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Digitized by tine Internet Arciiive 
 
 in 2010 witii funding from 
 
 Open Knowledge Commons 
 
 http://www.archive.org/details/mentalnursingorlOOhard 
 

 MENTAL NURSING. 
 
" To have nurses in every vrard vrho can make an intelligent 
 analysis of mental symptoms and detect many of the important 
 particulars in which disorder exists, is not only to have instru- 
 ments in one's hands for the precise application of remedial 
 influences of ' moral treatment ' of a kind before unavailable, 
 but it enlarges the physician's own knowledge of morbid con- 
 ditions. The asylum thus becomes a hospital in truth, and both 
 the humane and the scientific spirit are invited to dwell and 
 flourish in it." — Dk. Cowles, Burdett's " Hos^ntals and Asyhi?ns 
 of the World ". 
 
MENTAL NURSING 
 
 LECTUKES FOR ASYLDM ATTENDANTS 
 
 WILLIAM HAKDING, M.D. (Ed.)-, M.E.C.P. (Lond.) 
 
 ASSISTANT irED:ifeAL OFFICER, FEMALE DEPARTMENT, BERRYWOOD, NORTHAMPTON 
 
 WITH 3IAXY ILLUSTRATIONS 
 
 SECOND EDITION : ENLARGED AND REVISED 
 
 LONDON 
 THE SCIENTIFIC PEESS, Limited, 428 Steand, W.C. 
 
 1894 
 

 ABERDEEN UNIVERSITY PRESS. 
 
PilEFACE TO SECOND EDITION. 
 
 The fact that a Second Edition of this little Book 
 has been called for within twelve months is a satis- 
 factory proof it has helped to supply a long-felt want. 
 Its aim has been to give in as. simple and concise a 
 form as possible that information which is necessary 
 for all who have charge of the Insane. Chapters on 
 Puerperal Insanity, Hysteria and The Nursing of the 
 Insane in Private Houses have been added to the 
 present Edition. It is hoped that these additional 
 chapters may render the Book more useful to Nurses 
 engaged in private work. 
 
 W. H. 
 
 Berrywood, Jan., 1894. 
 
LIST or ILLUSTRATIONS. 
 
 1. Vertebral Column, ... 
 
 2. The Sternum, 
 
 3. The Skeleton, 
 
 4. Capsule of the Hip Joint, 
 
 5. Interior of the Hip Joint, 
 
 6. Posterior Muscles of the Left Forearm, 
 
 7. Anterior Muscles of the Left Forearni. 
 
 8. Section of Lungs, 
 
 9. Alimentary Canal, ... 
 
 10. Heart, 
 
 11. The Kidneys, 
 
 12. Section through the Skin, 
 
 13. General Plan of the Nervous System, 
 
 14. The Brain and Spinal Cord in Position, 
 
 8 
 10 
 10 
 12 
 12 
 14 
 17 
 20 
 24 
 25 
 36 
 41 
 
CONTENTS. 
 
 Chapter I. 
 ELEMENTAEY ANATOMY AND PHYSIOLOGY. 
 
 PAGE 
 
 Introductory. Skeleton. Joints. Muscles. Respiratory system. 
 Digestive system. Circulation and lymphatic system. Organs 
 of excretion, ... ... ... ... ... ... ... ... 1 
 
 Chapter II. 
 
 PRACTICAL LESSONS FROM PRECEDING CHAPTER. 
 
 Fractures, etc. Wounds. Haemorrhage. Heart disease. Fainting. 
 
 Food and choking. Strangulation. Poisoning. Burns, ... 27 
 
 Chapter III. 
 
 THE NERVOUS SYSTEM. 
 
 Brain and spinal cord. Nerve cells and nerve fibres. Organs of 
 
 special sense. Effects of disease. Sympathetic system, ... 35 
 
 Chapter IV. 
 
 FORMS OF INSANITY FROM THE NURSE'S 
 STANDPOINT. 
 
 Insanity a bodily disease. Idiocy. Delusions and hallucinations. 
 States of exaltation. Of depression. Delusional insanity. 
 States of mental weakness, ... ... ... ... ... 47 
 
 Chapter V. 
 VENTILATION 53 
 
X MENTAL NURSING. 
 
 Chapter VI. 
 
 PAnr 
 
 WARMTH 60 
 
 Chapter VII. 
 CLEANLINESS AND ORDER 66 
 
 Chapter VIII. 
 
 FOOD. 
 
 Dining-rooiix Epileptics. Paralytics. Acute maniacs. Melan- 
 cholies. Forcible feeding. The sick. Administration of 
 medicines. Cooking for the sick, 71 
 
 Chapter IX. 
 
 MANAGEMENT OF THE INSANE. 
 
 On admission. General management. Struggles. Delusions. 
 Employment. Destruction. Seclusion. Restraint. Suicidal 
 cases, ... ... ... ... ... 84 
 
 Chapter X. 
 EPILEPTICS. GENERAL PARALYTICS. IDIOTS. 97 
 
 Chapter XL 
 THINGS TO BE OBSERVED AND REPORTED. ... 106 
 
 Chapter XII. 
 ENTERTAINMENTS. ... „. .. 11.1 
 
 Chapter XIII. 
 THE CHARGE NUESE 117 
 
 Chapter XIV. 
 THE NIGHT NURSE. .„ ... ... 121 
 
CONTENTS. XI 
 
 Chapter XV. 
 THE SICK EOOM. 
 
 PAGE 
 
 General remarks. Bedsores. Wet pack. Dry pack. Hot bath, 
 
 etc. Catheter, etc., ... .., ... ... ... ... ... 121 
 
 Chapter XVI. 
 HOSPITAL AND ASYLUM NURSES 1.30 
 
 Chapter XVII. 
 PUEEPEEAL INSANITY 1C2 
 
 Chapter XVIII. 
 HYSTERIA 142 
 
 Chapter XIX. 
 NUESING THE INSANE IN PRIVATE HOUSES. ... 149 
 
MENTAL NURSING. 
 
 Chapter I. 
 
 ELEMENTAEY ANATOMY AND 
 PHYSIOLOGY. 
 
 Introductory. Skeleton. Joints. Muscles. Eespiratory system . 
 Digestive system. Circulation and lymphatic system. 
 Organs of excretion. 
 
 Among the most lowly of all living things is a little 
 creature which consists of but a tiny microscopic 
 speck of jelly-like material. It has no bones, muscles, 
 nor digestive organs as we understand these struc- 
 tures. That one little mass fulfils all the duties 
 necessary for the preservation of life. It takes food 
 into the interior of its substance, absorbs the nourish- 
 ment there is in it, and puts out the indigestible 
 portions from some part of its circumference. When 
 it wishes to alter its situation it simply protrudes a 
 portion of its jelly-like mass, and then, as it were, 
 flows in that direction. Thus the lowest forms of 
 animal life may consist of a simple structureless 
 
 single "cell". Creatures higher up in the scale of 
 
 1 
 
MENTAL NURSING. 
 
 life are made up of groups of these tiny bodies called 
 "cells". In the lower forms they may be few in 
 number or simple in structure. As we ascend still 
 higher, we find that animals are composed of myriads 
 of cells and that certain groups of these have taken 
 particular duties upon themselves, and are changed 
 or modified so as to best perform those duties. 
 Some are changed so as to form a support or frame- 
 work for the body, and these we find massed together 
 as the bones ; others devote themselves entirely to 
 the production of movement, and these are altered 
 into muscles ; another section have as their sole 
 duty the nourishing of the body ; others form the 
 organs of the circulation ; while another division 
 devote themselves to casting out waste and harmful 
 substances from the body. We have here a very 
 different state of affairs from that which prevailed in 
 the single celled, structureless little creature. Its 
 mass performed alone many duties which in us are 
 undertaken by separate organs, formed of collections 
 of cells specially adapted for that purpose. In order 
 that this complex machine, the body, may be kept 
 healthy and vigorous, it is necessary that these 
 different organs should be kept in touch with each 
 other and that there should be some central directing 
 and combining power. To fulfill this end certain 
 cells were set apart, and these cells constitute what 
 we call the nervous system. Thus all the organs of 
 the body are but parts of one complete whole ; the 
 different parts of which are linked tos;:ether by the 
 
ELEMENTAEY ANATOMY AND PHYSIOLOGY. 6 
 
 nervous system. Disease of any particular organ 
 must tell more or less upon the nervous system, and 
 disease of the nervous system reacts to a greater or 
 less extent upon the body at large. 
 
 We find that this body of ours is composed of : — 
 
 1. Bones, which buildup the general framev^ork 
 
 and afford protection to important struc- 
 tures. 
 
 2. Muscles, by v^hich the various movements 
 
 are produced. 
 
 3. Fat and loose fibrous tissue, which form 
 
 padding and bind the different organs 
 together. Skin, which forms an outer 
 covering over all. 
 
 4. Organs by which substances necessary for 
 
 nomishment and maintenance of life are 
 taken in. 
 
 (a) Respiratory system. 
 
 ip) Digestive system. 
 
 5. Organs by which materials necessary for 
 
 nourishment, etc., are distributed, and 
 waste materials collected for excretion. 
 
 (a) Circulatory system, 
 ip) Lymphatics. 
 
 6. Organs by which waste and poisonous 
 
 materials are cast out of the body. 
 {a) Lungs. 
 
 (b) Kidneys. 
 
 (c) Skin. 
 
 (d) Bowels. 
 
MENTAL NURSING. 
 
 7. Nervous system by which the whole body is 
 governed and its different parts made to 
 act in harmony. Through it the various 
 organs are put in motion or their activity 
 restrained as is best for the welfare of the 
 creature. In the lower animals the nervous 
 system is well developed as regards the 
 needs of actual existence ; in man it has 
 reached its highest point. By it he thinks, 
 wills, and feels ; thanks to it he is the lord 
 of living creatures. 
 The skeleton or bony framework of the body is 
 made up of more than 240 bones. Bones are com- 
 posed of grisly substance impregnated with earthy 
 matter. In childhood the grisly material is propor- 
 tionally in greater amount and at that period of life 
 bones may bend without snapping, or may only 
 break in part as a green twig does when it is over- 
 bent. In aged persons the earthy matter is in greater 
 amount ; their bones are therefore brittle and fractures 
 easily occur. The central column of the skeleton on 
 which the skull rests is called the spine. This is 
 composed of a number of small bones called vertebrae 
 placed one upon the other with a buffer- like arrange- 
 ment of elastic matter between each two. There 
 is not much movement between any two single 
 vertebrse, but the spine as a. whole is very flexible 
 and allows the body to be bent about freely in any 
 direction. Each vertebra has a hole through it and 
 these holes being placed one above the other make a 
 
ELEMENTARY ANATOMY AND PHYSIOLOGY. 5 
 
 long tube in which the spinal cord lies. By an 
 opening in the under-surface of the skull this tube 
 in the spinal column is directly continuous with the 
 cavity of the head in which the brain is protected. 
 The spine for convenience of de- 
 scription is divided into regions ; 
 thus we have the cervical or 
 vertebrae of the neck ; the dorsal 
 or back vertebrae ; the lumbar or 
 loin vertebrae ; and the sacral 
 and coccygeal vertebrae which are 
 firmly united together and with 
 the two haunch bones, to form 
 the pelvis. 
 
 The skull is composed of the 
 bones forming the vault in which 
 the brain rests, and those of the 
 face. With the exception of the 
 lower jaw, which is loose for the 
 purposes of mastication, these are 
 all firmly joined together. The 
 bones forming the brain case are 
 united in such a manner as to 
 give the greatest amount of 
 strength considering their weight 
 and bulk. The bones of the head 
 
 Vertebeal Column (lateral view). — 1 to 7. bodies of cervical vertebras. 8 
 to 19, bodies of dorsal vertebras. 20 to 24, bodies of lumbar vertebrae. A A, 
 spinous processes. B B, articular surfaces of ti-ansverse processes for the 
 tuberosities of the ribs. C, articular surface of sacrum. 
 
 also defend the organs of the special senses of sight. 
 
MENTAL NUESING. 
 
 hearing, smell, and taste. The inner ear is well 
 concealed within its bony walls, and the mucous 
 membrane of the tongue and nose are also under 
 cover. The eye must be o^Den to the rays of light 
 and at first sight appears much exposed to injury. 
 This is not so in reality. Epileptics fall and often 
 bruise their faces severely ; yet though black eyes are 
 common, injmy to the eyeball is very rare. 
 
 The upper two 
 cervical vertebrae are 
 specially adapted to 
 allow of free move- 
 ment of the head. 
 The cervical verte- 
 brae are the only 
 bones in the neck. 
 The dorsal ver- 
 tebrae are twelve in 
 number and to each 
 of them two ribs 
 are attached, one on 
 each side. These 
 are long slender bones which curve round from the 
 spine behind to the front of the body. With the 
 exception of the two lowest on each side, all are 
 directly or indirectly attached to the breast bone. 
 The spine behind, the breast bone in front, and the 
 ribs curving round between them, form the bony 
 walls of the chest or thorax. The breast bone and 
 ribs are movable and can be raised by the action of 
 
 The Sternum. — c, cla\T[cle. d, scapula, e, 
 truaribs. f, falseribs. h, sterniam or breast bone. 
 
ELEMENTARY ANATOMY AND PHYSIOLOGY. 7 
 
 certain muscles, thus allowing the cavity of the chest 
 to be increased in size. When these bones are 
 clothed with muscles, etc., they close in the sides of 
 the chest which is shut off from the belly below by 
 an arched muscle called the diaphragm. Very 
 important organs lie in the chest : viz., the heart 
 and large blood vessels, the lungs, and the oesophagus 
 or gullet. 
 
 The lumbar vertebrse have no ribs joined to them, 
 and the abdomen or belly is unprotected in the front 
 and at the sides by any bony structure except at the 
 very lowest part where the massive haunch bones 
 are united in front forming the walls of the pelvis. 
 The abdomen contains the stomach and intestines, 
 the spleen, the liver, pancreas or sweetbread, the 
 kidneys and large blood vessels. In the pelvis lie 
 the uterus or womb, the bladder (when empty), and 
 the termination of the bowel. The bladder when 
 distended and the uterus in pregnancy rise out of 
 the pelvis and reach up into the lower half of the 
 abdomen. 
 
 The bones forming the shoulder girdle, which 
 attaches the upper limb to the trunk, are the clavicle 
 or collar bone and the scapula or blade bone. The 
 clavicles are curved bones which stretch on each 
 side from the breast bone out to the shoulder. They 
 set out the shoulder from the chest and thus allow 
 greater freedom of movement to the arm. The 
 scapula is a broad flat bone lying on the back of the 
 chest and joining with the clavicle at the shoulder. 
 
MENTAL NURSING. 
 
 It strengthens the chest wall and affords attachment 
 
 to powerful muscles 
 which move the arm. 
 
 That part of the 
 arm from the shoulder 
 to the elbow is called 
 the upper arm, and 
 contains but one bone, 
 the humerus. The 
 round head of the 
 humerus plays in a 
 shallow socket in the 
 scapula and has free 
 movement in every 
 direction. Dislocation 
 sometimes occurs very 
 easily and is not infre- 
 quent in epileptics 
 during a fit. The 
 lower part of the arm 
 from the elbow to the 
 wrist is called the fore- 
 arm and in it there 
 are two bones : the 
 radius and ulna. When 
 the arm is extended 
 with the hand flat and 
 the palm upwards, the 
 radius is on the outer 
 If we now move the hand so as to 
 
 The Skeleton 
 
 or thumb side. 
 
ELEMENTAHY ANATOMY AND PHYSIOLOGY. \) 
 
 alternately bring the palm and the back of the hand 
 upwards, the radius alone moves while the ulna 
 remains fixed. There are a number of small bones 
 in the wrist and hand. 
 
 The bones of the lower limb are stouter and 
 stronger than those of the arm. They have to bear 
 the weight of the body which is transmitted to them 
 through the haunch bones. The arrangement is 
 much the same as in the arm. In a deep socket in 
 each haunch bone the rounded head of the femur or 
 thigh bone works. Like the forearm, the leg contains 
 two bones. On the inner side is the tibia or shin 
 bone, on the outer side is the slender splint bone or 
 fibula. The foot, like the hand, is made up of a 
 number of small bones. In man the leg is adapted 
 for progression, while the arm admits of great variety 
 of movement, and the hand is specially adapted for 
 grasping or holding objects. 
 
 Joints. The places where the bones are joined 
 together are called joints. It is evident that the 
 joints cannot be all alike. The bones of the head 
 (except the lower jaw) and those of the pelvis require 
 to be firmly united together. Those of the limbs 
 must be joined so as to allow the necessary move- 
 ments to take place. In the shoulder and hip we 
 find that the joints are of the ball and socket type 
 and permit movement in all directions. In the knee, 
 elbow, and fingers we find examples of the hinge 
 joint, that is a joint which, like the hinge of a door, 
 only allows a to and fro movement. The opposing 
 
10 
 
 MENTAL NURSING. 
 
 surfaces of the bones, covered with a glistening sub- 
 stance called cartilage, fit into each other and are 
 held together by strong fibrous bands which pass 
 from one bone to another, completely casing the 
 joint in. In joints hke the shoulder, where free 
 movement is needed, this fibrous capsule is looser 
 than in the case of a joint where the movements are 
 
 The Capsule of the Hip Joint. 
 
 Inteeior of the Hip Joint. 
 
 more limited. Within this capsule is a synovial 
 membrane which secretes a fluid for the purpose of 
 moistening and lubricating the opposing surfaces so 
 that they may glide easily upon each other. 
 
 Muscles are of two kinds : voluntary muscles, or 
 those which are under the control of our will, and 
 involuntary muscles, or those over whose action we 
 
ELEMENTARY ANATOMY AND PHYSIOLOGY. 11 
 
 have no control. Those which move the framework 
 of our bodies are voluntary ; that is, we can order 
 them to act or to rest as we please. Those which 
 are the moving powers in the heart, blood vessels, 
 stomach, intestines, bladder, and uterus are involun- 
 tary. Their action proceeds without our being able 
 to control it, and even in some instances without our 
 being aware of it. 
 
 A voluntary muscle consists of a mass of tiny 
 muscular fibres bound together with fine fibrous 
 tissue, and having tough fibrous cords firmly attached 
 to each end. By means of these cords the muscles 
 are attached to bones, etc. The tiny muscular fibres 
 have the power of contracting, that is, they shorten 
 and become thicker. This causes the bones to which 
 the muscle is fixed by its tendons or fibrous cords to 
 be drawn upon with a force corresponding to the 
 force with which the muscle contracts. If one 
 of the two bones between which a muscle is 
 stretched be fixed and the other movable, when the 
 muscle contracts the movable one will be drawn 
 towards the other. This may be easily proved. 
 Stretch out the arm to its full extent, and, after 
 laying your hand upon the middle of the front of 
 the upper arm, bend the arm forcibly. You will feel 
 the muscle shorten and thicken under your hand, 
 and near the front of the elbow you can feel the 
 tense tendon by which it is attached to the bone 
 of the forearm. 
 
 The bones and muscles have their irregularities 
 
12 MENTAL NURSING. 
 
 filled in and rounded off with a padding of fat and 
 are covered in by skin which serves as a protection 
 as well as an organ of excretion. 
 
 The Posterior Muscles of xhie The Anterior Muscles of the 
 
 . Left Forearm. Left Foeearji. 
 
 The body requires a constant supply of nourish- 
 
ELEMENTAHY AJSTATOMT AND PHYSIOLOGY. 13 
 
 ment to repair the waste which is always going on, 
 and life cannot be maintained without a supply of a 
 life supporting gas, oxygen, which we obtain from the 
 air around us. This oxygen is taken in through the 
 respiratory system. Water and the various kinds of 
 food are taken in by the mouth, and it is in the 
 stomach and intestines that digestion and absorption 
 go on. 
 
 The respiratory tract commences at the nostrils 
 through which alone we should take in breath. In 
 passing from the nose to the windpipe the air is 
 warmed, and dust, etc., partially filtered from it. 
 The sensitive mucous membrane of the nose and 
 throa.t also gives warning of foul smelling or irritating 
 substances in the air. At the top of the trachea or 
 windpipe is the cartilaginous box called the larynx 
 or organ of voice. This is familiar to us all as the 
 projection in the throat known as Adam's apple. 
 The entrance to the larynx is very narrow ; in fact 
 only a slit between two membranes, called the vocal 
 cords. When these cords are rendered tense by the 
 action of certain muscles they can be thrown into 
 vibration by a current of air and the sound which is 
 produced is the voice. The windpipe is composed of 
 a succession of rings of cartilage, and commences 
 immediately below the larynx. The upper rings can 
 be felt with the finger. It passes down into the 
 chest and, behind the breast bone, divides into two 
 branches, the right and left bronchus. Each bronchus 
 divides and subdivides until it forms a great number 
 
14 
 
 MENTAL NUKSING. 
 
 of small tubes. Each tube ends in a bunch of little 
 bladders like a small bunch of grapes. The walls of 
 these little bladders consist merely of a thin elastic 
 membrane, on the outside of which tiny blood vessels 
 with very thin walls are thickly placed. Thus the 
 air in the bladders is brought into close relation with 
 
 Section of Lungs. — 1, windpipe. 2, bronchi. 3, 3, bronchial tubes. 
 
 the blood in the blood vessels. The tubes formed 
 by the division of the right bronchus with the bladders 
 in which they end are bound together in a mass by 
 fine fibrous tissue and this mass forms the right lung. 
 The left lung is similarly formed. Each lung there- 
 fore consists of a collection of tiny elastic bladders, 
 which communicate with the windpipe through the 
 
ELEMENTARY ANATOMY AND PHYSIOLOGY. 15 
 
 tubes formed by the division of each bronchus. The 
 lungs are suspended freely in the cavity of the chest, 
 one on each side of the heart. The outer surface of 
 the lungs and the inner surface of the chest wall are 
 covered with a smooth membrane which allows the 
 lungs to glide freely as they become larger and 
 smaller during inspiration and expiration. The ribs 
 and breast bone being raised by the action of the 
 muscles attached to them, and the depth of the chest 
 being increased by the contraction of the diaphragm, 
 air rushes into the elastic bladders in the lungs 
 and distends them. This is what happens when we 
 take a breath. In ordinary breathing, at the end of 
 inspiration the weight of the ribs causes them to fall 
 back to their former position ; the elasticity of the 
 walls of the abdomen push back the diaphragm ; and 
 the elasticity of the lungs aids in expelling the air 
 from them. When breathing is difficult then certain 
 muscles are brought into action to assist in expelling 
 the air. This process of breathing in and breathing 
 out takes place in headth about eighteen times in a 
 minute. The rate of the breathing is much altered 
 in some diseases. 
 
 The air that is breathed in gives up oxygen to 
 the blood and receives a poisonous gas carbonic acid 
 from it. Thus the air which leaves the lungs is 
 poorer in oxygen and richer in carbonic acid gas than 
 that which went to it, while the blood in passing 
 through the lungs has been purified by giving up its 
 poisonous carbonic acid gas and receiving in return 
 
16 MENTAL NUESING. 
 
 the life-supporting gas oxygen. The lungs act both 
 as organs for taking in matter necessary for life, and 
 also for excreting poisonous material. 
 
 The digestive tract commences at the mouth and 
 ends at the rectum or lower end of the bowel. It 
 forms a continuous tube into which the secretions of 
 various glands are poured at various parts of its 
 course. These secretions act upon the different 
 constituents of the food and digest it ; that is, they 
 change it from an insoluble to a soluble form, or 
 from a state in which it cannot be absorbed into the 
 system into one which can be so absorbed. Food is 
 taken into the mouth where it is subjected to the 
 grinding action of the teeth and lower jaw ; in other 
 words it it masticated. This is necessary in order 
 that it may be broken up sufficiently to allow the 
 digestive juices to act upon it. It is, in the mouth, 
 mixed up with saliva, the secretion of the salivary 
 glands. It is then formed into a mass by the 
 muscular action of the tongue and projected back- 
 wards towards the back of the throat where it is 
 grasped by the muscles of the gullet. During this 
 action the opening into the back of the nose is 
 curtained off and the opening into the windpipe 
 covered up so that food cannot travel in either of 
 these directions. Up to the stage when we cause 
 the tongue to shoot the morsel of food backwards 
 the action of swallowing is voluntary or under the 
 control of our will. When this stage has passed we 
 have no longer any control over it. Indeed we 
 
ELEMENTAEY ANATOMY AND PHYSIOLOGY. 
 
 17 
 
 cannot start the action unless we pass something, as 
 a little saliva, into the back of the throat. When 
 the food has been grasped by the muscles of the 
 gullet, it is squeezod down 
 the oesophagus into the 
 stomach thus passing 
 through the chest and 
 through the diaphragm into 
 the abdomen. 
 
 The stomach is a saccular 
 dilatation of the digestive 
 tube in which the food is 
 retained for some time in 
 order that it may be mixed 
 with and acted upon by the 
 secretion of the numerous 
 little glands in its walls. 
 This secretion is called the 
 gastric juice. The stomach, 
 like the intestines with 
 which it is continuous, is 
 a hollow muscular organ 
 lined with mucous mem- 
 brane in which the numerous 
 little glands are embedded. 
 
