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THE NURSING OF MENTAL INVALIDS.*

BY SPENCER KINNEY, M.D.,

Proprietor of Easton Sanitarium, Easton, Fa.

PROBABLY no department of your work will ever tax you so much as looking after the welfare of this class of patients. In the first place, you must be well in body and mind. It is necessary to possess an equipoise of your mental faculties to such a degree that nothing will occur to interfere with your judgment in the exercise of duties you may suddenly be called upon to perform. No one can be master of another unless he has first control of himself. To be domineering is not to be masterful in the right direction.. To be quiet in manner; to possess a low tone of voice; to demonstrate that you know what you are about, and that incidents of an emergency character do not disturb you, are things that you must all learn to cultivate to the highest degree possible. To exercise your duties with the appearance of never being tired or exhausted, and of still having a reserve to draw upon is the acme of successful work with a disturbed class of patients.

With the sane sick, you will meet with trials and endless annoyances when engaged in private nursing; and the necessary restrictions to be found in hospital work will many times annoy you greatly; but with this class of patients, possessing understanding of their sickness and of what you are doing for them, you will meet with appreciation of your work that is a great offset in the line of compensation when recovery takes place, and you hear their words of thankfulness. With the insane sick this is all different. With their perverted minds, jealousy, anger, hatred, and al' uncharitableness seem to be their portion. Everything is unreal. The best friends they may have possessed are now their most bitter enemies. Not only are their minds changed, but their personalities have

Read before the Training School of the Easton (Pa.) Hospital, Dec. 7, 1909.

become completely warped through their perverted manner of looking at everyday affairs. You as a nurse, will probably, in their belief, be in league against their best interests, depriving them of their liberty; and you will be viewed with resentment in the many forms in which insanity makes itself manifest.

You can have no control of the patient you fear. You must be without fear; and you must possess control that comes from confidence in your knowledge of the work, in order to make a success of nursing the insane. At no time in your professional life will it be more necessary for you to be observant than in your work among this class of patients. The objective symptoms must be closely watched, and they are of the utmost importance. These you must take note of, informing the physician in attendance of what you have observed. Frequently no reliance can be placed upon replies by an insane patient in answer to questions; and you can readily see the necessity for attaching importance to the objective symptoms as they appear.

It is interesting to note what other physicians who have made this department a study think regarding a suitable nurse for the nervous and insane.

Dr. S. Weir Mitchell, whose life has been spent in promoting the good of those nervously ill, says of this branch of nursing: "A life spent beside such a sick bed is test, alike of character and health. It requires a strong body, a fortunate balance of moral and intellectual qualities to escape from being made morbid by constant contact with such suffering. Intensely sympathetic people are surely hurt by it, and themselves made morbidly sensitive. When the unhappy invalid becomes exquisitely ill tempered under the long pangs of illness the constant nurse must endure a thousand petty trials of temper, and must

know when to yield and when to resist the tiny and numberless oppressions of her sick tyrant. But incessant battle with one's self is exhausting and soon begins to show results upon the healthy nurse, cooped up in the sick room; and pallid face, loss of energy, and certain pensive obedience to routine duties are the usual consequence."

Every nurse is supposed to possess tact. No nurse can make a success with the insane without it. Dr. J. Wallace Anderson says: "Tact is a quality not easily defined; but if we go back to the original meaning we can construe a definition upon it. It means, literally, 'Touch'-Touch of skill and experience; but it has a wider significance. It includes a mental touch, something more complete; not a touch merely, but a grasp a grasp of the situation, the appreciation of a difficulty, the grasping of it on all sides so that it disappears under your hands."

Dr. Clara Barrus, in her book on "Nursing the Insane," says: "The ideal nurse is one whose bodily presence breathes health and cleanliness; one of quiet garb, of noiseless step, of soothing hand, of cheerful spirit, of hopeful heart, and one of ready. but judicious sympathy. We must not forget the 'Low and gentle voice,' which, if it be 'An excellent thing in woman," is especially so in a nurse. To these qualities must be added punctuality, truthfulness, patience, caution, courage, a spirit of untiring helpfulness, vigilance that never sleeps, a sympathy that is inexhaustible, and a tact that can cope successfully with the most trying and complex of situations.

"The nurse for mental and nervous invalids needs to be especially careful and conceal prejudices, to beware of showing favoritism, to conquer resentment and antipathy; study the art of peace-making; to learn when to speak, and when to refrain from speaking; when to act and when not to act. She must learn humility and forbearance-in short, she must cultivate the virtues that she becomes but little lower than the angels."

There are several definitions which it

will be necessary for you to know, and which you should not forget; and these are: Delusions, Illusions and Hallucinations.

A delusion is a false belief; as for instance, one may imagine that he is wealthy when he is not, and will attempt to spend money under the belief that he has it to spend, and cannot be led to believe that he is not rich.

An illusion is a mistaken perception of the senses; as a noise may be construed to be the voice of a friend; or an inanimate object may be thought to be an animal.

A hallucination is a false perception of the senses; as a person may believe that others are talking about him, that he hears voices when it is not so.

