Nursing and care of the nervous and the insane

Front matter

THE NURSING

AND CARE OF THE

NERVOUS ANDJ^E INSANE

Chapter I. Paob

Qualities and Qualifications of a Good Nurse for Nervous Patients — Social Service — General Management of Hysteria— Hysterical Seizures — Epileptic Seizures — General Management of Epileptics — Diet for Epileptics — Forms of Insensibility — Cases of Chronic Organic Nervous Disease — Sleeplessness — Delirium — Diet — The Alcohol, Opium, or other Narcotic Habit 9

Eorms of Electricity — Faradic Apparatus — The Mechanism, Management, and Care of Faradic Apparatus — Hints, Cautions, and Contraindications in Using Electricity — Electrodes — Conducting Cords — Methods of Applying Electricity — Motor Points 70

CHAPTER V. The Nursing and Care of the Insane 96

LIST or ILLUSTRATIONS.

FIG. PAGE

1. Continuous Bath 69

2. Faradic Battery 73

3. Dubois-Reymond Coil with Galvanic Apparatus ... 74

4. Faradic Apparatus for Office Table 77

5. Box of Electrodes , 85

6. Method of Holding Electrodes in one Hand .... 87

7. Motor Points of Arm, Anterior Surface 90

8. Motor Points of Arm, Posterior Surface 90

9. Motor Points of Thigh, Anterior Surface 90

10. Motor Points of Thigh, Posterior Surface 90

11. Motor Points of Leg, Anterior Surface 90

12. Motor Points of Leg, Posterior Surface 90

THE NURSING AND CARE

OP

THE NERVOUS AND THE INSANE.

Chapter I

Qualities and Qualifications of a Good Nurse for Nervous Patients — Social Service — General Management of Hysteria— Hysterical Seizures — Epileptic Seizures — General Management of Epileptics — Diet for Epileptics — Eorms of Insensibility — Cases of Chronic Organic Nervous Disease- Sleeplessness — Delirium — Diet — The Alcohol, Opium, or other Narcotic Habit.

The nursing and care of the nervous and the insane call for special training in a high degree ; and yet it is difficult to systematize and formally set forth instructions and regulations for such nursing. In fever, surgical, obstetrical, and other forms of nursing, much of the training has reference to instruments, dressings, temperature records, etc., to things which can be seen, handled, and illustrated. In the training of those destined to care for the nervous and the insane, a certain amount of instruction as to machinery and manual procedures must be given ; but much of the teaching, from

the very nature of the cases, must have reference to the conduct, habits, and characteristics both of nurses and patients.

In order, in the four chapters of the present book, to cover in a practical way my entire subject, I will not be able to give much time to theoretical considerations, and I believe that it is best that this course should be followed. While it is an advantage, and sometimes an important one, for non-medical attendants upon the sick to have some acquaintanceship with anatomy and physiology, or other branches of medical science, the amount of knowledge of this description absolutely requisite is limited.

The first chapter will be devoted to a consideration of some of the personal qualities and qualifications of nurses for nervous cases, and to certain miscellaneous matters in connection with nervous nursing; in the second, massage, movement, bathing, and certain instruments will be treated of; the third will discuss electricity ; and the fourth will be on the nursing and care of the insane.

Diseases of the nervous system cover an enormous field and experience has taught me that while nurses who are called upon to care for the nervous and the insane may be needed to aid the doctor in almost any one of the long list of nervous and mental disorders, a rough attempt at arranging the different classes of cases in which they are most likely to be employed can be made, based upon the special qualifications which will be required, and the particular duties that will be imposed. First come the cases of functional nervous disorders, so calkd, under which head are included cases which furnish' an important field for nurses thoroughly trained for their work, — patients suffering from hysteria in its manifold shapes; the neurasthenic or nervously exhausted ; neurotic people in general, some of them on the border-land between sanity and insanity ; the sleepless, the neuralgic, and the choreic. In the second place, we find patients suffering from some forms of insensibility and from certain acute organic affections, — cases of apoplexy, of uraemia, of sunstroke, of cerebro-spinal fever, of acute meningitis, tetanus, etc. Thirdly, there are certain cases of chronic, organic nervous disease, some curable and some incurable, — patients afflicted with meningitis cerebral or spinal, the victims of tumor of the brain or spinal cord, the hemiplegic, the paraplegic, or sclerotic, and the sufferers from atrophic or wasting diseases. Under a fourth head are included all cases of insanity.

