William D. Granger

“ Keeping this noble teaching and this high motive for right-doing ever in mind, an attendant cannot go far astray.
It is a development of character to care for the insane, and instead of being brutalizing, as some ignorant people say, it is elevating and humanizing.
Attendants should never gossip, either among or about themselves, or of their patients. It is a mean and degrading habit to indulge in; it will undermine a good character, and often become overpowering and malicious. ”

“ Occupation then means a great deal more than work; it is the way a patient spends his time. Unless encouraged and directed, patients may occupy themselves in thinking of their delusions, in noise, violence, or destructiveness, in idly walking up and down the wards, in the indulgence of secret vices, in gossip, in spreading discontent, in prayer, or in constant Bible reading. Some patients really work hard trying to do nothing, and have no more ambition than to sit around on the ward, and chew tobacco, and indulge in idleness. ”

“ It may truly be said that unless we are under the compulsion of some physical force, we always choose to do whatever we most wish to do. This liberty of choosing is called “freedom of the will,” and because we are free to choose, we are responsible for the consequences of our choice. ”

“ It may be so necessary to watch the patients that the attendant cannot work steadily, but he should have the appearance of doing something, and if possible join with them in work.
A party of women sewing, should be laughing, talking, telling stories, perhaps singing; they should be made to enjoy the time, and not to look upon it as something irksome.
Some patients are too feeble in mind, and some too feeble in body to work; many need rest, quiet, and nursing, and directions for the care and occupation of such patients should come from the physician. ”

“ Patients should be encouraged and sometimes made to take part in these natural and pleasant amusements; of course every patient cannot play the piano, or billiards, but among these many forms of recreation, all patients can find ways of diversion and means of enjoyment.
Thus early in the study of the care of the insane, it is learned that the life of patients is to be stripped, as much as possible, of restriction and restraint; that self-control is to be taught; that useful work is to be encouraged; that amusements and innocent pleasures are to be enjoyed ”

“ For instance, a person looks at a row of trees, and they appear to him to be a row of soldiers; or the whistle of a locomotive may be so changed as to seem to be the voice of God; or the odor of a rose, burning sulphur; food may taste like poison, or the hand of a friend feel like a piece of ice or a red-hot iron, and is so believed to be. These are deceptions of the senses.
In insanity, the truth and existence of delusions, hallucinations, and illusions are fully believed in, and the patient cannot be argued out of the belief, however absurd or unreal it may be. ”

“ Sometimes patients slyly save their medicine until they get enough to poison themselves.
About dusk in the evening, or at early morning, is the time when patients are most inclined to commit suicide. When patients are rising, going to bed, or to their meals, when going to chapel, amusements, or to walk, when all is busy and astir on the ward, are the times that offer the most favorable opportunities for the act.
Often patients have a certain way by which they will commit suicide, and they will do it in no other; one wishes to drown himself, another to hang, and another to take poison. ”

“ Mind thinks or remembers, reasons or wills, but these are faculties of the mind; it is what the mind does, not mind itself. Gold is yellow, but yellow is not gold; gold is hard, but hardness is not gold ”

“ Monomania.—This is a term belonging to common speech, but there is not an agreement of opinion as to the existence of such a special form of insanity, nor among those who believe in it, as to what it is and what are its symptoms.
Monomania really means an insanity with but one, or, at most, a small class of delusions of the same character, the rest of the mind showing no disease. Hardly any one believes in the existence of such a narrow limit to insanity, and, getting beyond this point, there is no agreement where the limit should be set up to mark and bound it. ”

“ Mind and Matter are the only forms of existence of which we have any knowledge.
We speak of matter as inorganic—that is, without life, as iron, water, oxygen; and as organic, or matter plus something we call life. Life appears in two forms, namely, vegetable and animal. The lowest forms of animal life have no nervous system, but as we ascend in the scale the nervous system appears, and becomes more and more complete. ”

