First Aid for theInsane.

By Jos. G. Rogers, M. D., Ph. D.Medical Superintendent Northern Indiana

Hospital for Insane,

Read, on invitation, before the MARIONCounty Medical Society at the CentralHospital for Insane, Indianapolis, April 10,

1898.

PRESS OFWM, B. BURFORD,

INDIANAPOLIS.

First Aid for the Insane.*

By Jos. G. Rogers, Ph. D., M. d.Medical Superintendent Northern Indiana Hospital for Insane.

EXPERIENCE has established the rule thatall cases of marked insanity should be, aspromptly as possible, placed in an insti-

tution devoted to the care of such cases. This isespecially true in regard to those evincing decidedmaniacal symptoms, in which a few days only oflack of sleep, rest and food, together with thewear and tear of incessant frenzy, are needed toreach a termination in fatal exhaustion. Usually,however, the horrifying manifestations and greatdifficulties of care in instances of this type force,promptly enough, efforts towards commitment toa hospital, where, ordinarily, methods are avail-able which successfully meet these elements of

* Read, on invitation, before the Marion County Medical Society at theCentral Hospital for Insane, Indianapolis, April 10, 1898.

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primary danger. It is very true, also, in thevarious types marked by general depression,mental and physical, for in these, hospital careaffords better safeguards against the usually pres-ent tendency to suicide than can be possibly se-cured by domestic control of any sort, and, be-sides, as a rule, a more conservative and saferattention to the somatic conditions which usuallyunderlie the psychic state. Indeed, in a greateror less degree, it is true in all cases, of all types,that early hospital care is desirable and for thebest interests of the patients as such. Neverthe-less, unfortunately, it is equally true that in themajority of instances there are circumstances andinfluences which conspire effectively to prevent aspeedy commitment; often months elapse beforeconditions force this action, and, not infrequently,before this occurs death comes to close the argu-ment and the case history at the same time.

Sometimes it happens that the patient can notbe moved because of conditions due to disease ortraumatic injury; sometimes aversion to thefancied stigma of a public announcement of di-agnosis, or a fear and uncertainty as to institution

3

methods, begotten of ignorance and “red journal-ism,” or sentimental adhesiveness, or failure toagree among themselves, prevent judicious actionon the part of kindred or next friends, and, un-happily, it often occurs nowadays and in our ownState that the patient can not be admitted to ahospital on account of lack of room.

In either event he remains at home, for a timeat least, and it becomes the duty of the homephysician to supervise the care of the case, aduty not usually sought for with enthusiasm formany reasons, but particularly because of diffi-culties, soon discovered, growing out of thegeneral unfitness of things—especially lack ofskilled nursing, lack of proper surroundings andmeans, and no lack at all of excited volunteer ad-visers and critics. The more serious the casethe greater become the difficulties, but they existin every instance, and the medical adviser isusually the first to advise, and even insist, onremoval to an institution.

It is the object of this paper to discuss the homecare of the insane; if it may fortunately be the

4means of aiding any medical brother in the per-formance of this trying duty, the writer will feelhimself fully repaid for his labor.

Early diagnosis is of the highest importance;not detailed differential diagnosis, but simply earlydetection of mental unsoundness. Has one tominister to a mind diseased with a train of decep-tive manifestations obscuring the truth, or withactual, tangible morbid conditions of the body, orwith real, extraneous relations, on the part ofthe patient, to other people and things? That isthe first question. Insanity is a condition, due todisease, in which the faculty of judgment ceasesto be guided by the experience of the individualin appreciating or accepting, or directing, or con-trolling, or applying the operations of the othermental faculties in part or whole. In every casethe individual should be fully studied in order todetermine what his mental action would be nor-mally under given conditions, in other words, hisnormal mental experience. Failure to apply ex-perience deliberately or automatically as a guideto action is a departure from the norm and indi-cates morbid mental conditions or insanity. I

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know of no better guide in diagnosis than this rule,and, in a long association with the insane, havefound it to be universally applicable. It mattersnot whether the person be congenitally defectiveor of the highest type of development. Insanitymay be superadded to idiocy and so may it disturbthe most highly wrought mind. In either case anabdication of normal experience from the control ofmental function, in whole or part, is the pathog-nomonic sign. Lack of apparent reasonable mo-tive for acts or thought expressions is evidence,prima faciae, of mental disease, and this rule sug-gests, in my judgment, the best primary test; butit is important that what would be reasonable tothe individual in his normal state shall be used asthe standard in any given case.

