THE CARE OF THE INSANE AT HOME.

BY JENNIE JENKINS, M. D., ASSISTANT PHYSICIAN AT EASTERN INDIANA HOSPITAL FOR INSANE, RICHMOND, IND.

This is a phase of the great question of caring for our insane, the importance of which seems to have been somewhat lost in the universal interest and endeavor for the perfection of the institutional care of those thus afflicted. But when we consider that either for a longer or shorter time almost every patient must be cared for at home, before admission to an institution is possible, and that much which may contribute to the future welfare of the patient depends upon this interval, then we see how it becomes of great interest, especially so to the general practitioner, for it is to his attention, almost invariably, that the case is first brought by anxious friends, relatives, or even by the patient himself.

And just here might be said a word in regard to the relation between family and physician in these days of the division of medical responsibility. In former days the family physician was a very important factor in the economy of each household. He looked after the physical interests of the family, from the most trivial ailment to the most serious, and his only specialty was the entire anatomy. Of course, in these later days, it is not expedient nor desirable that this state of affairs should obtain, but certainly the close relationship, the mutual confidence between family and physician is much to be desired. In bringing about this state of affairs much depends upon the physician himself. If he shows himself to be a capable and interested friend of the family in the minor matters pretaining to the family health, it is not probable that he will miss the greater opportunity occasioned by the graver afflictions liable to come upon them.

And in no other event is the tact, the patience, the wisdom of the physician taxed more severely than when the mental de

rangement of some member of the family is involved. Just here, where it is of prime importance that the earliest facts of the case be laid bare, and an early diagnosis be made possible, is when the physician often meets a disconcerting obstacle in the reluctance of the family to talk freely to him of the case. They usually act thus from the mistaken idea that such an affliction is a disgrace to themselves, or that loyalty to the patient demands a restriction of their statements regarding him. In these cases the physician who has the utter confidence of the family certainly works to an inestimable advantage.

The necessity for early diagnosis and consequent rational treatment is imperative. It is not absolutely essential that these cases be admitted to an institution, but experience teaches us, and statistics bear us out in the assertion, that more speedy and prompt recoveries are made, with the most comfort to the patient and the least anxiety to the family, if the patient is promptly placed under institutional care.

There is something in the routine and the daily round of hospital life which tends to control the patient, even when he little dreams that he is being controlled. Perhaps just here is the secret of the matter, that there is no direct controlling force to arouse his natural antagonism. The sight of dozens of others going to their meals quietly, retiring quietly, arising quietly, all at stated hours, and the evident but often unspoken expectation that he do likewise, all tend to create an influence which is hard for him to resist. Any patient who has sufficient mentality to observe and draw logical conclusions will soon feel and yield to this unspoken but ever-present influence. Even those more violently disturbed are in more or less degree affected by this system of repetition and example.

In a home, or even in a private institution, the controlling power must be exerted in a much more direct manner, and in most cases the more surely arouses the antagonism of the patient, the very thing that is most to be avoided.

In this connection the question may arise in the minds of some as to whether the personal interest in the individual patient can be what it should be under these circumstances.

There is no reason why it should not be. It is quite as much the duty of one having in charge the insane to learn their peculi arities, their particular temptations and inclinations, as it is to see that their rooms are properly kept.

The same method may have directly opposite effects upon different patients, according to their natural temperaments or their acquired ideas. These things a good nurse learns to see, and studies the proper thing to be said to each patient, to curtail some extravagant ideas, or to spur them on to greater effort in the right direction. A lack of this tact is considered a very grave fault in any attendant.

Such care as this is usually difficult to procure in a private family. Of course, if the patient has sufficient means to pay for the services of a trained nurse, the liability for good care is materially increased, but if, as in the vast majority of these cases, some member of the family or kind-hearted but inexperienced neighbor is the only dependence, then the difficulties are greatly multiplied. But even with the best of equipment possible, the care of an insane person at home is a grave responsibility, and one to be considered very seriously.