At the outset let me speak briefly of some of the qualities and qualifications of a nurse for nervous patients. My first remarks will apply more particularly to those who will have under their care the sufferers from hysteria, neurasthenia, and other functional nervous disorders. The care of these patients is in some respects one of the highest forms of nursing. They sometimes undergo a method of treatment which involves, among other things, more or less complete seclusion from all but physicians and attendants ; and, confined to their rooms for weeks or months, almost isolated from the rest of the world, their care demands high qualities and qualifications in the companion and care-taker.

Let me here quote the words of one* whose wide experience entitles him before all others to speak as to the trials and qualifications of those to whom fall the care of the nervously sick :

" A life spent beside such a sick-bed is indeed a test alike of character and health. It requires a strong body and a fortunate balance of moral and intellectual qualities to escape from being made morbid by constant contact with such suffering ; and intensely sympathetic people are surely hurt by it, and themselves grow morbidly sensitive. Where the unhappy invalid becomes exquisitely ill-tempered under the long pangs of illness, the constant nurse must endure a thousand petty trials of temper, and must know when to yield and when to resist the tiny and numberless oppressions of her sick tyrant; but incessant battle with one's self is exhausting, and soon begins to show its results upon the healthiest nurse, cooped up in the sick-room. A pallid face, loss of energy, a certain passive obedience to routine duties are the sure consequences."

While the fundamental qualifications for a good nurse for nervous patients are those for a good nurse of any description, it is important that she should have a few special qualities, and should be free from a few particular faults and foibles. It is in the highest degree important that she should possess the quality called tact, so

1 "Nurse and Patient," by S. Weir Mitchell, M.D., LL.D.

often wanting in all walks of life. " Tact," says Dr. Aiiderson/ " is a quality not easily defined ; but if we go back to the original meaning we can construe a definition upon it. It means, literally, touch, — ^the touch of skill and experience. But it has a wider significance; it includes the mental touch, something more complete than the other; not a touch merely, but a grasp, — the grasp of the situation, the comprehension of a difficulty, the grasping of it on all sides so that it disappears in your hands."

A domineering nurse will not succeed, while a decided one will have the best chance of success. Firmness should be combined with gentleness and fairness, and a genuine good temper is invaluable. Habits of close observation should be particularly cultivated. The nurse should carefully note differences in the condition of the patient when the doctor is present and when he is absent ; and any tendency to deceive or simulate symptoms should be quietly reported. She should be especially careful not to talk too much to the doctor about the patient before the latter. It is often best for her to retire from the room when the doctor is present, in order to give him an opportunity to talk to the patient in private. A good nurse will soon learn to discriminate as to when she should go and when she should stay, and when and how she should make her report.

It often falls upon the nurse to carry out plans and

1*' Lectures on Medical Nursing," by J. Wallace Anderson, M.D.

invent expedients for amusing and occupying the patients. She should, therefore, have intelligence and education to be able to interest her patient by either conversation, reading, or other measures. She may fail in this respect by attempting to do too much, or by having an erroneous notion of her own powers. A good reader may interest patients of a certain class ; a bad one may torture them. Judgment in carrying out directions as to amusement and occupation will call for exercise of high qualities. If reading is permitted, the right books should be chosen ; if cards are resorted to, they should not be made a source of excitement instead of relief; whatever the occupation or amusement, it should be such as is adapted to both the physical and mental conditions of the patients. In many cases the nurse can persuade the patient into usefully occupying moments which would otherwise be passed in introspection.