The influence which unsoundness of bodyalways exerts on soundness of mind must alwaysbe considered and used as a side light on the mainquestion. Undulations of mental tone, due di-rectly to somatic depression or excitement, mustnot be taken for insanity. A broad application offoregoing principles will be a safeguard againstany such erroneous conclusion. But, on the other

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hand, there are many morbid conditions of thebody which do exert a most decided influence incausing true psychoses.

It being determined that mental disease doesexist, differential diagnosis is then to be attainedas soon as practicable, for on this largely dependsprognosis of the course and final termination ofthe malady—so important to be known in suchcases on account of business, family and otherrelations. In most instances the diagnosis bringswith it uncertainty as to duration, course andending, but usually an approximate scheme ofevents may be made; in some it is a death war-rant, as in general paresis and progressive chorea—postponed, but sure. Hence the importance.

Adopting the symptomatic classification nowgenerally favored and in use in institutions inAmerica, insane conditions may be properly ar-ranged under three chief divisions—Mania, Melan-cholia and Dementia. An individual case may,in its course, present at different times all theseconditions, in varying degrees of intensity andvarying sequence.

7The essential feature of mania is a series of

delusions or false beliefs, disassociated, unsys-temized, often ephemeral, expressed by words oracts or concealed, but accompanied always bymore or less excitement of mind and body, oftenboth noisy and violent; sometimes, however,silent, quiet and only shown by occasional actsand facial expressions, both requiring close ob-servation to appreciate.

The chief character of melancholia is depressionof mind and body.

Dementia is marked by mental dullness andapathy.

The more elaborate subdivision of the variousinsanities is based upon the combination, se-quence, course, intensity and character of mani-festation of the above named chief types andupon the somatic complications co-existent.

Various systems of classification have beenurged upon the above basis. The following hasbeen found to be fairly satisfactory and is generallyused in the American hospitals for the insane. Ithas the advantage of simplicity and is welladapted for the use of the general practitioner.

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CLASSIFICATION OF INSANITIES.

Mania, Acute.Chronic.Epileptic.

Monomania.Paranoia.General Paresis.

Melancholia, Simple.Delusional.Agitated.Stuporous.

Dementia, Primary.Secondary.Paralytic.Senile.

Special characteristics warrant, to some extent,further differentiation, but the above is sufficientfor this discussion of the subject. As examples,however, it may be proper to note, Katatonia,Chronic Progressive Chorea, Puerperal, Recur-rent and Traumatic or Surgical Mania, CircularConfusional and Pubescent Insanity, Hystero-mania, etc. The many various phobias andmanias with long Greek and Latin names con-stitute a refinement of classification of use only tothe hair-splitting nosologist.

Acute Mania sometimes comes like a clap ofthunder in a clear sky, wild and noisy frenzybeing developed within a fraction of an hour,

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without premonition, but usually certain pro-dromata can be noticed. Among the most im-portant is insomnia. There is no better mentalbarometer than sleep ; when it is out of sightlook out for a storm. When it is persistentlyscant and fitful, in the absence of pain, a carefulexamination of every organ, every function andevery habit should be made, environment shouldbe studied, correction of evil conditions should besecured, as far as possible, by careful, conserva-tive methods and the case watched closely. Theuse of hypnotics should not be postponed too long.In my opinion, nothing is better than chloralhydrate, in doses of 15 grains, in water 2 ounces,every fifteen or twenty minutes, for two or threetimes, the patient being recumbent and preparedfor sleep. Often the first dose suffices. Whenthere is decided debility, or a weak heart, analcoholic stimulant should be given with thechloral as a safeguard, though in thousands ofadministrations without this I have remarked nodecided depression as a result. Liebreich, itsintroducer, insists, however, that only the recrys-tallized, free of free chlorine, be used, and I

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have followed his advice. With removal of irri-tating conditions, external and internal, quietude,rest, good food and sleep enough, even if forcedby chloral hydrate or its equivalent, the dangermay be bridged and health restored withoutfurther developments.

