind1 we find it has many different faculties or ways of working4 ,we did not study all the functions of the body1 so we will not study all the faculties of the mind4 ,the mind is very complicated in its action1 and difficult to understand4 ,men study it all their lives and are not agreed about some of its simple manifestations1 and argue and even contend about their differences4 ,there are1 however1 some seemingly natural divisions of the faculties of the mind1 and a knowledge of these is sufficient for our purposes4 ,we may say of the mind that it possesses3 a4 ,intellectual faculties4 b4 ,will4 c4 ,emotions or feelings4 d4 ,instincts4 e4 ,moral faculties or conscience4 ,the first three are commonly given as divisions of the mind2 the last two are included for convenience of teaching4 ,the ,intellectual ,faculties include those powers which in common language are called mind4 ,a few only will be considered--namely1 the perceptive faculty1 consciousness1 memory1 and reason4 ,the ,perceptive ,faculty is the power of the mind to perceive or know the sensations brought to the brain by the sensory nerves1 from the organs of sense1 and the action of this faculty gives us a knowledge of the existence and qualities of matter4 ,consciousness is that faculty by which we know we perceive1 reason1 remember1 will1 or possess emotions4 ,by its operation we know that we exist1 have a mind1 and what that mind does4 ,memory is that faculty by which we are able to recall to consciousness the knowledge we possess of past events4 ,reason is that faculty by which we are able to make use of what we know and to acquire new knowledge4 ,for instance1 ,i know the distance between two places is sixty miles1 and ,i know that the cars1 going between the places1 travel at the rate of twenty miles an hour1 and that they leave at four o'clock4 ,without reason1 ,i could never of myself1 know the two new facts1 that it would require three hours to make the journey1 and that the arrival will be at seven o'clock4 ,the faculty of reason is one of the most distinctive of the human mind4 ,the ,will4--,in consequence of our perceptions1 our consciousness1 our memory1 our reason1 we are in a condition to know a good deal of what is about us1 and of ourselves1 and we desire to bring ourselves into relation with the outside world1 and therefore we act4 ,there is a faculty of mind that allows us to choose how to act1 and this is called the will1 or that faculty of the mind by which we are capable of choosing4 ,by the action of the will1 we direct and control the voluntary muscles and motions of the body1 while the action of the mind is also largely under its control4 ,it may truly be said that unless we are under the compulsion of some physical force1 we always choose to do whatever we most wish to do4 ,this liberty of choosing is called freedom of the will1 and because we are free to choose1 we are responsible for the consequences of our choice4 ,we say1 in common language1 a person is responsible for what he does1 and both human and divine law holds each to a strict accountability for his conduct1 because all are free to choose how they will conduct themselves4 ,the ,emotions or ,feelings4--,the emotions are joy1 love1 grief1 hatred1 anger1 jealousy1 and other like conditions1 and we speak of them as natural1 because they appear without the operation of our intellect or will1 and the capacity for them seems to be a part of our existence4 ,they should1 however1 be under the control of reason and will1 and a person who gives way to his feelings1 as of jealousy1 and murders1 is held responsible by human and divine law4 ,but though we control them1 we cannot prevent their action1 and we must1 as long as we live1 feel love and joy1 be affected by grief1 suffer from anger1 or be jealous4 ,instincts4--,these belong largely to our animal nature2 our appetites and desires are instincts1 and we speak of them as natural4 ,children want food and drink before they know what it is they want1 and birds in the nest1 open their little mouths for the worm their mother brings them4 ,appetites indulged in become strong1 and are often uncontrolled by the reason and will2 as the indulged appetite for liquor4 ,a strong and healthy mind should control the appetites1 as we have learned it should control the emotions1 and we are justly held responsible for the consequences of an indulged appetite4 ,moral ,faculties4--,there exists in the mind of man a knowledge of right and wrong1 and a feeling of obligation to respect the rights of others4 ,we can hardly conceive of a man in his right mind who does not know it is wrong to lie1 or steal1 or murder4 ,the capacity to know right from wrong is called conscience4 ,most people1 perhaps all1 have a feeling of relation and obligation to a higher moral being than man4 ,the feeling to do right because it is pleasing to a ,god to whom we are directly responsible1 is the foundation of our religious convictions4 ,the mind is a most complex affair1 it is always active1 nor is one faculty at work and the rest idle1 but many parts are at work at the same time1 and act and react upon each other4 ,we may exercise our perceptive faculty1 or reason1 memory1 and will1 and be affected by our feelings at the same time4 ,there is with it all a regulating power that coordinates or brings these different actions into harmony1 and we get the working of a healthy mind4 ,,chapter ,,iii4 ,,insanity2 ,,or1 ,,disease ,,of ,,the ,,mind4 ,in common language we speak of the mind diseased4 ,this is not strictly true1 as it is the brain that is diseased and1 in consequence1 we get disturbed mental action4 ,every person has individual characteristics4 ,as no two faces are alike1 so the mind1 character1 and manner of no two are alike1 and it is by the manifestation of these1 that each is known4 ,when a person becomes insane there is always a change from his natural way of thinking1 feeling1 and acting1 due to disease of the brain4 ,sometimes the change is slight1 or concealed by the patient1 and is apparent only to near friends1 or after a careful examination4 ,sometimes it is so great as to attract immediate attention1 when it may present the features of raving madness1 or of the most abject melancholy4 ,to illustrate this change1 we may suppose both a king and a pauper to become insane3 there is1 of course1 a vast difference between them1 but the king may be so changed by the disease as to believe that he is a pauper1 and himself and his family starving1 and he may also wish and even try to work and dig like a laborer to support them2 or a pauper may think himself a king1 and try to act like one4 ,such conditions show a marked change in the manner of thinking1 feeling1 and acting1 which involves diseased action of the intellect1 the emotions1 and the will4 ,sometimes the appetites are also changed1 or control over them is lost1 and sometimes the moral nature is affected as well1 sometimes a single faculty of the mind appears more disturbed than do others2 it is1 however1 doubtful1 or at least denied1 that one faculty can show such disturbed mental action as to indicate insanity1 and the rest of the mind appear perfectly healthy and normal4 ,with the changes that have been spoken of1 there is generally disturbances of the physical health1 and often of a marked character4 ,it must be remembered that mere oddity of appearance or eccentricity of conduct1 however marked1 if natural1 do not of themselves constitute signs of insanity4 ,some ,mental ,symptoms of ,insanity4--,there are some important mental symptoms which quite generally accompany insanity1 and are found either alone or combined in the individual case4 ,these are3 a4 ,delusions4 b4 ,hallucinations4 c4 ,illusions4 d4 ,incoherence of speech4 ,delusions are false beliefs4 ,we think a belief in the religion of ,mahomet is a delusion1 but not an insane one4 ,insane delusions arise from disease of the brain1 and are a part of those mental changes that appear during its progress4 ,the king1 who1 under the influence of disease1 thinks himself a pauper and that he and his family are starving1 and the pauper1 who thinks himself a king1 with all the wealth and power of one1 have each insane delusions4 ,some delusions are fleeting and changeable1 lasting a few days1 weeks1 or months1 while others are fixed1 lasting a lifetime2 some are impossible and beyond rational belief1 as when a man thinks himself ,queen ,victoria1 or that his head is made of brass1 or that he is dead1 and yet sleeps and eats and talks2 other delusions are possible1 as when a king thinks himself a pauper1 because such a thing may and even has happened1 or when a pauper thinks himself a king1 because people of very low degree have risen to such a station1 but they are very improbable1 and we do not expect such things among ,americans1 much less among our patients4 ,other delusions are not only possible1 but relate to things that may or do happen1 or are within the bounds of a rational belief1 as that of a person who insists he has a cancer1 or that he has committed the unpardonable sin1 or that poverty is impending and the poorhouse not far off2 or that of a woman that she has been violated1 or that1 when her child was sick she so neglected it1 that it died4 ,such beliefs as these are delusions1 when they have no other reason for their existence than that they are caused by disease4 ,some delusions are called homicidal1 suicidal1 or dangerous1 because they cause a patient to do1 or want to do1 acts that are dangerous to himself or others1 or property4 ,hallucinations4--,when a patient has hallucinations1 he thinks he sees1 hears1 smells1 tastes1 or feels something1 when there is really nothing to cause the sensations or ideas except diseased action of the brain2 nothing being sent to the brain from any special organ of sense1 he really sees1 hears1 smells1 tastes1 or feels nothing1 it is all imagination1 though seemingly very real4 ,for instance1 a person thinks he hears a voice1 perhaps that of ,god1 or of some one who is dead1 or of an absent friend1 or thinks he sees these persons1 when there is nothing external to the brain to excite the sensation or give the idea4 ,illusions4--,when illusions are present1 the mind fails to perceive correctly what the eye sees1 or the ear hears1 or the impressions that are brought to the brain from any of the organs of sense4 ,for instance1 a person looks at a row of trees1 and they appear to him to be a row of soldiers2 or the whistle of a locomotive may be so changed as to seem to be the voice of ,god2 or the odor of a rose1 burning sulphur2 food may taste like poison1 or the hand of a friend feel like a piece of ice or a red-hot iron1 and is so believed to be4 ,these are deceptions of the senses4 ,in insanity1 the truth and existence of delusions1 hallucinations1 and illusions are fully believed in1 and the patient cannot be argued out of the belief1 however absurd or unreal it may be4 ,incoherence of ,speech4--,when a person is incoherent1 he rambles in talk2 there is little connection between different sentences1 or the sentence itself is meaningless1 being a mere jumble of words2 sometimes ideas come too rapidly into the mind1 and some new subject is begun and talked about before the first is finished2 sometimes the mind is slow1 and memory forgets what is being talked about4 ,general ,states of ,insanity4--,there are a few general mental states in insanity1 one of which being present gives the character and name to the disease4 ,these are3 a4 ,a state of exaltation of mind1 or mania4 b4 ,a state of depression of mind1 or melancholia4 c4 ,a state of enfeeblement of mind1 or dementia4 ,but one of these first two states of feeling can be present at the same time1 for a person cannot at any one moment be both exalted and depressed1 though he have mania to day1 and afterward be so changed in his feeling as to have melancholia to-morrow1 or next week1 or next month4 ,in a general way all disease is divided into acute and chronic forms4 ,an acute disease is one of recent origin1 and from which recovery is to be hoped for2 a chronic disease is prolonged and does not tend to recovery2 an acute disease may become chronic4 ,mania and melancholia are at first considered acute and curable1 but1 if recovery does not take place1 they pass into either chronic mania or chronic melancholia1 or1 if the mind is much enfeebled1 into a condition of dementia4 ,mania4--,in mania the mind is generally very active1 though lacking in control1 and is irregular and illogical in its action2 the patient talks rapidly1 and upon many subjects1 and is often incoherent1 or he laughs1 sings1 dances1 or cries1 perhaps in turn2 he is often irritable and unreasonable1 and perhaps threatening1 and becomes more violent if interfered with4 ,accompanying this mental excitement there is frequently persistent loss of sleep1 constant restlessness1 and great bodily activity1 and indifference to or refusal of food4 ,sometimes the brain excitement is so great that all self-control is lost1 and the patient becomes a raving maniac4 ,the delusions of mania are largely of grandeur and self-exaltation2 the patient thinks himself in the best of health1 and very strong1 or of a superior mind1 or1 that he is a great singer1 poet1 actor1 or preacher2 perhaps1 taking a higher flight1 he thinks himself possessed of the wealth of ,vanderbilt1 or that he is the ,pope1 or the ,president1 or even ,god himself4 ,sometimes the excitement comes on in paroxysms1 lasting a few days or weeks1 with periods1 more or less prolonged1 of comparative mental quiet4 ,melancholia4--,in melancholia the expression of the face often tells the character of the disease2 the eyes are downcast1 the lines of the face are lengthened1 and the whole appearance is that of unhappiness4 ,in this form of insanity the patient may refuse to speak or interest himself in any thing1 or he may moan1 groan and cry1 and walk back and forth wringing his hands2 when he is quiet1 the mind1 however1 may be very active and full of delusions1 which occupy it to the exclusion of every thing1 driving away sleep1 and making him indifferent to the taking of food or attending to his most necessary wants2 sometimes the patient talks a great deal1 but always about his delusions1 which are generally connected with himself1 his family1 or his affairs4 ,melancholiacs are often tortured by fears1 and1 therefore1 become frenzied and as wild and violent as in mania2 or they may be very suspicious1 thinking that some one is persecuting them1 or poisoning their food1 or following to kill them4 ,on account of their delusions they frequently refuse food1 they generally sleep poorly1 and are often very suicidal4 ,dementia4--,this form of insanity is most frequently the result of acute mania or melancholia1 and comes after the force and intensity of the disease has spent itself1 leaving the mind crippled and weakened4 ,the perceptions are blunted and distorted1 memory fails1 the reasoning powers are weakened1 the will has ceased to control1 the emotions and appetites are dormant or changed1 and the mind may become almost a blank1 though in the narrow circle of thought there is left remains of delusions1 illusions1 and hallucinations4 ,the patient is frequently careless of the ordinary necessities and decencies of life1 and requires constant care4 ,there are degrees of dementia3 it may be slight1 partial1 or nearly complete4 ,during the first few months or years dementia often ends in recovery1 but1 as it continues1 the case becomes more and more hopeless4 ,monomania4--,this is a term belonging to common speech1 but there is not an agreement of opinion as to the existence of such a special form of insanity1 nor among those who believe in it1 as to what it is and what are its symptoms4 ,monomania really means an insanity with but one1 or1 at most1 a small class of delusions of the same character1 the rest of the mind showing no disease4 ,hardly any one believes in the existence of such a narrow limit to insanity1 and1 getting beyond this point1 there is no agreement where the limit should be set up to mark and bound it4 ,some think there is a special insanity of the emotions only1 and call it emotional insanity4 ,there is not an agreement of opinion as to what emotional insanity is2 the idea seems to be that the emotions1 or one of them1 so overpower reason and will as to make the person irresponsible4 ,this condition is supposed to exist without disturbances of the intellectual faculties1 and to be unaccompanied by delusions1 hallucinations1 or illusions4 ,others see in these cases no evidence of insanity2 nothing but over-indulgence of the emotions1 or a want of exercise of self-control1 or an excuse for crime4 ,some persons believe that the appetites over-indulged become morbid and produce disease of the nervous system1 and as a consequence the reason and will are weakened in relation to this indulged appetite1 and the opinion is reached that it is a form of insanity4 ,an indulged appetite for drink is called dipsomania4 ,others believe that unless there are present the usual symptoms1 associated as they generally appear in insanity1 these cases are nothing but unbridled appetites or vices4 ,moral ,insanity4--,there are those who claim that the moral nature alone may be diseased1 and the persons in whom this occurs are said to lose the appreciation of right and wrong1 or have an uncontrollable propensity to do some wrong act1 and take a peculiar pleasure in so doing4 ,special names are given to these acts1 according to their character1 as kleptomania1 an impulse that