 When the food has 
 passed into the stomach 
 these glands begin to pour out their secretion, and 
 the muscular wall of the stomach begins to act. The 
 food is thus churned up and thoroughly mixed with 
 
 The Alijientaih' Canal —ce, 
 (Esophagus, s]}, spleen, s, stomach. 
 ]}, pancreas. I, liver, gb, gall 
 bladder, r, rectum, a, anus. 
 
18 MENTAL NUESING. 
 
 the gastric juice which dissolves or digests part ot 
 the contents. The tiny vessels in the wall of the 
 stomach at the same time are absorbing or taking up 
 the digested material. The food which is not digested 
 in the stomach is gradually passed into the small 
 intestine. Here it is mixed with the bile, the 
 secretion of the liver ; with the pancreatic juice, the 
 s'ecretion of the sweetbread; and also with the 
 secretions of the tiny glands in the mucous mem- 
 brane of the intestine itself The process of digestion 
 goes on, and as the food is passed along by the 
 contraction of the muscular walls of the intestine 
 the digested matter is absorbed, until, by the time 
 it reaches the lower end of the bowel, nothing remains, 
 when digestion is good, except the indigestible 
 portions. These, coloured with bile, form the great 
 proportion of the fseces. 
 
 The circulatory system.— Thi^ consists of the 
 blood, the heart, and blood vessels. 
 
 The blood is the medium by which all exchanges 
 between the tissues of the body and the outer world 
 take place. Into it pass all the nutrient substances 
 which are absorbed from the digestive tract; by it 
 oxygen is conveyed from the lungs to the tissues, and 
 carbonic acid from the tissues to the lungs ; by it 
 waste materials are removed from the tissues and 
 taken to the organs whose work it is to cast them out 
 from the body. Blood consists of a nearly colourless 
 fluid containing vast numbers of little bodies called 
 blood corpuscles. When viewed under the micro- 
 
ELEMENTARY ANATOMY AND PHYSIOLOGY. 19 
 
 scope the great majority of the corpuscles are seen to 
 be tiny disc-shaped bodies which singly appear to be 
 of a pale straw yellow tint but look red when a 
 number of them are seen together. From their 
 colour they are known as red corpuscles. Others, 
 much fewer in number and larger and more irregular 
 in shape, are called white or colourless corpuscles. 
 It is the red corpuscles which give the colour to the 
 blood. They are the oxygen carriers to the tissues, 
 and when they are charged with this gas the blood is 
 bright scarlet ; but after they have given up their 
 oxygen to the tissues and the blood has become im- 
 pure it then assumes a dark red tint. The bright 
 scarlet oxygen bearing blood is pure or arterial blood ; 
 the dark red carbonic acid bearing blood is impure 
 or venous blood. When the dark impure blood has 
 been passed through the lungs and purified, it again 
 assumes a bright scarlet appearance. 
 
 The heart is a hollow, somewhat cone-shaped, 
 muscular organ, which is divided by a central parti- 
 tion into a right and a left half One side of the 
 heart has no direct communication with the other, so 
 that no blood can pass directly from one side to the 
 other. Each side is again divided into two chambers 
 which communicate with each other : an upper 
 receiving chamber with thin muscular walls called 
 the right and left auricle respectively, and a lower 
 stronger chamber with thicker and more muscular 
 walls called the right and left ventricle respectively. 
 The auricles receive blood from veins ; the right 
 
20 
 
 MENTAL NUESING. 
 
 auricle receives impure blood from the veins of the 
 body generally, and the left auricle purified blood 
 from the pulmonary veins. The two auricles contract 
 at the same time and their contraction is immediately 
 followed by that of the two ventricles which also 
 act together. When any of the chambers contract, 
 
 Heaet (Right Axjeicle and Right Venteicle opened). 1, right ventricle. 
 2, left ventricle. 3, right auricle. 4, left auricle. 5, 6, veins opening into right 
 auricle. 7, aorta. 8, pulmoiaary artery. 9, tricuspid valve. 10, pulmonary 
 
 valves. 
 
 its cavity becomes smaller and its contents, like those 
 of an elastic bag when squeezed, are driven out with 
 considerable force. The auricles when they contract 
 squeeze the blood into their respective ventricles. 
 When the ventricles contract the blood would rush 
 back into the auricles, but, by an arrangement of 
 
ELEMENTAEY ANATOMY AND PHYSIOLOGY. 21 
 
 valves, this is prevented and it is forced into the 
 only path open to it. In the case of the right 
 ventricle this is the artery which conveys impure 
 blood to the lungs, and in the case of the left ventricle 
 it is the aorta or large artery which by its branches 
 conveys pure blood to every part of the body. The 
 left ventricle having much harder work to do than 
 the right is thicker and stronger. This contraction 
 of all the chambers of the heart occurs in an adult 
 between seventy and eighty times in every minute. 
 
 The Mood wssels form a closed system of tubes of 
 varying strength and size according to the needs of 
 the circulation. Those which spring from the ven- 
 tricles, and are therefore subjected to the strain of 
 bearing the full force of the rush of blood into them 
 after each contraction, have strong elastic muscular 
 walls and are called arteries. The pulmonary artery 
 conveys blood from the right ventricle to the lungs 
 in order that it may be there purified. This 
 vessel sends a large branch to each lung. These 
 branches divide and subdivide until they become 
 so small that in order to be seen they must be looked 
 at under the microscope. These tiny vessels with 
 extremely thin and transparent walls are called 
 capillaries. They are spread over the outer surface 
 of the thin air bladders in the lungs and the impure 
 blood in them is thus brought into close relation with 
 the air. It is here that the exchange of gases 
 between the blood and the air takes place. The 
 capillaries are not very long and again unite, forming 
 
22 MENTAL NURSING. 
 
 slightly larger tubes. These also continue to join 
 together forming still larger vessels which are called 
 veins. These pulmonary veins, whose walls are not 
 so thick and strong as those of the artery, carry the 
 now purified blood back to the left auricle of the 
 heart. This passage of the blood from the right 
 ventricle through the vessels of the lung and back 
 to the left auricle is called the pulmonary circulation. 
 The aorta, or great artery of the body, which 
 springs from the left ventricle, has stouter and 
 stronger walls than the pulmonary artery. The left 
 ventricle is more powerful than the right, and the 
 artery must be stronger to sustain the greater force 
 of the blood pumped into it. The artery, being 
 elastic, is distended each time blood is forced into 
 it. Before the next contraction blood has passed 
 into the veins, and the artery becomes small again. 
 It is this alternate enlargement and diminution of 
 the size of the artery which is the cause of what we 
 call the pulse. Each pulsation in the artery corres- 
 ponds to one contraction of the ventricle, and by a con- 
 sideration of the pulse we can gain information as to 
 the force and frequency of the heart's action. The 
 aorta gives off branches to all parts of the body. 
 These branches again divide until, like the arteries in 
 the lungs, they pass into capillaries. It is in the 
 capillaries all over the body that the nourishment in 
 the blood is given up to the tissues, and the waste 
 and harmful materials removed from them. It is in 
 these capillaries also that the blood gives up its 
 
ELEMENTARY ANATO-MY AND PHYSIOLOGY. 23 
 
 oxygen to the tissues and becomes laden with 
 carbonic acid. The blood, therefore, enters the 
 capillaries pure, but is impure when it leaves them. 
 The veins which are formed by the joining of the 
 capillaries, unite from all parts of the body into two 
 large veins which discharge their contents into the 
 right auricle, or the right receiving chamber of the 
 heart. This passage of blood from the left side of 
 the heart, through the vessels of the body generally, 
 and back to the right auricle, is known as the general 
 circulation. A portion of it is sometimes described 
 separately. The veins formed by the junction of the 
 capillaries which surround the digestive tract and 
 there absorb the nutrient fluids, before joining the 
 other veins of the body, pass their blood through the 
 liver. This is called the portal circulation. 
 
 In order to grasp the idea of the circulation 
 readily, the beginner must clearly comprehend that 
 the right and left sides of the heart are distinct : 
 that the right side contains venous or impure blood ; 
 that the lungs are, as it were, placed between the 
 two sides of the heart, so that all blood passing 
 from one side to the other must go through them ; 
 and that the left side contains only pure or arterial 
 blood. 
 
 Pure blood then leaves the left ventricle, and, 
 passing through the arteries, becomes impure in the 
 capillaries of the body generally. It returns through 
 the veins to the right auricle, which only receives it 
 n order to pass it on to the right ventricle. From 
 
24 
 
 MENTAL NUESING-. 
 
 that chamber it is forced into the pulmonary artery, 
 and, after being purified in the capillaries of the lungs, 
 is returned by the pulmonary veins to the left auricle, 
 which passes it on to the left ventricle again. 
 
 The lymphatic system. — The fluid part of the 
 blood is able to pass through the thin walls of the 
 capillaries and thus bring the nutrient substances 
 dissolved in it within reach of the tissues. It does 
 
 1, right kidney. 2, left kidney. 3, vena cava. 4, abdominal aorta. 5, the 
 nretus : the tubes -which convey the urine from the kidneys to the bladder. 
 
 not all pass back into the capillaries and the lym- 
 phatics act as a kind of drainage system to remove 
 this excess. Lymphatics begin as microscopic spaces 
 in the tissues but gradually form little tubes by which 
 this fluid is conveyed into the veins at the root of 
 the neck. The fluid passes through the lymphatic 
 glands in its course. The lymphatics of the intestine 
 have a somewhat different origin, and by them a 
 
BLEMENTAEY ANATOMY AND PHYSIOLOGY. 
 
 •25 
 
 great part of the fatty matters are absorbed from 
 the bowel. 
 
 Organs of excretion. — The action of the Imigs and 
 the bowel in casting out harmful or useless matters 
 from the body has been already mentioned. 
 
 The kidneys, one on each side, are placed deeply in 
 the abdomen in the region of the loins. Sheeps' 
 
 Section thbough the Skik showing Sweat Glands fmagnified). 
 
 kidneys are familiar to all. The human organ is 
 similar in appearance, but larger. Hurtful substances 
 are taken from the blood by the cells of the kidneys, 
 and these substances, when dissolved in the water 
 which is filtered from the blood, constitute urine. 
 The urine, a few drops at a time, is passed down 
 tubes which run from each kidney to the bladder. 
 
26 MENTAL NURSING. 
 
 Here it collects until sufficient has gathered t 
 necessitate the act of micturition. The bladder is 
 hollow muscular organ which contracts upon th 
 urine contained . in it and forces it out through th 
 urethra. In ordinary circumstances about 40-50 o: 
 of urine should be passed daily. 
 
 The skin contains a large number of sweat gland i 
 and these" are constantly excreting water and a sma 
 quantity of solids. The amount of water lost by tli 
 skin in twenty-four hours is about 30 oz. This go( 
 on without our being aware of it, and it is only whe 
 the secretion becomes excessive and collects upon tl 
 surface that we become conscious of it. 
 
Chapter II. 
 
 PRACTICAL LESSONS FROM PRECEDING 
 CHAPTER. 
 
 Fractures, etc. Wounds. HEemorrhage. Heart Disease. 
 Fainting. Food and Choking. Strangulation. Poisoning. 
 Burns. 
 
 The nurse must remember that she must give to the 
 charge nurse a full account of any occurrences, such 
 as the fall of an epileptic in a fit ; a struggle be- 
 tween nurse and patient, or between two patients ; one 
 patient striking or kicking another, etc. The charge 
 nurse will then see the patient concerned : observe 
 if there be any marks, bruises, or other injuries, and 
 make a full report of the matter in her daily ward 
 report. For the sake of both patient and nurse this 
 duty must on no account be omitted. 
 
 On account of the change that takes place in their 
 composition the bones of the aged become brittle 
 and easily broken. Fracture of the thigh bone, 
 close to the hip joint, is not infrequently caused by 
 falls. In some general paralytics the bones are 
 softened and break easily. They are often trouble- 
 some patients to deal with owing to their violence 
 
 and excitement, and this peculiarity of their bones 
 
 (27) 
 
28 MENTAL NUESING. 
 
 renders them especially liable to accidents. The ribs, 
 in these and in other violent and feeble cases, are 
 sometimes injured. Among excited patients, violence, 
 as by falls, kicks, or blows, is generally the cause ; 
 but in feeble, restless patients, it is sometimes caused 
 by accidental falls against a crib or bedstead. It is 
 well to let such cases occupy a padded room with a 
 bed on the floor, which is covered with mattresses. 
 
 A scalp wound, or any injury to the head, must 
 never be looked upon as of no importance. The 
 possibility of injury to the bone or the brain must 
 always be borne in mind. 
 
 In some mental states the lunatic is insensible to 
 pain. I have seen a woman, who had just broken 
 both bones of her leg, flourish the limb like a flail 
 most unconcernedly. If a bone in a limb is broken, 
 an endeavour should he made to prevent the patient 
 making the injury still more serious. The broken 
 limb should be firmly grasped with one hand above 
 and one below the fracture, and the broken ends of 
 the bones kept as quiet as possible until the doctor 
 can apply splints. 
 
 The abdominal organs are very imperfectly pro- 
 tected by bony framework, and are sometimes injured 
 by falls, kicks, or blows. A distended bladder may 
 be easily ruptured in this way. Again I repeat the 
 importance of reporting every kick or blow. Fatal 
 injury may be done without any bruise or mark 
 externally, and, as patients are often unable to give 
 any information themselves, the case is very obscure. 
 
PRACTICAL LESSONS FEOM PRECEDING CHAPTER. 29 
 
 I have known a lunatic, after his bowel had been 
 ruptured by a kick from another patient, to walk to the 
 dining hall, take his tea as usual, return to his ward 
 and proceed to bed, not only without any complaint, 
 but without anything unusual in his appearance. 
 
 The looseness of the shoulder joint, and the ease 
 with which dislocation there occurs, should not be 
 forgotten. I have seen it dislocated owing to a 
 patient suddenly jerking herself away when a nurse 
 had hold of her outstretched arm by the wrist. 
 
 Bleeding. — Before haemorrhage can take place 
 some part of the system of tubes in which the blood is 
 contained must be injured. Thus bleeding may come 
 from an artery, from the capillaries, or from the veins. 
 The character of the bleeding differs in each case. 
 
 When blood comes from a wounded artery it is 
 bright red, and rushes out with considerable force 
 and in a succession of spurts. Each sj^urt, of course, 
 corresponds to a contraction of the left ventricle. 
 Since the blood in the arteries travels from the heart 
 out to the circumference of the body if the particular 
 artery through which the blood is passing to reach 
 the wounded point can be blocked, the bleeding must 
 be stopped. In other words, pressure on the course 
 of a wounded artery on the heart side of the injury 
 will stop the haemorrhage. There are places where 
 the main arteries of the upper and lower limbs run 
 over bones against which they can be conveniently 
 compressed, and bleeding from a wound below these 
 points immediately checked. The nurse should be 
 
30 MENTAL NUESING. 
 
 familiar with these places, and should be able at once 
 to apply effective pressure on the artery. Two places 
 in each limb are practically sufficient. The one 
 enables us to control the artery as it passes out of 
 the trunk and thus practically cut off all blood from 
 the limb. At the other we can command the vessel 
 in its course through the upper part of the arm or leg. 
 
 In the arm these important places are : — 
 
 1st. The main artery for the arm (called in this 
 part of its course the sub-clavian) after leaving the 
 chest, runs over the first rib and can be compressed 
 against it. If the thumb be pressed down behind 
 the middle of the clavicle the artery will be felt 
 beating, and by firm pressure the flow of blood 
 through it can be stopped. That it is stopped can 
 be tested by feeling whether the pulse at the wrist 
 has ceased to beat. To compress the sub-clavian 
 properly is not an easy thing to do, and the nurse 
 will require practical demonstration, and frequent 
 trials, before she is com23etent to undertake the duty. 
 
 2nd. As the artery (now called the hracJiial) passes 
 down the inner side of the upper arm it can be readily 
 compressed by the fingers against the bone there. 
 The artery runs down the inner edge of the muscle 
 which is felt in the front of the upper arm. A tour- 
 niquet can here be readily applied. 
 
 In the leg : — 
 
 1st. At the centre of the fold of the groin the 
 main artery of the leg (the femoral) in passing out 
 of the pelvis runs quite superficially over part of the 
 
PEACTICAL LESSONS FEOM PRECEDING CHAPTER. 31 
 
 haunch bone. It can be readily felt beating under 
 the skin, and is easily compressed by the thumbs. 
 
 2nd. The artery then runs (comparatively super- 
 ficially for some distance) downwards and inwards 
 towards the back of the thigh, which it reaches about 
 its lower third. Pressure by the fingers here is 
 tiring, but the artery can be easily controlled by 
 means of a tourniquet. For the femoral and brachial 
 arteries no better ward tourniquet is needed than a 
 soft stomach tube. This must be applied tightly 
 round the limb and the ends tied. 
 
 The nurse should also be acquainted with the 
 position and the method of compressing the large 
 arteries which run up each side of the neck. In 
 cases of cut-throat the artery below the wound must 
 be at once compressed against the vertebrse behind. 
 This can only be taught by demonstration. 
 
 In every case where it can be at once applied 
 to and kept firmly pressed on the bleeding point, 
 the thumb will prevent any loss of blood. This 
 direct pressure on the spurting orifice is the best and 
 indeed the only method the nurse can use in cases 
 where the artery, as in the scalp, cannot be compressed. 
 
 The nurse must, by practice upon herself and 
 others, familiarise herself with the position of these 
 arteries. It is only in this way that she can obtain 
 the knowledge and confidence necessary to enable 
 her to do her duty in an emergency. 
 
 Capillary bleeding is merely an oozing, and is 
 generally easily controlled by cold and pressure. 
 
32 MENTAL NUESING. 
 
 Venous Ueeding. — -This occurs more frequently 
 than arterial bleeding because the veins being for 
 the most part on the surface are more exposed to 
 injury. The blood from a vein is dark red, and flows 
 out quietly and steadily with little force and without 
 the spurts which distinguish arterial bleeding. It is 
 readily stopped by elevating the limb and applying a 
 little pressure upon the wounded point. If any 
 further pressure is needed, it must be remembered 
 that in the veins the blood travels from the circum- 
 ference towards the heart. 
 
 Heart disease is common amongst lunatics. The 
 nurse should know which of her patients are so 
 affected, and should be especially watchful of them 
 at the bath, at stool, and when they are excited. They 
 should never be allowed to over-exert themselves. 
 
 Fainting is caused by the failure of the heart to 
 supply the brain with sufficient blood. It is easier 
 to pump a fluid along a horizontal tube than along 
 one which is placed upright. We therefore aid the 
 heart by laying the person who has fainted flat on 
 her back. The clothes around the neck, etc., should 
 be undone, and some cold water dashed on the face. 
 A little water may also be given to drink. It is only 
 in exceptional cases that stimulants are required. 
 
 Food. — The importance of having the food well 
 broken up before it is swallowed should be remem- 
 bered, and patients who bolt their food should have 
 it either crushed or cut up into very small pieces. 
 Owing to the nature of the act being involuntary, 
 
PEACTICAL LESSONS FEOM PEECEDING CHAPTEE. 83 
 
 small powders, etc., in almost unconscious patients, 
 will, if put quite on the back of the tongue, be 
 swallowed. The danger of food passing down into 
 the windpipe should not be forgotten. When the 
 act of swallowing is not properly performed, and 
 liquids are carelessly poured into the mouth, some 
 may find its way into the windpipe. Though the 
 patient may not be at once choked, yet a form of 
 inflammation of the lungs ^ill probably be set up. 
 In these cases tube-feeding is to be recommended. 
 When a patient chokes, an attempt should be made 
 (while assistance is being sought) to hook out the 
 food, or whatever the substance may be, from the 
 throat. If not too firmly impacted, it is sometimes 
 driven out by pressing against the front of the chest 
 and hitting the patient smartly between the shoulders. 
 This causes a rush of air out of the chest through the 
 windpipe and may dislodge the offending substance. 
 
 Hanging or strangulation. — The patient should be 
 at once cut down if an attempt at suicide by hanging 
 is made. In all cases the neck should be freed from 
 any constriction either by cord, handkerchief, or 
 clothing. The mouth must be looked into lest any- 
 thing should be crammed into the back of the throat. 
 If the patient is not breathing after the throat and 
 neck are free, hot and cold water may be dashed 
 alternately on the neck and chest. If these are not 
 at hand artificial respiration must be used at once. 
 This is done by alternately pressing the arms against 
 
 the front and sides of the chest, and raising them 
 
 3 
 
34 MENTAL NUESING. 
 
 above the head, so as to imitate the raising and 
 falKng in of the chest wall during ordinary breathing. 
 Artificial respiration can only be taught properly by 
 actual demonstration. 
 
 Poisoning. — Should such an accident occur in the 
 wards, the nurse should at once send for assistance. 
 There is little likelihood of the poison being either a 
 strong acid or alkah, so that the nurse may safely 
 give a household emetic of either mustard or salt 
 and water. The poison should be removed from the 
 stomach before it can be absorbed into the circula- 
 tion. By the time the doctor arrives, the stomach 
 pump, gag, and cold and luke-warm water should be 
 ready, with four nurses present, so that if needed, 
 the pump may be used at once. 
 
 Burns. — In case a patient's clothing has either 
 wilfully or accidentally been set on fire, the nurse 
 should snatch up a rug, blanket, or table-cover, and 
 at once wrap it around the individual. By this 
 means the flames will be smothered. Let the nurse 
 bear in mind the danger there is of the flames 
 spreading to her own clothes, and to prevent this she 
 must keep the rug spread out in front of her as she 
 advances towards the sufferer. Should the nurse's 
 dress get on fire when she is alone, she must not run 
 away screaming for assistance, but throw herself on 
 the floor on a rug and roll herself in it. She may 
 call for assistance while doing this, but to run away 
 is simply to fan the flames and increase the danger. 
 
Chapter III. 
 THE NERVOUS SYSTEM. 
 
 Brain and Spinal Cord. Nerve Cells and Nerve Fibres. Organs 
 of Special Sense. Effects of Disease. Sympathetic System. 
 
 The attendant on the insane does not need to have 
 a knowledge of the delicate anatomy of the brain and 
 spinal cord, but it would conduce to an intelligent 
 interest in her work if she were acquainted with the 
 outlines of the physiology of these organs. Without 
 such information the nurse can hardly take the 
 interest in her work that she should do, nor can she 
 give that assistance which the physician requires and 
 expects from her. There are many details and im- 
 portant points as to the habits, etc., of patients, with 
 which she alone can be cognisant, and these may pass 
 unnoticed, if there be no eye trained to note them, 
 and no mind educated to understand their significance. 
 The nervous system consists of : — 
 
 1. The brain and spinal cord with the nerves 
 which proceed from them. 
 
 2. The sympathetic system. 
 
 The cells which form the nervous system are 
 modified into two great classes, mz., nerve cells and 
 
 nerve fibres. Nerve cells, which are, so to speak, the 
 
 (35) 
 
36 MENTAL NUESING. 
 
 workshops in wliicli nerve force, or brain power, is 
 elaborated, and nerve fibres, by which messages are 
 
 GEN'EEiL Plan of the Nervous System. 
 
 carried to and from the nerve cells. These nerve 
 cells, embedded in soft tissue, which supports and 
 
THE NERVOUS SYSTEM. 37 
 
 protects them, are massed together in the central 
 organs of the nervous system, i.e., in the brain and 
 spinal cord. They are of vital importance to the 
 body, inasmuch as they direct and regulate the action 
 of organs upon whose activity life depends, and they 
 are, therefore, carefully shielded from injury by bony 
 cases. The brain is securely placed within the vault 
 of the skull, and the spinal cord, which is continuous 
 with the brain, is sheltered within the cavity formed 
 by the apposition of the various vertebrae. 
 
 The nerve fibres are found as fine threads in every 
 part of the body. They join together to form small 
 white cords which we call " the nerves ". The nerves 
 of the head pass into the skull directly ; those from 
 the body generally run to the spinal cord, which they 
 enter. The fibres pass up the spinal cord, and are 
 connected with nerve cells in it, and also with the 
 nerve cells in the brain. In the spinal cord the fibres 
 are placed superficially and enclose the nerve cells in 
 their centre ; in the brain the cells lie chiefly on the 
 surface, which is convoluted or arranged in folds so 
 as to present a large amount of surface when com- 
 pared with the space occupied. The fibres run into 
 the brain and then spread out in a fan-like fashion, 
 and pass to every part of its circumference. 
 
 We thus see that there are masses of nerve cells 
 in the brain and spinal cord which are connected by 
 means of nerve fibres with every part of the body. 
 
 We saw that there was a subdivision of labour 
 among the various kinds of cells in the body generally. 
 