" The nurse for these cases," says Mitchell,* " ought to be a young, active, quick-witted woman, capable of firmly but gently controlling her patient. She ought to be intelligent, able to interest her patient, to read aloud, and to write letters. ... It is always to be borne in mind that most of these patients are overrefined, sensitive women, for whom the clumsiness or want of neatness or bad manners or immodesty of a nurse may be a sore and steadily-increasing trial. To be more or less isolated for two months, in a room with

* " Fat and Blood : An Essay on the Treatment of Certain Forma of ^Neurasthenia and Hysteria," by S. Weir Mitchell, M.D., LL.D.

one attendant, however good, is hard enough for any one to endure ; and certain quite small faults or defects in a nurse may make her a serious impediment to the treatment, because no mere technical training will dispense in the nurse, any more than in the physician, with those finer natural qualifications which make tlieir training available."

"What is required,'' says Playfair,* in a similar strain, " is a woman of kindly disposition and pleasant manners, and of sufficient intelligence and education not only to fully appreciate and second the object of the medical attendant, and to report to him the peculiarities of each individual case, but also to form an agreeable companion to the patient during her long seclusion/'

A good nurse will always be loyal to the doctor ; and indeed, to be loyal to him is always the best service to the patient. "Loyalty to the doctor," says Miss Weeks,^ very forcibly, " includes encouragement of the patient's faith in him, so long as he is in charge of the case. The imagination is so largely active in disease that to infuse a doubt and distrust into the patient's mind is often to destroy all hope of doing him good. The nurse is a connecting link between doctor and patient, responsible to the one, and for the other, and can do much to promote good feeling between them." These words apply with particular force to nervous patients.

* " The Systematic Treatment of Nerve Prostration and Hysteria," by W. S. Playfair, M.D., F.R.C.P. » " A Text-Book of Nursing." Compiled by Clara L. Weeks.

Having detailed some of the qualities and qualifications of a good nurse, let me picture some of the types of faulty nurses, — at least so far as the care of nervous patients is concerned ; some of them faulty for any form of nursing. There is the nurse who talks too much. For some nervous patients, particularly for those who are just commencing a long course of treatment by rest and seclusion, too much talking on the part of the nurse is a serious drawback. With the constitutionally talkative nurse it is worse than useless to attempt to correct the habit. She will talk in season and out of season, and is usually unable to curb this propensity even in the presence of the physician ; indeed, she sometimes seems to exhibit it as one of her greatest acquirements. On the other hand, I occasionally meet with a nurse who does not talk enough ; or who never says anything when she does open her mouth ; that is, an individual constitutionally wanting in conversational powers. Either of these extremes is bad. It is well that a nurse for nervous patients should talk sensibly, intelligently, and with judgment.

An abomination of abominations is the habit which some nurses have of informing the doctor as to the exact nature of the patient's disease ; telling him that the case is one of hysteria ; whispering an opinion as to its treatment in a mysterious manner ; or boasting of some wonderful discovery with reference to the patient.

The too familiar nurse is also an abomination. Thr "iwn closely in contact for weeks, and it may be for months, it is natural that a patient isolated from family

THE NERVOUS AND THE INSANE yj

and friends should become attached to the nurse who is kind and sympathetic, and at the same time firm and just. Even some affection may at times grow between the patient and the nurse ; but it is the duty of the nurse, while neither morose nor distant, to preserve a quiet dignity and reserve of demeanor. The typical, natural, heaven-sent nurse will know just what to do in matters of this kind, but a few hints may be of value to some, who, although possessing many virtues, are not celestially endowed.

While it is of the utmost importance that all nurses should pay proper attention to personal appearance, the nurse who is vain and devotes too much of her time to self-adornment is especially obnoxious to nervous patients. She should not spend more time in preparing herself for exhibition than she does in attending to the interests of her patient.

