Insanity and the Nursing of the Insane

Kai Tiaki : the journal of the nurses of New Zealand, Volume II, Issue 2, 1 April 1909, Page 63

Insanity and the Nursing of the Insane

T. J. W. BURGESS

(by

During the early dawn of human histoiy, insanity was regarded as of eliv'ne origin, and its treatment was confided to the priests, who, as a rule, treated those so afflicted with kindness and consideration. In the fifth century, B.C. , for a period known as the Hippocrai 'c period, there were enlightened views of insanity, owing to the wise and advanced teaching of Hippocrates, justly designated ''The Father of Medicine." He first recognised the true nature of mental disorder, viz., that it : s only a manifestation of actual bodily disease, the brain being the part affected, and laid down rules for the humane and rational treatment of those mentally afflicted. The world, however, was entirely unprepared to follow the course advocated by Hippocrates, and from the commencement of the Christian era down to nearly the beginning of the past century, there was a return to primitive superstition, but with this great difference—insanity was no longer looked upon as of divine origin, but regarded as due to demoniacal possession. In consequence, lunatics were almost universally treated in the most brutal and barbarous way. It is only during the last century that insanity has again come to be recognised as a bodily disease, or that rational treatment of it has been practised. In fact, during the past 70 years the advance in the care and treatment of the insane has been greater than for two thousand years previously. Among the advances made in recent times, not the least has been the nursing of the insane, or, as it is now often termed, mental nursing. The problem of the proper nursing of this deeply afflicted class arose with Pinel and Tuke in 1791. For many years after their time, however, it was doubted by the majority of alienists whether the humane and sympathetic service required for the insane would ever be gained unless it were prompted by a purely religious spirit. Mental nursing proper, though said to date back over 70 years, that is, even prior to the development of the nursing of phyiscal ailments, nevertheless received no great attention until the period from 1880 to 1885,

(luring which years the movement to establish training schools for mental nurses, as well as emphasize the general hospital idea in asylum work, was successfully inaugurated by Dr. Edward Cowles, of the McLean Asylum, at Somerville, Mass. Since then the movement has grown so largely that to-day, the mental nurse differs as much from the ' keeper " of 50 years ago, as does the sick nurse of the present time from the " Sairy Gamp " of the immortal Dickens. As a rule the nurse trained only in general hospital work does not take kindly to the care of the insane. There seems to her to be little to do for a patient who has no appreciable bodily ailment, and so she is prone to think that the work is not calculated to call into activity the highest qualities of the nursing profession. Never was greater mistake. In the whole category of ill* that flesh is heir to, there is no disease that requires more skilful and careful nursing than mental disease. Patience, tact, watchfulness, courage, fertility of resource, forbearance under the severest provocation, ability to assert authority without violence, and to command the affection as well as the respict of a patient, presence of mind and judgment in emergencies, capacity to carry out intelligently the details of treatment as directed by the physician — all these qualities are required for the proper treatment of the insane in even a much higher degree than for those afflicted only physically. Some of you may feel disposed to dispute this. Take however; for example, the matter of nutrition, and you will sec at once how much greater an importance it assumes, when the object of your care is insane instead of sane. In the case of the latter, your patient is anxious to assist your efforts for his comfort, to meet you half way in all measures for his care — lack or capriciousness of appetite is all you will have to contend against. In other words, the sane patient, as a general rule appreciates his condition, is anxious to get Well, and helps all he can in any treatment that may be prescribed for him. Not so with the insane. Here, while there may still be lack or capriciousness of appetite, we

may have aeleled thereto absolute refusal of food, or even actual opposition to all efforts to induce the patient to cat. This, mayhap, from fear of being poisoned ; an idea that he does not need to eat to sustain life ; or a desire to commit suicide by starving himself to death. But, whatever the reason for the refusal of food, there is no disposition on his part to meet you half way, no effort to assist in any measures devised for his comfort or cure. There is thus, as you can easily see, a vast difference between the two forms of nursing, a difference thus aptly illustrated by Dr. Cowles in one of his reports on the McLean Training School : — " A nurse of large experience in mental nursing, after a term of service in a general hospital, was asked what the difference was between the two kinels of nursing. She answereel : ' In a general hospital, the patient must please the nurse ; with the insane the nurse must please the patient.' " Were I asked what, in my opinion, would constitute the ideal trained nurse, I would, without hesitation say : A thorough course of training in a hospital for the insane, followed by the regular hospital course. As a rule, the insane can be much better cared for in institutions devoted exclusively to the treatment of mental disorders, than at home ; but there are times when removal to such an establishment is for some reason deemed inadvisable. Consequently cases of insanity are liable, now and again, to be amongst those of which the ordinary sick nurse is asked to take charge. For this reason it is advisable that she should add at least some knowledge of mental nursing to her repertoire of accomplishments, a task in which I feel honoured by having been asked to assist you. To render intelligible what I have to say about the nursing of the insane, let me first devote a brief space to telling you something about what insanity is, and the forms of the disease most frequently met with. The fundamental principle of a mental nurse's education must be the fact that insanity is a disease ; that insane acts and ideas as surely spring from a morbid condition of the brain as a bilious attack springs from a morbid condition of the liver. It is hard to realise that it is possible for a person seemingly well and strong, able to eat three square meals a day, and capable of moving vigorously about, to be sick, as is really the