prompts to steal2 or pyromania1 love of setting things on fire2 or homicidal mania1 an intense desire to kill4 ,other persons considering these cases and finding no delusions1 or intellectual disturbances1 or change in feeling1 thinking1 or acting due to disease1 call the condition one of crime only4 ,these are difficult matters to understand1 and those who make a life-study of insanity do not fully understand them1 or agree together as to what they know4 ,they are1 however1 terms of common speech1 and it is well to have some idea of them1 as it will add interest to the study of the patients under care and charge4 ,,chapter ,,iv4 ,,the ,,duties ,,of ,,an ,,attendant4 ,what an ,attendant ,should ,first ,learn4--,the duties of an attendant upon the insane are varied1 arduous1 and exacting2 they are associated with irritations1 perplexities1 and anxieties1 bring grave responsibilities1 and call for the exercise of tact1 judgment1 and self-control4 ,these many duties are not quickly nor easily learned1 and the new attendant must be willing to fill1 at first1 a minor position1 to begin at the beginning and learn gradually all the details of ward work2 he must acquire habits of caution and watchfulness1 and learn in a general way the care of the insane1 before he can assume a position of authority over other attendants1 the control of a ward1 and the responsibility of the direct care of patients4 ,this last duty is the most difficult of all1 because it brings the attendant into intimate relations with a class of persons1 whose true appreciation of themselves1 of their conditions and surroundings1 is changed1 whose thoughts and desires are unreasonable1 whose conduct is unnatural1 and who are largely controlled by insane delusions1 hallucinations1 and illusions4 ,it requires an intimate association with the insane1 and a careful study of their manner of thought and conduct1 to be able to successfully guide1 direct1 and control them4 ,the ,relation of ,attendants to ,patients4--,the position of attendants is often a trying one2 they are liable to misrepresentation when they have faithfully done their duty2 they must learn to receive with calmness a blow or an insult1 or even so great an indignity as being spit upon2 they must bear with provocations that come day after day1 and are seemingly as malicious as they are ingenious and designing2 they must watch over the suicidal with tireless vigilance1 control the violent1 and keep the unclean clean4 ,to do all this requires the exercise of self-control and kindness2 the putting a curb upon the temper2 the education of judgment and tact2 faithfulness in the performance of duty1 and a knowledge of what to do and what to avoid4 ,these trials are1 however1 but a part of the experience of an attendant in caring for the insane1 for there is associated in this care much that is satisfactory and pleasurable4 ,it is a satisfaction to know that duty has been well done2 to be able to care for the sick2 to do something to alleviate suffering2 to tenderly watch over and soothe the dying2 it is a pleasure to see a patient improving1 going on to recovery1 and finally able to return home cured4 ,many delightful friendships are formed between attendants and patients1 some lasting for years within the asylum1 and some for a lifetime1 with those who have recovered4 ,most of the insane appreciate the services rendered them1 and have a feeling of gratitude for those who care for them4 ,attendants should always treat patients with politeness and respect2 it is something that is never thrown away1 and exerts a good influence1 however rude and disrespectful a patient may behave4 ,patients should not be ridiculed1 their mental weakness and peculiarities made light of1 nor should they be made a show to inquisitive visitors4 ,it is useless for attendants to try to argue patients out of a belief in their delusions1 and to do so often results in fixing them more firmly in the mind4 ,we should not however pretend to believe them1 nor humor their belief1 nor allow them to carry out their delusions in their dress1 conduct1 and general behavior4 ,the ,character of an ,attendant4--,the insane should always be treated with kindness1 and nowhere is the golden rule thou shalt love thy neighbor as thyself more necessary of application than in caring for them2 and it is well for attendants1 when tempted1 to stop and think how1 under like circumstances1 they would want their mother or sister or brother treated4 ,keeping this noble teaching and this high motive for right-doing ever in mind1 an attendant cannot go far astray4 ,it is a development of character to care for the insane1 and instead of being brutalizing1 as some ignorant people say1 it is elevating and humanizing4 ,attendants should never gossip1 either among or about themselves1 or of their patients4 ,it is a mean and degrading habit to indulge in2 it will undermine a good character1 and often become overpowering and malicious4 ,on the other hand1 never be afraid to speak the truth1 and never let a lie1 or the semblance of a lie1 pass your lips1 or remain for a moment in your heart4 ,of all things be truthful4 ,attendants must acquire a spirit of willing obedience1 of cheerful execution of all commands and directions1 and of faithful performance of every duty that devolves upon them4 ,unless they have this spirit1 they will be unable to successfully assume positions where obedience is to be exacted from others4 ,they should preserve their own self-respect2 in all things set a good example2 be neat and tidy in their dress1 gentlemanly or ladylike in their conduct2 considerate of the wants and feelings of other attendants2 they should cherish a high sense of moral obligation2 cultivate an humble1 self-denying spirit2 seek to be useful2 and maintain at all hazards their purity1 truthfulness1 economy1 faithfulness1 and honesty 7,utica ,asylum ,rules and ,regulations74 ,in their relation to the institution1 attendants should fulfil all their engagements with the same sense of right1 that they expect will be observed towards them by those who employ them4 ,it is a business contract that is assumed1 and brings with it mutual legal responsibilities1 rights1 and obligations4 ,attendants should strive to so conduct themselves1 that when they leave their employment they can go away with the respect of every one1 and bear with them the reputation of a good character and of work well done4 ,how and ,what to ,observe in the ,care of ,patients4--,it is important that attendants should early learn habits of close observation4 ,the exercise of the habit increases the ability to observe1 and one soon comes to see and know things he never saw1 or thought of before4 ,it is necessary to learn first the physical condition1 mental symptoms1 and habits of a patient1 before we are able to observe and appreciate any change4 ,observation1 to be of value1 should be systematically made1 and only one thing at a time can be noticed1 which must be understood before passing to another1 otherwise every thing is confused4 ,the condition and appearance of a single part should be looked at to see what is natural1 and what is evidence of disease4 ,in practice1 written notes taken at the time1 are extremely valuable in teaching close and accurate observation1 and cultivating an ability to clearly express to others the result4 ,for the purpose of suggestion and guidance1 the following system for observation is given3 ,observe the effect of medicine4 ,the face4--,observe if it is pale1 and if the pallor is sudden1 temporary or permanent2 if flushed1 if congested1 if blue with venous blood1 if there are any eruptions1 bruises1 or scars4 ,observe the expression of the face4 ,the tongue4--,observe if it is coated1 and if so1 if white1 brown1 red1 black1 glazed1 dry1 or cracked2 if it is tremulous1 or drawn to one side1 or protruded with difficulty4 ,the lips4--,observe if pale1 blue1 dry and cracked1 if there is tremulousness about the corners of the mouth2 the teeth1 if covered with sordes2 the gums1 if bleeding4 ,the breath4--,observe if sweet1 sour1 foul1 or offensive4 ,the respiration4--,observe if slow or fast1 quiet and natural1 or loud1 labored1 and difficult1 if puffing1 wheezing1 shallow1 or irregular4 ,the eyes4--,observe if congested1 the color1 if any blindness2 the pupils1 if contracted1 dilated1 irregular1 unequal1 or if they respond readily to light4 ,if there is cough1 observe if moist or dry1 if croupy1 if with pain1 or if prolonged4 ,if any expectoration1 observe if it is bloody or streaked with blood1 if thin and frothy1 thick and purulent1 or if it sticks to the cup4 ,the pulse4--,observe if it is slow or rapid1 full1 weak and thin1 if irregular or intermitting4 ,count it4 ,the temperature4--,observe by the hand or thermometer4 ,the body4--,observe for eruptions of the skin1 for sores1 bruises1 or deformities1 or if there is any paralysis4 ,the appetite4--,observe if it is poor1 changeable1 if food is relished or disliked2 if refused1 if it is constantly or occasionally1 and if from delusions or indifference2 if there is overeating and gluttony1 if food is bolted1 or chewed1 or if the patient has teeth to eat with4 ,the digestion4--,observe if natural1 or painful1 and if so1 whether upon taking food1 or if the pain is delayed2 if gas is discharged from the mouth1 if the stomach is sour1 if the food is heavy and distressing2 also observe what kinds of food give dyspepsia1 and what seem to be well borne4 ,of vomiting4--,observe if occasional or constant1 if immediately after food1 or delayed1 if sour or bitter1 if preceded by pain or nausea1 if it contains any undigested food4 ,of diarrhoea4--,observe how frequent the discharges1 if with pain1 and where it is situated1 the color1 the consistency1 if there is any blood or mucus1 if it alternates with constipation4 ,of constipation4--,observe if alternating with diarrhoea1 if habitual1 the effect of medicine and food2 if there are any piles4 ,the menses4--,the quantity1 if there is any pain1 its cessation and reappearance1 if any effect upon the mental condition4 ,of pain4--,observe the character and severity1 its location1 and any evidence of a cause4 ,of dropsy4--,observe if it is general or local1 if in the chest1 face1 abdomen1 arms1 or legs2 if there are any varicose veins4 ,of sleep4--,observe the length of time1 if quiet and natural1 if restless1 if deep or light1 if there is great drowsiness or continued wakefulness1 and the effects of medicine4 ,of unconsciousness4--,observe if it comes on slowly or suddenly1 if partial or complete1 if the patient can be aroused4 ,of convulsions4--,observe if slight or severe1 if of short or long duration1 if continued or interrupted1 if general or of one side1 or of an arm or a leg1 or the face1 or of a few muscles only4 ,of the mental condition4--,observe if fixed or changeable1 the nature of delusions1 illusions1 or hallucinations2 dangerous attempts or threats toward himself or others2 any change in the mental state4 ,of habits4--,observe if fixed or changeable1 how formed or how corrected4 ,of the general conduct4--,observe the dress1 if neat and tidy1 or otherwise1 private habits1 care of personal wants1 improvement in conduct1 the influence of attendants and other patients1 or the influence the patient himself exerts on others4 ,this by no means includes all that it is necessary to observe1 but it contains much that is important1 and the system1 if studied and used practically1 will suggest to the observer whatever may require attention4 ,the ,control and ,influence of ,attendants over ,patients4--,by a smart attendant is meant one who sees little to do beyond having a control of the ward by a rule that is close and exacting1 who maintains a strict discipline1 and who has a love for cleanliness1 order1 work1 and scrubbing4 ,but a useful attendant is one who tempers these mentioned traits1 by striving to gain the confidence of his patients1 by exerting over them a beneficial influence1 who is able to bring the individual patient into accord with his surroundings in the asylum1 so as to help his improvement or recovery1 meet his wants1 and increase his comfort and enjoyment4 ,in order to do this it is necessary that the attendant should give careful study and attention to each patient4 ,such a study will soon demonstrate to1 and teach the attendant the fact1 that the insane are very individual in their habits1 and while no two are alike1 there are resemblances that in an asylum are made the basis of classification by wards3 there is the convalescent1 the suicidal1 the demented1 the sick and feeble1 and the noisy or violent wards4 ,attendants must first learn that patients are not to be treated merely as a ward full of people to be kept in order1 to be clothed1 fed1 and put to bed1 but that the peculiarities of each patient are to be studied1 and that it is their duty to know thoroughly the wants1 and condition of each case1 and how best to care for and control it4 ,the better knowledge an attendant has of the individual1 the better he can care for a ward full of individuals4 ,the persons who are under our care are always to be considered as patients1 and it must be remembered that these sick people are sent away from their homes and given over to us1 though strangers1 because it is supposed that we can do better by them than their friends are able to do4 ,their position is one of helplessness and dependence upon those who are placed in charge1 and we are properly held responsible by the friends and the public1 for a judicious exercise of the power and influence we possess over them4 ,patients are not rightly influenced by the mere exercise of authority or by dictation or command2 these they fear and obey1 or resent and resist2 but we should always appeal to the highest motives for obedience and correct conduct1 and we should lead our patients to trust and not to fear us4 ,in our dealings with them we should be truthful1 straightforward1 and strictly upright1 and exercise over ourselves patience and self-control4 ,we can generally control our patients by the exercise of sympathy1 kindness1 and tact1 joined with a reason for what is required1 and where more is needed1 a firm1 kind authority and command will suffice4 ,the use of authority1 restriction1 and restraint is to be avoided1 while on the other hand patients are to be allowed all the liberty and freedom they can safely enjoy1 and taught to exercise all the self-control they are capable of4 ,the granting of more freedom and liberty of action than was formerly accorded the insane1 does not imply a change in the character of the disease1 but improved methods of care1 and places more responsibility upon the attendants4 ,the degree of liberty to be allowed must1 in each case1 be decided by the physician1 and the attendants should closely observe the patient1 and report any symptoms which makes the enlarged freedom dangerous to the patient or to others4 ,patients being sick1 are sent to the asylum that they may be kindly and judiciously cared for1 and1 if possible1 cured4 ,as many patients who may never fully recover may so improve as to be able to return to their homes1 and1 as it is impossible to say that any given patient will not recover1 each case deserves and should receive our best care and efforts to this end4 ,because our patients are sick they must be nursed1 and nursing means tender care4 ,and it is a nurse's duty to do all in his power to alleviate pain and promote bodily comfort4 ,the insane are subject to all the ills that flesh is heir to1 and there is always among our patients much sickness and bodily suffering4 ,many patients cannot tell when they are sick1 nor when they suffer pain1 but they show sickness and pain1 and often appeal by their manner for that care and sympathy1 we all feel in need of at such times4 ,these silent symptoms should be observed by the attendants1 who should always see and know when their patients are sick4 ,some of these symptoms are1 crying1 moaning1 weakness1 going to bed1 or lying down1 cough1 changes in respiration1 signs of fever1 a flushed face1 quick pulse1 or chills1 a pale face1 vomiting1 or diarrhoea1 and loss of appetite4 ,much insanity is associated with great physical disturbances which require careful nursing4 ,the old and feeble1 the paralytic and bedridden also require special attention and care4 ,from this it appears that the care of the insane calls for the exercise of self-control1 habits of close observation1 the using of good judgment1 the putting forth of ennobling influences1 and the tender care of the nurse4 ,,chapter ,v4 ,,the ,,general ,,care ,,of ,,the ,,insane4 ,the ,reception of ,new ,patients4--,attendants must at once study the peculiarities1 the physical condition1 and the mental symptoms of a new patient1 so as to know the case thoroughly4 ,new patients should receive special attention2 their fears quieted2 they should1 if in a proper condition1 be introduced to the other patients2 the effect of being in so large and strange a place1 where the doors are locked and the windows guarded should be noticed1 and unpleasant impressions overcome2 they must be told they have come among friends and will be kindly treated4 ,the necessary rules of the ward should be explained2 they should be invited to their meals1 shown to their rooms and told at bedtime the night watch will visit them1 and they must be assured that no harm will come to them4 ,the first impressions a new patient receives may be the lasting ones1 and influence their whole conduct in the asylum4 ,if they resist what is necessary to do for