The conceited nurse is a sore burden, but the nurse who is too humble is almost as bad. The nurse has her rights and a certain position to sustain. It is for her, like the soldier, to serve willingly and well, but not meanly and with mock humility.

The nurse who comes from a " good family^' is sometimes a very good nurse, but may nevertheless be a sore trial to patient and physician. On the whole, it is not a bad thing to have had respectable ancestors ; it is not to be placed to one's discredit if one's progenitors have been men and women of distinction ; but it is better that this fact should appear in good breeding and bearing rather than that it should be reiterated into the ears of all comers.

The Durse who assures you that she is nursing simply because she loves the business is particularly unfitted for the care of nervous patients. Such an assertion generally means that the one making it either only half believes in, or is half ashamed of, her vocation. While nursing should not be regarded from a mercenary point of view, while those engaged in it should love it for its own sake as well as for what it brings, it is a business, and, at least, the effort should not be made to impress the outside world that an individual who is receiving twenty dollars or more a week is actuated wholly by philanthropic motives. Such an effort will usually fail, particularly with those who settle the bills.

The nurse who quarrels with the servants is often a nuisance ; although I must say on her behalf, that in my experience the latter are most frequently the aggressors. In the rest treatment, and in some other lines of nursing, the nurse is required to look after some special matters of diet, sometimes at unseasonable times, or to otherwise disturb the normal equilibrium of housekeeping. Servants naturally dislike those who, while not in the same position as the family, are on a plane Higher than themselves. A nurse with tact and common sense who starts right in a family — except in special instances where an angel from heaven could not get along with the cook or chambermaid — will usually be able to at least so steer her course as not to come in actual violent collision with the servants ; but she who attempts to put on airs or to lord it over the denizens of the kitchen will usually be badly routed in the end.

-Before taking up special matters of nursing, let me say finally that I have noticed occasionally too great a disinclination on the part of the nurse who has been accustomed to a certain line of cases, to step out of that which she considers her particular sphere to take hold jf patients of any other type. I regard it as a high quality in a nurse to be willing to turn to any form of nursing in her general line in an emergency. Nurses are not to blame for wishing cases of a class to which they have been accustomed, or for which they have tried to especially prepare themselves ; but the practice of some of refusing, sometimes in an offensive way, to take anything unless they can get exactly what they wish, usually shows weakness of character, which will interfere with full success in their vocation.

Let me give here the views of a patient whom I asked, both because of her unusual intelligence and her experience with nurses as a patient, to give me her idea as to what should be said to a nurse just starting on her career. The physician has his point of view, the patient has his or hers, and by combining and comparing both the nurse will perhaps get a clear conception of what the world thinks and expects of her.

" As the nurse is about to start out on her own responsibility and merits, let her realize that she is now a business woman, and a part of a great profession, and she should never let herself drift from this realization. She should take the very highest view of her work and stick to it through everything. She will then not only do a high grade of work, but will avoid many difficulties of which she knows nothing when starting out. And the highest view of her work is this, that she is to help fight disease. When she goes to a case it should make no difference to her whether the patient is a man, woman, or child ; whether rich or poor, ignorant or educated. She should let no personal consideration, aside from doing good work, creep into her ambition. When she is at work her patient's welfare comes first, and her ultimate recovery is the goal towards which all the nurse's efforts should be directed. No false idea of what is suitable to her position should stand in her way to mar her singleness of purpose. Whatever is for the patient's good is suitable for the nurse to do.

" One of the best nurses I ever knew, and it is needless to say a successful one, worked with her patient for weeks on a farm at every variety of farm-work. She became quite skilled in handling a spade, and many a night went to bed with an aching back after hours of weeding, and she did it all in a manner that inspired interest and pleasure in the work. This nurse was a strict observer of all forms of professional etiquette, but had a broad enough view of her work to be willing to hoe a row of corn as well as to administer a dose of the more usual kinds of medicine.