Should frenzy supervene or appear as the pri-mary symptom, with incessant muscular activityand tendency to violence, some restraint will berequired: Roll the patient up tightly in one ormore sheets wrung from lukewarm water, thebody being stripped of other clothing, or nearlyso, the legs together and the arms close to thesides, like a mummy. Place him so on a narrowbed, and prevent rolling by a strong sheetstretched from rail to rail and fastened there.This done, still the delirium by a hypnotic, chloralhydrate by the mouth, as above, or by rectum in30 grains dose, if possible; if not, give hyoscinhydrobromate from 1-50 to 1-20 grain hypoder-mically. The salient conditions are usually over-come for a few hours by these means and thepatient sleeps. Constipation often exists, withaccompanying intestinal toxis, and this demands

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a clearance as soon as practicable, with preferablyan active saline, if it can be given, otherwise bya dose of calomel, X gr., slipped into the mouthnext the cheek or on the tongue, and large rectalirrigations, repeated every half hour till effective.Tendency to exhaustion must be additionally fore-fended by regular and sufficient food of a concen-trated sort, sterilized by cooking preferably.While in the pack it may be liquid or semi-liquid,and is then best given with a feeding cup pro-vided with a spout.

In the lulls of excitement, if such occur, re-straint should be removed and a liberal meal maybe taken in the usual way; and at such timesexercise, with a proper attendant, in a quietplace, will be advantageous. If practicable, twoor three drams of one of the alkaline bromidesmay be given daily, largely diluted, in divideddoses, for a week or more, especially if the frenzycontinues to be pronounced. Opium in any formis not indicated excepting there be physical paindue to disease or injury. Where possible, a dailywarm bath will help to soothe and may be im-peratively required to secure cleanness of body,

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evacuations often being unannounced and disre-garded by the patient. The hypnotic may berepeated nightly if required, but only to secure afew hours of sleep and the vital recuperation thatcomes with it, even when forced. It is better toomit this in the day time, for it can not throttlethe disease, nor even effect it otherwise than indi-rectly by affording temporary rest. In dosageshort of causing sleep promptly it is only a detri-mental disturber. The bowels and bladder shouldbe evacuated sufficiently and regularly, palpa-tion over the abdomen being used at each visit toprove it. If there has been protracted constipa-tion at the onset, io grains of salol may be givendaily, after free purgation, for two or three days,as an anti-toxic, if the patient will take it properly.It is best given mixed with granulated sugar dryon the tongue and washed down by a draught ofwater.

Use restraint only when absolutely required,but if used it should be efficient. If the wet pack,before referred to, seems undesirable for anyreason, it may be applied dry if the weather be

not too warm. If the patient be not in bed, mit-tens of leather or cotton duck firmly attached to abelt, buckled at the back, may be used. In anemergency, restraints may be made of sheets,roller tow'els and the like. A good rope, in con-junction with towel bandages, over hands andwherever needed, is a sure thing, but is lacking inelegance.

In the milder types of Mania, in which thereare insomnia and changing delusions, but withexcitement short of frenzy, the same therapeuticprinciples are applicable, but the means may beand should be modified somewhat. Personal careand control, day and night, is enough withoutmechanical restraint, and hypnotics and the bro-mides are needed only occasionally. The func-tions must be carefully regulated, toxic influenceseliminated and nutrition especially fostered.

