T HOME TREATMENT OF THE INSANE.* By WILLIAM MORRIS BUTLER, A.M., M.D., HE home treatment of the insane embraces all treatment outside of a regular institution, public or private, chartered for the treatment of the insane. The arguments for or against the home treatment thus far advanced have usually been largely discounted by the public from the ignorance of its advocates regarding the actual inside workings of institutions, and the prejudice of its detractors caused by their financial interest in the institutions which they have championed. Before entering upon the discussion of this question we desire to state that having been for nine years connected as physician with the New York State Homœopathic Hospital at Middletown, one of the best and most successful institutions for the insane in the world, and since then spent fifteen years as a specialist of mental and nervous diseases, in private practice, during which time we have had continually a greater or less number of insane under the home treatment, we can fairly claim to have a thorough knowledge of the subject in all its bearings. While daily engaged in testing the home treatment we hold at the same time the position of president of the board of stockholders and consulting physician to a private home for the insane, and therefore feel that we have a right to claim an honest judicial weight for the opinions advanced upon this subject. In our discussion we shall give first, a brief description of our plan. of treatment, showing the advantages and disadvantages which it offers, leaving to our hearers the decision as to its merits in comparison with ordinary institutional treatment. During the past fifteen years we have had, under our care, every form of mental aberrations, and thus far have met with no case that could not be subjected to this form of treatment. The following hints will briefly outline the plan of treatment thus far successfully pursued: If the environment is favorable to recovery the afflicted one is allowed to remain in his own family. This is not, however, always practicable, as the temperament of other members of the family may cause an exacerbation of the ailment in the patient himself, or render * Presented to the American Institute of Homœopathy at the meeting in Omaha, June, 1898. them liable to a similar attack, if constantly subjected to his influence. Also, as in other diseases, a change of scene and association not infrequently breaks up a painful train of thought, thereby unconsciously giving the patient a start in the right direction. In the latter case, we secure suitable accommodations for the patient in a private family, in which are not wanting education, Christian refinement, tact and plain, common sense. Next is secured an efficient and reliable nurse or two, if the case requires it (not members of the family). The room selected for the sufferer must be large, well ventilated, accessible to the morning sun, and as far as possible removed from household noise. The windows should be guarded (if necessary), and the doors securely fastened. All sharp instruments, such as razors, knives, scissors, etc., should, of course, be removed. Constant watchfulness is required that the patient secures no cord, bandage, or article of clothing by which strangulation might be accomplished, and that all dangerous drugs, or poisonous substances, common for household purposes, like carbolic or oxalic acids, etc., be kept under lock and key. Kindness, faithfulness, watchfulness, sympathy and tact are indispensable in every case. Beyond these mere generalities, the details of treatment must necessarily vary according to the nature of the individual case, his temperament, and liability to injure himself or others. In acute cases, like acute mania, acute delirious mania, or puerperal mania, in fact, in any case where the physical powers are much exhausted, the patient must be kept continually in bed, in a recumbent position; by mechanical means if necessary. During this time a liberal amount of nourishment is given in the form of milk and beef tea or some of the beef extracts, cereals and fruits. In this manner sleep is most easily induced, and the waning strength is conserved until the crisis is passed. The high temperature, rapid pulse, restlessness and maniacal fury may give the patient a semblance of strength. The appearance, however, is deceptive, and unless the greatest care is observed this waste of nervous force will result in death by nervous exhaustion, or what is far worse, complete dementia. During the continuance of rest treatment, care must be unceasing that patient and bedding are kept scrupulously clean, the patient being given a bath of alcohol and water night and morning, or at least once a day. Frequent vigorous rubbing of the entire surface. of the body and general massage will also prove useful adjuvants in keeping up an equable circulation and exercising the muscular system. Great care must also be taken in the ventilation and disinfection of the room. During the convalescence of acute, and in all chronic cases in which the physical strength will permit every suitable outside aid should be adopted to direct the sufferer's mind from its morbid channels of thought. Agreeable companions, pleasant surroundings, regular exercise in the open air, and any quiet amusement or occupation which will divert, without taxing the mind, should be provided. In the medical treatment the most careful study and examination of all the physical symptoms should be made. All causes of reflex irritation, whether existing in the uterus, rectum, prepuce or clitoris, should be removed. Then the most zealous care must be exercised in the selection of remedies. The patient must be regarded simply as a sick man or woman, demanding in conjunction with the closest attention and highest skill of his medical adviser, the best and most vigilant nursing. Having thus briefly and cursorily outlined this form of treatment, let us proceed to consider a few