38 MENTAL NURSING. 
 
 and that the most important work of all was under- 
 taken by that group of cells which we call the nervous 
 system. Then we noticed that this group was modi- 
 fied into two great classes, nerve cells and nerve 
 fibres. We will find that the duties of the nervous 
 system are so important that they are still further 
 subdivided, and this is the case both as regards nerve 
 cells and nerve fibres. 
 
 The nerve fibres are divided into three kinds, 
 which have been named according to their functions. 
 There are fibres which convey messages from the 
 various parts of the body to the brain, and these are 
 called sensory, or, better, afferent fibres (so designated 
 from a Latin word which signifies "carrying to- 
 wards"). Those fibres which convey messages out 
 from the nerve cells to the body are called efferent 
 (" carrying outwards "). Some of the efferent fibres 
 are called motor, because they convey impulses to the 
 muscles. The third kind are called communicating 
 fibres, because they run between cells in different 
 parts of the brain and so unite them all. 
 
 A nerve may be composed entirely of afferent 
 fibres, and is then called a sensory nerve ; or it may 
 be composed almost entirely of efferent fibres to 
 muscles, and is then known as a motor nerve. Some 
 nerves contain both afferent and efferent fibres, and 
 are then called mixed or sensori-motor nerves. 
 
 Certain of the purely afferent nerves carry special 
 kinds of messages, as, for example, the nerves con- 
 nected with the organs of special sense, which have 
 
THE NEEVOUS SYSTEM, 39 
 
 been called the ''gateways of knowledge". Each organ 
 of special sense is an apparatus specially adapted to 
 be affected by a particular kind of sensation and 
 conveniently situated for receiving such impressions. 
 It is connected by a nerve with a portion of the sur- 
 face of the brain. By this nerve the messages from 
 the organ of sj)ecial sense are conveyed to the brain 
 cells and by them interpreted. The efferent fibres 
 also are not all of one kind, but consist of fibres which 
 carry orders to muscles, glands, etc. 
 
 Various little collections of nerve cells have special 
 duties assigned to them. One of the great functions 
 of the nerve cells in the spinal cord, and especially 
 near its junction with the brain, is to preside over 
 reflex actions; that is, actions which can be carried 
 on independently of consciousness, but which are all 
 important to the health and even the life of the in- 
 dividual. These actions are called reflex because the 
 afferent message is not passed on to the brain, but is 
 reflected or bent back by the nerve cell in the spinal 
 cord and the necessary order sent out to the organ or 
 part of the body implicated. As instances of reflex 
 actions, we may mention the closing of the eyelids, 
 swallowing, respiration, secretion of saliva, and 
 micturition. Thus, when food is taken into the 
 mouth the afferent nerve carries the message to the 
 nerve cells, and the efferent nerve conveys a message 
 to the salivary glands to secrete saliva. A person's 
 foot may be tickled, and although he is quite un- 
 conscious of it, his foot may be twitched away. 
 
40 MENTAL NURSING. 
 
 The brain may be looked upon as the capital in 
 which are the various departments of the government. 
 Some of these departments are concerned entirely 
 with the collecting of intelligence, and others carry 
 on the work of the executive. The former are con- 
 stantly receiving reports from (afferent messages), 
 and the latter sending out orders to (efferent mes- 
 sages), every part of the kingdom (the body). The 
 various departments have communications with each 
 other (messages through the communicating fibres). 
 The spinal cord is the main trunk road along which 
 messages pass to and fro, and at certain stations 
 on it, subordinate government officials are placed 
 (nerve cells in the spinal cord). These officials are 
 able to transact routine duties (reflex actions) without 
 troubling the central authority. When, however, 
 anything goes wrong the matter is referred to head- 
 quarters, and the report then sent in is not a pleasing 
 one (pain is experienced). The nerves are the branch 
 roads which run to every part of the kingdom, and 
 by them the messages travel after leaving the main 
 road, the spinal cord. The organs of special sense 
 are outposts of the intelligence department, which 
 send in special reports to headquarters. The 
 muscles, glands, etc., are the agents by which the 
 orders of the executive department are carried out. 
 
 Any portion of the nervous system may be dis- 
 eased or injured, and the symptoms will vary in 
 character and in gravity, according to the nature and 
 importance of the function of the part affected. If 
 
THE NERVOUS SYSTEM 
 
 a sensory nerve be 
 divided, then sensibility 
 is lost in the area sup- 
 pHed by that nerve ; if a 
 motor nerve be divided, 
 the muscles supplied by 
 that nerve are paralysed. 
 In the one case messages 
 from the ends of the 
 nerve affected cannot 
 pass to the brain, and 
 in the other orders from 
 the brain to the muscles 
 are cut off. Thus the 
 muscles may be healthy, 
 the brain cells working 
 normally, and the track 
 down the spinal cord 
 clear, but there is a 
 block in the nerve which 
 conveys messages to the 
 muscle or from the sen- 
 sory area. Disease or 
 injury of one of the 
 nerves of the special 
 senses is followed by 
 impairment or loss of 
 the function of the 
 
 Skull and VEiiTEBBiE divided 
 SHOWING Brain and Spinal Coed in 
 
 POSITION. 
 
42 MENTAL NURSING. 
 
 organ or the part of it. Thus affections of the nerves 
 of the eye may be followed by blindness, etc. 
 
 If the spinal cord be diseased or injured, some or 
 all of the messages ascending to or descending fi^om 
 the brain will be cut off, and then the brain is isolated 
 from that part of the body below the level of the 
 affection in the spinal cord. No communications can 
 pass upwards if the whole thickness of the cord be 
 implicated, nor can any orders be transmitted down- 
 wards. The brain, nerves, and muscles are in good 
 working order, but the stoppage of the messages in 
 the sjDinal cord causes loss of both sensibility and 
 motion below the injury. If any part of the thickness 
 of the cord be left unaffected, then the messages 
 which pass by that portion of it will still be 
 transmitted. 
 
 The brain is the organ of the mind. The function 
 of some of its nerve cells is to produce thought, will, 
 consciousness, memory. Disease or destruction of 
 these nerve cells or of the communicating fibres may 
 reduce the eloquence of the most sagacious statesman 
 to the incoherent chatter of the drivelling lunatic. 
 The healthy brain, by its will power, sets in action 
 and directs the muscles of the body. The surface of 
 the brain is marked out into areas which have special 
 duties assigned to them. One area presides over the 
 movements of the upper limb, another over those of 
 the lower limb. Thus when, by the action of certain 
 cells in another part of the brain, the thought and 
 the will to do a certain action is elaborated, a mes- 
 
THE NEEVOUS SYSTEM. 4S 
 
 sage, by means of the communicating fibres, is sent to 
 the cells which preside over the muscles necessary to 
 perform the action willed. These cells, by means of 
 the efferent motor fibres, send the order out and the 
 muscles contract. 
 
 Certain areas receive and interpret messages from 
 the organs of special sense ; if the cells be diseased 
 the message may be misinterpreted, and we may have 
 a perverted sensation ; if the cells be destroyed the 
 special sense is lost altogether. 
 
 It is a cm^ous fact that the one side of the brain 
 presides over the other side of the body. The fibres 
 that pass between the brain and the two sides of the 
 body cross in the spinal cord, the fibres from the right 
 side of the body going to the left side of the brain 
 and vice versa. Thus a haemorrhage into the right 
 side of the brain may cause paralysis on the left side 
 of the body. 
 
 Disease may affect any part of the brain. We 
 said that the fibres entering the brain from the spinal 
 cord spread out to reach the various parts of the 
 brain to which they were distributed. These fibres 
 may be injured or destroyed by heemorrhage, and 
 according to the function of the strands of fibres 
 affected we have paralysis of motion or sensibility 
 over the part of the body with which they are in 
 communication. 
 
 According to the function of the part of the brain 
 attacked the symptoms of the affection vary. We 
 have seen patients helplessly paralysed but able to 
 
■44 MENTAL NUESING. 
 
 converse sensibly. We know cases whose physical 
 powers are as good as our own, but whose minds are 
 an utter blank. 
 
 We must distinguish between the effects of irri- 
 tation or undue action of the nerve cells and those 
 which follow upon their destruction. In the former 
 case we have an alteration or exaggeration of the 
 usual work. of the cells and in the latter the function 
 over which they preside is utterly lost. Any area of 
 the surface of the brain may be affected. If it be 
 that portion which presides over the muscles of the 
 arm, and the disease has not advanced beyond the 
 stage of irritation, we may have spasmodic con- 
 tractions of the muscles arising from the working 
 of the irritated nerve cells which have got beyond 
 the control of the will. If the cells be completely 
 destroyed then the muscles under their orders are 
 paralysed. Here the whole line is free for efferent 
 messages to be sent out, but owing to the destruction 
 of the nerve cells there are no orders to send. 
 
 Should a portion of the brain engaged in the in- 
 terpretation of messages from an organ of special 
 sense be affected, we may have symptoms due either 
 to the irritation or to the destruction of cells in that 
 centre. If we suppose the area for sight to be 
 affected, then, from irritation and perverted action of 
 the cells, the individual may see flashes of light, or 
 may even fancy that objects of a definite shape are 
 before him. Of course, if the cells be destroyed 
 entirely, then blindness results. Similarly, we have 
 
THE NERVOUS SYSTEM. 45 
 
 symptoms arising from the affection of areas, con- 
 cerned with smell, taste, hearing, etc. 
 
 The brain is a delicate structure ; slight injuries 
 or structural changes play great havoc with its 
 functions. It is easily affected by the condition of 
 the blood, as is seen in the delirium and convulsions 
 in various diseases. 
 
 Our asylums are in a great measure huge lumber 
 rooms for human wi'eckage, and seem standing 
 reproaches for the inefificacy of our efforts to treat 
 mental disorders. The explanation lies in the deh- 
 cacy of the nervous tissues. In most diseases some 
 slight permanent change is left in the structure of the 
 organ or tissue affected without materially impairing 
 its functions. In the brain, however, slight changes 
 mean the mental life or death of the patient. Hun- 
 dreds of cases exist in our large asylums as hopeless 
 lunatics who are as surely cured of the acute affection 
 from which they suffered as are those people who 
 have had pleurisy, are said to have recovered, and are 
 now doing their duty in the world. The difference 
 lies in the importance of the organ affected. In the 
 one case, even a considerable amount of structural 
 change may be a matter of comparative unimportance ; 
 in the other, a slight change means all the difference 
 between a useful life outside and a living death 
 within the walls of an asylum. 
 
 The sympathetic system consists of separate little 
 masses of nervous tissue situated down the front of 
 the spinal column. These are connected by means of 
 
4fi 
 
 MExNTAL NUESING. 
 
 fine nerves with each other, and with the nerves from 
 the bram and spinal cord. The nerves from the sym- 
 pathetic system are distributed to, and concerned in 
 the action of the digestive tract, heart and blood 
 vessels, uterus, etc. They are not under the control 
 of our will. 
 
Chapter IV. 
 
 FORMS OF INSANITY FEOM THE NUESE'S 
 STANDPOINT. 
 
 Insanity a bodily disease. Idiocy. Delusions and hallucinations. 
 States of exaltation. Of depression. Delusional Insanity. 
 States of mental weakness. 
 
 It is necessary that the nurse for mental cases should 
 clearly understand that the patients with whom she 
 has to deal are as certainly suffering from bodily 
 disease as are those who are afflicted with an 
 affection of any organ in the chest or abdomen. 
 The mind is not a thing apart from the body. 
 Intelligence is as truly the work of the brain as the 
 movement of the fingers is the result of the contrac- 
 tion of the muscles of the forearm. 
 
 We can now understand what is meant by an 
 idiot, as distinguished from a lunatic. In an idiot 
 there has been an imperfect development of the 
 nerve centres. Tie can no more be expected to have 
 a sound mind than a man born with stumps for his 
 legs could be expected to play football. His nerve 
 cells are defective, and though by education the 
 
 greatest possible use may be made of them, yet he 
 
 (47) 
 
48 MENTAL NURSING. 
 
 can no more reach the average standard of intelli- 
 gence than a weakling could by training ever hope to 
 rival a Hercules. In both cases the most that the 
 machine is capable of may be attained, but no more. 
 
 A lunatic, however, has had an average develop- 
 ment to begin with, but his mental powers have 
 become impaired owing to disease or injury. 
 
 Those cells or communicating fibres which are 
 employed in the production of the intellectual faculties 
 may be diseased. The result is that these faculties 
 become impaired or destroyed, and so delicate are 
 the structures affected that a very slight change in 
 them makes a serious alteration in the functions they 
 perform. We have said that an idiot is an individual 
 with an imperfectly developed brain ; an imbecile is 
 an individual whose brain is more highly developed 
 than that of an idiot, but yet does not reach the 
 ordinary standard. The possessor of a normally 
 developed brain in healthy working order is said to 
 be sane, or in other words to have a sound mind. 
 If those parts of the brain concerned in the produc- 
 tion of the intellectual faculties be diseased, then we 
 say that the possessor of such a brain is insane, or 
 that he has not a sound mind. It is with persons so 
 afflicted that we have to deal. 
 
 Any of the intellectual faculties may be impaired. 
 We find patients in whom reason, will, memory, 
 self-control, emotions, are affected, and in whom the 
 animal instincts are altered or perverted. These are 
 merely symptoms which show us that the highest 
 
FORMS OF IXSANITY FEOM THE NUESE's STAKBPOINT. 49 
 
 functions of our brains are disordered. The lunatic 
 cannot be held responsible for many of his doings ; 
 they are the result of disease. From his point of 
 view, behaviour which appears to us utterly wrong is 
 to him perfectly correct and justifiable. His will- 
 power or self-control may be impaired, and hence he 
 performs purposeless acts, or gives way to violent or 
 destructive impulses. Thus we account for delusions ; 
 for irrational language and conduct ; for incoherent 
 speech and noisy excitement ; for depression and 
 suicidal tendencies ; for dogged obstinacy and facile 
 changeableness ; for the forgetfulness which makes 
 the past of but a minute ago an utter blank. Hence, 
 also, we have the altered appetites, the duly habits, 
 and the indecent practices to which some lunatics are 
 subject. They are all indications of the mischief at 
 work in the higher brain centres. 
 
 A delusion is a " false belief arising from diseased 
 mental action," as when a pauper believes that she 
 is the Queen of England. An hallucination is a false 
 impression received through one of the special senses, 
 and if the individual believes in the reality of the 
 impression, then the hallucination becomes a delusion. 
 Thus a person may see animals in a room where none 
 exist, but by the exercise of his reason he may 
 convince himself that the object which he thinks he 
 sees is, in reality, non-existent. If, however, he 
 believed that the animals are actually present in 
 the room, then the hallucination has become a 
 
 delusion. 
 
 4 
 
50 MENTAL NURSING. 
 
 Lunatics may be divided into four great classes. 
 An insane person may be completely changed from 
 his state when in health as regards spirits, manner, 
 and behaviour generally. From being quiet and 
 retiring he may become the very reverse. He may 
 be restless, excitable, and talkative ; perhaps 
 incoherent, violent, and destructive. There is 
 exaggerated action of some of his mental powers, 
 an impairment of others, and a great want of self- 
 control. His whole condition is that of exaltation 
 or undue action. States of exaltation form the 
 first of these great classes. The individual may 
 have delusions, but they are not the outstanding 
 feature of his illness. 
 
 In contrast to this condition, however, the 
 patient may be dull, depressed, and utterly 
 miserable. There is to him no pleasure in life. 
 It is acute pain merely to exist, and he may seek 
 to put an end to it all by starvation or otherwise. 
 Often there are most distressing delusions, though 
 these are not essential. He feels that some awful 
 doom is impending. The unpardonable sin has been 
 committed, and the wretched sufferer ever sees hell 
 yawning open before him, while ghostly denuncia- 
 tions ring constantly in his ears. He spends his 
 days and most of his nights in a fearful waking 
 nightmare. It is no wonder that suicidal impulses 
 are frequent. Such cases as these form typical 
 examples of the " states of depression ". 
 
 Many cases lie between the extremes of exalta- 
 
FOEMS OF INSANITY FEOM THE NUESE'S STANDPOINT, 51 
 
 tion and depression, but may be referred to one or 
 the other as their symptoms indicate. 
 
 A third great class is formed by those who have 
 delusions, but who show no marked alteration in 
 their conduct either towards exaltation or depres- 
 sion. This class might be called " delusional 
 insanity". The first and third classes together 
 may be said to be suffering from "mania," the 
 second from "melancholia". 
 
 The fourth great class consists of " states of 
 mental weakness " occurring in persons whose minds 
 at one time were up to the average standard, but, as 
 the result of injury or disease, have become feeble. 
 This class comprehends the majority of the chronic 
 residents in our asylums. Their mental condition 
 varies from slight enfeeblement to the living death of 
 the utterly demented, who live the life of vegetables, 
 and require to be cared for like babes. 
 
 The mental condition of the epileptic and general 
 paralytic can, at the various stages in their careers, 
 be referred to one or other of these classes ; but, as 
 they have S2:)ecial characteristics of their own, they 
 will be dealt with separately when we speak of the 
 management of patients. 
 
 We have all experienced how the mind is 
 affected by the general health of the body, and 
 we know that the state of the mind reacts upon 
 the system. An unhealthy body is a great strain 
 upon a sound mind. We know how differently 
 things appear to us when we are in good health, 
 
52 MENTAL NURSING. 
 
 compared with what they do when we are ill and 
 irritable. A man suffering from the gout is not 
 situated in the best possible circumstances for 
 taking a calm, patient, and reasonable view of his 
 surroundings. Loaded intestines and an overworked 
 stomach are the cause of much misery and mental 
 pain in this world. Cold and uncleanliness are not 
 conducive to comfort, and when we are uncomfort- 
 able our mental peculiarities do not show up in a 
 favourable light. We have all felt that the state of 
 the atmosphere had an influence upon our feelings, 
 and that our views of men and things were much 
 influenced by our surroundings. All these things 
 influence us, and in a greater or less degree also 
 exert their power upon the insane. We have our 
 reasoning powers, and ought to know how best to 
 maintain the conditions necessary for our health ; 
 the insane in many cases are quite unable to do this, 
 and yet it is most essential that they should be 
 placed under the best hygienic conditions possible. 
 They must be thought for and provided for. The 
 nurse must remember that in many cases she must 
 think and act for the patient. She should be ac- 
 quainted with the state of each individual under her 
 care, as regards her clothing, appetite, excretions, 
 and cleanliness, and she should see that the ventilation 
 and warmth of her ward are kept up to the standard. 
 
Chapter Y. 
 
 VENTILATION. 
 
 To attend to the ventilation of her ward is one of the 
 most important duties of a nurse, and one which 
 requires constant attention. Perfect health cannot 
 be maintained without a plentiful supply of fresh air, 
 and it is vain to attempt to restore the feeble and 
 debilitated without it. The object of ventilation is to 
 provide this fresh air and to get rid of that which has 
 l^een breathed and rendered impure. To the nurse 
 personally this is all important. The constant 
 breathing in of foul air will soon pull down her 
 strength and sap her energies. Headaches, loss of 
 appetite, auEemia, and even phthisis may result. 
 Impaired health and irritability of temper will 
 certainly follow, and under such circumstances a 
 nurse can neither do justice to herself nor to those 
 under her charge. If she do not accustom herself to 
 look to the ventilation as a matter of routine it is 
 very likely to be overlooked, and she will have the 
 mortification of hearing those entering her ward 
 remark upon the closeness of it. The feeling of 
 stuffiness, which may be used as a practical test that 
 
 the ventilation is insufficient, is not apparent to 
 
 (53) 
 
54 MEiNTAL iSUESIXGr. 
 
 any Oije who has been in the ward for some time, 
 but at once strikes an individual who has just come 
 from the fresh air outside. To breathe in previously- 
 respired air is slowly to commit suicide, and this 
 form of self-poisoning is one of the most unpleasant 
 ways of affecting that end. 
 
 Air consists of a mixture of gases — oxygen, 
 nitrogen, and carbonic acid — the last in very small 
 amount. The oxygen and the carbonic acid are the 
 important constituents. The nitrogen plays no part 
 in respiration, but merely dilutes the other gases. 
 Oxygen is taken from the air in the lungs, and 
 carbonic acid with some water and organic matter is 
 returned to it. It is this organic matter which causes 
 the unpleasant stuffiness in a close, ill-ventilated 
 a^jartment. The air also takes up Vv^ater from the 
 sweat of our bodies, and is tainted by smells and 
 impurities from various sources, as from gas escapes, 
 etc. It also becomes loaded with particles of dust, 
 and in sick wards this is a very important element. 
 Some of the insane emit strong and very unpleasant 
 odours from their skins ; others, again, owing to 
 their dirty habits, soon polute the atmosphere of a 
 whole ward if not immediately looked to. Escapes 
 of gas are very dangerous. Fortunately its well- 
 marked smell at once attracts notice to it. 
 
 The air which leaves the ward is poorer in oxygen 
 than it was when it entered, but contains more 
 carbonic acid, water, organic matter, ar.d other 
 impurities which it has gathered. The chemical 
 
VENTILATION. 65 
 
 standard of impurity is the amount of carbonic acid, but 
 a practical guide is the feeling of stuffiness perceived 
 on coming in from the fresh air. The ideal to be 
 aimed at is to keej) the air inside as pure as that out 
 of doors, and to effect this without causing perceptible 
 draughts. This is not easy to manage even in a 
 room filled with the sane, who ought to be able to 
 appreciate the necessity for and to aid in maintaining 
 proper ventilation ; but among the insane it is often 
 very difficult. The perverse obstinacy of some 
 patients is very trying. They seem to think that an 
 open window is a positive danger, and must be closed 
 at once. 
 
 There is alvv^ays some change taking place in the 
 air of a room. The air outside mixes with that inside 
 through the pores of the walls, the chinks in the 
 windows, etc. The warmer and lighter air inside 
 also tends to rise and escape, while its place is taken 
 by the colder and heavier air which enters from 
 without. The fire causes a rush of warm air up the 
 chimney, and creates a draught up it, which assists 
 materially in ventilating the room. In an ordinary 
 apartment with only three or four persons in it these 
 means are effective enough, but are not sufficient for 
 a large room with a number of inmates. Under 
 the latter circumstances intelligent use must be made 
 of windows and special openings in the wall called 
 ventilators. With other and more elaborate methods 
 the nurse would not be concerned. The jooints for 
 her to keep in mind are : — 
 
56 MENTAL NURSING. 
 
 1. To see that the means for ventilation are in 
 working order. 
 
 (a) Ventilators. These are very liable to get 
 blocked. Even when the current of air can be 
 proved to be passing from within outwards many 
 patients will declare that they are being killed by the 
 cold draught, and if they possibly can do so will plug 
 up the gratings. Dust and fluff are apt to accumulate 
 and interfere with the free passage of air. Those 
 openings on a level with the floor may be used as 
 receptacles into which dust may conveniently be 
 swept, and some patients appear to believe that 
 their only use is to afford convenient hiding places 
 for odd slippers, stockings, etc. Obstructions may 
 also be caused by materials which get in from outside. 
 
 (b) The chimneys should not be blocked, and 
 should be kept free from accumulations of soot. 
 
 (c) The windows will require intelligent attention, 
 as by proper management even on very windy days 
 they can be made available, and in most wards by 
 their means cross-ventilation, or a stream of air 
 passing across the ward, can be obtained. A close 
 watch will be necessary, as many patients are ready 
 to shut the window whenever opened. Of course 
 the windows of single rooms and dormitories should 
 be thrown open as soon as the patients have left them. 
 
 (d) Doors should not be used as a means of 
 ventilation. As a rule to do so only means ad- 
 mitting air which has been already polluted more 
 or less. 
 
VENTILATION. 57 
 
 (e) Any dampness of the walls should be at once 
 reported. It interferes with the passage of air 
 through the pores in the wall, affords a resting-place 
 for dust, keeps down the temperature of the ward, 
 and also provides places in which infectious germs 
 may develop. 
 
 2. To prevent inside impurities. 
 
 (a) Dust must be removed. Particles from skin, 
 hair, clothing, etc., become deposited on the furniture 
 and walls, and with them some of the offensive 
 organic matter in the air. In the wards for the sick 
 special attention should be paid to this. 
 
 (b) Some of the patients will be found to give out 
 very offensive odours from their skin, and will require 
 particular care as regards washing and general 
 cleanliness. 
 
 (c) Wet and dirty cases if neglected will soon 
 pollute a whole ward. Patient endeavours to incul- 
 cate better habits would do much, and the bathing 
 and changing when required must be done at once. 
 
 {d) The foul linen should be at once conveyed to 
 some place where it cannot pollute the air within 
 the building. In sick wards, chambers, etc., should 
 be emptied and cleansed at once. 
 
 (e) Lavatories and water-closets should be kept 
 scrupulously clean, and inspected by the charge 
 nurse regularly and frequently. They should be 
 well ventilated, and the windows in the passage that 
 leads from the ward to the closets should be kept 
 open when possible, and the door that cuts off the 
 
58 MENTAL NURSING. 
 
 closets from the ward kept closed. For purposes of 
 observation this door is generally furnished with 
 large glass panels. It is important to notice the 
 under-surface of the seats in the water-closets. In 
 the male wards the urinals are often a great source 
 of impurity. Sinks should be kept very clean, and 
 their tra.ps in order, and any escape of gas should be 
 at once reported. 
 