In all types cases must be considered individ-ually and the conditions met according to theneeds, but, as a rule, mend the body, clear it ofpoisons, rest it and feed it, and the brain willgradually resume normal function. In hospitals,recovery occurs in more than 50 per cent, of

14cases of uncomplicated cases of Acute Mania; inhomes and jails, not so many, but still, in the lat-ter, often without anything whatever which couldbe called treatment.

The duration is usually from three to sixmonths, recovery, however, being sometimespostponed to the eighteenth month. In fatalcases, death usually occurs early, in from one tofour weeks, from exhaustion. Intercurrent dis-ease is rare. In my experience, indefinite chroni-city ensues in 20 per cent, of cases withoutdementia, and, with partial dementia, in about 10

per cent.As to danger of recurrence, it can only be said

that like causes produce like effects, but the state-ment is fully warranted that, in the majority ofinstances, after well established recovery, recur-rence is not noted in the registers of the Statehospitals. In short, the prognosis in Acute Maniais, without doubt, generally favorable. In themore complex insanities, in which mania occursonly from time to time as a temporary symptom,as in General Paresis, Epilepsy, etc., the plan of

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treatment above set forth may properly be ap-plied with required modifications to suit con-ditions.

Paranoia. Now and then the general prac-titioner must be the judge of the mental state incases in which extraordinary acts and expres-sions, carefully considered, in the light of circum-stances, lead up to the conclusion that they arebased on a single delusion or group of paralleldelusions, usually involving persecution, harm orinjustice in some or many forms, to the individ-ual in question. For nearly a century, followingthe suggestion of Esquirol, this mental conditionwas named Monomania, a very good Latin wordwhich meant what it said; nowadays it is Para-noia, by convention or fashion—a Greek wordconveying the idea of being out of one’s head.The propriety of the new name appears doubtful.

Early diagnosis of this type is of the highestimportance to the community. Unfortunately itoften happens that it is first made in a criminalcourt after some outrageous and motiveless crimehas been perpetrated, and then it is not oftenbelieved. Lack of reasonable motive is the best

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criterion in such cases. The Paranoiac is usuallyintelligent, quiet, well ordered and rational, ex-cepting in relation to his delusions, but thesecolor more or less every thought and deed.Vanity, suspicion and sensitiveness are prominentcharacteristics. He has unlimited faith in himselfand always thinks he is right, but he is usually avery unsafe citizen. Guiteau was a type.

As to treatment, he is inherently defective andusually incurable and requires only custodial safe-guarding, and should have this as soon and aslong as possible. It does occasionally occur, how-ever, that the manifest symptoms disappear underproper care of a regular, quieting sort, and thenthe doom of lasting crankhood may be lifted andthe citizen rehabilitated.

Melancholia. The simple, delusional, agitatedand stuporous forms of Melancholia are all super-structures built on a first laid foundation of de-pression, combining both physical and mentalmanifestations, readily recognized, as a whole, bythe medical adviser. As a rule, such cases areand may be properly kept at home (if it be a goodone and a fit one), for a time at least; but the

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danger growing out of the suicidal tendency,which is often concealed, must be kept in mindand guarded against constantly. Intelligent andjudicious association and supervision is a mostimportant factor of treatment in all cases of thisclass, and where not available commitment tohospital is proper without delay.

Functional and organic defects, and errors indaily life and habits, including those of the mindas well as body, should be carefully sought forand corrected as far as possible. There is alwayslack of tone, and tonics will be required in variety,with special reference to nutrition. The foodshould be of the best, regularly and sufficientlytaken, by urging or by force if necessary. Tothis end, the nasal feeding tube is all that can bedesired—simple, safe and easy to use, even underviolent opposition. In the absence of the specialtube furnished for this purpose by the instrumentmakers, an ordinary soft catheter (No. 12) maybe attached to the rectal tube of a good soft rub-ber syringe and you will have all that is needed.The patient lies on a couch with the head bent

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toward the sternum, so as to curve the pharynx,and the lubricated tube is passed directly backalong the floor of the nose until, with gentle, pro-gressive pressure, it takes the curve and entersthe esophagus several inches and is held there bythe left hand ; then, from a neighboring pitcher,held by an attendant, the right hand deliberatelypumps out into the stomach a mixture of two orthree eggs and a pint or more of milk, well beatenand previously warmed or Pasteurized at 165° F.Restraint may be required, but this is rarely so.The operation should be repeated twice daily,always by the physician. If there are signs ofsuffocation or strangling, on introduction, the tubehas gone wrong; withdraw it and try again, beingcareful to keep the nose in the median line.Very little practice makes one expert, if he knowsthe anatomy of the throat.