them1 do not struggle and contend with them1 and force them to bed1 or to the bath1 but first seek advice from the supervisor1 or the physician4 ,always search new patients1 unless otherwise ordered1 for money1 jewelry1 weapons1 medicine1 and other like articles1 or if in doubt what to do ask for directions4 ,the head1 body1 and clothing should be examined for vermin1 and the body for injuries and bruises4 ,if what is wished to be done in this particular is explained1 patients will generally quietly allow it4 ,work1 ,employment1 and ,occupation4--,by this is meant whatever occupies the patient's time and mind1 in useful and pleasant ways4 ,of all things idleness and loafing are the worst2 even games1 such as billiards and cards1 if indulged in to the exclusion of useful employment1 will degenerate a patient4 ,some willing patients are kept in a tread-mill of daily work1 their monotonous life never broken by a diversion1 an enjoyment1 or a hope4 ,it is very questionable if it is beneficial to make a patient drudge through such a daily routine4 ,asylum life should be made as home-like1 pleasant1 and natural as possible2 as a rule every patient who is able should do some useful work every day1 and to this should be added the diversion1 that comes from amusements and the enjoyment of innocent pleasures4 ,occupation then means a great deal more than work2 it is the way a patient spends his time4 ,unless encouraged and directed1 patients may occupy themselves in thinking of their delusions1 in noise1 violence1 or destructiveness1 in idly walking up and down the wards1 in the indulgence of secret vices1 in gossip1 in spreading discontent1 in prayer1 or in constant ,bible reading4 ,some patients really work hard trying to do nothing1 and have no more ambition than to sit around on the ward1 and chew tobacco1 and indulge in idleness4 ,patients should be encouraged to do something for themselves1 the women to make and mend their own clothes1 to keep their rooms in good order1 and assist about the ward4 ,they should be made to feel that they can add to their own comfortable surroundings by their own efforts4 ,for the men1 ward work is not so natural or tasteful1 but they will do with interest much of this kind of work2 to this may be added employment in decorating their own rooms or the ward1 and in caring for plants and flowers4 ,the women can add to ward work1 sewing1 knitting1 mending1 embroidery1 artificial flower making1 quilting1 care of flowers in the ward1 and it is often a real enjoyment for patients to make some little present for their outside friends4 ,the laundry offers an inviting field for some patients1 but it is often too hard work1 especially when they are sent twice a day to the wash-tub1 or kept in the hot ironing room4 ,a half day is enough for most patients1 and many are not strong enough to go there4 ,out-of-door work is well suited for the men4 ,the farm1 garden1 lawn1 barns1 and machine-shops offer much that can be made useful for the patients' employment2 the different mechanics and artisans about the asylum should have patients working with them4 ,thus it appears there are many directions for patients to work1 and it is also true that all patients are not suited to do the same work nor the same amount of work4 ,whatever they do should be for their benefit alone1 otherwise we might take a contract for a given number of patients to work a given number of hours every day1 a good deal as has been done in prisons and reformatories1 but no one would believe such a course for the interest1 improvement1 or recovery of the patients4 ,the only rule to go by is1 that the work and occupation shall be for their own good1 and1 that they shall not be made or encouraged to work for any other purpose4 ,as a rule1 patients should be allowed to employ themselves in ways that most interest them1 provided it is useful and seems to be beneficial4 ,over-work is as bad as idleness2 too much sewing will often give a sleepless night4 ,generally all patients may be allowed to engage in light work1 without special directions2 new patients1 however1 should not be sent off the ward1 or given tools that may become weapons1 unless by order of a physician4 ,it is a bad habit for attendants to sit idly by1 or stand around with their hands in their pockets1 and have patients do all the work4 ,it may be so necessary to watch the patients that the attendant cannot work steadily1 but he should have the appearance of doing something1 and if possible join with them in work4 ,a party of women sewing1 should be laughing1 talking1 telling stories1 perhaps singing2 they should be made to enjoy the time1 and not to look upon it as something irksome4 ,some patients are too feeble in mind1 and some too feeble in body to work2 many need rest1 quiet1 and nursing1 and directions for the care and occupation of such patients should come from the physician4 ,many of these patients will do a little1 others can be amused1 or read to1 and their minds thus diverted from their troubles1 and turned into pleasant and cheerful directions of thought4 ,it has been shown that work is not the only useful way that patients may occupy their time1 that nothing but work is as bad as no work1 and that they should have diversion1 enjoyment1 and entertainment4 ,for the entertainment and occupation of patients1 there are furnished1 dances1 concerts1 theatricals1 billiards1 cards1 pianos1 books and papers1 schools1 chapel services1 walks1 rides1 and excursions1 and they also receive visits from friends1 and write and receive letters4 ,patients should be encouraged and sometimes made to take part in these natural and pleasant amusements2 of course every patient cannot play the piano1 or billiards1 but among these many forms of recreation1 all patients can find ways of diversion and means of enjoyment4 ,thus early in the study of the care of the insane1 it is learned that the life of patients is to be stripped1 as much as possible1 of restriction and restraint2 that self-control is to be taught2 that useful work is to be encouraged2 that amusements and innocent pleasures are to be enjoyed2 in a word1 attendants are to learn1 that the characteristics of institutional life are to be lessened1 and those of a home life made prominent4 ,the ,patients' ,care of ,themselves4--,the general tendency of the insane is to mental enfeeblement1 to neglect of person1 and to slovenly habits4 ,patients should be encouraged as much as possible to care for themselves2 to be helpful towards others2 to do such work as they are able2 to seek amusements1 and to live as much as possible such a life as we ordinarily are accustomed to outside the asylum4 ,patients should be encouraged to keep themselves tidy1 and nicely dressed1 to have the care of their clothing2 if possible1 they should be given a room of their own1 which they should take a pride in keeping in order1 and ornamenting with pictures and flowers2 and should be allowed to do whatever will help maintain their self-respect1 self-care1 and a feeling of individuality4 ,there is great difference in patients as shown in their capacity for self-help4 ,some seem to be able to do nothing1 some everything4 ,nothing can lighten the burdens of attendants so much as to make the helpless self-helpful4 ,nothing benefits the patients more4 ,do not abandon effort for any patient4 ,unexpected and gratifying results are the rewards of earnest efforts4 ,out of ,door ,exercise--,walking4--,if possible1 patients should be out of doors every day4 ,in the summer much time can be spent in the fields1 on the lawn1 either walking or sitting under the trees2 in the winter time shorter walks only can be taken1 but on pleasant days1 often an hour may be spent out of doors4 ,warm clothing and good shoes must never be neglected1 and the person must be thoroughly protected1 because the insane are frequently cold-blooded1 that is1 the circulation is poor1 the hands and feet congested1 blue1 and cold1 they make animal warmth slowly and with difficulty1 and easily suffer from the cold4 ,many patients go out to walk on parole4 ,those who are allowed this liberty will be designated by the physicians2 any change in the patient that makes such liberty dangerous should at once be reported4 ,others go out in large parties1 with few attendants to care for them1 while the old1 sick1 and feeble1 the homicidal and suicidal1 the noisy and violent1 require special care and attention in their exercise and walks4 ,clothing of ,patients4--,in many asylums each patient has his own clothing4 ,every article should be plainly marked with his own name1 and should be used only by the patient to whom it belongs1 and never given to any one else to wear4 ,all clothing should be kept clean and well mended1 and should be properly put on and kept on during the day4 ,there should always be enough to keep the patient warm1 and changed with the changes in the weather1 or the temperature of the ward1 or the needs of the patient4 ,the sick1 feeble1 and old always need extra clothing2 that worn next the skin should be changed at least once a week1 and all clothing should be changed as often as soiled4 ,bathing of ,patients4--,every patient should be bathed once a week and as much oftener as is necessary4 ,the tub should be cleaned and the water changed for each patient2 the temperature should be about ninety-five degrees1 or not hot to the hand1 and the tub should be about two-thirds full4 ,the head1 neck1 and body should be washed with soap2 each patient should have a clean towel1 be wiped dry1 and given a change of clean clothing4 ,some patients object to bathing2 they fear the tub1 but will wash with water and a sponge1 and they should be allowed to do so4 ,others want to bathe first2 let them1 if possible4 ,others will not bathe the day the rest do2 it is sometimes best to humor them4 ,some patients have to be forcibly bathed4 ,in such cases always wait1 use every art to induce them to bathe1 and before acting send for advice4 ,attendants are too prone to think that every thing should be done by rule1 and that all must be forced to obey the rule4 ,most will observe it without trouble1 and the object sought can generally be gained by patience1 tact1 and kindness4 ,serving of ,food4--,the dining-tables should be neatly set and made attractive2 the food should be promptly served1 and while hot2 all patients should be at meals1 unless excused by the physicians4 ,economy should be practised1 and every thing should be used or saved4 ,each person should have enough1 but no one should be allowed to make a meal of a delicacy1 or take all of the best of a dish4 ,some patients would waste a pound of butter or sugar at each meal2 enough is sufficient for anybody4 ,the old and feeble should be served by attendants2 those without teeth should have their food prepared1 and the meat should be cut very fine4 ,those who will not eat must be kept in the dining-room and fed2 the attendants may use force by holding the hands1 and placing food in or to the mouth2 but it is dangerous to do more1 and holding the nose is something that is never allowable4 ,if these efforts to get them to take food do not succeed1 report to the physician4 ,some patients from delusions will eat certain kinds of food1 and either not get enough or not a sufficient variety4 ,a mixed diet is the best1 and patients should if possible be made to eat bread1 butter1 meat1 vegetables1 and drink milk and plenty of water4 ,no patient should be allowed to lose in flesh and strength on account of failure to take sufficient1 or proper food2 before these things happen it should be reported to the physician4 ,some patients will only eat enough if they are allowed to eat it in their own way2 they will eat it perhaps standing1 or after the others have finished1 or alone1 or in their room1 or they may steal it1 if given the opportunity4 ,such peculiarities often have to be indulged4 ,some patients will take nothing but milk1 then about three quarts a day are needed2 eggs may be added and are often readily taken1 and some may be got to eat bread and milk1 which is a very nutritious diet4 ,the food of the sick should be nicely and invitingly served1 and efforts should be made to meet their whims and fancies4 ,patients who are so profane1 violent1 or noisy1 that they are not allowed to come to the dining-room1 must always be fed by1 and in the presence of an attendant1 and meals should not be passed into a patient's room and left there4 ,knives and forks should always be counted by an attendant before and after each meal2 care should be used that they are not lost1 secreted1 or carried out of the dining-room by patients4 ,no one but an attendant should ever handle the carving knife and fork1 or the bread knife4 ,care of ,patients when ,going to ,bed1 or ,rising4--,the beds should be daily aired1 and always clean and nicely made up2 for a filthy patient a straw bed1 that can be changed1 alone is clean4 ,all patients do not need to go to bed at the same time1 and while some are able to care for themselves1 most need care1 attention1 and watching4 ,the helpless should be dressed and undressed1 and put to bed first3 the violent and homicidal need to be watched1 and should be put to bed early1 while the suicidal should be kept under supervision1 and put to bed at the most convenient time4 ,after a patient is in bed1 an attendant should go into the room1 with a lantern1 so as to see that every thing is in order and safe1 and1 with a cheerful good-night close the door4 ,patients who need care should be visited during the evening1 and left clean and in good condition to be cared for by the night watch4 ,in the morning patients need attention before any thing else is done4 ,first1 the suicidal1 sick and feeble1 the violent1 and those likely to be filthy should be visited1 and every patient should be washed and dressed before breakfast2 or1 if for any reason they do not come to this meal1 their faces and hands should be washed1 the bed put in order1 and the room made clean and aired4 ,after these things have been attended to1 the ward work should be done1 though generally the two can go on together4 ,care of ,patients during the ,night4--,after the patients have gone to bed the ward should be quiet1 doors should be quietly closed1 voices lowered1 and loud calls and laughter not indulged in1 squeaking boots should not be worn1 and heavy walking avoided4 ,many patients go to sleep early1 but are easily awakened1 and may remain sleepless till morning1 or at least a part of the night4 ,the night watchers have responsible1 arduous1 and trying duties4 ,attendants should always1 during the night1 quickly respond whenever a demand is made upon them for assistance1 though an unnecessary call should never be made4 ,the night watchers should be informed of any changes that have occurred during the day1 that will require their attention during the night2 they should see new patients and be made acquainted with their peculiarities2 they should visit the wards during the evening before they come to the medical office to receive instructions from the physicians4 ,it is the duty of a night watch to visit regularly all the wards under his charge2 to see and know the condition of the sick1 the helpless1 feeble1 the suicidal1 and the epileptic2 to attend to1 by taking up1 those who are inclined to be filthy1 and wash those who need it1 and make them1 their beds1 and rooms perfectly clean4 ,he should observe the conduct of new patients1 be watchful of the violent1 know how much wakeful patients sleep1 visit all associated dormitories1 wait upon all those who need attention1 and guard against fire and accident4 ,the night watch should place each day on the medical office table1 a detailed account of every patient that needed care or attention1 who was disturbed1 or did not sleep during the previous night4 ,patients should be left clean for the night watch1 who should leave them in as good condition in the morning1 for the day attendants1 and any neglect in these directions should be reported by either party4 ,sick patients frequently have to receive special night service1 to be watched1 and given food and medicine4 ,when this cannot be done by the night watch1 it devolves upon the day attendants1 and is a duty that should be cheerfully rendered4 ,during the night1 any accident1 attempt at suicide or to escape1 or unusual violence1 persistent sleeplessness1 or being out of bed1 a serious sickness or change for the worse1 or the approach of death1 should be reported to the physician4 ,it is1 in many institutions1 the duty of the night watch to report any neglect or misconduct on the part of an attendant or employe1 and it is something that should be faithfully and impartially done4 ,having briefly sketched the general duties of an attendant1 it seems best to again remind them1 that an asylum is built and maintained for no other purpose than for caring for the insane2 that each patient is entitled to the best our means can afford2 that while the attendants are not responsible for the medical treatment1 they are for that kind and intelligent care it is within their province to give2 and they are also reminded that1 so far as it can be done1 such personal attention is to be given to each patient as will assist in recovery or improvement1 or promote his well-being4 ,,chapter ,,vi4 ,,the ,,care ,,of ,,the ,,violent ,,insane4 ,a careful study of each violent patient1 of his habits1 delusions1 and hallucinations1 of his peculiar manner of showing violence1 and a knowledge of what is likely to provoke outbursts is necessary to properly care