 (/) Where the heating is effected by steam, dis- 
 agreeable smells are sometimes caused by the dirty 
 practices of mischievous patients wdio foul the steam 
 chests. Some patients also have a habit of drying 
 wet and filthy rags on the heating apparatus. 
 
 (.(/) The single rooms and dormitories occupied by 
 dirty patients will give much trouble, and will require 
 careful cleansing with hot water and Jeye's fluid, or 
 some similar preparation. The nurse should be 
 careful to see that the floor is well dried after being 
 scrulobed. She should also notice that the ventilators 
 are not daul^ed with filth, and that the cracks between 
 the boards of the floor, doors, and wall (if boarded) 
 are clear. 
 
 She must carefully supervise the patients who are 
 assisting her. They will sometimes begin to scrub 
 out a clean room with dirty water and cloths. The 
 result is not beneficial to the sweetness of the 
 dormitory or corridor. 
 
 The value of sunlight should not be forgotten, and 
 in order to gain its full benefit the windows should 
 receive regular attention. Each time the charge 
 
VENTILATION. 59 
 
 nurse enters the ward she should be on the outlook 
 for stuffiness, and should ask those under her who 
 have been absent from the ward for a while to 
 report on their return whether they notice any 
 closeness or smells. 
 
Chapter VI. - 
 
 WARMTH. 
 
 Many of the insane are peculiarly susceptible to the 
 influence of changes in the temperature, and are 
 markedly affected by even a slight fall in the 
 thermometer. There is no doubt that the popular 
 idea of the many evils which owe their origin to 
 " catching a cold " is very exaggerated. That ex- 
 posure to cold does bring in some forms of disease 
 is, however, certain, and the more debilitated the 
 individual, the more likelihood there is of his falling 
 a victim. The young, the feeble, and the aged 
 require a higher temperature and warmer clothing 
 than are sufficient for an adult in fair health. 
 Especially amongst the demented classes (or those 
 suffering from mental weakness) must this point be 
 carefully attended to. Their nervous force is small, 
 and their circulation is often weak. Cold and blue 
 extremities are common among them. Chilblains 
 are easily produced, and not readily got rid of In 
 such cases bronchial catarrh, diarrhoea, and low 
 forms of inflammation are the not infrequent results 
 of exposure to chills. In one class of cases, that of 
 
 acute dementia, the question of warmth is almost as 
 
 (60) 
 
WAEMTH. 61 
 
 important as that of food, and the patients will often 
 with advantage bear a temperature which seems un- 
 pleasantly warm to the other occupants of the room. 
 Such patients are generally much brighter in summer 
 than in winter. It will be noticed, too, that epileptics 
 do best who occupy beds in the warmest part of the 
 dormitory. 
 
 In cold weather the problem of keeping a ward 
 containing dirty cases up to the proper temperature, 
 and at the same time sweet and w^ell ventilated, is 
 one not always easy of solution. More especially is 
 it difficult when the wards are full of the very de- 
 mented. These, the very people who require most 
 warmth, are unable to help themselves, and are too 
 dull and stupid even to complain. They will plant 
 themselves in a direct draught with unfastened gar- 
 ments, and although they may become pinched and 
 blue with cold, have not enough intelligence to shift 
 their position. They are thus in a peculiar manner 
 dependent upon the thoughtfulness of the nurse. If 
 it be necessary that the part of the ward in which 
 they are seated should be blown through, they should 
 be removed out of the cold draught until this is done. 
 The early morning, before the sun has gained much 
 power, is the time when the heating arrangements 
 generally fail. Patients should not be brought from 
 warm beds to sit and shiver in the day rooms until 
 they are warmed up. The day rooms should be 
 raised to a temperature of 55 deg. F. before the 
 patients are allowed to enter them. If all the 
 
62 MENTAL NURSING 
 
 lunatics were able to employ themselves in ward 
 work, and thus keep themselves warm, the case 
 might not be so bad, but such as can do this are in 
 some of the wards but too few in number. It is a 
 painful sight in the early morning to see the poor 
 demented creatures sitting with chilled extremities 
 and blue noses, what little intellect they have almost 
 destroyed by the cold. 
 
 Where the heating arrangements consist of hot- 
 air or steam-pipes, they are out of the nurses' hands. 
 These are safer, and in many respects more con- 
 venient, than stoves and open fires. For dormitories 
 not under constant supervision, the latter are, of 
 course, out of the question. But for day rooms, 
 where nurses are constantly present, open fires are 
 more home-like, and are to be preferred. In large 
 rooms, of course, they have often to be combined 
 with some other method. If stoves are used, the 
 night nurses should see that they are well stoked up 
 on their last rounds, so as to warm up the corridors 
 before they are occuj)ied. The fires in the day rooms 
 should also be burning brightly before these apart- 
 ments are tenanted. Though at first sight it is a 
 subject which seems but remotely connected with 
 nursing of the insane, yet lessons in proper stoking 
 and making up of fires should form part of every 
 nurse's education. The one extreme of keeping the 
 grate piled right up the chimney is almost as much 
 to be found fault with as the other of neglecting a 
 fire until it is nearly out, and then extinguishing it 
 
WARMTH. 68 
 
 completely under a shower of small coals. By the 
 former method you run an unnecessary risk of that 
 awful calamity — an asylum on fire. If the grate be 
 kept properly stoked up to the level of the top bar, 
 and the fire be kept bright, the maximum heating 
 effect will be obtained with the minimum expenditure 
 of fuel, and the least risk of any danger. 
 
 The clothing of the patients must be closely 
 looked to. If the body be not properly clothed, a 
 great amount of heat is dissipated and lost to its 
 owner. . Clothes act as the preservers of the heat 
 produced by the food taken into the system. The 
 nurse should see that her patients have their proper 
 amount of underclothing. Many of them are very 
 apt, if not w^atched, to lay aside their flannel under- 
 garments. Those lunatics who are just on the 
 border-line between the fortunate few who can, and 
 the unfortunate many who certainly cannot, attend 
 Lipon themselves, are the ones who are liable to suffer 
 in this w^ay. Some patients ap|)ear to have most fanci- 
 ful objections to wearing flannel garments. These 
 peculiarities should be resisted on the patient's first 
 entrance to the asylum. Like many other bad habits, 
 they become more fixed and difficult to get rid of 
 every day they are indulged in, and a bad practice, 
 which might have been put right with little difficulty 
 at first, may if allowed to become fixed, develop into 
 a very troublesome and serious business. Other 
 patients again, from ideas connected with their 
 delusions, will give trouble about their clothing. 
 
64 MENTAL NUESING. 
 
 Those who are allowed to remain wet are in 
 danger of being chilled, owing to the cooling of the 
 body in the evaporation of the urine. This is a very 
 important point for the night nurse to attend to. 
 With but few exceptions, beds constantly wet mean 
 bad nursing. Regular getting up of doubtful cases, 
 and close attention to those known to be liable to this 
 mishap, will. do much to shorten the nightly wet and 
 dirty list. A demented lunatic, on a cold night, 
 partially uncovered and in a wet bed, presents a fine 
 target for disease. 
 
 It is a sad defect in our asylum construction that 
 the very parts of the building which should have their 
 heating arrangements most perfect, are often the 
 worst off in that respect. Very frequently the single 
 rooms occupied by noisy, dirty, and destructive cases 
 are inadequately warmed. The poor lunatic, too 
 excited to remain in bed, tears up her clothing and 
 bedding and then shivers until the night nurse gives 
 her a fresh supply and puts her into bed, probably 
 only to find her as comfortless on her next visit. It 
 would be difficult to have all such cases under con- 
 stant supervision, and the night nurse who has them 
 under her care cannot perform impossibilities. 
 
 Feeble and acute cases, who are not so destructive, 
 can be dealt with by putting them into thick flannel- 
 lined combinations, which lace up the back. In these 
 they are kept warm even when restless and out of 
 bed. The temperature of an ordinary ward should 
 be kept about 55 deg. F., and for the more feeble and 
 
WAEMTH. 65 
 
 demented it should be nearer 60 deg. F. The day 
 nurse ought to note the temperature as shown by the 
 thermometer at regular intervals during the day, and 
 enter it in her report sheet. The night nurse also 
 should mark the temperature in the corridors and 
 dormitories during her hours on duty, and show the 
 figures in her report for the night. 
 
 When a patient requires bathing in the night, or 
 when in bed during the day, slippers should be placed 
 on her feet, and her body carefully protected from 
 cold in going to and coming from the bath-room. On 
 bathing days the charge nurse should see that the 
 temperature of the dressing-room is comfortably 
 warm, and patients should not be allowed to get 
 undressed until the bath is ready for them. 
 
 Before going out for exercise it is the duty of the 
 nurse to see that each patient has her out-of-door 
 garments tidily put on, and her boots fastened. The 
 habit of many of throwing off hats, boots, and cloaks 
 vrill require constant attention. When the day is 
 cold, she must not allow the dull and demented 
 members of her flock to sit still and get chilled, but 
 should keep them moving. 
 
Chapter VII. 
 CLEANLINESS AND ORDEE. 
 
 To make a good nurse, much more is requisite than 
 habits of cleanliness and order, but no nurse can be 
 good without them. She cannot be held responsible 
 for the character of the furniture, nor for the nature 
 or taste of the decorations in her ward ; but upon her 
 rests the more important duty of seeing that every- 
 thing is scrupulously clean and sweet. If she herself 
 be untidy and slovenly in appearance when about her 
 work, it is j^robable that that work will be performed 
 in but a slip-shod manner. The example she will set 
 to the patients will be a bad one, and her influence 
 over those who have sufficient reason to notice these 
 things will be small. She will find that many keen, 
 and by no means friendly, critics are about her, who 
 are ready to pass judgment upon her work and 
 behaviour without being burdened with any scruples 
 as to the plain, and often scathing, terms they employ. 
 If one finds the window ledges and corners of a 
 ward littered with dust, and the backs of the orna- 
 ments wearing coverings of a similar nature, it is 
 more than probable that the store-rooms are untidy, 
 the boot-room higgledy-piggledy, the medicine chest 
 
 in disorder, and the lavatories ill kept. As much 
 
 (66) 
 
CLEANLINESS AND OEDEE. 67 
 
 pride should be taken in these places as in the 
 brightest corner of the day-room, and they should 
 always be ready for inspection. The nurse who is 
 attentive to matters which do not come under the 
 casual observer's eye, rarely allows her patients to be 
 neglected or to appear untidy and unkempt. 
 
 It is perhaps in the care of her dormitory that 
 the industrious nurse, with a love of order, is seen to 
 best advantage. The sleeping rooms ought to be 
 one of the pleasantest features of an asylum : bright 
 and sweet, with white and stainless linen, spotless 
 floor and well-trimmed beds. A little attention to 
 the position of the bedsteads, and the turning down 
 of the sheets so as to keep them uniform, makes a 
 wonderful difference in the appearance of the dor- 
 mitory. The work, too, must be thorough. A clean 
 upper sheet covering foul blankets or a dirty mattress ; 
 a pillow with a soiled side carefully turned down out 
 of sight ; the bedstead with an accumulation of dust 
 beneath it — these are the things which vex a charge 
 nurse's soul. Special attention is required in single 
 rooms for dirty cases. Even where a bed is made on 
 the floor with strong rugs, there is no reason why it 
 should not be tidy, and the rugs, though strong, 
 should be clean. We have already spoken about 
 the care requisite in scrubbing out dirty rooms. 
 
 I speak with all deference, but I think that, as a 
 rule, the dormitories are better kept in male than in 
 female wards. The order is more manifest, and the 
 beds are generally better made. Probably the more 
 
68 MENTAL NURSING. 
 
 soldier-like discipline and the greater physical strength 
 are the reasons for this difference. 
 
 The men's day-rooms, however, always seem to 
 possess more of the barrack-room character. They 
 cannot give that home-like appearance to their wards 
 that women can, and few men have an eye for dust. 
 
 The state of the patients' clothing should be a 
 matter for constant observation. It will not do to 
 rest content with changing at stated times. Active 
 and intelligent interest is needed, as well as attention 
 to a routine duty. Patients who are in the habit of 
 hoarding up rubbish, rags, and scraj^s of food should 
 l^e overhauled daily. A close watch should be kept 
 to see that no food is carried from the dining-room 
 to the day-room. Sufficient time should be allowed 
 for meals, but no food should be taken from the table, 
 and for important reasons other than those of cleanli- 
 ness. Dirty habits at meal times, such as smearing 
 the head with fat, etc., should be looked after. 
 
 Every individual, when it is possible, should have 
 a weekly bath ; in all cases for the sake of the 
 individual's own health, and in some for the sake of 
 the comfort of those who are compelled to associate 
 with him. It seems a very simple thing to say that 
 lunatics should be kept clean, but in practice it is 
 not always so easily carried out. Many patients, of 
 course, are extremely cleanly, and can attend to 
 themselves, but unfortunately this class is in the 
 great minority. In every ward there are persons 
 who would avoid the weekly bath if they could, and 
 
CLEANLINESS AND OEDER. 69 
 
 many are the complaints and manoeuvres to effect 
 that end. Very dirty cases will often require bathing 
 several times daily, and even then it will be difficult 
 to keep them sweet. Some patients, who perspire 
 freely and are very stout, are liable to have their skin 
 irritated and chafed, especially in the folds, as under 
 the breast and in the groin. These will require extra 
 attention. The feet of others mil give trouble to 
 keep them sweet and prevent them chafing. 
 
 A point of great importance, and more particularly 
 amongst those unable to attend to themselves, is the 
 cleanliness of the hands. In some cases, undoubtedly, 
 diarrhoea is caused, and j^arasites gain entrance to 
 the intestinal canal, owing to the dirty habit of eating 
 with unwashed hands and foul finger nails. In dirty 
 cases especially, the nails should be cut short and the 
 hands carefully cleansed before each meal. I am sure 
 that if this were regularly attended to there would 
 be fewer cases of diarrhoea among the very demented 
 and dirty. It is, I grant, difficult in a large ward to 
 carry out properly, but none the less, it should be 
 done. 
 
 The condition of the teeth and gums, too, should 
 not be forgotten. In some acute cases and in 
 melancholies this is of importance, and ought to be 
 seen to as part of the routine duty of the day. 
 
 In the admission ward, the condition of the heads 
 of newly received cases is often a source of trouble, 
 and even of anxiety to a careful nurse. Some cases 
 are so very full of vermin that it is necessary to cut 
 
70 MENTAL NDESING. 
 
 the hair short, but such extreme measures are seldom 
 required. Patience, perseverance, and the small- 
 toothed comb will do much, with the occasional 
 assistance of a little vinegar or other application to 
 loosen the nits. Apart from these importations from 
 without, it is a disgraceful thing to find a dirty head 
 in an asylum. I know that some of the insane 
 appear to fiirnish extremely favourable pastures for 
 these vermin, and that they seem to spring up by 
 magic, but there is no excuse for their presence. 
 The daily combing and dressing of the heads of those 
 unable to look after themselves ought to afford a 
 sufficient safeguard. The presence of dirty heads 
 means simply that some nurse has shamefully 
 neglected her duties. It is very seldom indeed that 
 a flea is seen in an asylum. 
 
Chapter YIII. 
 
 FOOD. 
 
 Dining-room. Epileptics. Paralytics. Acute Maniacs. 
 
 Melancholies. Forcible Feeding. The Sick. Administration 
 of Medicines. Cooking for the Sick. 
 
 The duties of the nurse with regard to the food of 
 her patients fall into two divisions. In the first j^lace, 
 with respect to the great mass of those under her 
 care who are able to take their meals in the common 
 dining-room ; and, secondly, there are those acute or 
 special cases which require more individual attention. 
 The condition of a dining-room at meal times is a 
 very good test of a woman's abilities as charge nurse, 
 and many excellent nurses are not suited for that post. 
 The comfort of the meals and the appearance of the 
 viands depend very much upon the attention paid to 
 the table appointments and the method of serving 
 the food. The charge nurse must use her head as 
 well as her hands. Tablecloths, where used, are a 
 sad trial. A clean cloth put on for breakfast is often 
 so soiled as to be hardly fit for use at dinner ; and 
 yet neither the resources of the ward stocks, nor the 
 capabilities of the laundry, will allow of a fresh cloth 
 
 for each meal. Everything should be made as 
 
 (71) 
 
72 MENTAL NURSING. 
 
 appetising and as bright as possible. When most 
 asylums are in the country, and wild flowers are 
 common, there is no reason why in the quieter wards 
 flowers should not be constantly present on the tables 
 in the summer months. In addition to their brighten- 
 ing effect, the arrangement and gathering of them 
 will give pleasure and light occupation to some of the 
 inmates. It is needless to remark that knives and 
 forks should be clean, and that salt-cellars and 
 mustard-pots should be kept freshly supplied. These 
 things appear to be matters of course, but in practice 
 they are curiously apt to be overlooked. 
 
 Meal times are occasions on which every patient 
 can be individually noticed. Each nurse should have 
 a table assigned to her, and to which she always 
 attends. The same patients should always sit at that 
 table, and in their usual seats. The nurse can then 
 perceive at once either want of appetite, or any altera- 
 tion in the patient's condition. She will become 
 acquainted with the peculiarities and habits at meal 
 times of those at her table, e.g., those who bolt their 
 food without masticating it ; those who eat slowly 
 and require extra time ; those who would steal from 
 the plates of their neighbours, and, if permitted, gorge 
 themselves to sickness. The class who bolt their food 
 are liable to choke, owing to their greedy or stupid 
 efforts to swallow large masses. Inability to take 
 food, or any change in appearance, should be at once 
 reported to the charge nurse. The latter will see to 
 the serving and exercise a general supervision. Some 
 
FOOD. 73 
 
 patients cannot take the ordinary amount, and others 
 will require, 23erhaps, more than an average helping. 
 It is natural that those who do much work and are 
 energetic will require more food than some of the 
 others, but the nurse should be careful that the 
 workers are not pampered at the expense of other 
 patients too stupid to comj)lain or look after them- 
 selves. It rests, to a great extent, with the charge 
 nurse whether, even in the noisiest wards, the dining- 
 room is quiet and orderly or noisy and turbulent. 
 The niaintenance of order and decency at meals has 
 a civilising influence upon the worst cases, and grace 
 before and after meat should not be slurred over, but 
 looked upon as j^art of the regular discipline of the 
 day. When a dining-room is entered unexpectedly, 
 and the nurses are found to have left their tables and 
 to be gathered together in knots gossiping, the prob- 
 ability is that the meals are badly served, and the 
 patients restless, quarrelsome and unsettled. 
 
 The food should be served as rapidly as possible, 
 in order that it may not become cold. In placing it 
 upon the plates also, the nurse should remember that 
 the appearance of the food often decides, in the case 
 of a dainty appetite, whether it will be eaten or left 
 almost untouched. A second course should not be 
 served luitil the first is finished. All stages of dinner 
 should not be going on at the same time. The 
 quantity of fluid taken should be noticed, and as far 
 as possible regulated within reasonable limits. The 
 amount that some lunatics will imbibe is extra- 
 
74 MENTAL NURSING. 
 
 ordinary. This at any time impairs the digestion, 
 and at the eyening meal in demented cases is of 
 importance from another point of yiew. 
 
 Such cases as are unable to masticate properly 
 will require soft food and eyen spoon feeding. In 
 any case of spoon feeding the nurse must carefully 
 remember that one spoonful must be swallowed 
 before another is taken into the mouth. A patient 
 can choke on a pharynx full of semi-solid bread and 
 milk as surely as on a chunk of beef Especially 
 among epileptics and paralytics there will be found 
 patients who are approaching this condition. These 
 should haye their meat, etc., cut up for them and be 
 kept under close obseryation. It is in this class that 
 accidents most frequently happen. Suicidal and 
 homicidal cases will of course be j^laced directly 
 under the eye, and within reach of the hand, of the 
 nurse who has charge of them. 
 
 Time must be giyen for all, eyen the slowest 
 eaters, to finish. Xo food can be permitted to be 
 taken away from the table. This is often a source of 
 great trouble, as some patients will endeayour day 
 after day to conceal bread, etc., about their person. 
 Paralytics must be esj^ecially watched and preyented 
 from indulging in this propensity. I haye seen a 
 death from choking occur in a paralytic who had, in 
 passing out of the dining-room, snatched up a crust 
 of bread unobseryed, and had crammed it into his 
 mouth unnoticed. 
 
 The forks and kniyes should be comited at each 
 
FOOD. 75 
 
 table separately, before the patients leave their seats. 
 Any missing article can then be localised, and at 
 once looked for. This should never be omitted. 
 
 Epileptics. — No epileptic should ever be allowed 
 to take food unless under observation. The obvious 
 danger is that the patient may have a fit and choke. 
 When a fit does occur during a meal the patient's 
 head should be turned to one side, and the mouth 
 cleared so far as is possible, care being taken that a 
 mass of food is not pushed to the back of the throat 
 in the operation. In the later stages of epileptic 
 dementia and in idiots, soft food and probably spoon 
 feeding will be required. Some epileptics eat very 
 ravenously, and do not masticate their food suffi- 
 ciently. These cases will require to have their 
 meat cut up for them or even to be supplied with 
 crushed meat and ^Dotatoes, etc. At times it is 
 necessary to give an epileptic her meals in a single 
 room ; on such occasions a nm^se must always have 
 the patient in sight. 
 
 Paralytics. — No paralytic should be allowed to 
 eat alone. The most dangerous period is when they 
 are nearly reaching the soft food stage, but have not 
 yet been put on crushed meat, etc. ; they eat greedily; 
 cram their mouths full without swallowing, and will 
 often steal anything from their neighbours' plates 
 that they can lay their hands on. This habit a care- 
 ful nurse will bear in mind. In the later stages they 
 must be spoon-fed, and in the last of all only liquids 
 can be taken. 
 
76 MENTAL NUESING. 
 
 The charge nurse should keep a list of those on 
 soft food in her medicine chest, and report any 
 patient who finds a difficulty in masticating or 
 swallowing. This power of observing and noting 
 changes in her cases should be encouraged. The 
 nurse has opportunities of gaining knowledge con- 
 cerning her patients' condition which the medical 
 man has not, and she can be of the greatest assist- 
 ance to him in this respect. 
 
 Acute Maniacs. — Patients in a state of acute 
 excitement call for careful feeding. Their recovery is 
 greatly a question of food and sleep, and the latter 
 requirement is often to a great extent dependent 
 upon the former. The continued excitement and 
 muscular exertions require a large amount of food 
 to repair the tissue waste and keep up the sufferer's 
 strength. This must generally be given in a liquid 
 form — as milk, eggs beaten up, beef- tea thickened 
 with arrowroot, etc. It is only in some cases that 
 the patient can be got to take a little solid food. In 
 the very acute cases they will not even attempt to 
 masticate. Some are quite unconscious of their need 
 of food, and instead of swallowing it will splutter 
 it out of their mouths, or simply blow into the 
 spoon or feeding cup instead of drinking. Such 
 patients must be nursed, cared for, and fed like 
 babies. Frequent trials must be made to induce 
 them to take food, as at one minute they will 
 take it and the next will refuse it. The favourable 
 moment must be used to get a fair amount of nourish- 
 
FOOD. 77 
 
 ment into the stomach, and then the nurse will en- 
 deavour to get the patient to rest in the recumbent 
 position, even if she has to lie down beside her. 
 Sometimes these cases will take food from one person 
 though they have refused it from another only a 
 moment before, and that without any apj^arent 
 reason for the preference. A nurse in charge of 
 acute cases who is an adept in the administration of 
 food is a treasure. Much anxiety and trouble is thus 
 spared the medical man. Undoubtedly there are 
 some persons who have a peculiar gift in this direc- 
 tion, and appear able to induce their patients to take 
 any amount of nourishment. Much patience, good 
 temper, and a sympathetic disposition, are probably 
 the secrets of their success. A note should always 
 be made of the amount taken, and the quantity 
 expressed in figures, as so many ounces of milk or 
 beef-tea with arrowroot, or so many eggs. The 
 doctor has thus definite information upon which to 
 decide whether it is necessary to supplement this by 
 forcible feeding. Puerperal cases will tax the nurse's 
 powers. They are generally debilitated, and are 
 often very excited. The use of milk or gruel which 
 has been artificially digested is sometimes of great 
 advantage. 
 