" If her work becomes uninteresting or monotonous, the nurse may be sure that one of two things has taken place. Either she is tired and needs a rest and change, or she is not working intelligently. A German philosopher says that the world is a mirror, and if a donkey looks into it he cannot expect to see the face of a sage looking out of it; and this can always be applied to ourselves. One gets out of his work what he puts into it.

" It is important never to deviate from a strictly professional relationship towards a patient and the household into which the nurse may enter. She can be the cause of much inconvenience and discomfort in a family, and herself be most unhappy, if she has a mistaken view of her own position. She is there for a definite purpose, which should occupy her whole attention, and she should not be concerned with anything outside of this."

Within the last few years a new field has been opened up to the nurse : that of social service work. For this purpose the special training obtained by a few months' experience in a hospital for mental diseases is desirable. There are a number of obsessed persons, psychasthenic and neuropathic individuals who may be cared for at home. Under good hygiene in general and good mental hygiene in particular, such persons may be almost or quite self-supporting. In others who may be discharged from insane hospitals before completely recovered, but in whom further detention is undesirable, the " follow-up " plan is a most fruitful field for the nurse with this special training.

I shall now briefly consider the management of hysteria and epilepsy. These are two of the most important functional diseases of the nervous system, and their nursing and treatment call for the exercise of unusual skill and discrimination. First, before all, let me caution the nurse not to make the diagnosis of hysteria.

Even physicians of large experience sometimes find it difficult to make a correct diagnosis in alleged hysteria, and it is a source of either amusement or amazement to me to see the self-confident nurse glibly pronounce a patient that she has seen perhaps once or twice as hysterical, or as an hysterical fraud. On the whole, I would advise the nurse never to use the word hysteria at all. To be hysterical is certainly not a disgrace ; it is a condition into which the best of women, or, indeed, of men, may fall ; but the idea which hysteria conveys to the common mind is too often that of shamming or fraud. Nine patients out of ten will feel that they are insulted if, in the midst of nervous suffering, they are called hysterical.

It is a foolish thing in a nurse who has charge of a patient suffering with hysteria to give way to every whim and fancy of the patient ; and yet, on the other hand, she cannot by denunciation or harsh measures get rid of the inconvenience and care which such patients may give her. She should not do too much on her own responsibility in the way of severe treatment. The nurse may be called up three or four times during a night, or in some other way may be sorely tried, but all that she can do is to be watchful and careful, and if she finds that a patient is disposed to make things uncomfortable, by some mild but positive words or measures try to prevent her. She must not, as has been done in some cases, plunge the patient into a cold bath without directions from a physician. The one to use threats and severe measures, if these are resorted to at all, is the physician.

Jt may be a question sometimes whether a patient is suffering from a hysterical or from an epileptic fit, and this doubt is not always easy of solution, although usually the two affections can be separated. Hysterical seizures differ in character. Sometimes they are purposive or voluntary, — ^that is, they are completely under the control of the patient, by whom they are induced or feigned ; at other times they are as completely beyond the control of the will as are the convulsions of epilepsy. The simulated or foolish fits of hysteria can generally be recognized. The screaming, shouting, and violent movements of the patient, at the same time that, perhaps, she can be discovered closely watching others, will put the physician or nurse on guard.

Some of the involuntary hysterical attacks, the paroxysms of hystero-epilepsy so called, closely resemble true epilepsy. These attacks are in some respects grave, although they are not either as incurable or as temporarily dangerous to life as genuine epilepsy. In the purposive or simulated hysterical fits consciousness is never lost. In the hystero-epileptic, or grave hysterical attack, however, it is not strictly true to say that loss of consciousness does not take place. It does occur, but there is a difference between the loss of consciousness in epilepsy and that in hystero-epilepsy. The question of consciousness is one of grade and degrees. A patient may be more or less unconscious. In epilepsy the unconsciousness is complete, profound, and persistent. In hystero-epilepsy consciousness is lost completely during only a short phase of the attack. The hysterical or hystero-epileptic patient rarely bites the tongue, while this accident commonly happens in epilepsy. I have observ^ed in hystero-epileptic cases that whether the patient is or is not responsive to external impressions the countenance usually retains an unusual placidity. On one occasion, at the German Hospital in Philadelphia, I watched for more than two hours the frightful contortions of a typical hystero-epileptic ; and, although during this long period she got into almost every imaginable grotesque and extraordinary position, during all the time her countenance remained as placid as a summer morning.