for him4 ,an attendant's ability to successfully manage a ward full of patients will depend largely upon the study given to1 and the thorough understanding of1 each case4 ,such study will soon teach him that every violent patient has peculiar and pretty constant ways of showing and exercising violence1 and that the same rule of individuality holds good among this1 as it does among other classes of the insane4 ,having learned what will cause violence1 it can often be avoided by removing the cause2 having learned the symptoms that precede a patient's outbursts of violence1 they can sometimes be averted1 or preparations made to control them2 having learned in what direction violence is shown1 how sudden1 blind1 or furious it may be1 or how slow1 deliberate1 and planned1 the attendant is better able to meet1 manage1 and control it4 ,few patients are so continuously and furiously violent as to need constant repression1 and the directions how to care for such patients can always be given by the physician4 ,most violent patients are subject to the firm1 kind control of attendants1 and can be kept sufficiently quiet and orderly2 they should never be left alone1 and mops1 pails1 brooms1 chambers1 and all other articles1 that may become weapons should not be left within reach4 ,strong comfortable clothing can generally be kept on the most violent and destructive1 with care and attention from attendants1 but not without4 ,many violent patients will employ themselves and be the quieter for so doing4 ,light out-of-door work is the best employment for this class1 and out-of-door walking and exercise should never be neglected4 ,on the woman's ward knitting1 sewing1 mending1 and ward work are suitable for many1 while some will work at the laundry1 and others will go quietly to church and entertainment2 books and illustrated papers should be furnished and will be much read and enjoyed4 ,as a rule the more violent patients are restricted1 kept continuously on the ward1 or in a small room1 and given no work1 amusements1 walks1 and exercise1 the more noisy and violent do they become4 ,attendants must learn that mere noise1 and much of maniacal activity1 such as running about1 jumping1 or pounding1 is not in itself harmful1 and that unless such patients are doing themselves injury1 or so disturbing the ward and other patients as to require interference1 it is better to control than to repress and restrict them4 ,many violent patients are subject to such paroxysms of great violence as to require immediate care and often temporary control at the hands of attendants4 ,generally these paroxysms spend themselves after a short time1 but if they do not1 advice and help can be called for4 ,by careful watching1 the approach of these paroxysms can be known and often avoided4 ,this may be done by removing the cause1 which is often the irritation of another patient or an attendant1 by a word1 a joke1 by simply letting the patient alone1 or by a firm show of authority1 or by any other means experience has taught to be useful in the particular case4 ,if necessary to hold a patient1 three persons should be able to care for the most violent4 ,this can be done by grasping each arm at the wrist and elbow1 and holding it out straight1 the attendants standing behind while another passes the arm about the neck and holds the chin1 to prevent biting and spitting2 the patient may then be walked backward and seated in a chair4 ,after the violence has subsided1 though the patient should continue to scold1 swear1 threaten1 or cry1 he should1 as soon as possible1 be left alone1 the attendants walking away1 but remaining watchful4 ,do not1 unless it is necessary1 interfere to stop the noise1 for it is often a substitute for the violence1 and the attack wears itself out in this way4 ,if necessary to carry a violent patient1 it can be done by four or six attendants4 ,the face should be turned downward1 thereby lessening the power to resist1 and1 to prevent dislocating the arms1 the patient should be carried by the shoulders and chest2 the bands about the neck should be loosened4 ,in using force in the care of violent patients1 it should always be done as gently as possible1 and struggling should be avoided2 he should never be choked or kicked1 receive a blow1 or be knocked down2 the arms should never be twisted1 nor a towel held over the mouth1 but if the patient persists in spitting it may be held in front of the face4 ,care must always be used not to injure a patient while exercising necessary control4 ,in the violence of a patient innocent injuries are sometimes received4 ,the attendant is excusable if he can show that he used necessary force only1 without malice4 ,a violent patient should never be struggled with alone1 and on a well-managed ward help will always be within call4 ,it may be necessary1 however1 to break this rule in order to prevent homicide or suicide1 or serious injury to another patient1 or setting the house on fire4 ,it is better not to visit the room of a violent patient alone1 and if an attack is feared1 especially with a weapon1 the door should be slowly opened1 and held so it can be quickly closed4 ,the patient usually makes an immediate attack1 and1 before he has recovered for a second1 can generally be disarmed and controlled4 ,violence usually consists of noise1 tearing the clothing1 breaking glass or furniture1 biting1 scratching1 striking1 hair pulling1 kicking1 or attacking others with weapons4 ,it is sometimes secretly and deliberately planned and skilfully executed1 though generally without reasoning or direction1 but blind and fierce4 ,the care of the violent insane involves the careful study of each case1 with constant watchfulness1 and the exercise of a control that is kind1 but firm and unyielding1 that does not repress except when necessary1 nor restrict without reason1 that indulges whenever possible1 that never drives1 scolds1 or threatens1 but influences1 guides1 and directs4 ,the greatest liberty possible should be allowed1 and self-control encouraged1 and work1 occupation1 and amusement should be furnished4 ,an attendant must always remember that fear is the lowest motive to govern by1 and that kindness will often be appreciated and returned4 ,care of the ,destructive ,patients4--,besides the violently destructive patients1 there are some who are maliciously destructive1 and who exercise all their ingenuity to escape the watchfulness of the attendants2 who glory in their wrong-doing2 who openly say they cannot be punished1 and exultantly tell the physician how they have outwitted the attendant1 or proclaim before him his shortcomings and neglect4 ,such patients will destroy their own or others clothing1 they will steal and hide1 or throw it out the window or down the water-closet1 or erase the name by which it is marked4 ,they will destroy bedding1 windows1 crockery1 pictures1 or furniture4 ,with a pin1 a nail1 or a bit of glass or wood1 they will mar and deface their room or the ward1 and often do damage that cannot be repaired4 ,the only way to meet such cases is by watchfulness4 ,they should be kept1 if possible1 at work1 or at least with a company of workers1 and therefore under constant observation4 ,when put to bed their clothing1 mouth1 hair1 and person should be thoroughly searched4 ,kindness often has but little effect1 but a threat is apt to make them more determined to destroy4 ,the ,care of ,patients by ,mechanical ,restraint and ,seclusion4--,all the restriction of an asylum is restraint4 ,the locking of bedroom doors at night is very restricted restraint4 ,most patients in an asylum have a feeling that they are under great compulsion and restraint1 in being deprived of their liberty4 ,it has already been taught that patients are to be given all the liberty possible1 that restraint over their freedom is to be exercised no more than is absolutely necessary1 and that the greatest good of the patients alone is to be thought of4 ,these teachings are equally true of special forms of restraint4 ,if used at all they are to be used for the good of the patient alone1 and an attendant should be able to care for any case without restraint4 ,restraining apparatus should never be kept on the ward4 ,an attendant should never ask that it be used1 nor say he cannot get along without it4 ,if ordered by the physician it is the attendant's duty to see that it is so applied as to do no injury1 that it does not bind or tie the patient down1 that it does not irritate and make the skin sore1 nor restrict the free movement of the limbs4 ,patients who are restrained are not to be further confined to a chair without specific order4 ,restraint used during the day is not1 unless so ordered1 to be continued at night nor reapplied the next day4 ,patients are to be taken frequently to the closet4 ,restraint should be taken off several times a day1 and kept off long enough to give relief to any feeling of discomfort1 and free movement should be allowed4 ,when patients are restrained they need unusual care and watching1 and should never be left alone4 ,the attendant should be informed why restraint is used1 and what is hoped to be gained by its use4 ,he should closely observe the effect upon the patient and compare his condition with what it is when not restrained4 ,the result of these observations should be reported4 ,thus used1 an attendant will soon learn that it is not the easiest way to care for a patient1 that its use involves increased watchfulness and care1 and greater discretion1 and that it is strictly a form of medical treatment4 ,it is a harsh remedy at its best1 and needs to be used with kindness1 intelligence1 and judgment1 and it is to be applied but for one purpose1 namely1 that the patient may be benefited4 ,the ,use of the ,covered ,bed4--,like restraint it is never to be used except by the orders of a physician1 nor is its use to be repeated without special orders2 it is always to be considered a method of treatment and something the attendant has no interest in1 except to know how best to use it when ordered to do so4 ,when in a covered bed the patient should be frequently visited2 he should be taken up at least once in three hours1 unless asleep2 the bed and the patient should be kept perfectly clean4 ,if used in the daytime an attendant should sit beside the patient for some hours and try to keep him quietly in bed1 and the same should be done in the evening when the patient is put to bed4 ,an attendant should be able to report how much the patient sleeps1 how much quiet and rest is obtained1 the effect of the treatment1 and compare the condition of the patient when in the bed with what it is when not used4 ,the ,use of ,seclusion4--,seclusion is shutting a patient alone in a room in the daytime4 ,if allowed to be done without orders from the physician it should be immediately reported4 ,if ordered to be continued the patient should be seen at least once in fifteen minutes1 while many need to be seen once in five minutes1 and an attendant should never be far from the door4 ,the patient should be frequently taken to the closet4 ,the effect and result of seclusion should be observed and reported4 ,many physicians never use any form of restraint1 while others make considerable use of it as a means of treatment4 ,an attendant should be able to successfully care for any case1 so as to meet the wishes and directions of the physician1 and only as he is able to do this can he give the patient the highest standard of attention1 care1 and nursing4 ,,chapter ,,vii4 ,,the ,,care ,,of ,,the ,,homicidal1 ,,suicidal1 ,,and ,,those ,,inclined ,,to ,,acts ,,of ,,violence4 ,patients with ,delusions of ,suspicion demand special care1 and are properly classed with those inclined to commit acts of violence1 because they are frequently fully under the control of delusions1 which make them dangerous and difficult to manage4 ,many patients have ideas that make them suspicious of those about them2 these may relate to the patients1 but more frequently to the attendants and physicians1 and they may arise from delusions1 hallucinations or illusions4 ,this class of patients is apt to be morose1 cross1 and irritable2 they sit brooding over their fancied wrongs2 repulse advances and friendly intercourse2 they refuse to employ themselves1 and do not respond willingly to the requirements of the attendants4 ,our most trifling and unmeaning acts may give rise to the most intense suspicions and hatred4 ,a look1 a shrug of the shoulder1 the manner of shaking the head1 a cough1 the squeaking of our boots1 are frequently enough to arouse1 these feelings4 ,suspicious patients often think they are the subjects of ridicule2 that their thoughts are read and proclaimed to the ward2 that their virtue1 truth1 or honor is called in question1 and the accusations openly told to others1 or that they are called vile and insulting names4 ,they often have delusions of conspiracy to do them or their families harm1 and connect the attendants and physicians with them1 thinking1 as they keep them locked in the asylum1 they are associated in the conspiracy4 ,sometimes these patients think themselves some great persons1 perhaps that they are a member of the ,deity1 or a ruler1 or prophet1 or that they have some great mission to perform1 and that they are deprived of their rights1 or their work interfered with1 by being kept in the asylum1 and that those in authority are imprisoning and persecuting them4 ,such persons may be1 on account of their fancied wrongs1 very suspicious1 and even violent towards those who care for them4 ,other patients have suspicions and fears of bodily harm4 ,they may think they are to be tortured1 that they are to be burned alive1 or that some one is trying to kill them4 ,to-day1 as ,i wrote these lines1 a patient told me she did not sleep last night for fear the night-watch would kill her--saying that ,god told her the watch was armed with a knife for that purpose1 and she threatened homicidal violence in defending herself4 ,many patients mistake ordinary sensations of pain and bodily discomfort1 and have delusions that they are being injured4 ,the feelings of dyspepsia may make patients think they have been poisoned2 ordinary pains or aches1 that they have been shot1 stabbed1 or pounded2 women may1 for some such causes1 think they have been violated or are pregnant4 ,peculiar sensations of various kinds may make patients think some one is affecting them by electricity or mesmerizing them4 ,it is very easy to trace from such ideas of persecution and suspicion1 the origin of homicidal1 suicidal1 incendiary and other violent tendencies and acts4 ,homicidal ,patients4--,patients are sometimes both homicidal and suicidal1 and sometimes they are inclined to only one of these forms of violence4 ,homicides are not of frequent occurrence in an asylum4 ,the better the care the less is the liability to homicide4 ,but there are always a great many homicidal patients1 and many more who have delusions and ideas that may cause such tendencies to arise4 ,many patients are homicidal merely from violence and frenzy1 and without any settled plan1 any fixed delusion1 or intense suspicion4 ,they may attack others suddenly and furiously2 they may commit the act while trying to escape1 or it may be the result of the violence of acute mania4 ,other patients become homicidal under the desire to protect themselves from supposed assaults4 ,they may think a person who is approaching them is coming to kill or torture them4 ,others are homicidal from any of the ideas of persecution and suspicion that have just been spoken of4 ,sometimes patients hear voices telling them to commit the act1 perhaps it is ,god's voice commanding a father to offer up his only son as a sacrifice1 or a mother to kill her little children to save their souls1 or keep them from some misery or crime that awaits them4 ,patients may think themselves ,god1 or a king1 or ruler1 and therefore have a right to take life4 ,homicidal patients are often among the quietest1 and are found in the quiet wards4 ,they frequently lay careful plans1 are secretive1 and only try to commit the act when they feel sure it will succeed4 ,patients who are homicidal should be especially watched4 ,they should1 if possible1 be kept employed1 but never given tools that may become weapons4 ,they should sleep in a room by themselves4 ,all persons against whom they have delusions should be warned4 ,patients against whom they harbor suspicious or homicidal ideas should be separated from them4 ,attendants should remember that a mop1 a pail1 or a chair1 may become a dangerous weapon1 or that a knife1 scissors1 or a sharpened piece of iron or tin1 may make a fatal wound4 ,suicidal ,patients4--,patients with this tendency will generally talk freely of their suicidal ideas1 tell why they wish to commit it1 what provokes the idea1 and how they would do the act4 ,they are frequently grateful for the care bestowed to help them resist the impulse1 and will sometimes tell the attendants when they feel the suicidal ideas coming on1 that they may be the more surely watched4 ,melancholic patients are most inclined to suicide1 but any insane person1 whatever the mental state1 may commit the act4 ,delusions of depression generally cause the suicidal ideas1 but hallucinations sometimes play an important part4 ,some persons are simply tired of life1 and see no hope in living2 some think they are a burden to their friends1 and that they are taking food away from their children2 others wish to die to escape from their misery1 which is generally a mental1 and not a physical suffering2 others that