 Acute Melancholics. — Acute melancholies will 
 generally require great quantities of food. In many 
 cases, before their arrival at the asylum, they have 
 for days or weeks been insufficiently nourished. The 
 friends are unable to exercise that amount of moral 
 
78 MENTAL NURSING. 
 
 control which is wanted, and the patients are, in 
 some instances, positively half-starved. Their feeding 
 must be begun carefully, and be steadily persisted in. 
 If the nurse can make her patient gain in weight, she 
 may reasonably expect mental improvement. It is 
 amongst the melancholies that the most obstinate 
 cases of refusal of food occur. Frequently they will 
 be found to have some derangement of the digestive 
 system, and the discomfort they feel after meals may 
 be the origin of the common delusion that their food 
 is poisoned. The administration of nourishment in 
 proper amounts and at proper times is all-important, 
 but, at the same time, presents many difficulties. The 
 nurse must strive to acquire some control over her 
 patients, and this she must endeavour to obtain at 
 the very beginning of her acquaintance with them. 
 While she tries to gain their confidence and to make 
 them feel that she is their real friend, let her not 
 forget the old saying about the evil effects of fami- 
 liarity. The admission of a patient to the asylum, 
 and her entrance upon entirely new surroundings 
 in which a regular routine must be followed, is an 
 excellent opportunity to insist upon a return to 
 normal habits as regards food, as well as other 
 matters. Often those who come with dreadful repu- 
 tations from outside give no trouble whatever, but 
 fall at once into the ordinary ways of the institution. 
 The worst examples of refusal of food occur in 
 those whose delusions are of a religious character. 
 These are often very obstinate, and difficult to 
 
FOOD. 79 
 
 manage. Among the delusions which we may meet 
 with every day are the following : God has com- 
 manded that no food will be taken : The food is 
 poisonous, or contains filth : The patient has neither 
 throat nor stomach : The bowels are blocked, etc. 
 Such cases as these may require forcible feeding. 
 
 There is another class who, from some hysterical 
 notion of attracting attention to themselves, will 
 begin to decline to take food. Forcible feeding, or 
 any fuss made over them, is what they would prefer. 
 They are not likely to injure their health by absti- 
 nence, and the best treatment is to let them severely 
 alone. After a short fast, they will return to their 
 food with their digestive apparatus all the better for 
 the rest it has had. There are other individuals who 
 will obstinately refuse to eat so long as any notice is 
 taken of them, but who will do so if they think they 
 are unobserved, and will even pilfer food from other 
 patients, and eat it on the sly. Not infrequently a 
 single feeding with the tube is sufficient to induce 
 the patient to give up her determination to starve 
 herself; others will persist in their refusal for long 
 periods, and, in some instances, appear to enjoy the 
 operation of being fed. In this, as in most other 
 respects, male lunatics are more easily managed than 
 those of the opposite sex. 
 
 A nurse should never exercise any force in feeding 
 a patient. If the patient will not take food without 
 a struggle, she should leave the matter for the doctor 
 to decide whether forcible feeding is necessary in that 
 
80 MENTAL NUESINGi^. 
 
 particular instance, and by what method food is to 
 be administered. It is at times a matter of great 
 difficulty for the doctor to decide whether it is wise 
 to use the tube, and, in some cases of organic disease, 
 useless suffering may be entailed upon the patient by 
 misguided zeal for her welfare. In cases where there 
 is no weakness of the digestive system, the stomach 
 jjump possesses one great advantage. By it ordinary 
 and varied diet can be given in the form of meat and 
 vegetables which have been crushed, passed through 
 a fine sieve, and moistened with gravy or beef-tea. 
 The details of feeding can be best explained practi- 
 cally in the wards. 
 
 Nearly every asylum has its own method of 
 holding a patient for forcible feeding. The following 
 plan is very convenient, and by it the most excited 
 patient is easily managed without any risk of injury 
 or exhausting struggles. The pump clean and working 
 properly ; soft rubber stomach tube ; gag ; and the 
 feeding mixture in a basin must be ready before the 
 patient is interfered with. She is then, whenever 
 practicable, placed on a mattress on the floor, so that 
 there is no danger of her hurting herself against a 
 bedstead. The charge nurse, kneeling down, places 
 the patient's head between her knees, and at the 
 same time steadies it with a hand on each side of it. 
 With her right hand she holds the gag firmly in 
 position. One nurse on each side places her open 
 hand on the patient's shoulder, and with the other 
 holds her wrist. Each leg is controlled by a nurse. 
 
FOOD. 81 
 
 unless the patient be weak, and then one nurse can 
 look after both. Xo pressure is applied to chest or 
 abdomen, and when the assistants are competent 
 injury is almost impossible. In feeding a man the 
 charge attendant may sit down on the mattress with 
 his back against the wall, and the patient's head 
 between his thighs. The whole operation is com- 
 pleted in a few minutes. 
 
 We know that even in the nursing of sane persons 
 it is not always easy to induce the invalid to take 
 sufficient food, but the difficulties are often greater 
 when disease attacks the chronic lunatic; much 
 depends upon the amount of influence the nurse has 
 gained over her people. Occasionally we find that 
 some inter-current disease has a good effect upon the 
 mental condition of a patient who has been refusing- 
 food. This chance of eradicating bad habits, and of 
 teaching better ones, would be utilised by a capable 
 nurse. The attempt to keep the insane sick upon 
 special diet, as, for example, in diabetes, is generally 
 futile. 
 
 Difficulties also arise with regard to the adminis- 
 tration of medicines, and at times are so great that 
 it is next to impossible to carry on any continuous 
 medical treatment. Some lunatics will, with pleasure, 
 swallow the filthiest concoctions and ask for more ; 
 others will demand purgatives daily. There is 
 generally little difficulty in getting epileptics to take 
 drugs, but it is often otherwise in the very cases to 
 
 whom we are most anxious to give them. The hypo- 
 
 6 
 
82 MENTAL NUESING. 
 
 dermic method, when available, is very useful. The 
 questions that will often arise are, whether is it 
 better to omit medicines, give them forcibly, or to 
 try to deceive the patient into taking them ? The 
 last method is not one to be recommended. It is 
 sure to fail if any continuous administration is desired, 
 and frequently is unnecessary for single doses. If the 
 patient herself does not see the drug put into her 
 food, others may do so, and a spirit of suspicion is 
 apt to arise. In cases where the patient is so insane 
 as to be unaware of the nature of what she takes, 
 there are no objections to the method, and at times 
 it may be useful in giving single doses to chronic 
 lunatics. When the question of nourishment is of 
 the first importance, as it so often is, the plan should 
 not be used. The insane person may have sufficient 
 intelligence to detect the presence of the drug, and 
 may begin to refuse her food. Those, also, who have 
 delusions that their food is poisoned, should certainly 
 not have it tampered with in this way. The en- 
 deavour to gain the lunatic's confidence is not very 
 successful when the patient discovers that you are 
 the individual who has been placing noxious articles 
 in her diet. It is better to produce the dose openly 
 as medicine. As a rule, a confident manner, with an 
 assurance that it is for the patient's good, and must 
 be taken, are sufficient when the administration is 
 not long continued. Here again it must be remem- 
 bered that no force, must be used by the nurse. 
 
 A small kitchen should be attached to the ward 
 
FOOD. 83 
 
 in which acute cases are received. It is impossible 
 to have the small amomits necessary for sick diet for 
 special cases prepared in the general kitchen, and the 
 present arrangement of having it made in mass is not 
 satisfactory. The nurse could herself, with the same 
 materials, vary their preparation, and make them 
 palatable. In the long run it would probably be 
 cheaper, while the advantage to the patients would 
 be very considerable. The monotonous dietary of 
 our sick wards could then be varied in a way which 
 it is impossible to attain under the present system. 
 
Chapter IX. 
 MANAGEMENT OF THE INSANE. 
 
 On admission. General management. Struggles. Delusions. 
 Employment. Destruction. Seclusion. Eestraint. Suicidal 
 cases. 
 
 Did you ever reflect what an awful thing it is for a 
 person not altogether unconscious of her situation to 
 be brought to an asylum ? The public are not yet 
 fully educated up to looking upon such an institution 
 as an hospital. There is still a lingering inclination 
 to consider it a species of penitentiary, and the idea 
 of entering it as a patient causes a shudder of horror 
 to run through most people. Indeed, in the case of 
 some melancholies the dread of the asylum has played 
 a part in deepening the depression into which they 
 have fallen. It is all essential that an endeavour 
 should be made on the lunatic's first arrival at the 
 asylum to teach her that her dark forebodings were 
 groundless, and that she has arrived not amongst 
 jailers, but friends. 
 
 You all know the influence of first impressions. 
 Even on your first arrival as a nurse in an asylum 
 you can recall how firm a hold your first ideas of the 
 
 place took upon you. You were keenly sensitive to 
 
 (84) 
 
MANAGEMENT OF THE INSANE. 85 
 
 the nature of the greetings you received, and even to 
 the tone of your companions' conversation. One who 
 has been a patient in an ordinary hospital will tell 
 you how helpful to him on his arrival was a cheering 
 word and pleasant smile. How much more then is 
 that friendly welcome essential in the case of the 
 lunatic, whose future is often enshrouded with gloomy 
 thoughts and dreadful apprehensions. Even if we 
 considered the matter merely from the standpoint of 
 convenience, without any higher motive, we would 
 come to the conclusion that it is to our advantage 
 to calm the patient's fears and allay her suspicions. 
 If she once begins to look upon her nurse as her 
 friend the latter will find her labours and anxieties 
 lightened. There will be less danger of trouble with 
 regard to food, etc., and the new-comer will more 
 rapidly settle down amid her unusual surroundings. 
 We often see a patient who has been difficult to 
 manage outside calm down at once, and give little 
 trouble when she finds herself amongst those who, 
 while kind and sympathetic, are yet neither irritable, 
 fussy, nor afraid. Few, unless quite demented, are 
 utterly lost to outside influences. A smile or a 
 friendly tone of the voice will frequently soothe and 
 prevent an outburst of violence. The very way in 
 which a patient's clothes were removed may be keenly 
 remembered by her. Even if they have to be taken 
 ojff against her will, this should always be done with 
 every sign of good will. 
 
 It might be well to mention here some points 
 
86 MENTAL NUESING. 
 
 which should not be overlooked on the admission of 
 a new case. The doctor will of course examine for 
 himself, but the nurse should none the less know 
 what to take notice of when undressing the patient. 
 Bruises or injuries should be carefully noted, and for 
 two reasons. 
 
 Firstly : In order that any necessary treatment 
 may be carried out. 
 
 Secondly : In order that an accurate note should 
 be made of their existence and character. Even in 
 my experience attempts have been made to throw 
 the responsibility for injuries, received before admis- 
 sion into the asylum, upon the officials of that 
 institution. It is only fair to the nurses in charge of 
 the patient that the bruises present before admission 
 should be recognised. It is enough that she be called 
 upon to give an account should any bruises be re- 
 ceived afterwards. 
 
 The presence of any marks on the body should be 
 observed at the same time. Careful attention should 
 be given to ascertain whether the patient be ruptured, 
 and in the case of males whether there be any stric- 
 ture of the urethra. The condition of the abdomen, 
 if at all prominent, should be seen to, as the fulness 
 may be due to a distended bladder, or even to preg- 
 nancy. In puerperal cases, and in nursing women, 
 the condition of the breasts should be noted. One 
 point that is very important, but is sometimes over- 
 looked, is to make certain that there are no false 
 teeth. These should always be borne in mind, as in 
 
MANAGEMENT OF THE INSANE. 87 
 
 some cases it may be necessary to remove them. I 
 have known accidents occur from neglect of this 
 precaution. The condition of the hair as regards 
 vermin, etc. , will not be forgotten. 
 
 When we come to speak of the general manage- 
 ment of a body of the insane, we find that much 
 depends ujDon the temperament of the individual 
 who has them in charge. The post of charge nurse 
 is a difficult one, and calls for the exercise of high 
 qualities in her wdio would fill it successfully. A 
 clear head, strict impartiality, a subordination of her 
 own feelings to her duty, an ability to see things 
 unbiassed by the personal element, tact — these are 
 the qualities one would like to see in a model charge 
 nurse. She must, if she wishes to make the best of 
 things for the patients, for her subordinates, and for 
 herself, exercise that useful quality, tact. She must 
 try to steer clear of tender places ; must be careful 
 not to hurt the feelings of those aromid her ; and 
 must practise the art of putting disagreeable things 
 in their most pleasant aspect. We cannot expect 
 human beings to be perfect, but there are a few rules 
 that the nurse should bear in mind. 
 
 1st. Try from the very beginning to get the patient 
 to understand that you are sincere and in earnest in 
 your desire for her welfare. This is not always easy. 
 The suspicious mind of the lunatic is often disposed 
 to look upon all about her as enemies, and the nm-se 
 will frequently find her eff'orts misunderstood, and her 
 kindly advances repaid with insolence or even violence. 
 
MENTAL NUESING. 
 
 2nd. Xever hurt a patient's feelings by letting her 
 see that you have gained a victory over her when you 
 have been compelled to insist upon her doing some- 
 thing which she did not wish to do. If any such 
 difficulty should arise, the nurse should try to raise 
 a bridge by which the patient may cross without 
 injuring her self-love. In dealing with the insane, it 
 is quite possible to stoop to conquer without any loss 
 of dignity or self-respect. The hectoring, loud-voiced 
 individual is not always the strongest, nor the one 
 who exercises most influence over her fellows. 
 
 3rd. Xever force yourself into a position in which 
 you must either sacrifice your influence, or do some- 
 thing you would much rather have left undone. 
 Thus never, unless under very exceptional circum- 
 stances, tell a 23atient that "she shall" or "she 
 must" do so and so. " I think you had better" is 
 much more efficacious, and, even if it has to be 
 enforced, does not leave the same sting behind it. 
 Always try to note the patient's mood and catch the 
 favourable opportunity. In cases where there is 
 likely to be any conflict of opinion, get the order 
 repeated in the hearing of the patient. If she have 
 any reason at all left, the fact that in insisting upon a 
 thing being done you are merely doing your duty, will 
 have an influence with her. Unless when acutely 
 excited, it is generally possible to let such a patient 
 see that it is easier and better to do the right thing 
 than the wrong. There are, of course, many lunatics 
 whose reasoning powers are so impaired that they are 
 
MANAGEMENT OF THE INSANE. 89 
 
 quite unable to form any judgment, but that is not 
 the class of whom I am speaking. The utterly 
 irrational are, even when very violent, easily borne 
 with as compared with the impertinence and insults 
 from a perverse reasoning lunatic. You will rapidly 
 find out those individuals who are most easily 
 managed by being made much of; those who prefer 
 a more distant greeting, and those generally incurable, 
 hopeless cases, who are best dealt with by being left 
 alone, so long as they fall in with the rules of the 
 house and do not interfere with their fellows. 
 Occasionally, cases will arise where physical force 
 must be resorted to. If possible a nurse should 
 never attempt single-handed to deal with an excited 
 or violent lunatic, but should always call assistance, 
 and for the following reasons : — 
 
 1st. A patient, who would fight and struggle 
 against one, will often submit quietly when two 
 nurses are present. 
 
 2nd. There is less likelihood of either the patient 
 or the nurse being injured. 
 
 3rd. The patient is not so likely to make false 
 accusations of ill-usage when two are present. Those 
 who have had dealings with the insane, and more 
 especially with epileptics, will appreciate the force of 
 this last reason. 
 
 When aggravated by a patient's wilful perverse- 
 ness, the nurse will at times feel a disinclination to 
 call for assistance. She will be disposed to look 
 upon this as an expression of weakness or cowardice, 
 
90 MENTAL NURSING. 
 
 and will want to manage the patient by herself. 
 From every point of view this feeling is wrong and 
 must be resisted. The power of self-control must be 
 exercised. In fact, if a nurse be without that quality 
 she will not be likely to be an asylum nurse for any 
 lengthened period. It says much for the nursing 
 staffs that so much is patiently borne, and uncom- 
 plainingly suffered, by them. Violence, insults, and 
 abuse from the patients are more easily endured 
 than the suspicions and impertinences of some of the 
 relatives of the insane. As a rule, it is those indi- 
 viduals who behaved badly to the patient before 
 admission who are most troublesome, and insolently 
 suspicious of ill-usage afterwards. 
 
 No insane person was ever yet cured of a delusion 
 by means of reasoning or argument. It is much 
 more probable that an endeavour to do so would 
 have the effect of concentrating the patient's atten- 
 tion upon her false beliefs, and causing the delusions 
 to become more fixed than they were before the 
 attempt. On the whole, the best way is to avoid 
 the subject as much as possible, at the same time 
 giving the j^atient to understand that the ideas are 
 delusions in your opinion ; that they form part of 
 her illness, and that she is only increasing her 
 troubles by dwelling upon them. Sometimes a 
 delusion may arise from the brain exaggerating or 
 misinterpreting messages received from a distant 
 part of the body which is diseased. If this local 
 affection be cured we may hope to see the delusion 
 
MANAGEMENT OF THE INSANE, 91 
 
 disappear. In every case, however, the nervous 
 organisation must be weak, and liable to be upset by 
 influences which would have no eff'ect if l^rought to 
 bear upon a healthy brain. Many patients are fond 
 of bringing forward their troubles, and tales of perse- 
 cution, on every occasion. Probably their doing so, 
 in some cases, provides an outlet for feelings, which, 
 if bottled up, might burst forth in some more un- 
 pleasant fashion. 
 
 When patients are strong enough, every endeavour 
 should be made to induce them to employ themselves. 
 Work is one of our chief curative agents. Of course, 
 if possible, the patient should be got to do useful 
 work, but it should be borne in mind that the object 
 to be aimed at is the good of the patient, and not the 
 amount of useful work turned out. The lunatic had 
 better be employed in doing sewing which has all to 
 be unpicked afterwards than be living in idleness. 
 If not occupied at all, it is not to be wondered at 
 if bad habits and violent or destructive propensities 
 develop themselves. In cases of acute restless excite- 
 ment in robust individuals, who are too insane to 
 settle to any occupation, it is sometimes necessary to 
 send them for long walks with two nurses, or even to 
 have relays of nurses. This is very exhausting work 
 when the patient is powerful and very lively. These 
 are the cases, especially in acute delirious mania, in 
 which the w^et pack is so useful. The method of 
 packing a patient properly can only be taught practi- 
 cally in the wards, but every nurse should be familiar 
 
92 , MENTAL NURSING. 
 
 with the process. The excitement which is found in 
 weakly, debiUtated individuals requires different treat- 
 ment. Here nourishing diet and stimulants are es- 
 sential, and the all-important question of feeding 
 comes in. Food and rest are required, and the 
 patient's recovery to a great extent depends upon 
 careful nursing. 
 
 Destructive patients are a trial to a nurse who is 
 careful of her stock. They may be divided roughly 
 into twos classes : those who tear up with the wilful 
 intent to destroy, and those who tear and pick at 
 their clothes without being fully conscious of what 
 they are doing. Amongst the latter we may include 
 those cases of restless mania who must be doing some- 
 thing and cannot keep still for a few minutes together. 
 Here we need some means of expending this energy, 
 and in a useful channel if possible. Scrubbing, wash- 
 ing, or any rough household work may be tried, along 
 with open-air exercise. But for all cases of destruc- 
 tiveness continuous supervision and constant atten- 
 tion are necessary. It is not enough that the nurse 
 be present in the ward. She must have eyes and 
 ears for what is going on around her. Because a 
 patient is not quarrelsome and excited, she must not 
 conclude that she can leave her unnoticed. It is this 
 habit of leaving such patients alone to their own sweet 
 wills that leads to the formation of dirty and destruc- 
 tive habits. A woman with restless fingers, who is 
 left alone and unnoticed, is very likely to begin pick- 
 ing her dress to pieces. A nurse with a head on her 
 
MANAGEMENT OF THE INSANE, 93 
 
 shoulders would observe this tendency, and try to find 
 some means of employing the uneasy hands to better 
 purpose, even if it were only to tease out something 
 of little value. Strong dresses and leather-bound 
 clothes may be required in some extreme cases, but 
 constant attention by an intelligent nurse will do 
 much to bring down destruction to a minimum. At 
 night with bad cases the tearing up is nearly unavoid- 
 able. The patient, who generally requires a single 
 room, during her restless hours has nothing to do but 
 tear her bedding, or do worse. 
 
 It will be necessary occasionally to seclude a 
 patient, that is, to put her into a room alone. In 
 many cases of excitement this allows the patient to 
 calm down without being distracted and upset by 
 those about her. It is the method that one would 
 naturally prefer oneself if agitated and disturbed. 
 When the lunatic is in such a condition that it is 
 thought necessary to keep her apart from the others 
 against her will, and the door is, therefore, locked 
 upon her, this is called seclusion. No patient should 
 ever be secluded without distinct orders to that effect, 
 and on every occasion, no matter for how short a 
 period, the fact of such an occurrence having taken 
 place and its duration should be entered in the ward 
 journal. Seclusion is much less frequently used than 
 it was at one time, and the same remark applies to 
 restraint. Restraint is the term applied to any 
 mechanical appliance which hinders the freedom 
 of the movements of the body. The chief use of 
 
94 MENTAL NURSING. 
 
 restraint now-a-days is in cases where it is necessary 
 for surgical reasons, and also sometimes in acutely 
 suicidal individuals. It is now very seldom required, 
 and a nurse may be in an asylum for a long time 
 without seeing it employed. She should, however, 
 know how to put the jacket on if necessary. 
 
 Acutely suicidal cases are a great worry to all 
 who have to deal with them. They are a constant 
 strain upon the mind, and the anxiety about them is 
 at times very harassing. The knowledge that you 
 are responsible for the safe keeping of a woman who 
 requires, during the whole twenty-four hours, to be 
 kept under continuous notice because she is just 
 waiting for an opportunity of injuring herself, is very 
 wearing. If, in addition, the patient is, as is fre- 
 quently the case, uneasy, worrying, and always 
 wishing not to do those things which ought to be 
 done, the life of the nurse in whose care she is placed 
 is not a happy one. In such cases the nurses receive 
 a printed or written notice with the patient, which 
 informs them of the suicidal tendency, and warns 
 them that she must never be permitted to escape 
 from observation. 
 
 It will be necessary to examine such patients' 
 clothes each evening at bed time, to see that nothing 
 has been concealed in them which might be used for 
 the 23urpose of self-injury. There are attempts made 
 by lunatics to smuggle tapes, string, jDieces of corset 
 steel, etc., into bed with them, in the hope of being 
 able to attain their end under cover of the bed- 
 
MANAGEMENT OF THE INSANE. 95 
 
 clothes. The teeth of a small buckle have been used 
 for this purpose. Male patients, who have not been 
 thought suicidal, have smuggled sharp instruments 
 into bed, and destroyed themselves during the night. 
 Of course, in cases where no warning has been given 
 by the patient in any way, such accidents are liable 
 to happen. Some patients try to conceal such things 
 in the mouth, the armpits, and between the buttocks. 
 In the case of women, tapes and apron-strings 
 must be borne in mind ; among men, neckties are 
 always a danger. Patients will frequently tear their 
 clothing into strips, and either attempt strangulation 
 or choking by pushing the pieces into the back of the 
 throat. Handfuls of hair, pulled from the patient's 
 own head, have been used in this way. The fact 
 that injury may be attempted by precipitation down a 
 flight of stairs should be borne in mind. I have known 
 a patient to push his head through a window, and 
 attempt to cut his throat by sawing his neck against 
 the jagged fragments of glass that remained fixed 
 in the wood. A special word of caution with regard 
 to scissors is needed in the female wards. They are 
 such everyday articles that the chance of their be- 
 coming dangerous weapons is apt to be forgotten. 
 The ways in which very suicidal cases will try to 
 effect their purpose are numerous. A woman, who 
 appears to have no idea of anything in the world, 
 will all the while be pondering methods of putting 
 an end to her existence. The only way of meeting 
 such cases is by continuous and careful supervision. 
 
96 MENTAL NUESING. 
 
 The nurse must not allow her vigilance to be relaxed 
 on any account until the caution given with the 
 patient has been withdrawn. It is not always easy 
 to say whether the suicidal tendency has gone or not, 
 but the nurse must clearly understand how great her 
 responsibility is until the doctor has taken the weight 
 upon his own shoulders by deciding that the patient 
 is sufficiently recovered to have a little more freedom. 
 In coming to such a decision the opinion of an ex- 
 perienced nurse is always of great value. 
 
Chapter X. 
 
 EPILEPTICS. GENERAL PARALYTICS. 
 IDIOTS. 
 