In Melancholia, the faculty of attention is alwaysat fault; words pass in one ear and out the other;the mind’s eye sees only the pictures which theimagination bodies forth, and pays little heed to•external perceptions; the needs of the body areunfelt or disregarded more or less; sensation,

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even to pain, is blunted, and, in some cases, inwhich catalepsy occurs, the concentration of at-tention is so intense that there seems to be com-plete inhibition of all mental, motor and sensoryfunction and the patient is said by the layman tobe in a trance, during which life is so modified asto be but little removed from mere vegetation.Sometimes this state may continue for years.

In many cases of Melancholia much can oftenbe accomplished by “talk”—large and vigorousdoses of logic regularly repeated. The physicianmay well spend time in a series of judicious drillsin mental gymnastics, in which attention shall befirst developed; this done so that the ear of thepatient is opened, the logic may be poured intothe brain, and some of it will take root sooner orlater and grow to a healthful plant, unless theground be already too barren from the changesincidental to established dementia. Persistencewill often be rewarded most remarkably after atime, and mind and body, hand in hand, willjoin in the return to vigorous health.

Prognosis is favorable in 50 per cent, of cases ;

the duration in recovered cases is from six months

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to three or four years. Change for the bettercomes slowly at first. Permanent dementia mayensue and death may occur from intercurrentdisease, often acute and inflammatory ; not rarelymalignant, for the melancholiac offers defectiveresistance to morbific influences.

General Paresis. An elaborate practical knowl-edge of General Paresis is not to be expected ofthe general practitioner for the reason that herarely has an opportunity to study its clinical his-tory excepting in its primary stages. When fullydeveloped, conditions are such as to force com-mittal of the patient to an institution in almostevery case, usually under a diagnosis of Mania,Melancholia, or what not, according to the promi-nent symptoms, and his physician sees him nomore. But in view of its insidious approach, thesly mutations of character and conduct in its vic-tims, and its fell nature when developed, everyphysician should certainly have at least an ac-quaintance with the outlines of this fatal diseaseand particularly with its primary symptoms, forin no mental malady is early diagnosis of greaterimportance, not only to the patient and his family,

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but to the community in which he lives. Whena Mr. Hyde, who has reached middle life with areputation for sobriety, morality, caution, judg-ment, integrity, civil rectitude and general con-servatism, is quietly converted into a Dr. Jekyl,who takes to wine and women, or reckless specu-lation, or extravagance in spending or giving, orinordinate boasting, or swindling, or general dis-regard of social and civil rules, in aversion fromformer tendencies, it may be that disease is atthe bottom of it all, and then it is to the physicianthat falls the duty to be the first to suspect thisand to lead the investigation which will developthe truth, for the protection of the community aswell as of the irresponsible culprit.

General Paresis is a disease of middle life,much more frequently affecting men than women,involving both mind and body and leading invari-ably, as far as observed and recorded, to a fataltermination in from two to five years. Thesalient motor symptoms are those of ataxia—inco-ordination of muscular movement, absence of re-flexes, notably the patellar and pupillary. Thetongue, when protruded, is tremulous, speech is

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quavering, the gait is uncertain, penmanship isdeteriorated and shaky, the pupil is often smalland irresponsive to changes of light, and degluti-tion is defective, sometimes to the extent ofchoking. At long intervals usually, convulsionsmay occur, sometimes followed by apoplexy of afatal sort, and temporary paralyses are not un-common.