by so doing they may get forgiveness of their sins2 others because they think they will save their children from a fate like theirs2 sometimes it is the result of hallucination1 as a direct command from ,god1 telling them to commit the act4 ,but few patients are constantly determined to commit suicide4 ,the opportunity offered1 as a bath-room door left open1 a rope1 a knife1 often prompts the desire and allows the accomplishment of the deed4 ,attendants must remember that it takes but a few minutes to commit suicide1 by drowning or hanging--but a moment to cut the throat2 that persons can drown themselves in a pail of water1 hang themselves by the hem of the sheets1 cut their throat with a piece of glass or tin4 ,sometimes patients slyly save their medicine until they get enough to poison themselves4 ,about dusk in the evening1 or at early morning1 is the time when patients are most inclined to commit suicide4 ,when patients are rising1 going to bed1 or to their meals1 when going to chapel1 amusements1 or to walk1 when all is busy and astir on the ward1 are the times that offer the most favorable opportunities for the act4 ,often patients have a certain way by which they will commit suicide1 and they will do it in no other2 one wishes to drown himself1 another to hang1 and another to take poison4 ,sometimes patients will appear cheerful to avoid suspicion and so find their opportunity1 while others may suddenly and while convalescent commit the act4 ,the only way to care for patients who are suicidal1 is by constant watchfulness day and night4 ,during the day they should be employed and kept with other patients1 they should be especially looked after at those times when opportunities for suicide are increased4 ,at night it is better to have them sleep in an associated dormitory with some one to watch them4 ,if a patient is found hanging he should at once be cut down1 all restriction about the neck removed and artificial respiration set up1 or if drowning1 the mouth and lungs should be first emptied of water2 if there is hemorrhage compression should be made upon the artery1 or if this is not possible1 then directly upon the wound4 ,how to control hemorrhage and do artificial respiration will be described in the chapter on emergencies4 ,patients ,who ,have ,tendencies to ,self-,mutilation4--,some patients horribly mutilate themselves4 ,they may gouge out an eye1 cut off a hand1 pull out their tongue1 or even disembowel or dreadfully burn themselves4 ,some patients persistently beat their heads against the wall or floor1 others scratch the skin1 making large sores4 ,such patients frequently think certain passages from the ,scriptures apply to them1 and they must obey the application and command4 ,they quote in justification of the acts1 ,an eye for an eye1 ,and if thy right eye offend thee1 pluck it out1 ,and if thy right hand offend thee1 cut it off4 ,talk of this kind should make an attendant very careful and watchful of the patient4 ,the origin of the ideas that lead to the attempts at self-mutilation is to be found in delusions1 and arise in the same way as do ideas of suicide and homicide4 ,these patients are all of the same class and need the same character of care1 attention1 and watching4 ,patients with ,tendencies to ,setting ,things on ,fire4--,patients with these tendencies generally desire to commit incendiary acts under the influence of delusions or hallucinations2 added to these there are frequently suspicions and feelings of wrong treatment1 and the patient takes this way of showing revenge1 or1 as he may say1 of repaying the wrong4 ,sometimes patients are so feeble in mind that they light a fire because they think it is a pretty sight to see it burn4 ,there are some conditions accompanying epilepsy where patients are liable to commit any of the class of violent acts described in this chapter4 ,the special care demanded by these patients will be fully spoken of hereafter4 ,there are some patients whose minds are so distorted by disease that they seem to take a pleasure in wrong-doing1 and are much inclined to do great mischief1 and sometimes to commit acts against life or property4 ,the care demanded by patients who are inclined to acts of violence is practically the same for all4 ,the attendant should thoroughly know the habits1 peculiarities1 and delusions of each person under his care2 he should exercise constant watchfulness1 and remember that a moment of thoughtless inattention may give the opportunity for a patient to commit some violent act1 that will cause him lasting regret4 ,the mind of a faithful attendant will1 when upon duty1 always be full of anxiety1 and there should be in the care of very troublesome patients of this class frequent relief4 ,,chapter ,,viii4 ,,the ,,care ,,of ,,some ,,common ,,mental ,,states1 ,,and ,,accompanying ,,bodily ,,disorders4 ,care of ,patients in the ,earlier ,stages of ,insanity4--,patients in the earlier stages of insanity act differently1 one from the other1 when first brought to the asylum and placed under care and restriction4 ,sometimes patients accept the situation and fit into asylum life without any friction4 ,they may even come willingly1 knowing they need care and treatment1 or from confidence in their friends or their physician's advice4 ,to some patients the restrictions of an asylum are irksome and misunderstood2 the quiet1 regularity1 and routine of the life on the ward does not at first affect them2 they may1 and often do1 become fretful1 are irritated by their confinement1 sleep poorly1 eat little1 and may make violent efforts to escape4 ,these conditions1 if nothing is done to occupy the patient's time and mind1 and so relieve them1 will often be sufficient to provoke violence4 ,these patients should be carefully watched and their condition studied2 they should be brought under the kind control and influence of attendants1 induced to take part in the regular order of the ward1 and1 if strong enough1 should be furnished with proper work and occupation4 ,patients1 when first brought to the asylum1 frequently have much anxiety about their homes1 their families1 or their business affairs4 ,this is particularly true in recent cases of insanity1 because such patients often have cares and responsibilities1 or they have tried to continue to assume them1 up to the time of coming to the asylum4 ,special care should be taken to quiet fears in these directions2 they should be assured that they are groundless1 told they will be allowed to communicate with their friends1 that they will be visited by their family1 and that all their interests will be cared for4 ,it is impossible to speak of the varied causes of insanity1 or of the equally varied manifestations of the disease and conduct of the patient at its onset1 but there are a few conditions which1 being present1 give a character to a particular case1 and suggest the care required4 ,sometimes1 as has been said1 the patient partly realizes his condition1 and is willing to come to the asylum1 and in every way to conduct himself in accordance with the rules and requirements4 ,sometimes the onset is slow and the symptoms so obscure as to attract little attention4 ,following this1 more decided symptoms may appear2 the patient may become violent1 noisy1 destructive1 or sleepless1 or he may try to commit suicide or homicide1 or do some other act of violence2 or the great restlessness1 moaning1 crying1 and sleeplessness of melancholia may come on1 or the patient may refuse1 for several days1 all food4 ,the reason for bringing such patients to the asylum is that they can no longer be kept at home4 ,following the treatment that has been described1 these patients will frequently in a short time become more quiet1 self-controlled1 and more easily influenced and cared for4 ,the earlier stages of insanity are frequently accompanied by considerable disturbance of bodily health4 ,the appetite is poor1 the digestion disordered1 the bowels constipated1 the breath foul1 the secretions of the skin changed and often offensive1 the temperature a little elevated1 the pulse rapid1 and the heart weak4 ,sometimes1 on the other hand1 the temperature is normal1 or a little below1 while the hands are cold and clammy4 ,in addition1 nutrition is frequently impaired1 so that the food taken by patients does not seem to properly nourish and strengthen4 ,all of these symptoms are not present in a given case2 sometimes most of them may be1 and again but few are to be noticed4 ,the important lesson to learn in the care of these cases is that such patients may rapidly pass into a more serious condition1 in which there is great exhaustion1 which is always alarming1 and may even result fatally4 ,recent cases1 such as have been spoken of1 need our best care1 closest attention1 and kindest nursing4 ,the patient should daily take sufficient food1 which1 if necessary1 should be enforced1 and the opportunity for sleep promoted4 ,a few days1 or a day1 without food and sleep may bring on alarming symptoms4 ,for these patients1 milk is the best article of diet2 it is most easily given and readily taken2 it should be given by the glassful1 or if not able to do this by the spoonful4 ,some patients1 for reasons not always known1 will refuse food one hour and take it freely the next2 it should1 therefore1 be frequently offered4 ,with milk as a basis1 we may add to it1 as we are able4 ,raw egg1 gruel1 boiled rice1 oatmeal1 custard1 and bread are adjuncts that are nutritious and easily given4 ,it makes but little difference why patients refuse food1 except that a knowledge of the reasons may enable us to overcome their disinclinations4 ,the thing to remember is that they must in some way be made to get enough4 ,care of ,patients with ,insanity1 ,accompanied by ,exhaustion4--,there is a condition associated with acute mania or melancholia--though it is sometimes seen in connection with the more chronic forms of insanity1--of exhaustion so overpowering1 that it may be rightly compared with the exhaustion of typhoid fever4 ,it may last a few days or a month1 or more1 if it does not sooner terminate fatally4 ,instead of the quiet delirium of typhoid fever there is generally violent mania or frenzy4 ,neither mind nor body is quiet2 sleep seems to have fled4 ,the patient may be destructive1 constantly out of bed1 fighting care1 refusing food1 and wetting and dirtying himself4 ,with these unfortunate conditions there generally is fever1 often to a considerable degree1 the heart is feeble1 the pulse rapid1 the tongue and lips dry and cracked1 the teeth covered with sordes1 and the body emaciated4 ,every case does not present all these symptoms1 nor show such alarming exhaustion4 ,there are many degrees of severity in this sickness4 ,such patients must never be left alone and need constant nursing day and night4 ,they must have food1 even if it is given forcibly4 ,they must1 if possible1 be kept in bed1 and covered with clothing1 and they must be kept clean4 ,if wakeful1 food must be administered during the night1 and especially towards morning1 which is the time of greatest weakness and physical depression4 ,hot baths may be ordered for these patients1 and stimulants and medicine to produce sleep left in the care of attendants4 ,how to give the baths and medicine1 what results are to be expected1 and what dangers are to be feared1 will be described later1 in the chapter on the administration of medicine4 ,there are certain symptoms which should warn the attendant of danger1 and which often precede death4 ,when any of these are present they should be reported to the physician4 ,they are3 partial or complete unconsciousness1 slow and labored1 rapid1 shallow1 or irregular breathing1 increased weakness and rapidity of heart or pulse1 cold hands and feet4 ,picking at the bedclothes1 or at imaginary objects in the air1 or vacant staring1 are bad symptoms4 ,the ,care of ,patients in a ,condition of ,dementia4--,it is to be remembered that dementia may be either1 a condition of chronic insanity without recovery1 or a less permanent state of mental enfeeblement following the acute attack1 and from which recovery may be hoped4 ,in the first of these conditions there is little to be done except to care for the patient4 ,many are able to do some work1 and should be allowed1 encouraged1 and taught to do it4 ,others do not know enough to dress1 feed1 or care for themselves4 ,these must be kept neatly dressed1 taken to the table and their food prepared1 taken to the bath and closet1 taken to walk1 and put to bed4 ,if not so attended to1 they will degenerate into a ragged1 dirty1 and even filthy state1 and the ward upon which they live will be offensive to the smell4 ,they should be frequently examined for body vermin1 as these pests are liable to breed and flourish among these patients4 ,the condition of the demented affords the best evidence of the care given to the patients in an institution4 ,attendants will often be gratified to see some of these apparently hopeless cases greatly improve and sometimes recover4 ,if attendants will watch their patients as they come out of acute mania or melancholia and become quiet1 they will often notice that they gain in flesh and become demented4 ,the dementia may be but partial1 or so very complete that the patient knows nothing4 ,from this they may gradually go on to improvement1 or even recovery4 ,they need all the care demanded by the confirmed dement1 and1 in addition1 advantage must be taken of every means to promote recovery4 ,they must be well fed1 regularly taken out for exercise1 and1 as they are able1 encouraged to employ themselves4 ,any symptoms of a return of their more violent condition1 any failure to sleep1 or change noticed in the health of the patient1 should be at once reported4 ,care of the ,convalescent ,patients4--,this is the period that precedes recovery from disease4 ,with the insane it is often a critical time1 and if not properly cared for they may fail to get well1 and become chronic lunatics4 ,the patients1 and frequently their friends1 think they are well and should be at home4 ,it is the attendant's duty to encourage the patient1 and to promote his confidence in the physician4 ,they should not be told of their past conditions1 or the disagreeable features of their sickness called to mind1 and their last1 as well as their first impressions of the asylum should be made pleasant4 ,sometimes there is a slight return of depression or mania1 and the patient may suddenly begin to lose sleep4 ,these conditions must be observed and reported1 for it is very easy for patients who are recovering to become as disturbed as when they were first insane1 and to suffer a relapse from which they may never recover4 ,it is hardly necessary to remind the attendant that employment1 amusement1 and all the healthful means of occupation afforded by the asylum1 should be judiciously allowed these patients4 ,sometimes patients feel too well4 ,they are too contented1 happy1 and indifferent1 and are very active in body and mind4 ,they want to work all day1 from early in the morning until late at night4 ,they sing as they work1 and talk rather loud and fast4 ,these patients need restriction2 they should not be allowed to work too much1 so as to overtax their strength4 ,so long1 however1 as they continue to gain1 and sleep well1 little is to be feared1 and they generally become quieter and recover4 ,the ,care of the ,epileptic ,insane4--,not all epileptics are insane1 but they are all liable to insanity4 ,generally the most hopeless and difficult to be cared for are brought to the asylum4 ,epileptics are liable to have fits at any time1 but some patients have them at night only4 ,the attack is generally sudden1 though sometimes patients have feelings that warn them of their approach4 ,this may precede the fit for a very short time1 or the patient may know during the day that he will have a fit during the night4 ,epileptic fits are accompanied by convulsions and unconsciousness1 and are the type of all convulsions4 ,the unconsciousness may be but momentary1 or last an hour or longer1 and even prolonged several days2 the convulsions may be but the twitching of a few muscles1 as of the face1 or may consist of the most terrible writhings1 and last for several minutes1 and be often repeated4 ,sometimes the fits are ushered in by a scream4 ,the fit itself is not dangerous to life1 but patients may at night turn their face downward and so smother2 they may fall from high places1 or down stairs1 or into the water1 or into the fire1 and so injure themselves4 ,there is little to do during an epileptic attack4 ,patients should not be held to prevent the convulsions1 but so that they shall not injure themselves4 ,a pillow should be placed under the head and the bands about the neck loosened4 ,the nurse is sometimes given remedies which1 if properly administered when the attack is felt to be coming on1 may ward off the fit4 ,nitrite of amyl in small glass pearls is a common remedy4 ,it is to be broken in a handkerchief and several strong breathfuls taken4 ,at their best1 epileptics are cross1 irritable1 quick-tempered1 unreasonable1 and quarrelsome1 and they will often give a blow at slight1 or even for no provocation4 ,after a fit they are frequently dangerous and always require guarded care and watching4 ,as has been said1 they may soon recover their natural condition1 or remain in a more or less prolonged state of unconsciousness1 or they may pass into a condition that appears natural1 but in which they have but little or no appreciation of their situation or surroundings1 or remember