In speaking of the early diagnosis of these cases, it is not so important that an exact psychological diagnosis be made, as it is that the irresponsibility of the patient be recognized and that the subsequent management and treatment be considered with this in mind. There are certain duties owed all insane persons by their friends and caretakers which are too often lost sight of. It must be remembered that an insane mind is only one enfeebled and the normal functions of which are diverted by some pathological agent, and that when health is restored the person thus afflicted is apt to remember his delusions, his violent, absurd or obscene acts, and that this memory is often the cause of much mortification to him when he meets those who may have seen him at such times. So it becomes a duty to protect him from all unnecessary observation, to save him as far as is possible from all unpleasant results of such insane acts. It is a duty to the patient, no less than to the intended victim, to prevent as nearly as possible all acts of violence.

The exact psychosis of any given case can often be determined only after months of careful study by those experienced in this line of work. For our purpose in this paper, a very broad classification will answer the purpose: First, those violently disturbed, dangerous to themselves and to their attendants; and, second, those quietly delusional, tractable and amenable to reasonable authority.

The former class, including acute manias, some paranoias and the melancholias with suicidal intent, are pre-eminently cases for institution care, either public or private. But even these must often be cared for at home some days, at least, before removal to a more suitable place can be effected. Of these the acute manias constitute by far the most trying problem. What to do with them and how to control them are questions which confront the physician in charge, and are for individual solution in each case. Keeping in mind first, last and all the time the welfare of the patient, conditions must be met as they arise.

The first consideration is the preparation of a room, securing the safety and comfort of the patient. It matters not how crude this may be, so that it is effective. This preparation would include the securing of all exits against his possible escape and consequent exposure to the elements, or to unkind observation and remark, also to protect him against possible acts of violence toward those he might meet. If possible, without making it too apparent, the windows should be protected from his violence, thus preventing danger of injury to himself or others from the broken glass. All sharp instruments, such as knives, scissors, all glass, such as picture frames or fancy ornaments, all cords, and, in fact, anything that he could use for self-injury must be removed. In addition to these precautions must be added that of a constant attendant. One person must be responsible for the patient all the time, or for stated intervals, changing frequently as is necessary, but on no account must the patient be from under observation. And it is now that in the interests of humanity the patient must be protected from the curiosity of unnecessary observation. The neighbors are well-meaning, but, excepting the times that they can be

used as nurses, they must be kept away from the vicinity of the sick-room. Perfect quiet, pure air, sunshine, clean linen and a clean room are as necessary in this as in any other sickness. Good, nourishing food in normal quantities must be given, avoiding, for obvious reasons, all coarse, indigestible foods. The patient often refuses to eat, and in such case a degree of tact on the part of the one in charge may relieve the difficulty. But if all persuasion and reasonable force fail, then the physician himself must administer by means of the stomach tube, sufficient fluid, such as milk and eggs, or beef tea, to sustain life and energy. If the patient has persistently refused necessary medicines, this is a good time to give them, with the food.

The subject of medication is an important one. The first consideration is to obtain a healthy condition of the alimentary canal and keep it thus as nearly as is possible. This is to be accomplished by giving only light, easily digested food, by the administration of laxatives as is required, and by the use of intestinal antiseptics if desired. The condition of the urinary secretion is very important. In these cases of profound disturbance, complete retention is frequently found, making catheterization necessary. More often is found a marked diminution of secretion, amounting at times almost to suppression. In these cases, after determining definitely by examination of abdomen, or by catheterization, that there is no retention, an active diuretic should be. given and continued until normal secretion is established. The urine is usually found to be of high specific gravity, loaded with phosphates and often with mixed urates. Albumen is not usually found unless there is a pre-existing lesion producing it. The same is true of sugar, excepting in some cases of specific brain lesion.

The condition of the skin is important, and at times a hot bath, opening up the pores, and producing a profuse perspiration, will be the means of the patient procuring some hours of restful sleep. No phase of this altogether difficult problem is more difficult than that of giving the patient the necessary rest, which almost always means sleep, from the wear and tear of his exciting or painful delusions.