 One of the things which make the greatest impression 
 upon a beginner in asylum work is the matter-of-fact 
 way in which ''fits" are treated. It is part of a 
 nurse's duty to record the number of fits that patients 
 may have during her period on duty, and also to make 
 a report, should there be anything unusual about any 
 of the seizures. She ought, therefore, to be familiar 
 with the forms in which epilepsy may show itself 
 The ordinary fit is a convulsive seizure, accompanied 
 by loss of consciousness, and frequently preceded by 
 a characteristic cry. The convulsion is the marked 
 feature in the great majority of our cases, but there 
 are some who do not show this prominent symptom, 
 and such cases should be carefully watched. In these 
 individuals the seizures are manifested merely by a 
 loss of consciousness, sometimes so temporary as to 
 be unnoticed by any but one who knows the nature 
 of such a symptom, and is on the lookout for it. The 
 patient may simply appear dazed for a few minutes, 
 and be unconscious of what is going on about her ; 
 
 she may look as if she had a slight fainting attack ; 
 
 7 (97) 
 
98 MENTAL NUESING-. 
 
 or she may perform some ordinary or out-of-the-way 
 action without being aware of what she is doing. 
 These are as surely indications of the disease as is 
 the ordinary fit, and should be looked for and noted. 
 Undoubtedly there are patients who have seizures of 
 this kind which pass unnoticed for a long time, but 
 would not do so if the nurses were aware of the full 
 significance and importance of such things. The 
 nurse will find that the fits of different individuals 
 vary much in character. She will also find that there 
 are great variations in the sensations of which patients 
 complain, as well as in their behaviour, immediately 
 before having a fit. She should make herself familiar 
 with these warning symptoms, and when they appear 
 she should try to put the patient in a situation such 
 that she is not likely to injure herself when the fit 
 occurs. Of course there are many who have the 
 seizure withovit any such warning, and often disfigure 
 themselves in the severe falls they have. The danger 
 of an epileptic falling near the open fire, the stove, 
 or the steam coil, is apparent. There is also danger 
 in the going up and down stairs, and those patients 
 who are likely to have fits should be closely looked 
 after on such occasions. At night epileptics must be 
 kept under constant supervision, with the face un- 
 covered and in the nurses' view. There is always iL 
 danger that the patient may have a fit without any 
 cry to attract attention to her, and in turning over 
 on her face may be suffocated. So far as attention 
 during the night is concerned, the pauper lunatic is 
 
EPILEPTICS. 99 
 
 the pampered child of civilisation. How many 
 sufferers from epilepsy, even amongst the highest 
 classes, are watched day and night as she is ? No 
 patients suffering from epilepsy should be permitted 
 to mount on step-ladders to clean windows, nor, in- 
 deed, to get into any position where they would be 
 likely to injure themselves in falling in a fit. 
 
 When a fit does occur, the patient should be laid 
 down on the floor, or on a couch, and a cushion placed 
 under her head. No more force should be used, 
 nor, indeed, any interference other than is sufficient 
 to prevent the patient injuring herself The clothing 
 about the neck and the chest, if necessary, should be 
 loosened. It is not likely in our asylum patients 
 that there will be any tight-lacing to undo : that is 
 one of the insane habits which are dropped at the 
 asylum doors. When the convulsive stage is over 
 the patient should be left quietly on a couch to 
 recover. 
 
 When the epileptic is "having her fits" she is 
 generally much disturbed in mind, and is a great 
 strain upon the nurse's patience and temj)er. The 
 usual effect of epilepsy is to cause the mind to become 
 gradually weaker until at last a stage of nearly com- 
 plete dementia is reached. Some of the more intelh- 
 gent, in their periods of calm between the fits, are 
 grateful for what is done for them, and anxious to 
 assist the nurses. Such individuals are, as a rule, 
 the best workers amongst the lunatics. As a class, 
 however, the epileptics are bad patients. They often 
 
100 MENTAL NURSING. 
 
 display deep religious feeling, and at the same time 
 are untruthful, given to stealing, prone to making 
 false charges, and are always ready to quarrel. With 
 them the blow generally comes before the word. A 
 fancied insult is frequently the only reason assigned 
 for a savage onslaught upon an unoffending and 
 harmless bystander. If, in passing through the wards 
 of an asylum, you see a man or woman intently 
 searching the Scriptures, you may with safety, in five 
 cases out of six, risk the statement that the indivi- 
 dual is an epileptic. If spoken to, they will very 
 probably make complaints of ill-usage which are 
 utterly unfounded, but which they will back up with 
 fervent appeals to the Deity to witness the truth of 
 what they say. They will also show marks, received 
 in a fit, and accuse some nurse or patient near of 
 having inflicted them. These are the individuals, 
 and especially if hysterical, who bring the great 
 majority of the charges of cruelty against the nurses. 
 This is probably due to a morbid longing for sym- 
 pathy, a warped moral sense, and in a great measure 
 to the stiffness and aches after a fit being attributed 
 by the sufferer to ill-usage from those about her. 
 As the nurses have frequently to exercise some con- 
 trol over the patient's movements during or im- 
 mediately after a fit, and she finds them by her when 
 her glimmering consciousness returns, she naturally 
 refers her sufferings to their agency. 
 
 When excited, the epileptic is difficult to manage. 
 She is suspicious, impulsive, abusive ; quickly roused 
 
EPILEPTICS-. 101 
 
 to violence ; and in the heat of passion will do deeds 
 of which she is perfectly ignorant when her wild fury 
 has passed away. Many of our criminal lunatics 
 belong to this class. The homicidal impulse may be 
 quite irresistible, and murder may be committed 
 without the patient being afterwards in the least 
 aware of what has happened. It is curious, also, 
 how often we find the propensity to steal, and after- 
 wards conceal what has been stolen. They will, even 
 if caught in the act, stoutly deny the possibility of 
 their ever dreaming of doing such a thing. A nurse 
 should always be extremely careful in handling an 
 epileptic. When irritable they will resent a hand 
 being laid on their arm, even in the most friendly 
 way, and will impulsively stribe out. When in that 
 mood, coaxing methods should always be tried and 
 abrupt dealings avoided. A nurse should never 
 engage in a single-handed struggle with an ejDileptic. 
 In such circumstances there is great danger of the 
 patient or nurse being injured. The former's powers 
 of self-control are much weakened, and, when in a 
 state of maniacal excitement, she is utterly lost to all 
 sense of reason. If the attention of the epileptic be 
 fixed upon an object, it is not easily diverted, and the 
 persistent way in which she will with stammering 
 utterance repeat again and again the same pointless 
 question is very trying. During their periods of 
 excitement such cases are best treated by being put 
 to bed in a room by themselves until they are calmer. 
 Such a course is much the best both for themselves 
 
102 MENTAL NUESING. 
 
 and for the other occupants of the wards. It must, 
 of course, be always borne in mind that they must be 
 kept under continuous observation lest suffocation in 
 a fit should occur. 
 
 The condition of the bowels should be remembered. 
 Constipation is common, and the nurse should report 
 if any under her care are suffering in that way. The 
 free unloading of any epileptic's intestine will in some 
 cases do more towards lessening excitement than any 
 amount of sedatives. 
 
 General paralytics. — This disease is much more 
 common among males than among females. The 
 sufferers are often individuals in the prime of life and 
 strength, and consequently, when excited, are all the 
 more difficult to deal with. Along with the mental 
 affection, there is a gradually advancing paralysis of 
 the muscles of the body generally. This, affecting 
 the muscles of the lips and tongue, produces a curious 
 hesitation and impairment of speech, so that the 
 patient is unable to pronounce some words distinctly. 
 
 To the nurse general paralytics present themselves 
 in three well marked stages, though there are of 
 course cases which shade off from the one into the 
 other. 
 
 1st. The excited, restless, noisy, violent, utterly 
 irrational maniac, who, to an uneducated eye, appears 
 anything but a paralytic. 
 
 2nd. The quiet, placid, easy-going dement, with 
 hesitating speech and uncertain gait, who is careless 
 and forgetful, but quite happy and more than satisfied 
 
GENEEAL PAEALYTICS. 103 
 
 with himself and his surroundings. In passing from 
 this stage to the next they are sometimes very restless 
 and troublesome. 
 
 3rd. The helpless paralysed being, only able to sit 
 in an invalid chair or to be in bed ; hopelessly wet and 
 dirty, and requiring spoon feeding or indeed able to 
 swallow liquids only. 
 
 General paralytics have generally most exalted 
 ideas of their wealth and powers. They are the 
 richest and strongest men on earth, and yet are 
 unable to recognise the absurdity of such individuals 
 being inmates of a pauper asylum. They will proffer 
 millions of pounds and gold watches, and in the 
 same breath ask for a copper or a chew of tobacco. 
 Even when helplessly paralysed, they will, with slow 
 and hesitating utterance, cheerfully remark that they 
 are better and stronger than they ever were. Those 
 few cases who are depressed and suicidal, cause much 
 anxiety. Their depression seems as exaggerated as 
 is the sense of well-being in their happier brethren. 
 
 In the maniacal, excited stage they are very trouble- 
 some, and are noisy, violent, restless, destructive, and 
 dirty. In this stage they are liable to be injured 
 owing to the furious way in which they struggle. 
 Believing in their almost omnipotent powers, they 
 will attempt deeds which no ordinary lunatic would 
 dream of It is folly to attempt to manage such 
 cases without sufficient attendants to handle them 
 safely. When, along with these violent propensities, 
 it is remembered how easily their bones are broken, 
 
10-1 MENTAL NURSING. 
 
 it is not surprising that accidents sometimes happen. 
 When an excited patient is breathing out threats ot 
 slaughter and brandishing some weapon which he has 
 obtained, it is well to remember that a mattress 
 makes a very good shield behind which he can be 
 safely approached. 
 
 The quieter demented cases can generally, with 
 tact, be easily managed. They have their little dis- 
 plays of temper, but calm clown under judicious 
 management. In many respects, they behave like 
 spoilt children, and need much coaxing to keep them 
 right. Any hectoring treatment is resented at once, 
 and only leads to trouble. Towards the end of this 
 stage they are often very destructive in a quiet way, 
 owing to their habit of picking at their clothing. 
 
 In the last stage of all, they require nursing like 
 babies. The condition of their bladders must be 
 remembered, and if not wet regularly, the matter 
 should be reported. They are very liable to bedsores, 
 and, in some cases, the utmost care will not prevent 
 their appearance. Even in a night, blisters will 
 appear between the fingers, or where one leg has 
 been lying against the other. 
 
 As a rule, except in the depressed cases, the 
 general paralytic gives no trouble with his food. 
 The danger is rather that he may choke, owing to 
 his greedy endeavours to gulp it down too hastily. 
 The feeble cases are very susceptible to cold. 
 
 General paralytics are liable to be attacked by con- 
 vulsive seizures, which much resemble epileptic fits. 
 
IDIOTS. 105 
 
 The patient's state, mental and physical, is generally 
 worse after such a seizure. The average duration of 
 life, after the disease shows itself, is from two to 
 three years. Some few last much longer, but the 
 affection is at present incurable. 
 
 Idiots. — The tendency now, and very properly, is 
 to send idiots to an idiot asylum where they can be 
 taught, and not to allow them to mingle with the 
 adult lunatics. An endeavour is made to teach them 
 to use their faculties, and, as far as lies in them, to 
 be useful. Sometimes the most hopeless individuals 
 in appearance make the best pupils. 
 
 Some idiots are very dirty, and addicted to filthy 
 practices. They must be taken to the lavatory at 
 regular times, and an effort made to teach them 
 cleaner and better habits. Many idiots are epileptic, 
 and the more closely they are observed, the greater 
 proportion do we find to suffer from that affection. 
 
Chapter XI. , 
 
 THINGS TO BE OBSERVED AND REPORTED. 
 
 The nurse into whose ward a patient is placed on 
 admission will, as early as possible, obtain a sample of 
 that patient's m4ne in order that it may be examined. 
 This should be done in every case as a matter of 
 ordinary routine. It is not always easy to get a 
 specimen, owing to the patient's mental condition. 
 An effort, however, should always be made to get 
 enough for an examination, and at times it is 
 necessary to collect the total amount passed in the 
 twenty-four hours for measurement ; this will require 
 the patient to be kept under the closest observation. 
 The nurse who has charge of the dormitory should 
 notice each morning and observe whether there be 
 anything unusual in the urine of the respective 
 patients as regards quantity, colour, or sediment. If 
 there be anything out of the common she will save 
 the specimen and report the occurrence to the charge 
 nurse. Frequency of micturition, or any difficulty or 
 pain in doing so, should be noted. In the male wards 
 this is more especially important, since the patient 
 may be suffering from stricture of the urethra which 
 
 prevents him passing urine. An excitable or violent 
 
 (]06) 
 
THINGS TO BE OBSEEVED AND EEPOETED. 10^ 
 
 patient with a distended bladder is in a dangerous 
 condition, and in the event of a struggle, serious 
 injury may unintentionally be done him. The bladder 
 when distended is easily ruptured, and this accident 
 might readily occur in the case of a patient attacking 
 an attendant or other patient. More especially might 
 it be likely to happen should the struggling pair fall 
 to the ground. The charge attendant should on 
 admission, or as early as possible afterwards, note 
 the manner in which a newly-arrived patient passes 
 urine, whether it is passed with ease or with much 
 straining and difficulty. 
 
 It is often almost impossible, even in presumably 
 sane individuals, to get accurate information as to 
 the state of the bowels. Many women who ought to 
 know better are dreadfully careless of themselves in 
 this respect, and constij)ation is a very common 
 affection among the female lunatics. It is frequently 
 associated with anaemia, and, indeed, helps to keep 
 up that condition. In all cases, but especially 
 amongst epileptics, the nurse should take notice 
 whether any of her patients suffer in this way. We 
 every day meet lunatics who declare that they are 
 purged while passing normal motions. There are 
 others who, with bowels freely moved, affirm that 
 they are obstinately constipated, and demand a daily 
 purgative. Observation alone can decide as to the 
 truth of these statements, and they should always be 
 investigated. The patient, though often making 
 false complaints, may on that particular occasion be 
 
108 MENTAL NURSING. 
 
 really suffering. The first symptoms of colic or any 
 diarrhoea should be at once reported. This is 
 especially important, as abdominal affections in the 
 insane are often very obscure. The chai^cter of the 
 diarrhoea should be noticed, with particular regard as 
 to whether there be any blood in the motion. The 
 nurse should also notice whether the patient has 
 anything in the nature of piles, for even should the 
 doctor think it necessary to make an examination, 
 with some patients it is very convenient to have a 
 preliminary examination made by the nurse. No 
 patient with purging or abdominal pain should be 
 given the ordinary diet until the case has been 
 reported and instructions as to diet, etc., received. 
 Whenever possible, the patient's temperature should 
 be taken, and form part of the report. This is a 
 matter of the utmost importance, seeing that the 
 treatment of the form of dysenteric diarrhoea some- 
 times met with among the insane is successful in 
 proportion to the earliness of the stage of the disease 
 at which the patient is put under treatment. Ex- 
 treme cleanliness and early attention to the slightest 
 abdominal symptoms will reduce these cases to a 
 minimum. 
 
 The first appearance of menstruation after a 
 patient's admission should be duly reported. In all 
 cases anything unusual as regards the amount or 
 frequency should be noted, and also whether it is 
 accompanied by pain or is attended by any marked 
 change in the patient's mental condition. The nurse 
 
THINGS TO BE OBSEEVED AND REPOETED. 109 
 
 should also be careful to report the presence of any 
 abnormal discharges. Another point which must 
 have the nurse's attention is whether there be any 
 excess in the amount, or any peculiarity in the 
 distribution of the sweat, as, for instance, whether 
 it be confined to one limb or to one side of the body, 
 etc. 
 
 Vomiting is not an infrequent symptom among 
 the insane. There are idiots who can with ease 
 regurgitate their food, and, indeed, like ruminants, 
 appear to chew the cud. Some patients eat too 
 rapidly or too much, and vomit almost at will. There 
 are others who, from hysterical ideas, or from sheer 
 stupidity, will induce vomiting by putting their fingers 
 down their throats. The appearance of any nausea, 
 paleness, or sweating before vomiting should be 
 noticed ; also whether the act was performed easily 
 or with difficulty. The nurse should examine the 
 matter vomited for blood, foreign bodies, etc. Some- 
 times buttons, pieces of straw, or such like articles, 
 may be found. If there be anything unusual it should 
 be kept, in order that the doctor may inspect it. 
 Especially with regard to hernia is vomiting to be 
 borne in mind. Attempts at vomiting are sometimes 
 the only symptoms of a strangulated hernia in a 
 dement. At bath, and on every occasion when the 
 nurse has an opportunity of observing, she should 
 take notice whether there be any swelling or fullness 
 in the regions where hernias are commonly found. 
 It is possible that she may find mare's nests, such as. 
 
110 MENTAL NUESESTG. 
 
 an enlarged lympliatic gland, but such things have an 
 importance of their own, and at the same time the 
 nurse shows that she is taking an intelligent interest 
 in her work. Any blood, whether brought up by 
 coughing or vomiting, should be carefully saved with 
 whatever came up with it. Patients will sometimes 
 declare that they have coughed or vomited up blood 
 when it only -proceeds from the gums. In these cases 
 the pocket-handkerchief, or apron which is stained, 
 should always be kept and submitted to the doctor. 
 
 Any change, however slight, in a lunatic's appear- 
 ance or mental condition should be reported. The 
 way in which some of the insane, when excited, 
 appear to be unconscious of pain and maladies that 
 would collapse a sane individual is wonderful. Many 
 will make no complaint, and will give no assistance 
 whatever in finding out from what complaint they 
 suffer. Others will give misleading information, and 
 struggle against any examination. Diagnosis is often 
 very difficult. Patients with acute peritonitis have 
 been known to dance and laugh merrily. Any 
 depression in a general paralytic is of importance. 
 In many cases it means some commencing illness. 
 The appearance of any skin eruption will, of course, 
 be reported immediately. 
 
Chapter XII. 
 
 ENTERTAINMENTS. 
 
 To superintend the amusements of the patients be- 
 comes, after a time, the hardest part of one's duties. 
 It requires an immense amount of perseverance to 
 carry on such entertainments, year after year, without 
 getting wearied and Hstless about the business. If, 
 however, the interest of the staff in these matters is 
 allowed to flag, they speedily degenerate and become 
 flat, stale, and unprofitable. We must remember to 
 suit the style of our entertainments to the people 
 whom we wish to amuse. To send a party of patients 
 to a performance which they are unable to appreciate, 
 and from which they return bored, and disinclined 
 to attend another, is worse than a mistake. There 
 is something very wrong when strong moral suasion 
 has to be used to induce patients to go to the hall. 
 Probably the most generally popular of all entertain- 
 ments are the dances. There is lively music, with 
 dancing, for the active ; and, when discipline is not 
 too rigidly maintained, there are opportunities for 
 gossip for those who are past such exercises. In 
 some asylums the nurses are allowed to dance with 
 
 the female patients ; in others this is forbidden. 
 
 (Ill) 
 
112 MENTAL NUESING-. 
 
 When there are private dances in the female wards 
 for women only, the objections to the latter system 
 are greatly overcome. It often happens that it is in 
 the very cases which would be taken up to dance by 
 the nurses, but would not be likely to dance with 
 males, that we hope for most benefit from the exer- 
 cise. Each asylum has its own traditions in such 
 matters, and, undoubtedly, each has its good points. 
 There is always a danger that we hold too closely 
 to the old form after the life and spirit have fled. 
 Concerts and coffee parties are other favourite enter- 
 tainments. The latter are very successful when 
 cheerful and lively, but are most depressing when 
 the patients cannot break through the bonds of 
 routine and enjoy themselves heartily and rationally. 
 A subdued whispering murmur with no individual 
 daring to make his or her voice ring out clearly is a 
 fatal sign. Patients will never thoroughly enjoy 
 themselves until the staff are sufficiently interested 
 to start the entertainment off' with a swing. Fancy 
 dress balls are held in some asylums. The great 
 advantage of these is that, for weeks before the ball 
 comes off, and after it is over, there is something to 
 talk and think about. Cricket matches in summer 
 practically take the place of theatrical entertainments. 
 In addition to the benefit derived by those who play 
 during the week, the regular match provides a 
 weekly spectacle and subject for conversation. 
 
 The entertainments which are most successful are 
 those given by individuals known to the patients, and 
 
ENTEETAIXi'IENTS. 113 
 
 more especially if the performers are those with 
 whom they are intimately associated. In such cases 
 a high degree of excellence is not demanded. Any- 
 thing done in this way with a desire to interest and 
 amuse, by nurses or attendants, is more appreciated 
 than performances given by expensive professionals. 
 
 We want more social life amongst the insane. 
 There might with advantage be more mingling of the 
 sexes, under, of course, due restrictions and pre- 
 cautions. Men and women who are quite capable 
 of associating with their fellow creatures, and of 
 benefiting by such society, have the social side of 
 their nature slowly starved to death. Just picture 
 the daily life of many a female patient. She plods 
 the same eternal round : she gets up, eats, works, and 
 goes to bed ; sees no one but her fellows, and is con- 
 tinually subject to their squabbles and petty annoy- 
 ances. Life in a nunnery is a rollicking picnic to 
 such an existence. Men, too, spend their years in 
 tramping from sunrise to sunset in the same old rut, 
 which only gets deeper day by day, while they grow 
 more and more demented. This is simply creating a 
 species of asylum dementia, and doing it in those 
 cases which might with least advantage be hurried 
 into that living death. We want more cheerfulness 
 in some of our patient's gatherings — a greater sense 
 of freedom, and absence of formality. In large 
 gatherings, as in dance halls, this is very difficult ; 
 but there is no reason why selected parties of men 
 
 and women should not meet together, and mingle 
 
 8 
 
114 MENTAL NURSING. 
 
 freely with mutual advantage. There are, of course, 
 many who could not be admitted to such gatherings. 
 Still it is wonderful how self-control develops when 
 there is something which is worth the exercise of that 
 quality. Social evenings of this kind imply constant 
 watchfulness, and necessitate a very accurate know- 
 ledge of the patients amongst whom you are living. 
 It is in circumstances such as these that one appre- 
 ciates nurses and attendants who have intelligently 
 observed those under their care. Though every 
 patient in such a meeting is under observation, such 
 a fact need not be made apparent. Men and women 
 from the same town can meet and discuss acquaint- 
 ances ; they can play cards, draughts, chess, or they 
 can listen to the music as they please. Small carpet 
 dances under such circumstances are generally suc- 
 cessful. In the better wards the female patients 
 may occasionally invite those of their acquaintance 
 amongst the men to tea, after which are dances, 
 games, etc. 
 
 As a rule in county asylums few patients are 
 found who can assist in theatricals. These, almost 
 invariably, are left to the staff. An effort should be 
 made to render one of the entertainments the peculiar 
 property of the patients, that is, to make it an 
 entertainment by patients for patients. Such a 
 weekly evening's amusement has been carried on for 
 years in one asylum. The patients themselves sing, 
 play, and recite, and they ask members of the staff to 
 assist by invitation. Each programme is submitted 
 
ENTERTAINMENTS. 115 
 
 beforehand to the medical officer. He strikes off the 
 name of any individual who is not thought then in a 
 fit state to take an active part. The doctor, with, of 
 course, nurses and attendants, is present, but takes 
 no part in the proceedings unless anything unusual 
 occurs w^hich calls for his intervention. The chair- 
 man of the concert presides and manages the business. 
 In this case the concert was held in one of the male 
 day-rooms and female patients went to it regularly. 
 It was one of the most popular entertainments in an 
 asylum where amusements were rather a speciality. 
 Anything in which all can take a part is much 
 appreciated; hence the popularity of songs with a 
 good chorus. This, combined with the lively airs, 
 is the reason why the singing of Sankey's hymns 
 on a Sunday evening is always so much looked 
 forward to. 
 
 Entertainments are employed as curative agents, 
 and also to lighten the lot of those unfortunate 
 people who are condemned to live apart from their 
 fellows. We endeavour by such gatherings to civi- 
 lise, and build up again a little self-control. I would 
 rather see a few turbulent patients removed from a 
 meeting, than have the chairs filled with utter 
 dements, safe to give no trouble, but past salvation, 
 and quite beyond being influenced either one way 
 or the other. Entertainments are not to be used 
 indiscriminately. I have seen harm done by allowing 
 cases in the first stage of convalescence from acute 
 mania to attend such things too early. On the other 
 
116 MENTAL NUESING. 
 
 hand, I have known very marked benefit result, and 
 I have seen cases where individuals appeared to be 
 sinking into dementia, and have been, as it were, 
 dragged back by the revival of their social instincts. 
 
 Let us by all means try to give the patients 
 something to think about ; to occupy their minds to 
 the exclusion of their individual worries, and the 
 everlasting "discharge day". If even for only a couple 
 of hours in an evening, we can make them forget that 
 they are confined within the walls of an asylum, our 
 time and trouble will not have been thrown away. 
 
Chapter XIII. 
 
 THE CHAEGE XUESE. 
 
 A CHAEGE nurse must use her head as well as her 
 hands. She must be able to show her juniors how 
 their work should be done, and must have sufficient 
 strength of character and influence over them to see 
 that they do it properly. The efficiency of the under 
 nurses, and the general tone of the ward, depends 
 much upon the woman who is at its head. The 
 position is no light one and there are many troubles 
 and worries awaiting its holder at every turn. As 
 the charge nurse must render to her superiors, so 
 must she exact ready and implicit obedience from 
 her subordinates. She must insist upon a fuU and 
 immediate report being made to her of every occur- 
 rence, or of any change in a patient's condition. Any 
 struggles, bruises, or other injuries must be entered 
 in the ward journal with a full account of the circum- 
 stances attending the incident. In addition to this 
 it would aid the much tried memory of the charge 
 nurse if she kept a note book in which new delusions, 
 habits, etc., of patients could be noted, and orders, 
 etc., written down at the moment they were given. 
 