case with the insane, and yet it is all-impor-tant that this fact should never be lost sight of. Very often the victims of disordered mind imagine that their best friends are their worst enemies, and frequently, under the influence of insanity, the most kindly and refined ladies become notoriously obscene lewd, and irritating. Not rarely, too, we come across patients who, let the nurse be ever so kind, will persist in formulating charges of neglect, inattention, and even cruelty against her. To bear such charges with equanimity, knowing them to be utterly baseless, is one of the hardest tasks imposed upon the clinical nurse. It is only by the full recognition of the fact that such patients are sick, and not answerable for what they say, that this can be done. It takes a hard struggle, I grant you, to keep down the " old Adam," innate in us all, under such circumstances. It must be done, however, if you are to have any success in the care of the insane. Perhaps it may help you in the struggle if you will put it to yourselves in this light : I would never dream of taking to heart any of the absurd things said by a delirious fever patient, why then should I feel aggrieved at the remarks of an unfortunate lunatic, who is equally sick, and equally irresponsible for what he may say ? The general term " insanity " embraces a number of forms of mental disorder, and the question of an accurate definition of it has been much puzzled over. Even yet, alienists are not agreed upon one that will embrace all those who are insane, and exclude all those who are sane. Perhaps the simplest definition, and one as good as any, is that which defines it to be a prolonged departure from an individual's normal standard of thinking, feeling and acting. As to the forms of the disease, I need only say that it will commonly present itself to you in one of four aspects. There will be a departure from the normal condition, either in the direction of depression, of exaltation, of enfeeble ment, or of perversion. These constitute the four great forms of mental disorder to which the technical names melancholia, mania, dementia, and paranoia have been applied. That a nurse's duty must differ greatly in the different forms of insanity will be obvious. If the patient should be depressed her manner should be brisk, and her conversation lively and pleasant, though not flippant. If, on the other hand, the patient be

maniacal,' it will be her eluty to soothe, moderate and restrain, for which purpose her demeanour should be quiet and deliberate, her speech subdued. Even the most apparently demented patient must be treated with friendliness and politeness, because stupidity is often only an appearance, and experience shows that such patients are sometimes receptive of impressions and influences from minds stronger and clearer than their own, as well as from the surroundings which such minds create for them. Remember too, that although they do not always show it, the insane have likes and dislikes, often very strong ones, the same as the sane. They are often extremely sensitive to rude or unkind treatment, and, on the other hand, they are very grateful for favours or kindness. The nurse who has the patience and tact to take advantage of these facts can obtain a great influence over a patient — -an influence which may be a powerful factor in his restoration to health. In all cases, her main object should be to gain the confidence of her charge. Let her do this, and she will have much more comfort and ease in her attendance upon him, and much more success in carrying out any indicated line of treatment. Among the insane just as among the sane, the mental condition is very greatly affected by the state of the body, and anything that tends to promote the bodily welfare has a beneficial influence in promoting mental health. Hence, in all cases, but especially in those where the mental condition is such that the patient cannot take proper care of himself, everything possible should be done by the nurse to preserve and improve the bodily health. Your hospital training will have taught you the necessity for good ventilation, cleanliness, warmth, nourishing food, and attention to the proper discharge of the various bodily functions. I shall, therefore, pass over these points, merely warning you that sanitary surroundings are very apt to be neglected in the case of the insane, though they are just as necessary to their well-being as to that of any other sick patient. In the care of the insane, the nurse is an even more important agent than in the care of those only physically ill ; not only because she is the immediate agent to carry into effect the prescribed treatment, but because she is the one upon whom the doctor must depend for the bulk of his information,