These terms must not be confused, as they are clear and distinct, and represent different mental conditions; so do not use the words interchangeably.

An insane delusion, as has been said, is one from which the possessor cannot be argued. A sane delusion is one that can be explained away; that is, the man has sufficient reason and judgment to see that the position he has taken is untenable.

Among the first patients to whom you may have your attention called may be a case of MELANCHOLIA. With this class of patients, there is one rule that you must always bear in mind, and never forgetand that is, to take no chances. These patients are generally suicidal. Frequently they may never have expressed anything of a suicidal character, because their will power has not become so much impaired that they cannot control their utterances -then the culmination of all their melancholy days and nights may terminate in a successful suicidal attempt. Such patients should never be left alone; should never go in dangerous places; should not have access to any sharp instruments nor poisonous drugs of any kind. If they are intensely suicidal, you must recollect that all of the mental strength that they possess may be directed towards some suicidal act. For this reason it will be necessary to

employ two nurses-one for the day and one for the night-and watchfulness and wakefulness must be constant.

The case of Melancholia that will probably give you the most trouble in the line of nursing will be in the form known as "Resistive" Melancholia. There is nothing that you can think of doing for them to add to their comfort and well-being but that you will be met with a strong protest; and by this I mean both physical and mental. Desiring death, they refuse to eat. Believing, perhaps, that they have committed an unpardonable sin they will want to die, as nothing can be done for them they think; and consequently there is no form of resistance possible for a perverted mind to summon to its aid that will not be exercised in active protest against anything that you may attempt to do for them. This is carried to such an extent that one who has not seen to what degree this resistance can go, can have no intelligent appreciation of it.

And yet, these patients must be looked after and bathed with just as great a degree of care as that of any sick child. They must be fed. Frequently, for years, they are fed by a nasal tube, an extra long catheter that is well oiled and passed down the nose into the œsophagus and stomach. Eskay's or Mellin's food, Bovinine or Trophonine with whites of eggs and milk in such proportions as the physician may prescribe may be given from time to time. Ordinarily twice a day is sufficient for this class of patients to be fed, unless they have become very weak before reaching you.

A thing to be considered in giving food to cases of Resistive Melancholia is that they are not in a condition to assimilate food quickly, and if given very frequently the danger of toxemia, to which this class of patients are subject, is greatly increased.

And here I wish to say that in my experience I have found nothing that equals colonic flushing by sterilized water, at a temperature of 105 or 110 degrees, as the patient can bear without discomfort. The clean-up, clean-out and keep-clean, in ref

erence to the intestinal canal, is one of the most important suggestions to be observed in cases of melancholia.

Frequently these patients wish to exercise more than is good for them. This must not be allowed, as you must always bear in mind that any patient after whom you are looking must not be allowed to overdo; that is, to become so tired that the usual hours of sleep do not bring about a complete rest.

There is a restlessness manifested in cases of melancholia that, if allowed to go on unchecked, brings a patient down to a condition in which there is little hope of recovery. The rule must be kept in mind to save such strength as the patient has. and add to it, in order to bring about an improvement or recovery.

These patients are peculiarly sensitive to their mental associations; and an indifferent manner, a sarcastic or cynical remark of the nurse may long be remembered, and an importance may be attached to it that will be simply startling to you.

The mental attitude of the nurse with this class of patients must be the very best possible. Confidence that is born of experience, kindness that comes from the heart, a quick intelligence, and a neverceasing watchfulness, with a general good nature are the best faculties for everyday work. Cultivate in your patients a feeling of hopefulness on every possible occasion.

These cases, when taken early in their development are likely to recover completely within from three to five months-at least about forty per cent. of them will do this. Others will go on for a year or two, or even longer, and finally recover; leaving perhaps about fifteen per cent. to go into terminal conditions.

Another class of patients that you may be called upon to care for, will be those of SENILE DEMENTIA. Now this means the failing mentality incident to old age.

These patients, as a rule, live in the past. Their memory for recent events amounts to little. Frequently they cannot recollect whether they have eaten or not,

although they have just arisen from the table. Their restlessness is constant and their walk is aimless. As a rule, they have little pain, but everything must be done for them. Dementia has been said to be "The grave of the human mind."

The bowels with this class of patients must be as carefully cared for as those in Melancholia.

It is but seldom that you will be compelled to care for a case of PARANOIA or ACUTE MANIA, as these cases sooner or later seek the State Hospital.

In nursing the insane, one of the best rules by which to be governed is to take no chances, and by this I mean guarding yourself against being outwitted in any manner through the delusions of your patients. They may be able to conceal from you their desire to accomplish a certain thing, and may act upon it only when they feel that the time is ripe and they are likely to win out. There are many of the insane whose acts are impulsive, and they are so quick in their physical activities that they are likely to accomplish what they wish before anyone can arrest their efforts.

Never make your patient your confidant under any circumstances, no matter how much attached you may become.