 This would also help her to acquire the useful power 
 
 (117) 
 
118 MENTAL NUESING. 
 
 of putting the results of her observations into words. 
 When she leaves the ward in charge of her second 
 (as for instance at her meals) she should be careful 
 that the latter is posted up in such matters as ought 
 to be reported to the medical officer should he visit 
 the ward during her absence. 
 
 She is responsible for the condition of the ward 
 and the patiefits, and will depute to her subordinates 
 their special duties. She must see that they are 
 made acquainted with the suicidal tendencies, or any 
 other peculiarities, of those requiring special attention. 
 The times when supervision is likely to be imperfect, 
 and when accidents are liable to happen, are when 
 the patients are being got up in the morning and 
 being bedded in the evening. A strict attention to 
 special cases is needed on these occasions. 
 
 By the exercise of tact and good temper the 
 charge nurse can do much to allay excitement, and 
 prevent squabbles and troubles amongst the inmates 
 of her ward. Her eye must be always around 
 marking quietly the habits and dispositions of those 
 under her care. She should be aware of the evil 
 effect of bad associations, and should be quick to 
 remove a woman from the influence which a dis- 
 contented, querulous, or evilly disposed fellow patient 
 may be acquiring over her. 
 
 In the morning her duties will begin by visiting 
 with the night nurse, and speaking to, every one of 
 her patients before signing the night report and so 
 taking over the responsibility for them. When the 
 
THE CHAEGE NUESE. 119 
 
 patients are scattered over the house to sleep, it is 
 sometimes convenient to depute part of this duty to 
 her second, but it is very foolish to sign the night 
 report until either she herself, or a subordinate in 
 whom she has confidence, is satisfied from personal 
 observation that the patients are all right. A note 
 should be made of all beds found wet in the morning. 
 
 The temperature and ventilation of the day-room 
 and corridors will call for her special attention. The 
 former is especially important early in the morning, 
 and the first duty of an under nurse should be to 
 light the fires. 
 
 The charge nurse must exercise a general super- 
 vision at meal times. She must see that each patient 
 gets her fair share of food, and that those on special 
 diet get it. In the sick wards care must be taken 
 that those on milk, or special diet, do not steal from 
 their neighbours. 
 
 The patient's clothing will need constant looking 
 to, and it would be well occasionally to overhaul a 
 dement who is unable to complain, and see whether 
 she has been properly attended to as regards clothing 
 and cleanliness. The flannel underclothing is apt to 
 be forgotten. On no account must the bathing, or 
 changing, of dirty cases be left in the hands of other 
 patients, no matter how sensible or capable they 
 may be. There can be no objection to patients 
 assisting a nurse : indeed, in some instances, im- 
 provement in a woman's mental condition has gone 
 on rapidly after she began to take an interest in a 
 
120 MENTAL NUESING. 
 
 more helpless fellow-sufferer. In conveying cripples 
 and feeble cases from one part of the ward to another, 
 the nurse must always assist. 
 
 The charge nurse should insist upon constant 
 trials being made to induce patients to employ them- 
 selves. It is unfortunately true that when a ward 
 is well supplied with good workers, the duty of 
 trying to get troublesome patients to work does not 
 seem so important as it should do. It is curious how 
 efficacious efforts in this direction become when these 
 working patients are removed to another ward, and 
 the want of patients' assistance is acutely felt. 
 
 The extra diet sheet with a list of those patients 
 requiring special supervision and of those under 
 medical or any special treatment (with the nature of 
 the latter), should be kept in the medicine chest 
 ready for inspection at any time. 
 
 The charge nurse is responsible for the care of 
 the ward stock. She can do much to prevent waste 
 and lessen destruction even in the worst wards. 
 Attention to mending and forethought in this direc- 
 tion will do much towards reducing expense. She 
 must administer medicines and dress wounds. 
 
 The daily report sheet will be a record of the day's 
 work in the ward. It will give the numbers of patients 
 employed, and how ; the number out walking ; those 
 in bed ; those who have been excited and destruc- 
 tive, etc., etc. There are usually printed forms with 
 the various headings given under which the nurse 
 makes her entries. 
 
Chapter XIY. 
 
 THE NIGHT NURSE. 
 
 To make a good night nurse a woman requires 
 common sense, calm judgment and self-reliance. Her 
 duties are at times very trying. They begin with 
 visiting her patients in company with the day nurses 
 who are in charge, and seeing that they are alive 
 before taking them into her care. All alterations 
 in the sleeping arrangements should be reported to 
 her, as well as any change in the condition of any 
 of the patients. 
 
 The night report must be accurate, and given with 
 sufficient regard to details. It is not enough to say 
 that a patient had a draught and slept fairly. She 
 must name the time at which the draught was given ; 
 how long it was before the patient dropped off to 
 sleep ; and the number of hours slept. Bad habits, 
 restlessness, or excitement should be reported and the 
 hour given at which they occurred. A new admission 
 must have a specially detailed report stating whether 
 she slept, and for how many hours ; whether the 
 bowels were moved, and if she passed urine. The 
 latter should be saved for examination. Suicidals 
 
 and epileptics should sleep with the face uncovered 
 
 (121) 
 
122 MENTAL NURSING. 
 
 and within the nurse's view. Those epileptics who 
 have fits not preceded by the characteristic cry should 
 have their beds placed as conveniently near the nurse 
 as possible. The nurse must be watchful. It is not 
 enough that she peg the recording clock at proper 
 intervals. The whole of her duty does not consist in 
 keeping awake. The habit of reading is dangerous. 
 Attention cannot be given both to patients and an 
 interesting book without the former suffering. 
 
 Wet and dirty cases must be got up at regular 
 intervals. Their names, and the times at which they 
 are got up, must be noted. A sharp look out must 
 be kept on such cases, and when wet, they should be 
 changed immediately. With a few exceptions, wet 
 beds are a blot on good night nursing. If the day 
 nurses strive hard to prevent bed-sores in feeble and 
 bed-ridden cases, it curdles the milk of human kind- 
 ness to find those patients wet, with skins red and 
 tender, on coming on duty in the morning. The 
 nurse who visits the dirty, destructive, and violent 
 cases has an arduous and trying task. It is not 
 always safe for a night nurse, single-handed, to under- 
 take the changing of a dangerous lunatic. There are 
 some few cases, indeed, whose rooms it is not always 
 wise for her to enter alone at night. Some single 
 rooms have arrangements by which they can be 
 lighted up, and the night nurse can, from without, 
 see if these exceptional cases are all right. In cold 
 weather, destructive cases need frequent looking to. 
 They often tear up their bed clothing and leave them- 
 
THE NIGHT NURSE. 123 
 
 selves uncovered. When a patient requires to be 
 bathed she must be wrapped in a blanket both in 
 going to and coming from the bath. A note should 
 be made of any patient whose chamber is found 
 empty. Though some appear to suffer but little from 
 the practice of drinking their urine, there are cases in 
 whom unaccountable attacks of prostration have been 
 due to this habit. Violent and dangerous patients 
 should not be given earthenware chambers. They 
 are dangerous weapons in the hands of excited 
 lunatics. The india-rubber articles are with difficulty 
 kept sweet but are not so dangerous. 
 
 The night nurse must not forget her own health, 
 and should have daily exercise out of doors. 
 
Chapter XV. ' 
 
 THE SICK ROOM. 
 
 It is not possible here to enter into the details of 
 sick nursing. Every asylum nurse should have 
 instruction in the ordinary everyday duties of the 
 sick room. She should be able to make and apply 
 poultices ; give an enema ; change sheets, etc. 
 Without such training, she is unfit to take charge 
 of private mental cases. The nursing of the insane 
 sick requires all the care, and double the patience 
 and forethought, requisite in tending upon the sane. 
 Strict obedience to orders is all-essential. No medi- 
 cines ; not even a teaspoonful of castor oil, must be 
 given without definite orders to that effect. It is 
 hardly necessary to say that all drugs must be kept 
 out of the way of the patients. 
 
 Bedsores. — Occasionally in brain and spinal cases, 
 and more especially in general paralytics, all the care 
 and attention possible will not prevent the appear- 
 ance of bedsores. They should not, however, be 
 allowed to form in ordinary cases. Patients liable 
 to them should be placed on a water bed or cushion. 
 They should not be allowed to he for any length of 
 
 time in one position, but should be moved, so as to 
 
 (1'24) 
 
THE SICK BOOM. ' 125 
 
 prevent pi^essure being applied for too long a period 
 on any one part. Those with a glimmer of reason 
 should be encouraged to ask for the bed-pan. When 
 changing is needed, it must be done at once. The 
 sheets must not be allowed to get into creases, and 
 crumbs, etc., must be kept out of the bed. The 
 parts likely to be affected may be sponged with 
 spirit lotion, or such application as the doctor directs. 
 Frequent examination is necessary to detect the first 
 signs of any tenderness. When a sore does form, the 
 pressure should be taken off' it as much as possible 
 by padding around it with cotton wool, and paying 
 cai'eful attention to the patient's position in bed. 
 The sore will be dressed as directed. 
 
 The various forms of water treatment will be 
 carried out under the personal supervision of the 
 head attendant or head nurse. Amongst these are : 
 
 The Wet Pack. — This is a very useful method of 
 treatment in some cases, but to be effective must be 
 thoroughly and carefully carried out. It is not easy 
 to pack an excited lunatic without the aid of four or 
 five skilful assistants. Sufficient nurses must be 
 present to manage the patient without risk of injury 
 in her struggles, and to pack tightly. The wet 
 sheeting must be arranged without creases. These 
 cause great discomfort and pain, and may leave 
 wheals or bruises. 
 
 The following articles are required : — 
 
 1. An iron bedstead, one with sacking bottom for 
 preference. 
 
126 MENTAL NURSING. 
 
 2. Four sheets folded rope-fashion must be passed 
 between the framework of the bedstead and the 
 sacking frame on one side : carried under the bed- 
 stead, and brought through between sacking and 
 frame on the other. They must be arranged in cor- 
 responding situations to the middle of the legs, lower 
 part of the thighs, the hips, and the chest of the 
 patient. 
 
 3. Three or four blankets. If large sized let them 
 be spread over the bedstead in the usual way ; if 
 small, let them be spread crossways. They must be 
 broad enough to wrap well round the patient, and long 
 enough to be folded up comfortably over the feet. 
 
 4. Vulcanized sheeting. Either one large sheet 
 or several small ones must be spread over the 
 blankets. The sheeting must be sufficiently large 
 to wrap round the patient. 
 
 5. A thin blanket rolled up along its broad width 
 roller-fashion. 
 
 6. A sheet dripping-wet with cold or lukewarm 
 water, according to medical orders, is spread out on 
 the vulcanized sheeting. 
 
 The patient is undressed and laid on the wet 
 sheet. Her arms are held close to her sides and her 
 hands, fully opened, are applied close to her body. 
 She is wrapped tightly and carefully in the wet sheet, 
 which reaches from her neck to her feet. This is the 
 part of the packing which is most troublesome and at 
 the same time most important. Without a sufficient 
 number of nurses who understand their worlc it is 
 
THE SICK ROOM. 127 
 
 almost impossible to arrange the sheet tightly and 
 without creases. The thin roller blanket is then 
 taken, and applied in like manner. Next the vul- 
 canized sheeting is smoothly and evenly wrapped 
 around, and then, one after another, the blankets. 
 The packing must be done tightly, or the patient will 
 be able to struggle and chafe herself in it. Each 
 successive fold is of course more easily applied than 
 the preceding one. Pillows are then placed over the 
 chest, lower part of the abdomen, thighs, and legs. 
 The blankets are folded comfortably over the feet, and 
 secured under the pillows which are placed upon the 
 legs. The four sheets, which had been previously 
 arranged, are now tied over the pillows sufficiently 
 tightly to keep the patient secure. A low pillow is 
 placed beneath her head, on which cold cloths or cold 
 coils are placed. A nurse remains with the patient 
 to sponge her face and attend to her generally. She 
 is taken out of pack every hour, and, while the bed is 
 being rearranged, she is douched with warm water 
 and receives beef-tea or hot milk, etc. 
 
 The dry pack is carried out in a similar way but 
 without either the wet sheet or vulcanized sheeting. 
 Packing is considered restraint, and similar articles 
 to those used in the process must be shown to the 
 Commissioners in Lunacy on their visit. 
 
 Hot Bath. — The temperature of a hot bath ranges 
 from 98 deg. to 110 deg. F. : usually it is ordered be- 
 tween ]00 deg. and 103 deg. F. The danger of 
 injuring a struggling patient against the framework 
 
128 MENTAL NUESING. 
 
 of the bath must not be forgotten. The water in the 
 bath is brought up 99 cleg. F. before placing the patient 
 in it. Hot water is then added gradually until the 
 water reaches the desired temperature, which is ascer- 
 tained by means of the thermom.eter. The patient 
 has cold cloths or sponges applied to her head while 
 in the bath. When taken out she is dried and well 
 rubbed ; is clothed in a flannelette night-dress and 
 wrapped up warm in bed. Sometimes a little stimu- 
 lant is given before the bath, and beef-tea, hot milk, 
 or egg flip after she has been put back to bed. 
 
 When a hip bath is given it must be remembered 
 that the water cools rapidly. Hot water must 
 therefore be added frequently, and the thermometer 
 kept in constant use. The patient's shoulders should 
 be covered with a blanket. A warm bath is one 
 between 92 deg. and 98 deg. F. ; a tejnd one between 
 85 deg. and 92 deg. F. 
 
 Sometimes douching is combined with the hip 
 bath. Turkish baths are in use in some asylums. 
 
 Rules for ordinary bathing are hung up in every 
 bath room. Patients confined to bed, and who 
 cannot be bathed, should be regularly sponged over. 
 In some cases the addition of a little " sanitas " or 
 some similar preparation is advisable. The nurse 
 should be careful to sponge, and dry carefully, under 
 the breasts, the folds of the groins, and surrounding 
 parts. Sometimes the use of a little dusting powder 
 is of advantage. 
 
 It is verv convenient to have the nurses in charge 
 
THE SICK EOOM. 129 
 
 of the female sick room taught how to use the 
 catheter. The nurse must never forget how all- 
 important it is that the catheter should be kept 
 scrupulously clean. After being used it should first 
 be washed through with a good jet of clean water 
 and then washed with carbolic lotion (one in twenty). 
 Before being used again, it must be washed in the 
 carbolic lotion and lubricated with carbolic oil. The 
 nurse must remember that carbolic acid is a poison, 
 and must be carefully kept out of the patient's reach. 
 
 Great caution is requisite in taking the tempera- 
 ture of lunatics. They are occasionally inclined to 
 mistrust the clinical thermometer, and it is apt to 
 get broken. , 
 
 Massage is sometimes very useful in the treatment 
 of the insane. Every nurse who has the opportunity 
 of getting practical training in the methods of carrying 
 it out should certainly take advantage of it. 
 
Chapter XVI. ' 
 
 HOSPITAL AND ASTLUM NURSES. 
 
 It is true that no asylum nurse can be efficient who 
 has not had training in the duties of the sick room, 
 but it is equally true that no hospital nurse can be 
 considered thoroughly trained who has not had some 
 instruction in dealing with mental cases. The duties 
 of the two classes of nurses are not distinct. Each 
 could learn much from the other. It might be 
 possible to meet the difficulty in the case of the 
 asylum nurse by making each probationer pass 
 through the infirmary wards under a charge nurse 
 who would take an interest in and try to teach her, 
 but for the hospital nurse there is no chance of 
 practical training. Why should not our asylums 
 work hand in hand with the neighbouring hospitals : 
 receiving their probationers for a period of months, 
 and giving them instruction both practical and 
 theoretical? The next great advance in our treat- 
 ment of the insane lies in the improvement of our 
 nursing staffs. Each asylum should train its own 
 staff, and, if it can turn out a good article, why not 
 place its own brand upon it ? Let each asylum give 
 
 certificates which testify to the training and pro- 
 
 (130) 
 
HOSPITAL AND ASYLUM NURSES. 131 
 
 ficiency of their bearers. If some of those so trained 
 leave the asylum for private work, let them go, 
 carrying with them our best wishes for their success. 
 Those best suited for work in the asylum will remain, 
 and the service should be made sufficiently attractive 
 to retain them. The. asylum nurse of the future 
 must be more an aid to the physician than she could 
 be in the past, though her work has been deserving 
 of all praise. Of her wo can say with truth — She 
 did what she could. It rests with us to see that 
 her power to do good in the future is greater than 
 it was in the past. 
 
Chapter XVII. ' 
 
 PUERPERAL INSANITY. 
 
 The term puerperal insanity has been used to denote 
 those forms of mental disorder which arise during 
 pregnancy, at or shortly after delivery, or during the 
 months when the mother is suckling the infant. It 
 thus includes very different conditions which are 
 more conveniently described as : (1) the insanity of 
 pregnancy, (2) puerperal insanity (properly so called), 
 (3) the insanity of lactation, or that form of mental 
 disorder in the production of which the exhaustion 
 caused by nursing the child plays an important part. 
 1. Insanity of Pregnancy. — Though the pregnant 
 state ought to be a perfectly normal and healthy one 
 it unfortunately is often far from being so. It is a 
 matter of everj^lay observation that many pregnant 
 women have their disposition and characters materially 
 altered without the change going so far as to con- 
 stitute insanity. They are not uncommonly fretful 
 and filled with anxious forebodings and indefinable 
 dread that something very shocking is going to 
 happen to themselves or the unborn children. The 
 well-known cravings and morbid appetites are also 
 
 evidences how profoundly the nervous system is 
 
 (132) 
 
INSANITY OF PEEGNANCY. 133 
 
 affected by this state. These are in the vast majority 
 of instances perfectly harmless manifestations, but 
 would become very serious should the craving take 
 the form of a liking for opium or alcohol. But 
 although these symptoms may not be very grave in 
 themselves they still afford warnings of what might 
 occur, and make the physician more watchful of the 
 case, more particularly if she have an inherited pre- 
 disposition to nervous disease. 
 
 The insanity of pregnancy is said to occur most 
 frequently in first pregnancies, and more especially 
 so if the woman be unmarried or over thirty years of 
 age when she was married. The mental affection 
 may appear before the third month or later than that 
 period. In the former cases recovery frequently 
 takes place during pregnancy, but the latter generally 
 go on until delivery and may then pass into puerperal 
 insanity. Only the worst of these cases find their 
 way into our public institutions. It is a very sad 
 thing for a child to be born in an asylum, and the 
 friends of the patient naturally make every attempt 
 to treat her outside. Though some of the cases are 
 acutely maniacal the greater number suffer from de- 
 pression. The evil forebodings deepen, the patient 
 becomes more fretful, sleeps badly, and is influenced 
 by jealous suspicions of those about her. The case 
 may go no further than this and be easily enough 
 managed. The jealous suspicions, however, may grow 
 into actual delusions, and the husband is generally 
 the victim. He is accused of being mifaithful and 
 
134 MENTAL NURSING. 
 
 cruel. The woman's moral nature becomes changed, 
 and she makes dreadful charges against him and 
 others about her. She fancies strangers have designs 
 upon her husband and children, and the nurse will 
 not unlikely be included in her accusations. If the 
 patient be in an asylum some particular nurse may 
 be singled out as the object of her special dislike. 
 The moral twist may even assume the form of taking 
 things which do not belong to her, and a true klepto- 
 mania may develop. Regard for her personal 
 appearance may be lost and she may become utterly 
 careless about her attire. It is in some of these 
 cases that we find the worst examples of suicidal 
 impulses. The intense jealousy and dislike of un- 
 offending individuals may also lead to homicidal 
 attempts, and necessitate the most careful watch 
 after delivery lest injury be done to the child. 
 
 The insanity of pregnancy must be managed like 
 other cases of acute mania or melancholia, but with 
 special care and precautions adapted to the peculiar 
 circumstances of the patient. The great danger of 
 suicide must be borne in mind. The possibiHty of 
 precipitation downstairs or from windows must be 
 guarded against, as well as the chance of the patient 
 rushing violently against the corner of a table or 
 piece of furniture with the intention of injuring 
 herself or the child. Such cases are all the more 
 anxious on account of the danger of struggles with 
 the pregnant woman, and sufficient aid should be 
 at hand to manage her without any risk of falls if 
 
PUEEPERAL INSANITY. 135 
 
 possible. Accurate observation as to the condition of 
 the patient's bladder and bowels is important, and 
 note should be made of the quantity of food she 
 takes and the amount of sleep she has. In some in- 
 stances very close observation is required as the time 
 of confinement approaches, and more especially so if 
 the patient be very excited or in a state of stupor. 
 Sometimes no indications are given that labour is 
 going on, and if the delivery be very rapid the patient 
 may be able to injure the child before the nurse can 
 interfere. 
 
 There is a form of passing insanity which may 
 occur during delivery, or immediately after, and, 
 though not dangerous so far as the patient's health 
 is concerned, it is of great importance, since under 
 its influence she may injure either herself or the 
 infant. 
 
 2. Puerperal Insanity. — The form of insanity which 
 may rightly be called "puerperal" is that which occurs 
 either immediately after delivery or within a period 
 of six weeks from that event. This is perhaps the 
 most terrible of all forms of mental disorder. Insanity 
 is a very dreadful affliction at any time, but its sudden 
 and often quite unexpected appearance after childbirth 
 is particularly saddening. Though many causes may 
 assist in its production, yet hereditary predisposition 
 is one of the most powerful, and a patient who has 
 once suffered is liable to be affected in subsequent 
 confinements. Sometimes a nervous shock, such as 
 the sight of the placenta, seems to have precipitated 
 
136 MENTAL NURSING. 
 
 an attack, and nurses should be careful not to discuss 
 details of "bad" or "interesting" cases with, or in 
 the presence of a woman about to be confined. It 
 is an affection which is perhaps more common among 
 the rich than among the poor and hardworking. 
 
 The insanity may take on any form, mania, 
 melancholia, or a condition of stupor or dementia. 
 When the attack occurs within a few days after 
 delivery the disorder is more likely to assume a 
 maniacal type. It is doubtful in some instances what 
 part blood-poisoning, either from the internal surface 
 of the uterus or from injuries caused during delivery, 
 may play in the production of the disease. This, 
 however, is only another reason for extreme care on 
 the part of both the medical man and nurse. For a 
 day or two the patient seems to go on favourably, but 
 then a change takes place. She is unreasonable, and 
 it is difficult to do anything to please her. Her 
 expression changes and she^becomes sleepless and 
 talkative. Perhaps she shows some indifference with 
 regard to the child, or it may be even actual dislike. 
 Her appetite fails, or she may refuse food altogether. 
 If her temperature be taken it is found to have gone 
 up, and she may complain of tenderness over the 
 lower part of the abdomen. The vaginal discharge 
 may cease or may become fetid, and the bowels are 
 frequently constipated. It is important in such cases 
 to keep the child away, as the mother may, under the 
 influence of some sudden impulse, attempt to destroy 
 it. In severe cases, which alone come into asylums, 
 
PUERPEEAL INSANITY. 137 
 
 the 2^atient becomes restless, noisy and incoherent, 
 while her language and behaviour are often very 
 obscene. Indeed, some women who have been 
 carefully brought up will use expressions and lan- 
 guage which cause us to wonder wherever they could 
 have heard them. As the case progresses the patient 
 will probably refuse to stay in bed, and may have 
 hallucinations of sight and hearing. She may be 
 violent and even have homicidal impulses of which 
 the nurse may be the victim. It is wonderful what 
 an amount of strength such patients can exert, even 
 when to all appearance they are very weak or almost 
 exhausted. In the more severe cases the restlessness 
 increases : the j^atient is nearly always on the move, 
 and often keeps up an incessant, incoherent chatter. 
 The desire for food is quite gone, as well as the 
 knowledge of her need of it. Her lips become dry 
 and cracked and her general appearance is haggard 
 and worn-out. It is difficult to get any food into her 
 mouth, and even when that is accomplished the 
 patient is quite regardless of its presence, and will 
 make no attempt to swaUow it. This, the more 
 severe type of the disease, sometimes exhausts the 
 sufferer very rapidly. 
 
 Instead of this acutely maniacal condition the 
 patient may fall into a state of stupor, being quite 
 lost to her surroundings and making no attempt to 
 take food or attend to herself in any way. 
 