of its advantages. First-The public commitment of the patient as a lunatic is avoided. This commitment, according to the law of New York State, is exceedingly cumbersome, requiring an examination by two qualified registered examiners in lunacy, a petition to the judge by some near relative or qualified authority, a personal service upon the patient, the signature of the judge, and a recording of the commitment. Or this private commitment, at the option of the judge may be made public, and the alleged lunatic be summoned before a jury and all the facts of his sickness be brought into the light before the judge affixes his signature to the commitment which declares to the unfortunate invalid, "Thou art no longer a free man, but a lunatic, deprived by law during the term of thy illness of all thy rights of citizenship." The stigma which this temporary act of legal disfranchisement and a subsequent confinement as a prisoner in an asylum places upon a man will rest upon him for the remainder of his life. Let him recover ever so fully, his actions never cease to be severely scrutinized and regarded with distrust. When treated as a private patient this initial act of violence is avoided. No one need know the nature of the malady; all unkind curiosity and publicity is avoided, and no more injury is inflicted upon the future of a patient than had his illness been an attack of delirium in typhoid fever. He remains a citizen. No jury deprives him of property and ac countability, when attacked, or restores the same to him when cured; when he resumes his place in the world no evil genii in the form of public distrust is looking askance at him, and whispering to his neighbors, "Look out for him, he has been in a madhouse!" Under the home treatment for the insane, furthermore, the patient receives individual care, and is freed from any possibility of abuse. With but one patient to attend, and continually exposed to the oversight of the family, the friends, and the physician, the nurse has no opportunity, if so inclined, to give the patient other than the kindest care, the most devoted nursing. The food can also be prepared individually (a natural impossibility in a large institution), and being more temptingly served, is more in accord with the needs of a sick person. In the severest forms of insanity, acute delirious mania, puerperal mania and melancholia with stupor, where the physical powers are tried ot the utmost and the fever runs to almost incredible heights, the chance of recovery is greatly enhanced by avoiding the necessity of removal from home and a railway journey which must still further weaken the patient and help to exhaust what little strength he may have. No physician would advise a long railway journey for a severe case of typhoid in the worse stage of the disease, yet the temperature and pulse of a patient with acute delirious mania or melancholia with stupor is usually much higher than that of any typhoid case. It is no wonder that the records of our hospitals for the insane show such enormous death rates in these cases. When the cases arrive at the hospital their vital powers are completely exhausted, and they are beyond the skill of any physician. Let these cases be properly treated at home, and much of this danger is avoided, and their prospects of recovery greatly enhanced. These are the cases which usually die or are entirely restored to reason, hence their proper treatment is of the highest importance. Another advantage is the lessening of anxiety to relatives and friends. There is no vantage ground for the imagination. The family know all. With the patient in his own home where the friends are cognizant of every means employed for restoration, as well as of changes occurring in the course of the disease, that indescribable burden of doubt and suspicion is lifted. Another advantage in home treatment is the freedom from the bad effects of association with insane companions. Imagine the sensations of a delicately reared young girl, accustomed to the refinement and culture of a Christian home, listening to the strings of oaths and revolting obscenities, constantly poured forth by many of the insane. Can you believe that the society of companions filled with every form of mental delusion, conducive to a speedy return to the reasonable modes of thought and action? The effect of the insane upon one another is recognized by every experienced asylum nurse, who justly dreads the entrance of a patient who has been the rounds of many institutions. He is sure to bring with him the tricks and cunning which he has seen tried in each. Another advantage is the lessening of danger of a relapse into melancholia when the patient is issuing from a state of excitement, and first realizes his condition and surroundings. Often have we sorrowfully watched patients who, from a high degree of excitement, existing at the time of admission to the asylum, realized nothing of their situation, when recovered sufficiently to be conscious of their surroundings, drop into the profoundest melancholia from which nothing seemed able to rouse them. In a private house, restoration from insanity is like the convalescence of any other illness. In a private family also exists for the patient every form of diversion open to any one. Graduated to his stage of convalescence, lectures, concerts, operas, theatres can all be utilized as useful aids in the process of cure. Hospitals for the insane, like other general hospitals, have a noble and legitimate work to perform for the poor and unfortunate, and, in order that their usefulness be not curtailed from lack of sufficient means, it is eminently fitting that they receive ample recognition and support from the State. For these, however, who by business thrift and ability or by the rights of inheritance, have acquired a liberal amount of this world's goods, the home treatment offers a surer and more humane method of cure for the disordered mind, and one that leaves no black trail behind. |