I have mentioned feeding with a nasal catheter, and I want to say that this is the most humane method of forced feeding of which we have any knowledge. The oldfashioned wedge in which the teeth were forcibly separated can be spoken of only with horror, as teeth are likely to be broken and the lips cut in the struggle that frequently follows its employment. With a nasal tube well oiled no amount of resistance is effective, and the catheter may be attached to the rubber tube with an ordinary bulb syringe; or, still better, a rubber tube and a funnel into which the desired nourishment can be slowly poured.

Care must be taken in the introduction of the tube, not to allow it to enter the trachea. This, of course, will be readily recognized by the air coming out of the

end of the catheter that you hold in your hand.

Auto-intoxication.-The more you practice your profession, the greater importance you will attach to Auto-intoxication in the treatment of your patients. Elimination of all unnecessary waste is absolutely essential in the maintenance of good health. When this elimination becomes imperfect through weakness of function, inattention or carelessness of the individual, results of a devitalizing nature at once ensue. Headache, loss of appetite, indisposition for exercise, lethargy of mind as well as of body, foul breath, coated tongue, and suffused eyes, mark the patient with symptoms denoting a condition of Auto-intoxication, self-poisoning, or toxemia, as it is called.

In some instances the physician gives one-tenth grain of calomel every half-hour until a grain has been given; and after the first movement follows with salts, that the entire intestinal canal may be free.

When this is not done, or afterwards when the bowels move, hot water enemas may be freely used before and after the movement. Those who have ever tried the effects of hot water in this way will be surprised at the relief that this treatment gives. When powerful medicine or drink has been taken this assisting the active elimination of the poison is one of the very best of all treatments to pursue.

Medicines.-Be very careful to get explicit directions of how and when medicines are to be administered.

Massage. Whenever a patient comes to you thoroughly exhausted in body and mind, and needing absolute rest in order to recuperate wornout energies, there will come a time when the patient begins slowly to improve, that massage may be recommended for him. Now, no one can with success give massage who has cold, clammy hands, weak muscles, bad habits in the matter of personal care of herself, and an unpleasant personality. One who gives massage should be strong physically and mentally, good-natured, quiet, with a firm dry hand, and a personality that is unob

jectionable. If the one who is to give massage to a sick person has not these qualities, and the patient finds objection to him. as an individual, no good will result from attempting to give treatment. Massage of itself will enable a person to remain in bed, absolutely inactive so far as he is concerned, and yet gain in strength without the loss of energy, and after awhile to be able through this treatment to get out of bed, walk and take exercise possible only with returning health.

Those of you who have not given the subject of massage special study, I would advise to consult the best works upon the subject, try it among yourselves, familiarize yourselves with the methods pursued, and I believe it will repay you. There is this thing that you will find in practicing the art, that there are some people upon whom you cannot work without becoming thoroughly tired out in a very short time, and you will experience a weariness wholly out of proportion to the amount of effort you have been putting forth. Among the symptoms you may have will be headache, dizziness, forgetfulness, a confused state of mind, dryness of the mouth and a restlessness of manner, attended by more or less. apprehension. When a patient causes these symptoms it would be best to withdraw quietly from the case.

The work of a masseuse is hard and exacting at its best, and probably three full operations during the day are as much as the average individual can safely attempt. Much, however depends upon the patients themselves, as your experience will abundantly demonstrate. In your work, should you attempt massage, you must study to keep yourselves in absolutely the pink of physical condition.

Study habits of personal neatness. Your clothes should be thoroughly free from all odor or perfume; nails trimmed and cleaned. Care must be exercised in reference to your breath. Do not work over a sensitive patient when your breath is not absolutely free from any suggestion of odor; consequently, onions must be ta

booed. Many an operator has lost a case that he would not have lost had he been more particular along the lines mentioned.

Personal Cleanliness.-There is nothing so refreshing to a sick person as the feeling that comes to him after being bathed, and he is ready for the day's rest. With some cases of insane there is an indifference to personal cleanliness that is most trying, which will tax you to the utmost to overcome and to offset.

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Dual Personality. You will occasionally run across cases of Dual Personality. When you recognize one of these cases quietly and without attracting notice take as full notes of the time, place and circumstance, and of what he does and says, as is possible.

By this dual personality I mean where a person by reason of accident, excitement, drink, drugs or shock loses his identity for a time and lives a life other than that to which he has been accustomed.

Obsessions.-Frequently you will have patients who feel impelled to do certain things in a certain way: For instance, never sitting down in a chair until they have walked twice around it; never taking up a book from the table until they have moved it to another location on the table; never wanting to step on a crack in the sidewalk; never entering a house or crossing a door sill without changing step so that the right foot will be the first over the threshold; not wanting to walk out from an outside door, but to back out.

These obsessions can only be hinted at, as they vary with the individual, his education, his powers of imagination, and the degree to which his judgment and will power have become perverted. When you have a patient inclined to do these things, or acts of a similar character, you must firmly and quietly, but with all kindness, attempt to dissuade him from these practices. Teach him that the unusual, the foolish, the needless and the noticeable actions about one's manner should be carefully avoided. You may thus be able, if the patient is not too far gone, by appeal

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