“ Care of the Destructive Patients.—Besides the violently destructive patients, there are some who are maliciously destructive, and who exercise all their ingenuity to escape the watchfulness of the attendants; who glory in their wrong-doing; who openly say they cannot be punished, and exultantly tell the physician how they have outwitted the attendant, or proclaim before him his shortcomings and neglect. Such patients will destroy their own or others clothing, they will steal and hide, or throw it out the window or down the water-closet, or erase the name by which it is marked. ”

“ The care demanded by patients who are inclined to acts of violence is practically the same for all. The attendant should thoroughly know the habits, peculiarities, and delusions of each person under his care; he should exercise constant watchfulness, and remember that a moment of thoughtless inattention may give the opportunity for a patient to commit some violent act, that will cause him lasting regret. ”

“ In this form of insanity the patient may refuse to speak or interest himself in any thing, or he may moan, groan and cry, and walk back and forth wringing his hands; when he is quiet, the mind, however, may be very active and full of delusions, which occupy it to the exclusion of every thing, driving away sleep, and making him indifferent to the taking of food or attending to his most necessary wants; sometimes the patient talks a great deal, but always about his delusions, which are generally connected with himself, his family, or his affairs. ”

“ Patients are not rightly influenced by the mere exercise of authority or by dictation or command; these they fear and obey, or resent and resist; but we should always appeal to the highest motives for obedience and correct conduct, and we should lead our patients to trust and not to fear us. In our dealings with them we should be truthful, straightforward, and strictly upright, and exercise over ourselves patience and self-control. ”

“ If attendants will watch their patients as they come out of acute mania or melancholia and become quiet, they will often notice that they gain in flesh and become demented. The dementia may be but partial, or so very complete that the patient knows nothing. From this they may gradually go on to improvement, or even recovery. They need all the care demanded by the confirmed dement, and, in addition, advantage must be taken of every means to promote recovery. They must be well fed, regularly taken out for exercise, and, as they are able, encouraged to employ themselves. ”

“ By the action of the organs and nerves of special sense we get all our knowledge of the external world, and, probably, if we had no organs of sense, we would have no consciousness of our existence.
Pain is due to abnormal action of sensory nerves, caused by disease, injury, or pressure, and the irritation made, being carried to the brain makes us conscious of the peculiar sensation we call pain. So the want of food or water makes an impression upon nerves, which being carried to the brain causes a peculiar sensation, and we say we feel hungry or thirsty. ”

“ As many patients who may never fully recover may so improve as to be able to return to their homes, and, as it is impossible to say that any given patient will not recover, each case deserves and should receive our best care and efforts to this end.
Because our patients are sick they must be nursed, and nursing means tender care. And it is a nurse’s duty to do all in his power to alleviate pain and promote bodily comfort. The insane are subject to all the ills that flesh is heir to, and there is always among our patients much sickness and bodily suffering. ”

“ Having learned what will cause violence, it can often be avoided by removing the cause; having learned the symptoms that precede a patient’s outbursts of violence, they can sometimes be averted, or preparations made to control them; having learned in what direction violence is shown, how sudden, blind, or furious it may be, or how slow, deliberate, and planned, the attendant is better able to meet, manage, and control it. ”

“ Most patients in an asylum have a feeling that they are under great compulsion and restraint, in being deprived of their liberty. It has already been taught that patients are to be given all the liberty possible, that restraint over their freedom is to be exercised no more than is absolutely necessary, and that the greatest good of the patients alone is to be thought of. ”

“ The Motor Nerves arise in the cells of the brain and cord. Those which go to the voluntary muscles cause them to contract, and are under the control of the will. If the cells are diseased, if they do not get enough arterial blood, or are poisoned by carbonic acid, or if the nerves are diseased, injured, or cut, so that nerve impulses cannot be sent from the brain to the muscles, we have paralysis of a muscle or a group of muscles, according to the extent of the injury. ”

“ Sometimes patients accept the situation and fit into asylum life without any friction. They may even come willingly, knowing they need care and treatment, or from confidence in their friends or their physician’s advice.
To some patients the restrictions of an asylum are irksome and misunderstood; the quiet, regularity, and routine of the life on the ward does not at first affect them; they may, and often do, become fretful, are irritated by their confinement, sleep poorly, eat little, and may make violent efforts to escape. ”