afterwards what they do4 ,in these states they may1 without warning1 make violent assaults1 commit murder or suicide1 or set things on fire4 ,sometimes they do outrageous acts1 such as beating their own children to death against the wall1 or mutilating them1 or roasting them to death on the stove4 ,many often suffer from hallucinations or illusions of sight or hearing1 and have delusions of impending harm or assaults1 and think they must defend themselves4 ,care of ,patients with ,paresis4--,this is a form of insanity characterized by progressive dementia and increasing bodily enfeeblement and paralysis4 ,the paralysis is partial1 not complete2 the patient's walk is feeble1 unsteady1 and shuffling2 the hands are tremulous1 lose their fineness of touch and ability to do work and write2 there is twitching in the muscles of the tongue and about the mouth1 and the speech is thick and indistinct4 ,as the disease progresses the patient becomes helpless1 bedridden1 wet1 and filthy4 ,the result is always death4 ,convulsions like those of epilepsy are liable to occur1 from which the patients may rally1 or in which they may die or linger a few days4 ,in the earlier stages the patients are often strong1 and controlled by delusions and hallucinations that make them violent4 ,sometimes they are simply good-natured and easily managed4 ,they generally have very exalted and extravagant delusions1 and are without appreciation of their condition or surroundings1 and are irritated at the control of the asylum1 and on account of their unreasonableness they can rarely be allowed the liberty others enjoy4 ,paretics often eat ravenously and rapidly1 they stuff their mouths full of food and so choke themselves4 ,their condition of paralysis may render them unconscious of danger and powerless to help themselves4 ,the care needed by bedridden1 filthy paretics is practically the same demanded by helpless paralytics1 the old1 feeble1 or demented class1 and all others who cannot care for themselves4 ,care of the ,paralytic1 ,helpless1 ,bedridden1 and ,filthy ,patients4--,there are many patients in an asylum who are indifferent to all the wants of nature1 who wet and dirty themselves4 ,some of these patients are bedridden2 some are about the ward1 but demented2 some are violent and maniacal1 and some from delusions make their persons and rooms as filthy as possible4 ,much can be done with many of these patients by regularly taking them to the closet1 and their bad habits may in this way be broken up4 ,patients of this class should be visited during the evening1 attended to frequently by the night watch1 and seen the first thing in the morning4 ,patients1 when dirty1 should be thoroughly washed and carefully dried4 ,their beds should be cleaned and changed1 and during the day clean clothing should be given them as often as required4 ,the greatest danger that comes from not keeping patients clean is the formation of bed-sores4 ,bed-,sores4--,bed-sores occur in patients long confined to bed1 and who suffer from exhaustive diseases4 ,paralytics and paretics are particularly liable to them1 the diseased condition of the nerves allowing the tissues to break down easily4 ,sometimes the fingers or toes of a paretic become gangrenous or large surfaces of the skin die1 and sometimes deeper tissues slough away rapidly4 ,these conditions may come on in a day or a night4 ,patients who are wet and dirty are more liable to have bed-sores4 ,they will always appear in a bedridden paretic in a few days if not kept perfectly clean4 ,they most frequently occur over bony projections where the weight comes in lying1 as upon the hips1 back1 or shoulders4 ,such patients1 should1 if possible1 be made to sit up several hours every day1 or placed first on one side1 then on the back1 and then on the other side4 ,if it can be done1 they should1 as they lie in bed1 rest their hips on an inflated rubber ring1 and if the skin is red the part should be bathed in diluted alcohol4 ,after being bathed and dried the skin about the hips should be dusted with some dry powder4 ,powdered oxide of zinc is perhaps the best1 but ordinary corn-starch flour is valuable and serves a good purpose4 ,insane patients frequently will resist all care and every effort to prevent bed-sores1 tearing off the bandages and dressings and picking and irritating the sores4 ,bed-sores should never be allowed to come because of want of attention or cleanliness1 but there are conditions in which they will appear in spite of every preventive4 ,bed-sores once formed should be treated as ulcers and according to the direction of the physician4 ,,chapter ,,ix4 ,,some ,,of ,,the ,,common ,,accidents ,,among ,,the ,,insane1 ,,and ,,the ,,treatment ,,of ,,emergencies4 ,the insane1 like others1 may suffer from almost any accident4 ,it is not intended to treat of all accidents1 nor how to care for every emergency4 ,this is so large a subject as to demand a separate text-book1 and there are several excellent ones1 that attendants would do well to read4 ,but there are among the insane certain kinds of accidents that are likely to occur1 certain classes who are liable to receive accidents1 and certain emergencies that frequently have to be cared for by the attendant1 and these will be described4 ,every injury received by a patient should be immediately reported to a physician4 ,attendants1 in the care of the insane should always remember the liability to accident and guard against it4 ,the old1 the feeble1 the paralytic1 and paretic need special care4 ,they are weak1 easily pushed over1 or stumble and fall1 and they cannot break the weight of their fall1 or so defend themselves2 they are irritable1 childish1 and often provokingly troublesome to the other patients1 and their bones seem to be easily fractured4 ,some injuries are self-inflicted1 some come to the patient in consequence of his own or others' violence1 and some1 as has been said1 from the very weakness of the patient4 ,care of ,fractured ,bones4--,any of the bones may be fractured1 and from slight cause4 ,the bones most frequently fractured are3 the collar bones1 the ribs1 the bones of the forearm just above the wrist1 the bones of the lower leg and of the thigh4 ,this last bone1 the femur1 is among old people most frequently broken at its neck1 which is the constriction of the bone just below the rounded end that fits into the joint at the hip4 ,fractures should1 as much as possible1 be let alone till the physician comes4 ,the parts should be kept quiet so as not to cause unnecessary pain1 and do further injury4 ,by rough handling it is very easy to push a fragment of bone through the skin1 thus making a simple fracture a compound one4 ,when a rib is fractured a sharp end may pierce the skin or the lung2 either complication is serious4 ,if the lung is injured the sputa will be bloody1 and the appearance of such a condition should be at once reported4 ,sometimes patients are violent after the injury and need to be firmly held1 and sometimes they have to be carried to the ward from the outside1 or placed upon a bed4 ,always carry the fractured limb as well as the patient4 ,if temporary splints are put on do not make them too tight1 and loosen them from time to time as needed4 ,the extremities sometimes swell rapidly after a fracture1 and the splints may so stop the circulation that1 in a few hours1 gangrene may be caused by them4 ,besides1 many patients cannot tell us if the part is swollen or painful4 ,the ,care of ,wounds4--,bites4 ,insane patients often bite others and penetrate the skin4 ,they may be very angry1 their mouths foul and running with saliva1 and this irritating substance introduced into the wound by the teeth may set up an ugly inflammation4 ,the wound should be immediately and thoroughly washed4 ,it should be well cleaned with a wet sponge or cloth1 and soaked in warm water4 ,a good after-dressing is powdered iodoform1 sprinkled over the wound4 ,wounds of the ,head4--,these wounds are quite common4 ,they should be thoroughly washed and cleaned from dirt and hair4 ,hemorrhage may be controlled by continued pressure upon the bones of the skull1 and if an artery is cut1 it can in this way be kept from bleeding till the physician arrives4 ,most wounds of the head1 even though large1 generally heal quickly1 but the most trifling ones may assume serious proportions1 and even prove fatal4 ,if within two or three days heat1 pain1 redness1 and swelling appear1 pus is probably forming beneath the scalp1 and this1 within a few hours1 may spread under a large surface and do serious injury1 or erysipelas may be set up4 ,injuries from ,blows on the ,head4--,persons are sometimes stunned by blows on the head4 ,they should be placed in bed with the head elevated1 and kept perfectly quiet till the doctor comes4 ,efforts should not be made to arouse them1 they should not be given liquor of any kind1 but ice may be applied to the head4 ,the danger to be feared is from the skull being fractured1 or from bleeding vessels inside of the skull4 ,either of these conditions may1 by pressure upon the brain1 cause unconsciousness1 paralysis1 and death4 ,the ,care of a ,cut ,throat4--,patients may cut their throats from ear to ear and do really little injury1 or they may make a small stabbing wound and divide a large blood-vessel and die almost immediately1 or they may cut the windpipe and not cut the blood-vessels4 ,the windpipe you can notice upon yourselves as a large1 stiff tube1 prominently situated in the middle and front of the neck2 the blood-vessels are together on each side of the windpipe1 and situated quite deep down among the muscles1 and the carotid artery may be felt beating by the finger4 ,little can be done by the attendants to stop the flow of blood1 even if the great blood-vessels are not cut4 ,the head should be kept bent forward and the chin pressed against the chest4 ,after the physician has dressed the wound1 constant watching day and night may be required to prevent the patient tearing off the bandages and reopening it4 ,this same rule of watchfulness applies to the after-care needed to be given to many cases of fracture1 and other serious injuries among the insane4 ,care of ,wounds of the ,extremities with ,hemorrhage4--,the hemorrhage from most simple wounds involving the cutting of skin and flesh or small arteries1 can usually be controlled by direct and continued pressure4 ,this may be done by a pad made of cloth1 packed and pressed into the wound1 or lint may be used in the same way4 ,water as hot as can be borne poured into the wound will frequently stop a hemorrhage when other means fail2 cold applications and ice are also useful4 ,if dirty1 a wound should be thoroughly cleaned1 being washed1 and1 if necessary1 soaked in warm water4 ,iodoform sprinkled so as to cover wounds1 is the best dressing for all attendants or nurses to apply1 while awaiting directions from a physician4 ,it keeps them clean1 promotes healing1 and lessens the danger of inflammation or the formation of pus4 ,when the arteries of the extremities are cut1 pressure should be made on the large artery leading to the part4 ,when the wound is high up on the arm1 pressure is made by the fingers or a padded key upon the artery that lies back of the collar bone1 and the attempt should be made to press it against the bone4 ,this is a difficult thing to do1 but nevertheless it should be attempted4 ,when the wound is lower down1 pressure is to be made by the fingers on the inner side of the upper arm1 at about the middle point and against the bone4 ,the artery runs downward1 near the inner border of the biceps muscle1 which is the large1 bulging muscle of the upper arm1 and can1 with a little care1 be felt beating by the fingers4 ,patients in breaking glass often cut one or both arteries at the wrist-joint where the pulse is felt4 ,these are large and bleed rapidly1 and when cut need the care just described4 ,when the artery in the leg is wounded1 pressure is to be made on the inner side of the thigh1 just below the groin4 ,the position of these large arteries1 and how to press against the bone1 is best learned by instruction and demonstration from a physician1 and with a little practice attendants will be able to easily and successfully do the act4 ,it is very tiresome to continue pressure with the fingers for a long time1 and attendants should relieve one another till the physician comes4 ,the ,care of ,sprains4--,sprains are a common accident and easily produced4 ,the great end of treatment is to keep the sprained joint quiet4 ,if the ankle or knee is sprained1 the patient should be carried to bed4 ,perhaps the best early treatment1 and the one that gives the greatest relief to pain1 is to place the joint in a tub of water as hot as can be borne1 and keep it hot by pouring in more4 ,the part should be kept in the water until it is parboiled4 ,the skin of some feeble or paralytic patients is easily scalded1 and some cannot tell when it is too hot2 the water therefore should never be uncomfortable to the hand of the attendant4 ,care of ,patients ,choking4--,this is a frequent accident1 and in order to know what to do when it occurs1 it is necessary to have a knowledge of the air passages of the throat4 ,we breathe through the mouth and nose4 ,they open into a common passage1 the pharynx1 which can be seen by looking into the mouth1 lying back of the tonsils4 ,passing downward1 it divides by branching into two tubes2 one the windpipe1 which is in front1 behind it is the oesophagus or gullet4 ,the point of division is just beyond the tongue1 and is almost within reach of the forefinger when crowded into the mouth4 ,the air we breathe passes through the mouth and nose to the pharynx1 thence to the lungs by the windpipe4 ,the food we eat passes from the mouth to the pharynx1 and thence to the stomach by the oesophagus4 ,there is at the opening of the windpipe a cover1 the epiglottis1 which is generally open1 but which closes when food is swallowed and helps to keep food from entering4 ,when a substance touches the opening of the windpipe1 we instantly cough to expel it4 ,a person may choke1 when the mouth and the pharynx back of it are filled with food2 or when a piece is lodged in the wind-pipe1 or a large piece in the oesophagus at the point of division1 and which crowds upon the windpipe1 or covers the opening4 ,food gets into the windpipe1 by being drawn in by a sudden and unexpected inspiration of air4 ,this may happen while eating or in vomiting solid food4 ,with this accidental exception all breathing stops during the act of swallowing4 ,some patients1 from paralysis1 especially paretics1 do not feel food when it is lodged in the throat2 others1 from great dementia1 may not know when they are choking1 and show no emotional signs of distress4 ,paretics are particularly liable to bolt their food1 and cram the mouth and throat full4 ,the symptoms of choking are immediate1 and if no relief is obtained1 the sufferer will die in a few minutes4 ,if the patient knows any thing1 he will show immediate signs of distress1 violent but ineffectual attempts to breathe1 and the face quickly becomes a dark blue color1 from the accumulation of carbonic acid in the blood4 ,immediate effects should be made to remove the obstruction1 and continued until the physician arrives1 who is to be sent for at once4 ,whatever is in the mouth and throat can be easily removed by the fingers2 the forefinger should then be crowded down the throat to feel for other obstructions1 care being taken not to push a piece of food into the windpipe4 ,if any thing is felt1 it can sometimes be pulled out by the fingers1 or a hair-pin may be straightened and bent1 or a piece of wire1 and an effort made to fish it out4 ,when in the gullet and beyond the fingers1 it may be pushed into the stomach by a feeding-tube4 ,artificial respiration may be needed1 but attendants must remember it is of no use until the obstruction to breathing is removed4 ,marbles1 coins1 buttons1 pieces of pencils1 needles1 pins1 and fish-bones1 are frequently swallowed4 ,the physician should be informed at once4 ,directions how to ,perform ,artificial ,respiration4--,what is to be done must be done quickly2 tight clothing about the neck and chest must be removed1 and the mouth should be cleaned of dirt1 water1 or any obstruction to the flow of air4 ,the body is then laid out flat on the back1 covered1 if possible1 with light warm blankets1 and some article should be folded and placed under the shoulders1 so as to raise them three or four inches4 ,the mouth must be kept open1 and the tongue pulled well forward1 as it is liable to fall backwards1 and cover the opening of the wind-pipe4 ,one person1 kneeling behind the head1 should grasp each arm at the elbow1 and1 draw them steadily around so that the arms will meet above the head4 ,a strong pull should be made upon them1 and they should be held a few seconds4 ,these movements elevate the ribs and enlarge the chest and produce an inspiration4 ,the arms are then to be brought to the side1 and pressed strongly against the lower ribs4 ,this last movement drives the air out of the lungs1 and makes an expiration4 ,these manipulations should be repeated1 slowly and regularly1 about sixteen times a minute1 and should1 when there is the slightest hope of life1 be continued at least thirty minutes4 ,the heart should be listened to1 in order to hear if it still beats4 ,warmth1 by hot-water bags1 bricks1 and soapstones should be secured1 care being taken not to burn the skin4 ,the limbs may be gently rubbed with warm cloths1 though it is not so important