The sensory symptoms are also those of ataxiaand are varied according to the location and de-gree of irritation or degeneration in the spinalcord. Localized anasthesia or hyperesthesia maybe manifest and should be sought for. Fre-quently lightning-like pains pervade the thoraxand cause momentary outcries from the patient,who is unable to explain, and hence they aretaken for signs of temporary rage by uninformedattendants. Trophic changes, especially in theskin, are very apt to occur. Bed sores, deep andextensive, are often rapidly developed, after a fewdays in bed for any cause, in the terminal courseof the disease.

The mental symptoms are varied, and not char-acteristic when considered alone. There may be

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Mania, Melancholia or Dementia in varied se-quence and degree, according to the stages of thedisease. A radical subversion of mental andmoral tendencies or an unsymmetrical exaggera-tion of some of these, accompanied by greater orless exaltation, is usually the first mental signgiven. Sooner or later, grandiose delusions arevery commonly prominent. The patient isstronger, better, happier and richer than any-body, and insists on sharing his wealth and hap-piness with everybody. Fortunately this fanciedwell-being lasts to the fatal end. Whatever thenature of the delusions, they are usually of ahappy sort; not always, however, sometimesthey are distressing enough, but even then thepatient generally sees a silver lining in his darkcloud; absolute melancholy is rare, and I knowof no instance of a paretic suicide. Dementiacomes in the latter stage as a result of progres-sive organic lesion. Aphasia and agraphia arenot uncommon long before dementia is declared.Spoken language may be reduced to a few words,repeated to convey every idea, and, in writing,

24words are incessantly repeated or omitted to suchextent as to destroy sense.

In no case, at any one time, are all these symp-toms conjoined. Sometimes the motor conditionsare most prominent or precede the mental degen-eration, and, 'vice versa, the latter may exist ormay have progressed to a marked extent beforethere are any pronounced signs of musculartrouble. This relation depends upon the relativeprogress of the lesions of the cord and those ofthe cerebrum. Certain symptoms may be en-tirely absent during the whole course of a givencase, but all cases bear a resemblance to thestandard described. As an aid to diagnosis, it isimportant that the medical adviser bear in mindthe following suggestion : Where ataxia, howeverslight, or however manifested, exists together withmarked change of character or conduct, suspectParesis. Where marked and motiveless changesof character and conduct arise, which are inex-plicable by any apparent conditions of disease orinjury, especially if attended by grand and fanci-ful ideas, await ataxia and expect Paresis.

25The prognosis is always unfavorable, though

remarkable periods of arrest have been observed.In my own clientele are two cases who have beenactively engaged in business away from the hos-pital for three years and whose friends deem themwell; I expect them to return, however.

This disease can not be said to constitute anypart of the history of syphilis, yet it is neverthe-less true that in nine out of ten cases a story ofluetic infection, ten or twenty years before, maybe obtained, and there can be no question thatsuch infection, whether well treated or neg-lected, establishes a predisposition to Paresis.Vocation, too, seems to have its influence in thisdirection. I have observed for years the prepon-derance of railway engineers, conductors andmail agents among its victims.

Cure there is none, but the way may bemade smoother by obvious symptomatic treat-ment according to principles before referred to.

Dementia, or pathological mental dullness, isusually secondary or terminal insanity, followingthe more acute states, but occasionally a case ap-pears in which the normal mind is rapidly covered

(3)

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with a fog, not due to melancholy or any otherassignable depressing condition; to such has beengiven the name of Acute or Primary Dementia.The prognosis is uncertain. In this, as well as inall other types of this class, the treatment issymptomatic.

Pathology. I have made little else than apassing reference to pathological conditions be-cause more is uncalled for here and because,though neurology is rich in its findings in thisdirection, the ultimate secret of how men think,whether sane or insane, is still hidden from allmen, and none of the many lesions found can bedefinitely assigned to any mental state beyondquestion, and the wise seeker after truth mustremain still an agnostic.

LONGCLIFF, near Logansport,April io, 1898.