“ During the night, any accident, attempt at suicide or to escape, or unusual violence, persistent sleeplessness, or being out of bed, a serious sickness or change for the worse, or the approach of death, should be reported to the physician. It is, in many institutions, the duty of the night watch to report any neglect or misconduct on the part of an attendant or employé, and it is something that should be faithfully and impartially done. ”

“ All patients do not need to go to bed at the same time, and while some are able to care for themselves, most [Pg 42] need care, attention, and watching. The helpless should be dressed and undressed, and put to bed first: the violent and homicidal need to be watched, and should be put to bed early, while the suicidal should be kept under supervision, and put to bed at the most convenient time. After a patient is in bed, an attendant should go into the room, with a lantern, so as to see that every thing is in order and safe, and, with a cheerful “good-night” close the door. ”

“ The Care of Patients in a Condition of Dementia.—It is to be remembered that dementia may be either, a condition of chronic insanity without recovery, or a less permanent state of mental enfeeblement following the acute attack, and from which recovery may be hoped. In the first of these conditions there is little to be done except to care for the patient. Many are able to do some work, and should be allowed, encouraged, and taught to do it. Others do not know enough to dress, feed, or care for themselves. ”

“ Care must always be used not to injure a patient while exercising necessary control. In the violence of a patient innocent injuries are sometimes received. The attendant is excusable if he can show that he used necessary force only, without malice.
A violent patient should never be struggled with alone, and on a well-managed ward help will always be within call. It may be necessary, however, to break this rule in order to prevent homicide or suicide, or serious injury to another patient, or setting the house on fire. ”

“ Instead of the quiet delirium of typhoid fever there is generally violent mania or frenzy. Neither mind nor body is quiet; sleep seems to have fled. The patient may be destructive, constantly out of bed, fighting care, refusing food, and wetting and dirtying himself. With these unfortunate conditions there generally is fever, often to a considerable degree, the heart is feeble, the pulse rapid, the tongue and lips dry and cracked, the teeth covered with sordes, and the body emaciated. Every case does not present all these symptoms, nor show such alarming exhaustion. ”

“ Any symptoms of a return of their more violent condition, any failure to sleep, or change noticed in the health of the patient, should be at once reported.
Care of the Convalescent Patients.—This is the period that precedes recovery from disease. With the insane it is often a critical time, and if not properly cared for they may fail to get well, and become chronic lunatics. The patients, and frequently their friends, think they are well and should be at home. It is the attendant’s duty to encourage the patient, and to promote his confidence in the physician. ”

“ Homicides are not of frequent occurrence in an asylum. The better the care the less is the liability to homicide. But there are always a great many homicidal patients, and many more who have delusions and ideas that may cause such tendencies to arise.
Many patients are homicidal merely from violence and frenzy, and without any settled plan, any fixed delusion, or intense suspicion. They may attack others suddenly and furiously; they may commit the act while trying to escape, or it may be the result of the violence of acute mania. ”

“ To illustrate this change, we may suppose both a king and a pauper to become insane: there is, of course, a vast difference between them, but the king may be so changed by the disease as to believe that he is a pauper, and himself and his family starving, and he may also wish and even try to work and dig like a laborer to support them; or a pauper may think himself a king, and try to act like one. ”

“ A state of enfeeblement of mind, or dementia.
But one of these first two states of feeling can be present at the same time, for a person cannot at any one moment be both exalted and depressed, though he have mania to day, and afterward be so changed in his feeling as to have melancholia to-morrow, or next week, or next month.
In a general way all disease is divided into acute and chronic forms. An acute disease is one of recent origin, and from which recovery is to be hoped for; a chronic disease is prolonged and does not tend to recovery; an acute disease may become chronic. ”

“ Some willing patients are kept in a tread-mill of daily work, their monotonous life never broken by a diversion, an enjoyment, or a hope. It is very questionable if it is beneficial to make a patient drudge through such a daily routine.
Asylum life should be made as home-like, pleasant, and natural as possible; as a rule every patient who is able should do some useful work every day, and to this should be added the diversion, that comes from amusements and the enjoyment of innocent pleasures. ”