as some well-meaning people think4 ,the rubbing should be towards the heart4 ,as the breathing begins1 it should be still aided by the artificial means as long as necessary4 ,when the patient can swallow1 teaspoonful doses of brandy or whiskey1 to two or three of water1 may be given and repeated several times4 ,as soon as possible the patient should be put in a warm bed1 and milk and light food given4 ,care of ,patients when ,first ,burned4--,when a patient's clothing is first on fire1 dash water over him if near at hand1 if not wrap him in a blanket or some heavy woollen garment1 and smother the fire4 ,then unroll the patient and extinguish the smouldering pieces of clothing4 ,the clothing must be cut and clipped off4 ,great care must be taken not to tear open the blisters4 ,if any application is made1 it may be by linen cloths soaked in sweet or castor oil1 or equal parts of linseed oil and lime-water1 or a layer of flour and molasses may be applied over the burned surface4 ,these bland substances act largely by excluding the air1 which1 if blowing ever so quietly1 is always painful and irritating1 and they also protect the wound from the irritation of the bed and body clothing4 ,burns from scalding are practically treated in the same way as burns from fire4 ,care of ,frost-bites4--,toes1 fingers1 ears1 and noses are most frequently frozen4 ,they will sometimes freeze in a few minutes on a very cold day4 ,after a part is frozen there is no feeling of cold or pain1 and it looks perfectly white1 and is so stiff it may be broken4 ,persons who are frost-bitten should not be taken into a warm room4 ,they should be left in a cool room1 and the frozen part rubbed with cold water1 or ice1 or snow4 ,as these last melt they melt the frozen flesh4 ,if the parts are thawed too quickly gangrene is liable to follow4 ,care of ,patients in ,states of ,unconsciousness4--,this is not an accident1 but a frequent emergency4 ,the medical word for unconsciousness is coma4 ,it may be partial or complete1 may come on suddenly or slowly1 or may be accompanied by convulsions or paralysis4 ,the more frequent causes of coma1 are epilepsy1 the convulsions of paresis1 blows on the head1 hemorrhage in the brain or apoplexy1 some diseases of the brain1 sunstroke1 and some poisons4 ,when coma comes on1 attendants should observe1 if it is slow or sudden2 if the patient complains of pain in the head2 if the respirations are changed1 and how2 the condition of the pupils1 whether large1 contracted1 uneven1 or changeable2 if the mouth and face are drawn to one side2 if there is any paralysis of the arms or legs2 if there are any convulsions1 or twitching of muscles2 if the patient can be aroused1 and from time to time observe and count the pulse4 ,apoplexy is a term that is much used1 and is a condition of coma1 caused by pressure on the brain4 ,this organ is in a tight1 rigid box1 the skull4 ,if the fluid of the brain is much increased1 or blood-vessels ruptured1 pressure is the result1 and the soft tissues yield1 rather than the bony covering4 ,this pressure may destroy or injure the cells and fibres1 and so interfere with the function of the part4 ,another way that apoplexy occurs is by plugging of an artery of the brain1 so that it cannot deliver blood to the part to which it goes1 and consequently the part loses its ability to perform its function4 ,the plugging is most frequently due to a small clot floating in the blood1 and which is usually formed in the heart4 ,paralysis and apoplexy are often1 through ignorance1 used synonymously1 but they really mean very different conditions4 ,paralysis is a loss of power of contracting a muscle1 due to disease or injury of the nervous system2 it frequently follows or is associated with apoplexy4 ,in the case of apoplexy1 and most conditions of coma1 there is generally little for the attendant to do4 ,the patient should be put to bed1 with light coverings1 and the head raised on pillows4 ,do not annoy the patient by trying to rouse him1 and do not give stimulants4 ,care of ,sunstroke4--,a sunstroke is a very serious condition1 and when it occurs1 requires immediate efforts to save the life of the one suffering from it4 ,it generally comes on suddenly1 the patient first complaining of the head2 he soon becomes unconscious1 the skin hot and dry1 and the pulse full and bounding4 ,the treatment consists of taking the patient to a cool1 shaded place1 removing all unnecessary clothing1 applying ice or cold water to the head1 and bathing or sponging the body in cold water4 ,if the patient recovers1 the temperature will fall under this treatment4 ,if the heart begins to fail1 or the pulse becomes weak or fluttering1 small doses of whiskey and water may be given and repeated4 ,patients should not be taken out in the fields nor exposed places on very hot days1 except as ordered by the physicians2 they should wear light clothing and a straw hat2 if permitted to go out1 they should not overwork1 and should be allowed frequently to rest in the shade4 ,patients are easily injured by working in the sun2 headache caused1 recovery retarded1 and bad symptoms brought back1 without having the alarming conditions of sunstroke4 ,unconsciousness from ,poisoning4--,opium and its preparations1 including morphine1 chloral1 and the two extracts of hyoscyamus1 now so much employed in asylums1 namely1 hyoscine and hyoscyamine1 are medicines frequently given1 that poison in over-doses and produce coma4 ,these medicines and their effects will be described in the next chapter1 and at the same time the symptoms of poisoning by them1 and the treatment4 ,poisoning4--,poisonous drugs are not kept upon the wards4 ,attendants frequently have strong ammonia in their rooms to clean their clothing1 and a patient may get it and drink it4 ,it is a strong alkali1 and burns the throat and mouth4 ,vinegar is the best ready antidote1 but should be given immediately or not at all4 ,soft soap is a strong alkali1 and if eaten becomes an irritating poison4 ,again vinegar is the best antidote4 ,the best antidotes for acids are soda1 lime-water1 soap-suds1 and chalk2 for alkalies1 weak acids1 such as lemons1 oranges1 vinegar1 or cider4 ,olive oil1 eggs1 and mucilaginous drinks are the most bland and soothing remedies to give4 ,to vomit a person who has taken poison1 give a pint or a quart of lukewarm water2 to it may be added one or two teaspoonfuls of mustard4 ,syrup of ipecac is a common remedy1 the dose is a teaspoonful1 and repeated in ten minutes if necessary4 ,it assists vomiting to tickle the throat with a finger or a feather4 ,if after poisoning there is depression or approaching coma1 very strong tea or coffee is the best stimulant1 and it is as well an antidote to many poisons4 ,if the heart and pulse are very weak1 whiskey diluted with water may be given and repeated4 ,injury from ,eating ,glass4--,patients sometimes eat glass4 ,this injures by the edges cutting and inflaming the walls of the stomach and intestines4 ,this may be so severe as to cause death4 ,in the treatment do not give an emetic or a cathartic4 ,such food as has a tendency to constipate the bowels1 and such as will also enclose the glass and coat its sharp edges1 is to be given4 ,potatoes1 especially sweet1 oatmeal1 or thick indian-meal pudding1 are appropriate4 ,cotton1 which is generally at hand1 will1 if swallowed1 engage the glass in its fibres1 and so protect from injury4 ,injury with ,needles4--,this is a self-injury1 but it may be severe and require immediate attention4 ,patients may open a vein or an artery with a needle1 or plunge it into the eye4 ,but the more common way is for a patient to stick many needles under the skin1 sometimes to the number of several hundred4 ,sometimes patients introduce them near the heart or lungs1 and as a needle will often travel when in the flesh1 it may work its way into a deeper part1 and so a number get into the lungs or the heart1 causing death4 ,within a few weeks ,i saw two needles taken from a man's heart1 who died in consequence of their presence there4 ,an attempt or desire to so injure one's self should be guarded against by the attendants1 and if accomplished should be at once reported to the physician1 that efforts may be made to extract the needle4 ,,chapter ,x4 ,,some ,,services ,,frequently ,,demanded ,,of ,,attendants1 ,,and ,,how ,,to ,,do ,,them4 ,the ,administration and ,effect of ,medicine4--,the only proper way of giving medicine is by using standard weights and measures4 ,dropping medicine1 or using spoons or cups1 is not sufficiently accurate4 ,a drop may be half a minim1 or as large as two or even three4 ,the modern teaspoon holds ninety or more minims1 and a tablespoon more than half an ounce4 ,medicines are introduced into the system through the stomach1 the lungs1 the rectum1 the skin1 or by being injected into the tissues1 under the skin4 ,they are either local or general in their effects4 ,a blister or a poultice is a local remedy1 so is an emetic1 that acts by irritating the walls of the stomach4 ,general medicines are absorbed into the blood1 and carried to different parts of the body4 ,the following are a few of the reasons for which medicine is given3 to relieve pain1 to give sleep1 to produce vomiting1 to check vomiting1 to move the bowels1 to check diarrhoea1 to assist digestion1 to produce a greater or diminished flow of urine1 to increase the perspiration1 to increase the red blood corpuscles1 to check hemorrhage1 to regulate the action of the heart1 to overcome the effects of poison1 to increase or diminish the amount of blood in the brain1 to control spasm1 to diminish the temperature in fever4 ,in some cases the effect desired and expected from a medicine given to a patient is told to the attendant1 who should closely observe and be able to report the result4 ,sometimes medicines are left in the hand of the attendant1 to give in repeated doses1 at stated intervals1 till a desired effect is produced4 ,the attendant is also instructed to watch for certain symptoms which show that the medicine is doing harm1 when it is to be discontinued4 ,an attendant1 who has studied and learned1 how and what to observe in his patient1 will be able to give intelligently any medicine ordered by a physician4 ,sometimes medicines1 given in large or long-continued doses1 cause symptoms that an attendant should notice and report to the physician2 some of these are1 eruptions on the face and body1 puffiness about the eyes1 irritation and running of the eyes1 a metallic taste in the mouth1 bleeding of the gums or soreness of the teeth and profuse flow of saliva1 nausea1 vomiting1 diarrhoea1 constipation1 indigestion1 ringing of the ears1 feeling of fulness in the head1 headache1 dizziness1 drowsiness1 coma1 convulsions1 or convulsive movements of muscles4 ,in asylums1 medicines are mostly sent to the wards in single doses1 each cup or bottle being marked with the name of the patient for whom it is intended4 ,the tray in which they are carried should never be set down and left1 for a mischievous or suicidal patient may poison himself by taking every thing he can get hold of4 ,no patient1 unless ordered by the physician1 should be allowed to keep his cup and take his medicine at his leisure4 ,suicidal patients often ask to do this1 and then save the medicine1 until they have enough to poison themselves4 ,others will throw the medicine away4 ,the way to administer medicine to the insane is to give it personally to the patient1 and also see that it is swallowed4 ,it is a frequent custom of many patients to retain the medicine in the mouth1 and1 when the attendant has left1 to spit it out4 ,it is often very important that patients should take the medicine ordered1 and every effort should be made to induce them to take it4 ,such patients should be designated by the physician4 ,night medicines1 or those given about bedtime1 are usually of great importance4 ,all patients who refuse to take their medicine should be reported to the physician4 ,the reasons for refusing medicines are various2 some say they are perfectly well and need no medical treatment1 others think the medicine injures them1 that it turns their skin black1 or poisons them1 or that it is wrong to take it1 or displeasing to ,god2 ideas much like those that we learned were the causes for the refusal of food4 ,attendants are to use every effort to get patients to take medicine1 and may employ as much force as they were instructed to use in giving food1 but no more4 ,patients should not be deceived about medicines1 nor told by attendants that it is nothing1 that it is only a little water1 or some nice drink that is sent to them1 nor should an attempt be made to give them1 by trying to disguise them in food or drink1 except by the permission of a physician4 ,patients should1 on the other hand1 be told that it is medicine1 that the doctor ordered it for them1 that it is for their good to take it1 that it is given to help them get well4 ,the giving of medicine and food is among the most important and frequent duty that an attendant is called upon to perform1 or assist others in doing4 ,attendants must remember that many medicines are injurious or even poisonous1 if not properly given1 or if mixed with other medicines1 or if given to the wrong patient2 they should therefore1 never make a mistake1 or1 if by carelessness they commit one1 should immediately report it4 ,opium and ,some of its ,preparations4--,opium is a medicine that is very frequently given to patients in an asylum4 ,the ordinary dose is one grain4 ,tincture of opium1 or laudanum1 is opium dissolved in alcohol4 ,ten minims equal one grain of opium4 ,camphorated tincture of opium1 or ,paregoric1 is a weaker alcoholic solution1 with some camphor1 and flavored with a pleasant aromatic4 ,one half a fluid ounce equals a grain of opium4 ,morphine is a white powder extracted from opium4 ,an eighth of a grain about equals a grain of opium4 ,opium1 in some of its forms1 is a common household remedy4 ,to an adult1 not more than one grain should be given2 it should not be repeated more than once1 nor less than six hours after the first dose4 ,it would be better if never given1 except by a physician's order4 ,under no circumstances should any one but a physician give it to a weak or old person1 or to a young child4 ,opium1 is given in ordinary doses to relieve pain1 to check diarrhoea1 to relax spasm of muscles1 and to produce sleep4 ,the sleep from opium is generally quiet and refreshing1 and one from which the patient can be easily aroused4 ,an attendant will frequently be told when the medicine is given and directed to note and report its effect4 ,opium ,poisoning4--,the taking of opium is a frequent way of committing suicide by persons outside of asylums4 ,sometimes patients manage to save their doses1 or they steal it from the tray1 or1 if there is some sent to the ward for repeated doses1 they secure it through the carelessness of an attendant1 or occasionally it is secretly sent to patients by officious outside friends1--thus poisoning by opium sometimes occurs among asylum patients4 ,the full symptoms of poisoning are profound coma1 pupils contracted to pin-points1 and which do not respond to light2 very slow respiration1 often not more than four or six times a minute1 but heavy and labored4 ,sometimes the effect of the drug is but partial1 the patient can be aroused for a moment1 but falls to sleep again1 or the symptoms may be even less pronounced4 ,the treatment of opium poisoning1 before the physician comes1 consists in giving very strong coffee1 or tea1 an emetic1 and in trying to keep the patient awake by walking him about1 or1 if this is not possible1 to keep him from falling into deeper coma1 by shaking1 calling loudly in the ear1 and striking and slapping the body with wet towels4 ,chloral4--,this is a white crystal1 with a pungent1 burning taste4 ,it is always dispensed1 dissolved in water1 and should be further diluted when given to a patient4 ,the dose is from ten to thirty grains4 ,it is too powerful a drug to be given1 except upon the order of a physician4 ,chloral is given to produce sleep1 which is usually quiet and natural4 ,the effect lasts about four or six hours4 ,the symptoms of poisoning are not so marked as to make it easy to know that they are caused by chloral4 ,there is generally a weak heart and pulse1 and feeble respiration1 and the patient is in a deep sleep1 from which he may be aroused2 or the coma may be profound1 and continue uninterrupted till death4 ,the treatment consists in giving an emetic1 stimulants1 coffee1 and1 if necessary1 performing artificial respiration4 ,hyoscyamine and ,hyoscine4--,these are extracts1 from the leaves and seeds1 of the plant hyoscyamus4 ,these are very powerful medicines1 and are never given except on the order of a physician4 ,they are always given in solution4 ,the action of both is practically the same4 ,in ordinary doses they quiet restlessness1 produce muscular weakness1 flushing of the face1 dryness of the tongue1 wide dilatation of the pupils1 and frequently cause sleep4 ,these effects should be noticed and reported4 ,these medicines are mostly given to patients who are continually restless1 violent1 and sleepless1 and the object is to bring quiet1 repose1 and sleep4 ,large doses may produce coma1 very heavy breathing1 and great muscular weakness2 the pulse however is full and strong1 but if it should fail1 the physician should be at once sent for4 ,alcohol and ,stimulants4--,it is the alcohol in liquors that intoxicate1 and it is that part1 also1 of liquor that stimulates