A nurse, or even a physician, sometimes make« a mistake with reference to the diagnosis between an epileptic and an hystero-epileptic seizure through ignorance of the fact tliat sometimes the patient is the victim of both hysteria and epilepsy. A patient so afflicted is sometimes designated as a case of hystero-epilepsy, with separate crises. In the wards for diseases of the nervous system in the Philadelphia Hospital was a female patient who has had at long intervals well-marked epileptic seizures, accompanied by profound unconsciousness with biting of the tongue. In addition, however, at more frequent intervals she had had violent hysterical outbreaks. In such a case as that the nurse who is not well informed about such matters might readily make a mistake.

The nurse should have a clear idea of the characteristics of a genuine epileptic seizure. Usually such an attack comes on very suddenly, often preceded by a cry of pain or great fright. The patient falls suddenly with great force, sometimes in the most dangerous places.

Convulsions then begin. Usually they are at first what ib' termed tonic, — that is, the limbs and body become rigid and immovable in certain positions. Then the so-called clonic movements occur, — that is, the patient is violently twisted, contorted, and tossed about. Frequently these movements begin in one limb or part and extend raj)idly until all portions of the body are involved, and the convulsion becomes general. The face, at first pale, changes to red, gray, or purple, or becomes absolutely livid ; or alternates between pallor, flushing, or livid ity ; the p\4pils are dilated and fixed ; the eyes are frequently turned upwards ; the patient froths at the mouth, ejecting often a mixture of saliva and biood. The tongue is bitten generally early in the seizure. The breathing is irregular and sometimes stertorous. The attacks vary in length, always seeming longer than they are, usually not lasting more than a few minutes at most. As the convulsive movements cease the patient sometimes becomes semi-conscious, but continues much dazed, or more commonly falls into a profound stupor. Sometimes urine is passed unconsciously, or the bowels are involuntarily evacuated. The pulse shows great variations.

When satisfied that a patient is suffering from an epileptic attack, it is important not to be too meddlesome. More harm may be done by unnecessary interference than by comparative neglect. It is important, however, that a person in an epileptic fit should be watched. If the clothing is binding anywhere, it should be loosened. The patient should be placed so as to have as little injury as possible result from the violent movement.

It is better to have the head slightly elevated. If the room is close, fresh air should be allowed to enter it in abundance. It is not well to roughly seize and hold the patient, or to force open the clinched hands with great effort. It is not always best to make great efforts to open the mouth by means of a towel, or wedge, or bandage. The object of this would be to prevent the patient from biting the tongue, and as this commonly occurs early in the seizure, the mischief will usually have been done before the treatment can be applied. Here, as in so fnany other cases, no fixed rule applies ; but good sense iiud quick wit come into play.

An epileptic attack cannot be aborted by brute force. Sometimes epileptics have, preceding the paroxysm, what is termed an aura, — that is, a peculiar feeling in some part of the body. It may be the sensation of a vapor passing up a limb, or a feeling of crawling, or a sharp pain. When it is known that such a sensation is felt at the extremity of a limb at each recurrence of the seizure, if the nurse is at hand the attack may sometimes be stopped by seizing and tightly holding the limb above the point where the aura begins. If with a patient known to be an epileptic, the nurse should see to it that the patient is never in any unnecessary danger ; clothing should be worn a little loose, and the patient should be guarded from danger from fire or machinery.