Her relations with the patient are of the most intimate nature, and, having him under constant observation, she, better than anyone else, can learn all the subtleties of his mental state, and so, if observant, can add much to the physicians' knowledge of the case, and in this way do much to help toward a cure. As regards a patient's delusions, and your behaviour with reference to them. My advice to you is to avoid them as much as possible, but never to admit their truth. One is apt to think that to humour a patient by acquiescence in them will help to make things go along easily. This is very far from being the case. To appear to admit, either specifically or by your conduct, that delusion is truth, will eventually lead to your confusion. Let us suppose, for example, that the patient imagines himself to possess superhuman strength, and you humour him by assenting. Shortly after you have to give him a dose of medicine, and he objects to taking it. Inspired by his delusion that he is stronger than you, in which you have coincided, he will resist taking the dose, and your trouble will begin. Nor is it wise, on the other hand, to ridicule or needlessly contradict his erroneous ideas, for neither ridicule, contradiction nor argument will convince him of his error. Ignore delusions if possible ; but, if they are forced upon you, say kindly, but plainly and firmly, that you cannot agree with him, and you think the patient must be mistaken. Let the matter rest there, and on rto account allow yourself ' to be drawn into an argument. Instead, try to divert your patient's mind with other thoughts by getting him, if possible, to engage in some amusement or occupation. Patients with delusions of suspicion demand special care, and with such, a nurse must be doubly careful as regards her manner and conduct. If these be frank and open, natural and unembarassed, they will go far towards allaying suspicion. If, on the contrary, the nurse has an insincere look, avoids her patient's eyes, is giv^n to whisperings aside, or mysterious movements, she need not wonder if the distrust of her charge be excited, and he sets her down as a fellow-conspirator against his life or property. With such a patient, always be sure that it is made perfectly plain to him at the outset, that you are a nurse, and he is a patient ; that you are there because he is sick and you have been engaged to take care ot him ; let there be no deceptions as to your

relations one to the other, or as to the meaning of your presence. An important point in the management of the insane is never to manifest fear of a patient. If you have any such, you should carefully conceal it in his presence. Lunatics are very quick to detect evidences of such weakness, and to take advantage of it whilst for one who, though always kind is cool and self-possessed, showing no signs of timidity-, they have a very wholesome respect. It is a common characteristic of insanity to show itself most prominently in an entire change of the natural feelings and affections. Those whom a man has loved and trusted most dearly, whilst he was in good health, are the very ones towards whom he shows the greatest dislike and distrust when his reason is overthrown. This peculiarity forms one of the strongest reasons for sending insane patients to asylums, because continued contact with relatives or friends who have become objects of suspicion or dislike is not conducive to recovery. If a patient is to be treated at home, the physician should make it a condition that his friends shall abstain from seeing him, and the wisdom of withholding from his sight all those who might excite or irritate him, w r ould seem evident to the common-sesne of anyone. Unfortunately, however, the relatives of insane persons do not appear to be blessed with much of this quality, and, consequently, one of a nurse's duties, and one of her hardest tasks, may be to enforce the doctor's orders in this respect. Friends will appeal to you, coax you, even try to bribe you to ignore your instructions and let them see the patient. Of course, you must, for both your own and your patient's sake, refuse them courteously, but with a firmness that will admit of no appeal. Baffled in this, they may want you to speak to the patient on some subject for them, or to ask him some question. In this also your refusal should be definite but polite. Make your reports to the family as regards the patient's condition as encouraging as you fairly can, but avoid

descriptions of his behaviour or repetitons of his remarks. Above all, never let the patient's friends tempt you to express an opinion as to the prospects of recovery ; refer them to the doctor, in whose province alone it is to answer such questions. When friends are admitted to see a patient, regulate their conduct, as far as you can, by precept and example, deprecating any display of emotion, or aught that is calculated to excite or depress him. Be careful that nothing is said, even in the case of the dullest of patients, that it is not advisable that he should hear. If anything has to be said about him,let it be said aloud,not in a whisper, because all lunatics are prone to be suspicious. It is far better, however, that anything of the kind should be communicated outside the sick room. Another thing that the nurse should always bear in mind is this — the insane utterances of her patient, no matter how droll or strange they may be, must be regarded as confidential disclosures, and never repeated. The skeleton that is said to exist in every household is very apt to be unveiled in the ravings of madness, and it is quite possible that secrets may be revealed which your charge, while in health, saw fit to keep from those nearest and dearest to him. In such cases, the thoughtless repetition of what may have appeared to you to be only a senseless fancy, might be the cause of grave annoyance, or worse, to the patient's family and friends, or to the patient himself should he recover. The law which forbids a doctor to disclose any information gained whilst acting in a professional capacity, applies with equal force to the nurse. The only exception to your silence, which your position of nurse imposes on you, must be in favour of the attending physician. To him the patient's sayings should be freely known, because in them he may find some clue to the mental trouble, or some warning of a danger, such as suicide, to be guarded against.

(To be continued.)

Dr. Leo B. Meyer, m an article m the " New York Medical Journal" urges a greater care m the application of even weak solutions of carbolic acid where continuous action is required. It should never be applied to terminal parts, such as fingers or

toes, when the amount of tissue between skin and bone is small. Gangrene, dermatitis, or burns, more or less severe, may result from its use. Weak bichloride of mercury, or boric acid solution, is recommended instead.