when given as a medicine4 ,whiskey1 brandy1 and gin are about one half alcohol4 ,the dose is a tablespoonful1 in water1 and not repeated oftener than two or three times4 ,wines are about one fifth alcohol1 beers and cider about one twentieth4 ,liquors containing alcohol are never to be given to patients as a beverage1 but always as a medicine1 and1 except in emergencies1 never without a physician's order4 ,do not give them in emergencies1 without a good reason for so doing1 and not simply because you feel you must do something1 for in some emergencies they may do a great deal of harm1 and perhaps1 a fatal injury4 ,alcohol is mostly given to stimulate the action of the heart4 ,a stimulant is something that arouses or excites to action4 ,it is given 7in the doses just mentioned7 in accidents1 when the heart is very weak1 the pulse almost or quite imperceptible1 the face pale and pinched1 and the extremities cold4 ,in continued sickness1 with exhaustion1 stimulants are sometimes left with the attendant to give1 with directions about the size of the dose and its frequency4 ,if it quiet the patient1 strengthen the heart and pulse1 it is doing good2 but if restlessness comes on1 the face becomes flushed1 or if the pulse is made more rapid and feeble1 it is probably doing harm1 and should be discontinued1 and the physician informed4 ,dry and ,moist ,heat4--,in applying heat1 either dry or moist1 to the insane1 care must always be used to protect the skin from being blistered4 ,this happens very easily when it is applied directly to old1 feeble1 paralyzed1 or paretic patients1 and also to those who are too demented to complain if they are being burned4 ,burns are very serious accidents among this class of patients1 and may1 if they extend over a large surface1 even though not deep1 heal with difficulty1 and even prove fatal4 ,dry heat is applied by means of rubber bags filled with hot water1 hot-sand bags1 bricks1 or soapstones1 and by the lamp bath4 ,moist heat by hot baths1 fomentations1 turpentine stupes1 and poultices4 ,hot ,baths and ,wet ,packing4--,hot baths are sometimes prescribed for patients4 ,the water should be about #ajj degrees ,f41 and1 if ordered1 slowly increased to #aaj deg4 ,the patient is to be left in as long as directed1 which may be but a few minutes1 or half an hour1 or even longer4 ,sometimes a blanket is ordered thrown over the tub1 the head only being uncovered4 ,when the bath is being given1 the pulse should be counted2 if it become weak and rapid1 if the face become flushed1 and the patient complains of dizziness1 or if the lips show venous congestion1 the patient should be at once removed1 and1 unless there is immediate recovery from these evil effects1 the physician should be informed4 ,in giving a wet pack1 the patient is wrapped in a sheet1 without any clothing1 wet either in cold or warm water1 as ordered1 and then rolled in a blanket1 put to bed1 and left in it as long as directed4 ,these methods of treatment are frequently ordered by physicians for patients who are restless1 violent1 and sleepless1 with a view of giving quiet and sleep4 ,the attendant should observe and report the result4 ,application of ,cold4--,the attendants are frequently ordered to apply ice to some part of the body1 for the purpose of producing local cold4 ,the ice should be broken into small pieces and put into a bladder1 or rubber bag1 partly filling it4 ,it remains sufficiently cold until all the ice is melted4 ,another way is to put a piece of ice in a sponge and bathe the part4 ,when cold cloths or compresses are applied1 the heat of the body soon warms them1 when they become warm applications and act as a poultice2 they should therefore be frequently changed4 ,in applying moist dressings care must be used not to have any leaking nor wetting of the bed or clothing4 ,hypodermic ,injections4--,morphine1 hyoscyamine1 or hyoscine1 in solution1 are frequently injected under the skin4 ,the direction to do this1 and the quantity to be given1 will1 in every case1 be ordered by the physician4 ,a fold of the skin is held between the finger and thumb1 while the needle held in the other hand is quickly pushed straight under the skin to the depth of about half an inch4 ,care should be used to inject no air1 and not to inject the contents of the syringe1 into a vein4 ,forcible ,feeding with the ,stomach-,tube4--,attendants are frequently called upon to assist in the forcible feeding of patients1 and in some cases may themselves be directed to do it4 ,the dangers of feeding are that the pharynx may be filled with fluid1 and the patient choke1 or it may be drawn into the lungs1 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 injured1 and occasionally it happens that the mere pressure of the tube causes choking4 ,attendants should watch the process of feeding1 and particularly the face1 for symptoms of venous congestion1 and report to the physician any thing they see that denotes danger4 ,in preparing for feeding1 attendants must see that the food is properly made ready4 ,if any thing is to be mixed with milk1 it should be mixed so as to be perfectly smooth1 without lumps1 and so it will run easily through the tube4 ,if some concentrated food is used1 it is better to put it in a small quantity of milk1 just enough to make it liquid1 that it may be given first4 ,medicines ordered for feeding are not to be mixed with a large quantity of milk1 but saved1 that they may be given directly from the dispensing bottle whenever the physician desires to do so4 ,every thing should be got ready for feeding before the physician arrives4 ,upon a tray should be all the feeding apparatus--the food and medicine1 several spoons1 and cups1 and a pitcher4 ,near at hand should be plenty of water1 soap1 and towels1 and a tin basin4 ,it is very provoking to have to wait for many things to be brought after the patient has been got ready4 ,many patients are easily fed4 ,some like it1 but some violently and furiously resist4 ,such patients should be restrained to a chair fixed to the floor1 and the more securely this is done the more easily can they be fed1 and with less fatigue and danger of their being injured4 ,the patient's clothing should be well protected from being soiled1 by towels about the neck1 and a basin should always be held under the chin to catch falling liquids and any thing vomited4 ,the holding the head and wedge is an important matter1 and is some thing that belongs to the attendant to do4 ,the attendant stands behind the patient1 and holds the chin by the right hand1 and with the left firmly grasps the wedge1 which is inserted straight into the mouth1 between the back teeth1 about two or three inches4 ,the wedge should be grasped with the palm upwards1 and the little finger and side of the hand should be pressed firmly against the chin4 ,if held in this way there is little danger that in violent struggles1 the wedge can be suddenly driven backward and wound and tear the soft parts of the mouth4 ,if the throat fills with fluid1 the attendant who holds the head should bend it far forward1 that it may1 if possible1 run out of the mouth4 ,after feeding1 patients' faces should be washed4 ,they should be watched for some time to see that they do not vomit1 or1 as is often the case1 that they do not make themselves vomit4 ,there is no special difference in caring for a patient fed with a nasal tube1 except that the wedge is not used4 ,if attendants are allowed to feed1 they must remember all the dangers1 and guard against them4 ,in introducing the tube1 the forefinger of the right hand is to be introduced at the same time1 and1 as the tube passes over the tongue it is to be turned downward by the finger and gently pushed into the oesophagus4 ,if there seem to be unusual difficulty in so doing1 severe and unusual struggling1 or the slightest symptom of danger1 cease the effort to feed1 and report to the physician4 ,of course no attendant would undertake to feed any patient unless ordered to do so by the physician1 which order would be given1 if at all1 only after careful training and in cases easily fed4 ,nutritive ,enemata4--,it is often necessary to feed patients by the rectum4 ,this is done by injecting food1 to the amount of four or six ounces4 ,care should be used to inject no air4 ,the nozzle of the syringe well oiled is to be gently introduced1 and the fluid slowly forced into the bowel4 ,the patient should lie on the left side1 near the edge of the bed1 with the knees well drawn up4 ,if the patient resist1 he must be placed upon the back1 the legs separated and firmly held4 ,this may require four or six attendants1 but enough should always be at hand to thoroughly and easily overcome the patient4 ,before giving the first injection of food the bowels should be moved by an injection of soap and water4 ,sometimes the injected food escapes from the rectum4 ,the patient should be watched to see if this happens4 ,in such a case a long tube can be introduced into the rectum1 about four or six inches1 and the food injected through it4 ,the tube should be well oiled1 and introduced slowly and with gentle force4 ,patients often thrive upon this way of feeding4 ,the character of the food will be ordered by the physician4 ,,publications ,,of ,g4 ,p4 ,,putnam',s ,,sons4 ,,students' ,,manuals4 ,manual of ,prescription ,writing4 ,by ,,matthew ,d4 ,,mann1 ,m4,d41 late ,examiner in ,materia ,medica and ,therapeutics in the ,college of ,physicians and ,surgeons1 ,new ,york4 ,revised edition4 #afmo1 cloth4 #a4jj4 ,manual of ,practical ,normal ,histology4 ,by ,t4 ,,mitchell ,,prudden1 ,m4,d41 ,director of the ,physiologica1 and ,pathological ,laboratory of the ,alumni ,association of the ,college of ,physicians and ,surgeons1 ,n4 ,y41 etc4 #afmo1 cloth4 #a4be4 ,students' ,manual of ,venereal ,diseases1 being the ,university ,lectures delivered at ,charity ,hospital1 ,b4 ,i41 during the ,winter ,session of #ahgi-hj4 ,by ,f4 ,s4 ,,sturgis1 ,m4,d41 ,clinical ,lecturer on ,venereal ,diseases in the ,medical ,department of the ,university of the ,city of ,new ,york1 etc41 etc4 ,fourth edition4 #afmo1 cloth4 #a4be4 ,students' ,manual of ,diseases of the ,skin4 ,by ,l4 ,d4 ,,bulkley1 ,m4,d4 ,large #afmo4 #a4be4 ,students' ,manual of the ,diseases of the ,nose and ,throat4 ,by ,j4 ,m4 ,w4 ,,kitchen1 ,m4,d4 #afmo1 illustrated1 cloth4 #a4jj4 ,students' ,manual of the ,pharmacopoeia of the ,diseases of the ,throat4 ,by ,,george ,m4 ,,lefferts1 ,m4,d4 #a4jj4 ,students' ,manual of ,rational ,electro-,therapeutics4 ,by ,r4 ,w4 ,,amidon1 ,a4,m41 ,m4,d41 ,lecturer on ,therapeutics at the ,woman's ,medical ,college of the ,n4 ,y4 ,infirmary1 etc41 etc4 #afmo4 #a4jj4 ,students' ,manual of ,diseases of the ,nerves4 ,by ,e4 ,c4 ,,seguin1 ,m4,d4 7,in preparation47 ,,suggestive ,,therapeutics4 ,a ,treatise on the ,nature and ,uses of ,hypnotism4 ,by ,h4 ,,bernheim1 ,m4,d41 ,professor in the ,faculty of ,medicine at ,nancy4 ,translated from the second and revised ,french edition1 by ,,christian ,a4 ,,herter1 ,m4,d41 of ,new ,york4 ,octavo1 cloth #c4ej ,i present this volume to the ,english-speaking medical public in the belief that it throws important light upon a subject which has too long been misunderstood and ignored4--,,extract ,,from ,,translator',s ,,preface4 ,,psychiatry4 ,a ,clinical ,treatise on ,diseases of the ,fore-,brain1 ,based upon a ,study of its ,structure1 ,functions1 and ,nutrition4 ,by ,,theodor ,,meynert1 ,m4,d41 ,professor of ,nervous ,diseases and ,chief of the ,psychiatrical ,clinic in ,vienna4 ,translated 7under authority of the author7 by ,b4 ,,sachs1 ,m4,d4 ,octavo1 cloth #b4ge ,we most earnestly urge our readers to put this work in their libraries as one that will prove indispensable4--,quarterly ,journal of ,inebriety1 ,jan41 #ahhf4 ,,the ,,insane ,,in ,,foreign ,,countries4 ,by ,,william ,p4 ,,letchworth1 ,president of the ,new ,york ,state ,board of ,charities4 ,octavo1 cloth #c4jj ,,the ,,errors ,,of ,,refraction4 ,by ,,francis ,,valk1 ,m4,d41 ,new ,york4 #bde pages4 ,numerous illustrations 7some in color7 #c4jj ,,physiological ,,notes ,,on ,,primary ,,education ,,and ,,the ,,study ,,of ,,language4 ,by ,,mary ,,putnam ,,jacobi1 ,m4,d4 #abmo1 cloth4 #a4jj ,,essentials ,,of ,,physics ,,and ,,chemistry4 ,by ,,condict ,w4 ,,cutler1 ,m4,s41 ,m4,d4 ,third edition1 enlarged and revised4 ,cloth #b4jj ,,the ,,story ,,of ,,the ,,bacteria4 ,by ,t4 ,m4 ,,prudden1 ,m4,d41 author of ,a ,manual of ,practical ,normal ,histology4 #afmo1 cloth 4#ge ,,hysteria ,,and ,,other ,,nervous ,,affections4 ,a ,series of ,essays1 by ,,mary ,,putnam ,,jacobi1 ,m4,d4 #b4jj ,,contents--#a4 ,loss of ,nouns in ,aphasia4 #b4 ,case of ,nocturnal ,rotary ,spasm4 #c4 ,the ,prophylaxis of ,insanity4 #d4 ,antagonism between ,medicines1 and between ,remedies and ,disease4 #e4 ,hysterical ,locomotor ,ataxia4 #f4 ,consideration on ,tumors of the ,brain4 ,,alt4 ,the ,human ,eye in its ,normal and ,pathological ,conditions4 ,by ,,adolph ,,alt1 ,m4,d41 ,lecturer on ,ophthalmology in ,trinity ,medical ,college1 ,toronto1 with the editorial assistance of ,t4 ,r4 ,,pooley1 ,m4,d4 #hvo1 illustrated4 #c4jj4 ,,althaus4 ,on ,sclerosis of the ,spinal ,cord4 ,including ,locomotor ,ataxy1 ,spastic ,spinal ,paralysis1 and other ,system ,diseases of the ,spinal ,cord2 their ,pathology1 ,symptoms1 ,diagnosis1 and ,treatment4 ,by ,,julius ,,althaus1 ,m4,d4 ,with nine illustrations4 #hvo1 cloth4 #b4ge4 ,,browne ,,and ,,behnke4 ,voice1 ,song1 and ,speech4 ,a ,practical ,guide for ,singers and ,speakers1 from the ,combined ,view of the ,vocal ,surgeon and the ,voice-,trainer4 ,by ,,lennox ,,browne1 ,f4,r4,c4,s41 ,surgeon to the ,throat and ,ear ,hospital1 ,london1 and ,,emil ,,behnke1 author of ,the ,mechanism of the ,human ,voice4 ,with numerous illustrations by wood-cutting and photography4 #hvo1 cloth4 #d4ej4 ,,buhl4 ,inflammation of the ,lungs1 ,tuberculosis1 and ,consumption4 ,by ,professor ,,ludwig ,,buhl1 of ,munich4 ,translated by ,drs4 ,m4 ,d4 ,,mann and ,s4 ,b4 ,,st4 ,,john4 #hvo1 cloth4 #a4ej4 ,,bulkley4 ,eczema and its ,management4 ,a ,practical ,treatise ,based on the ,analysis of ,two ,thousand ,five ,hundred ,cases of the ,disease4 ,new and ,revised ,edition4 ,by ,l4 ,d4 ,,bulkley1 ,m4,d4 ,large #hvo4 #c4jj4 ---- ,acne and its ,treatment4 ,a ,practical ,treatise ,based on the ,study of ,one ,thousand ,five ,hundred ,cases of ,diseases of the ,sebaceous ,glands4 #hvo1 illustrated4 #b4jj4 ,,clarke4 ,a ,manual of the ,practice of ,surgery4 ,by ,,fairlie ,,clarke1 ,m4,d41 ,f4,r4,c4,s41 late ,assistant ,surgeon to ,charing ,cross ,hospital4 ,third ,edition1 ,revised1 ,enlarged1 and ,illustrated by #aij ,engravings on ,wood4 #b4ej4 ,,corning4 ,brain-,rest4 ,by ,j4 ,,leonard ,,corning1 ,m4,d4 #afmo1 cloth4 #a4jj4 ,,croom4 ,manual of the ,minor ,gynecological ,operations and ,appliances4 ,by ,j4 ,,halliday ,,croom1 ,physician to the ,royal ,maternity ,hospital1 ,edinburgh4 ,second ,edition1 ,revised and ,enlarged1 with #ab ,plates and #dj ,wood-cuts4 #b4be4 ,,cutter4 ,a ,dictionary of the ,german ,terms ,used in ,medicine4 ,by ,,george ,r4 ,,cutter1 ,m4,d41 ,surgeon of the ,n4 ,y4 ,eye and ,ear ,infirmary1 etc41 etc4 #hvo1 cloth extra4 #c4jj4 ,,darling ,,ranney4 ,the ,essentials of ,anatomy1 prepared as a ,text-book for ,students1 and a ,work of ,easy ,reference for the ,general ,practitioner4 ,by ,,wm4 ,,darling1 ,professor of ,anatomy1 and ,a4 ,l4 ,,ranney1 ,adjunct ,professor of ,anatomy1 in the ,medical ,department of the ,new ,york ,university4 #hvo4 #c4jj4 ,,ranney 7,a4 ,l41 ,editor74 ,anatomical ,plates4 ,arranged as a companion volume for ,the ,essentials of ,anatomy1 and for all works upon ,descriptive ,anatomy4 ,comprising #dci designs on steel by ,prof4 ,j4 ,n4 ,,masse1 of ,paris1 and numerous diagrammatic cuts selected or designed by the ,editor1 together with explanatory letter-press4 ,large #hvo1 cloth extra4 #c4jj4 ,,dowse4 ,syphilis of the ,brain and ,spinal ,cord4 ,showing the part which this agent plays in its production of ,paralysis1 ,epilepsy1 ,insanity1 ,headache1 ,neuralgia1 ,hysteria1 ,hypochondriasis1 and other ,mental and ,nervous derangements4 ,by ,,thomas ,,stretch ,,dowse1 ,m4,d41 ,fellow of the ,royal ,college of ,physicians in ,edinburgh1 ,president of the ,north ,london ,medical ,society1 etc41 etc4 #hvo1 illustrated4 #c4jj4 ---- ,neuralgia3 ,its ,nature and ,curative ,treatment4 ,forming ,part ,,ii4 of ,diseases of the ,brain and ,nervous ,system4 #hvo1 cloth extra4 #b4be4 ---- ,the ,brain and the ,nerves4 #hvo1 cloth4 #a4ej4 ,,jacobi4 ,infant ,diet4 ,by ,a4 ,,jacobi1 ,m4,d41 ,clinical ,professor of ,diseases of ,children1 ,college of ,physicians and ,surgeons1 ,new ,york4 ,revised1 enlarged1 and adapted for popular use by ,,mary ,,putnam ,,jacobi1 ,m4,d4 #abmo1 boards4 #ej cents4 ,,kitchen4 ,consumption3 ,its ,nature1 ,causes1 ,prevention1 and ,cure4 ,by ,j4 ,m4 ,w4 ,,kitchen1 ,m4,d4 #abmo1 cloth4 #a4be4 ,,knapp4 ,cocaine and its ,use in ,ophthalmic and ,general ,surgery4 ,by ,h4 ,,knapp1 ,m4,d4 ,with supplementary contributions by ,drs4 ,f4 ,h4 ,,bosworth1 ,r4 ,j4 ,,hall1 ,e4 ,l4 ,,keyes1 and ,,wm4 ,m4 ,,polk4 #hvo1 cloth4 #ge cents4 ,,mattison4 ,the ,treatment of ,opium ,addiction4 ,by ,j4 ,b4 ,,mattison1 ,m4,d4 #hvo1 cloth4 #ej cents4 ,,mittendorf4 ,a ,manual of ,diseases of the ,eye and ,ear4 ,by ,w4 ,f4 ,,mittendorf1 ,m4,d4 ,third ,edition1 ,revised4 ,fully ,illustrated4 #hvo1 cloth extra4 #d4jj4 ,,parker4 ,cancer3 ,its ,nature and ,etiology4 ,with ,tables of #cig ,illustrated ,cases4 ,by ,,willard ,,parker1 ,m4,d4 #hvo1 cloth4 #a4ej4 ,g4 ,p4 ,,putnam',s ,,sons1 ,,new ,,york ,,and ,,london