 The cases which arise at a later period are gener- 
 ally more inclined to the melancholic type. The 
 
138 MENTAL NURSING. 
 
 patient is fretful and discontented with everything. 
 The nurse is always in fault and whatever she does 
 is wrong. Not infrequently the patient influences 
 her friends, who behave unjustly to the attendant, 
 under the idea that she is in some way to blame for 
 this change in the invalid's disposition. The patient 
 may show intense dislike to her husband and hatred 
 towards the child. She may fancy her food is 
 interfered with and refuse to take any. As the de- 
 pression becomes more marked she may begin to hear 
 voices and to believe that she is very wicked and can 
 never be forgiven. In this stage of the disease 
 suicidal tendencies are not uncommon. Some patients 
 pass into a curious state in which they resist and 
 struggle against everything that is done for them, no 
 matter what it may be. She will not allow herself to 
 be dressed nor will she permit her clothes to be taken 
 off". She will not get out of bed nor will she return 
 to it when once she is up. She will not take food 
 nor will she leave the dining-room, but clings to the 
 furniture when wanted to move into another room. 
 It is very often a tiresome business to get such a 
 patient's hair seen to, and it is not at all unusual for 
 patients to complain of cruel treatment afterwards, 
 owing to their indistinct recollections of these strug- 
 gles to keep her tidy. Many cases appear unable 
 to understand what is said to them, but keep repeat- 
 ing some phrase over and over again. Sleeplessness 
 is a prominent feature, and such cases rapidly waste 
 and lose flesh. 
 
PUERPEEAL INSANITY. 139 
 
 The nursing of puerperal insanity demands un- 
 ceasing and vigilant care. In the very excited 
 and acutely maniacal cases it is difficult, owing to 
 their restlessness, to keep them clothed and warm. 
 Thick flannel combinations which lace up the back 
 and are provided with feet will be found very useful. 
 In place of feet joined to the combinations thick 
 woollen stockings may be used, but generally the 
 patient will not allow them to remain. Occasion- 
 ally in suicidal and in some very dirty cases it is 
 best to cut the hair, but it is well to refrain from this 
 extreme step if possible. The room should be dark- 
 ened and quiet. The floor should be padded or 
 covered with mattresses, and the bed made on the 
 floor. If at any time the patient should lie down, 
 the nurse should see that she is warmly covered 
 with clothing and a pillow placed under her head. 
 This allows her a chance of getting a little sleep, 
 and is better than rousing her by an endeavour to 
 get her into bed. If the patient be suicidal it will 
 be necessary to provide her with warm but untear- 
 able rugs. If she once fall asleep great care should 
 be taken not to disturb her. It will sometimes be 
 observed that immediately after a nap the excitement 
 is even greater than it was before sleeping. She 
 will probably be quite lost to the calls of nature and 
 will need changing and bathing. This must not be 
 attemjDted without sufficient assistance. Nourishing 
 food, which in most instances will require to be in 
 liquid form, should be kept at hand and frequent 
 
140 MENTAL NURSING. 
 
 attempts made to induce her to take some. Though 
 generally it is not a plan to be recommended, draughts, 
 etc., may be given in food to acute cases who are 
 quite lost to their surroundings. To supply nourish- 
 ment and obtain sleep are the important aims of 
 the treatment. 
 
 The condition of the bowels must be noticed, 
 and whenever practicable the mine should be saved 
 for examination if thought necessary. If the patient 
 do not pass urine the fact must be noted and re- 
 ported. The use of vaginal injections will perhaps 
 be called for, but this method of treatment is much 
 more easily ordered than carried out in every case, 
 though careful attention to cleanliness is requisite 
 in all. 
 
 The state of the breasts must be attended to and 
 it may be necessary to use the breast-pump. Per- 
 haps rubbing and some application may be required. 
 
 Though this period of acute excitement is a very 
 trying one for the nurse it is more easily borne than 
 a subsequent stage through which many puerperal 
 cases pass. This is a condition in which they are 
 able to give an apparently coherent and sensible 
 account of themselves, but are discontented with 
 everything about them, and charge all who have 
 had to deal with them with cruelty and ill-usage. 
 It is very hard to find that patient's relatives refuse 
 to recognise this condition as a phase of the insan- 
 ity, but show by their manner, if not by their words, 
 that they are of opinion that the patient has been 
 
THE INSANITY OF LACTATION. 141 
 
 harshly and unfairly treated. The melancholic cases 
 require to be managed in the same way as ordinary 
 cases of depression. 
 
 3. The Insanity of Lactation. — The influence that 
 prolonged lactation exerts upon different women 
 varies very much. Anaemia and nervous exhaustion 
 are produced much more rapidly in some individuals 
 than in others. Of course many things must be taken 
 into consideration when searching for the causes of 
 this difference. The strength of the woman, her 
 social position, the quality of her food, etc., would all 
 have to be considered. As might be expected lacta- 
 tional insanity differs from puerperal insanity in being- 
 more common among the poor than among the rich 
 and well fed. The disorder may take the form of 
 either mania or melancholia. It rarely develops sud- 
 denly, but is preceded by a period of altered disposition 
 during which the woman is irritable, suspicious and 
 hard to live with generally. The severity of the 
 symptoms varies : some cases are extremely noisy 
 and violent, while others are depressed and suicidal. 
 Sleeplessness is generally a prominent feature of the 
 illness. 
 
 The majority of these cases are maiiaged at home. 
 The child must be weaned at once, and abundant 
 nourishing food given to the mother, who should be 
 removed as far as possible from all worrying in- 
 fluences. In their general management these cases 
 do not differ from that required for ordinary mania 
 or melancholia. 
 
Chapter XVIII. 
 
 HYSTERIA. 
 
 Hysteria is a functional disease of the nervous 
 system. By a functional disease we mean one in 
 which there is no known change in the structure of 
 the organ affected to account for the symptoms. 
 Hysteria may simulate almost any affection of the 
 nervous system, and that so closely as to require 
 great skill and experience to distinguish between 
 them. It is not that side of this strange disease 
 which we have to deal with, but rather the way in 
 which it affects the mind. That it does do so and 
 very profoundly is evident to all. Hysteria comes 
 very near to insanity : indeed it is sometimes very 
 hard to say where hysteria ends and madness begins. 
 There is a popular idea that all sufferers from hysteria 
 are shamming and ought to be treated accordingly. 
 This is wrong. It is true that we find instances 
 again and again of what it is hard to believe are 
 anything but wilful attempts to deceive, but at the 
 same time the illness is real and the sufferer is 
 deserving of pity, though it would be very foolish to 
 let her know it. She cannot help herself. Her will- 
 power is affected and she needs external stimulus 
 
 (142) 
 
HYSTEEIA. 143 
 
 to rouse it to action. It has been said that there 
 is not so much the presence of the will to do wrong 
 as the absence of the will to do right. This aj^plies 
 with much more truth to the physical than to the 
 mental symptoms. We frequently meet with hysteri- 
 cal lunatics who, while certainly deficient as regards 
 the will to do right, are by no means weak in the 
 will to make mischief. 
 
 The chief causes of the disease may be said to be 
 inherited weakness of the nervous system and a bad 
 bringing-up. The faults of the child's disposition 
 have been fostered rather than rooted out by the 
 system of education under which it has been reared. 
 When we think that it has, in most cases, been under 
 the influence of relatives who are themselves emo- 
 tional and wanting in self-restraint this will be easily 
 understood. Instead of being taught patience and 
 self-control it has been allowed to have free play for 
 emotional outbursts, and has been accustomed to be 
 made a great fuss over on every occasion. 
 
 Both sexes may be affected. In this country the 
 victims are more frequently women, but in France it 
 is found that men are affected at least as often as the 
 opposite sex. When it is a male in this country the 
 symptoms are generally of a melancholic type, and 
 somewhat resemble a case of hypochondriasis, or that 
 state in which individuals are morbidly anxious about 
 their health. 
 
 Hysteria may disj^lay itself at almost any age, but 
 it is most frequent among girls and young women 
 
144 MENTAL NURSING". 
 
 from about fourteen years of age and upwards. 
 Some well-marked cases, however, are seen in chil- 
 dren, especially among the weak-minded inhabitants 
 of our large institutions. The child is self-conscious 
 and always anxious to attract attention to herself. 
 She will do silly and extraordinary things to bring 
 herself into notice. Attacks of vomiting, or scream- 
 ing of hysterical origin, occur, and occasionally such 
 children become regular little furies, biting, scratching, 
 kicking, destroying clothing, etc., until the fit ends in 
 convulsive sobbing. These outbreaks are quite 
 different in character from the excitement seen in 
 cases of acute mania in children, and when once seen 
 are easily recognised again. 
 
 In the older cases the same desire for notoriety is 
 displayed. To be an " interesting case " is the height 
 of the patient's ambition and her great endeavour is to 
 secure attention from the opposite sex. Sexual ideas 
 are often very prominent. Hysterical young women 
 will sometimes make advances to men, and, when these 
 are not responded to, will accuse them of indecent 
 assault. Even without the incentive of wounded self- 
 love they are apt to bring such unfounded charges, and 
 it is always dangerous for a medical man to make any 
 examination of such patients unless he have reliable 
 witnesses present. They will write slanderous, ob- 
 scene, anonymous letters, set fire to houses, haystacks, 
 etc., and even go the length of murder in order to bring 
 themselves before the public. Doubtless, too, this 
 phase of the hysterical character is more common in 
 
HYSTEEIA. 145 
 
 males than is generally believed. After such proceed- 
 ings as these she finds her way into the asylnm — if 
 she have escaped being sent to prison. Here she is 
 a positive nuisance. She is constantly complaining 
 of illness and is the victim of extraordinary and con- 
 tradictory symptoms. It is not micommon for her to 
 declare that she is " bringing up blood," the real origin 
 of which is from her gums or it may be menstrual. 
 She will cut or break her hair off short, will refuse 
 food, make attempts at suicide, or even mutilate 
 herself in order to render herself an object of interest. 
 Retention of urine may be present, but hysterical 
 cases are seldom wet or dirty. She is very jealous, 
 and attention paid to another patient easily upsets 
 her. She will then occasionally break out into a 
 paroxysm of noisy excitement, during which she will 
 scream, tear her clothes, smash glass or make attempts 
 (not always very serious) at suicide. 
 
 Often also she will endeavour to give the nurses 
 all the trouble and annoyance in her power, while 
 being extremely polite and pleasant to, and in the 
 presence of, the superior officers. It is this class of 
 patient that makes charges of ill-usage against nurses 
 which on examination are found to be groundless. 
 As a rule the patient has some insane reason for 
 being jealous of the nurse whom she accuses. Such 
 a patient will make great demonstrations of attempt- 
 ing suicide, or will perha23S, even while the nurse is 
 looking at her, secrete tapes, pieces of glass, corset 
 
 steel, etc., about her clothing. She knows that the 
 
 10 
 
146 MENTAL NURSING. 
 
 nurse will be anxious about, and will have to pay 
 special attention to, her. It is very trying to be in 
 charge of such cases, because though they are not 
 likely, unless by accident, to do themselves any serious 
 injury, yet this accident might happen, and they are 
 setting a bad example to and unsettling other patients. 
 Some will also take a delight in secretly instigating 
 others to be insubordinate. The association of two 
 or three such individuals always causes trouble and 
 they should be kept apart as much as possible. 
 
 There is a very close connection between hysteria 
 and hypnotism, and there are few hypnotic persons 
 who are not hysterical. We find among hysterical 
 subjects cases of prolonged sleep, who will take food 
 when it is brought to their lips but again sink into 
 the drowsy condition. Some again will walk about 
 and perform acts in an automatic way, and yet have 
 no recollection of the occurrence afterwards. These 
 conditions are, of course, very rare. 
 
 The popular idea of hysteria centres around the 
 '' fit of hysterics " which is known to every one. 
 This outburst of emotional excitement and convul- 
 sive exercises is generally brought on by some dis- 
 turbing influence upsetting the patient's emotional 
 balance which is never very stable. It consists of 
 uncontrollable laughing or screaming, and may end 
 there or pass into regular convulsions. It may last 
 but a short time or may continue for one or two 
 hours. In many cases the patient appears able to 
 select the time and place for the performance, but 
 
HYSTERIA. 147 
 
 this is not always so. Such " fits " may occur when 
 there are no spectators and without any known cause 
 to excite the emotions. As a rule the patient 
 manages to avoid injuring herself, but this again is 
 not without exception. Very severe cuts or bruises 
 may be received in the fall or struggles, though the 
 tongue is seldom bitten, as so often occurs in epi- 
 lepsy. There is an exaggerated kind of hysterical 
 seizure, of which examples are found in asylums, 
 in which the symj^toms more closely resemble epi- 
 leptic convulsions. This affection is called hystero- 
 epilepsy, but must not be confounded with true 
 epilepsy. 
 
 In the management of these cases the less active 
 the part taken by the medical man the better. The 
 nurse must firmly and kindly, but without any dis- 
 play of sympathy, carry out the details of the treat- 
 ment. It is well to let the patient see that the nurse 
 is quite convinced that the treatment the patient is 
 under is certain to effect a cm^e. 
 
 In children a regular routine must be established 
 and adhered to : self-control should be encouraged, 
 but self-consciousness and the craving for sympathy 
 and notice should be restrained. Without neglecting 
 what might really be genuine symptoms of serious 
 disease, the child must not be led to expect that 
 every complaint of hers will meet with ready sym- 
 pathy and make her an object of general attention 
 and pity. In most cases it is well to remove hys- 
 terical patients entirely from their friends' influence, 
 
148 MENTAL NUESING. 
 
 and ill some to subject them to definite treatment 
 as regards food, massage, etc. The nurse must dis- 
 tinctly understand that while, as part of the treat- 
 ment, it is necessary to isolate the patient and avoid 
 displays of sympathy, yet the hysterical individual 
 is suffering from a disease and is not merely sham- 
 ming. We want to try to rouse the will to get well. 
 The influence- of the sexual element must be borne 
 in mind, and if retention of urine should ever call 
 for the use of the catheter it will be better for the 
 nurse and not the medical man to draw off the urine. 
 If the patients are in weak health regular supplies' 
 of food at stated intervals must be given : if they 
 are in good health it is just as well, while watching 
 them closely, to appear to leave them severely alone. 
 
 No rej^orts about any hysterical patient should 
 be made to the doctor in her presence. 
 
 Though it is a hard task to accomplish, the nurse 
 must strive not to show that she is irritated by the 
 tricks of the patient. She must try to keep her 
 closely under observation without apparently l3eing 
 concerned about her. Dm^ng a " fit " this is also the 
 best method of treatment, but at the same time care 
 must be taken that the patient does not b}" accident 
 or otherwise injure herself. There are means of 
 cutting short such attacks (as cold bath, cold douche, 
 electricity, etc.), but in an asylum these can only be 
 employed by the doctor himself or under his personal 
 supervision. 
 
Chapter XIX. 
 
 NURSING THE INSANE IN PRIVATE 
 HOUSES. 
 
 Friends of the insane are often, and rightly, anxious 
 to have their relatives nursed at home if it can be 
 possibly managed. This is generally so in cases of 
 the insanity of pregnancy, and it is often a necessity 
 in severe and early puerperal cases. The stigma 
 which unfortunately still clings to a residence in an 
 asylum is thus avoided, while the patient is retained 
 under the care of her usual medical attendant. The 
 desire of the friends to take part in the management, 
 though very praiseworthy, is of doubtful benefit to 
 the invalids and may seriously hamper the efforts of 
 a conscientious nurse. We may say that almost in- 
 variably it is better that the patient be left entirely 
 in the hands of the medical man and the nurses, and 
 that friends be admitted only when such an experi- 
 ment is deemed advisable. We have seen patients 
 whose recovery has been much retarded, if not pre- 
 vented altogether, by the injudicious interference of 
 well-meaning friends. They are over-indulgent at 
 one time and irritable at anothei', and are often in- 
 capable of exerting any moral influence over the 
 
 (149) 
 
150 MENTAL NURSING. 
 
 patient. Their feelings are too much interested in 
 the sufferer to allow them to maintain a calm temper 
 and exercise a clear judgment ; firmness is apt to be 
 confounded by them with harshness, and they are a 
 hindrance to others doing what is best for the insane 
 person. By their presence, also, they prevent that 
 complete severance from old ideas and associations 
 which is often of so great benefit. Among the worst 
 examples of mismanaged lunatics received into our 
 asylums are those who have been under the care of 
 their own relatives. 
 
 For an ordinary chronic or quiet case, who needs 
 no attention at night, one nurse will be sufficient, but 
 it is not always easy to say how many should be 
 provided for acute cases ; so much depends upon 
 the strength of the patient and the character of her 
 symptoms. In an acutely maniacal or restless melan- 
 cholic with suicidal tendencies, three, at least, will be 
 required. If the patient be very feeble two might 
 be enough. The provision for night duty, meal 
 times and daily open-air exercise for the nurse must 
 be borne in mind. It will probably be found cheaper 
 in the long run, and certainly better for the patient, 
 to provide sufficient help from the outset of the 
 illness. It is so difficult in insanity to foretell what 
 an hour may bring forth, and how much the subse- 
 quent history of the case may be influenced by 
 judicious treatment or the reverse at an important 
 crisis. The sleeping accommodation for the day 
 nurses should not be far from the patient's rooms, so 
 
NURSING THE INSANE IN PRIVATE HOUSES. 151 
 
 that they may be quickly summoned to assist the 
 night nurse if required. 
 
 The following are a few practical points which 
 will be found useful in private mental nursing. 
 
 Nurse's Dress. — This must be such as to allow 
 her the free use of her limbs and not to interfere 
 in any way with her free movements. Trains are 
 objectionable, and may actually become dangerous 
 in an emergency by entangling the nurse's feet. 
 Streamers to caps will afford a tempting object for 
 a mischievous patient to clutch at, and chatelaines 
 with a jingling accomj^animent of scissors must be 
 laid aside. When a restless patient is to be fed, it 
 would be well to wear an apron with a bib large 
 enough to cover the whole of the front of the dress. 
 
 Selection of Rooms f<yr the Patient. — This must, of 
 course, be decided to a great extent by the nature of 
 the case and the accommodation available. For a 
 quiet or chronic case without any special features 
 there need be no great change made in the ordinary 
 bedroom and sitting-room. In mild cases of melan- 
 cholia it is well to make the precautions taken as 
 little noticeable as possible, and to remember that 
 the best safeguard of all is incessant vigilance and 
 unremitting supervision. In feeble, or in very acutely 
 excited, or in markedly suicidal, cases, the situation 
 and furnishing of the rooms become a matter of 
 much more importance. Those on the first or second 
 floor have the advantage of being more private, and 
 the bathroom is generally more conveniently situated 
 
152 MENTAL NUESINCt. 
 
 than if rooms on the ground floor were chosen. This 
 latter consideration will sometimes be of great 
 weight. In very noisy cases it is, of course, desirable 
 to have them as private as possible. Two rooms will 
 be required ; one for use by day and the other by 
 night, so that each may get thoroughly ventilated 
 and cleaned. Only those who have nursed acute 
 dirty cases know the necessity for this. After the 
 very acute stage the rooms will probably be used as 
 bedroom and sitting-room and furnished accord- 
 ingly, but in very acute and excited cases this 
 distinction can hardly be made. The rooms and the 
 bathroom should, if possible, be on the same level, so 
 that there is no difficulty in moving the patient from 
 the one to the other. 
 
 Rooms on the ground floor have the great ad- 
 vantage of affording ready access to the open air. It 
 is imj^ortant to have a garden or some place where 
 exercise can be taken without being overlooked by 
 curious spectators. Even in the worst phases of the 
 complaint it will then be possible to get the patient 
 outside for a little while every day on which the 
 weather permits. This gives an opportunity for 
 throwing both rooms open to the air and sunlight. 
 By having the patient on the ground floor the risk 
 of precipitation from windows or down the staircase 
 is also avoided, as well as the danger of struggles on 
 the latter. 
 
 The ideal arrangement would be to have the 
 rooms on the ground floor and facing towards the 
 
NURSING THE INSANE IN PRIVATE HOUSES. 16H 
 
 south, with bathroom and lavatory adjacent and a 
 large private garden close at hand. 
 
 When a patient is very excited and inclined to 
 be violent it will be found convenient to have the 
 doors opening outwards and not into the room. The 
 floors should be of polished or varnished wood or 
 waxed linoleum. They are then easily cleansed and 
 do not roadily become foul by becoming saturated 
 with urine, etc. ( krpets are not to be recommended ; 
 they are easily soiled and difficult to clean. Eugs 
 can be placed about where they are required, and 
 can be taken out daily and aired. They are some- 
 times dangerous when dealing with a violent patient, 
 as they may slip in a struggle and cause falls. 
 
 Furniture. — As mentioned before it is in many 
 cases unnecessary and even inadvisable to make any 
 change from the usual homelike character of the 
 rooms occupied. In some cases a few alterations 
 should be made, but in the very acute stage of the 
 worst cases it will be necessary to furnish or rather 
 unfurnish the rooms in accordance with the symptoms. 
 It is to the latter forms of the disease that the follow- 
 ing remarks refer. The removal of hangings, etc., 
 which might interfere with ventilation, is as necessary 
 here as in am' ordinary acute disease. 
 
 Bedstead. — In very feeble and not too restless 
 
 cases it will be well to retain them on a bedstead as 
 
 long as ever possible, as they can then be more 
 
 easily changed and attended to. If the patient be 
 
 very restless and excited, or if very feeble and tottery, 
 
 10* 
 
154 MENTAL NUESING. 
 
 there is a risk of her falKng against the bedstead, 
 either from weakness or when strugghng with the 
 nurse. In these circumstances it will be better to 
 remove the bedstead and make up a comfortable bed 
 on the floor which should be padded with mattresses. 
 Sometimes a low framework with spring mattress is 
 used on which the bed is made. If the patient be 
 very restless and, as they often are. given to pulling 
 their bedding about, this framework may become dis- 
 placed and accidents may occur through a fall on it. 
 
 We may say that, as a rule, in very restless and 
 feeble and in acutely excited cases the bedstead 
 is better away. In doubtful cases a short experience 
 will decide the question. Some j^atients rest better 
 on the bedstead, and the election must be made 
 between removing it and running the risk (which 
 may be small) of an accident. It is at times advis- 
 able to have the bedstead firmly fixed to the floor. 
 
 Windoius. — These should be made to open only 
 about five inches at the top and bottom. Thi^ i ; 
 easily done by placing wooden stops in the frame- 
 work which allow the sashes to move only a certain 
 distance up and down. It will be well at times to 
 be able to darken the room, as well as to protect 
 the glass at night from a restless or violent patient. 
 This should be done by means of a locked shutter 
 which can be easily put up in a very short time by 
 any carpenter. 
 
 In all doubtful cases not under continuous super- 
 vision the following points are worth remembering. 
 
nuesinct the insane in private houses. 155 
 
 Window cords should be removed. They have 
 been used for strangulation. 
 
 Door-handles should be taken off on the inner 
 side. As the invalid will require visiting at regular 
 intervals, and if asleep should not be distui'bed, it 
 must be seen to that the door-handles and locks work 
 silently and easily and that the door does not creak. 
 Gas brackets and pendants should be arranged so 
 that suspension from them is impossible, and gas 
 taps should be out of the patient's reach. 
 
 Fireplace. — This, and more especially if the patient 
 be epileptic or very feeble, should be protected by a 
 large fire-guard. Unless the case be one in whom 
 full confidence is placed she should never be left 
 alone with a fire. Safety matches should be used 
 and they should be sharply looked after. 
 
 Chamber Utensils. — It is sometimes desirable that 
 these should be made of india-rubber, or some similar 
 material, and not of crockery. 
 
 Clothin/j of the Patient. — In the most acute stage 
 thick flannel-lined combinations are best and will 
 keep the patient warm however restless she may be. 
 We thus escape the painful struggles to keep her 
 dressed or in bed. As soon as ever possible ordinary 
 clothing should be used. It will probably be neces- 
 sary for a while to sew the dress at the back in order 
 to prevent the patient from stripping herself. When 
 able to be taken out laced boots should be used and 
 the laces tied securely. If the patient became ex- 
 cited out of doors and got her boots off it would not 
 be an easy matter for the nurse to replace them. 
 
156 MENTAL NURSING. 
 
 Feeding Cu2)s, etc. — During the very acute stage 
 when probably only fluids will be taken, some form of 
 feeding cup will be required. The ordinary shape 
 with the rounded spout is not always suitable, 
 although it is useful for nasal feeding either by itself 
 or with the tube attached. One of the most con- 
 venient forms is that of an ordinary butter-boat with 
 rather long spout. Feeding cups for the insane should 
 not be made of crockery but of some such material as 
 Britannia-metal which does not chip off nor crack 
 between the teeth when bitten. The arrangements 
 for special means of feeding will be attended to by 
 the medical man. Probably fork and spoon will be 
 used when the very acute stage is j^ast, and then if 
 there be no special suicidal or homicidal tendency the 
 use of ordinary forks and knives will be permitted 
 under close supervision. It is as well that the knives 
 should not be very sharp, but it is sometimes bene- 
 ficial to allow the patient to see that some confidence 
 is put in her. In these exceptional cases the special 
 forms of knife and fork should be used, in which the 
 length of the fork prong is limited and the knife is 
 pointless and has only a portion of the blade 
 sharpened. 
 
 Wet-packing (p. 125) is a form of treatment which 
 will be found very useful in private cases. The nurses 
 will probably be obliged to get in outside help and 
 it would be well to have a rehearsal, showing the 
 strangers the method fully before beginning on the 
 actual patient. 
 

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