362.6 N17n UNIVERSITY OR ILLINOIS LIBRARY AT URBANA-CHAMPAIGN BOOKSTAC.KS Digitized by the Internet Archive in 2015 https://archive.org/details/neglectofagedOOnasc THE NEGLECT OF THE AGED. I. L. NASCHER, M.D., NEW YORK. REPRINTED FROM THE MEDICAL RECORD September' 12, 1914 WILLIAM WOOD & COMPANY NEW YORK. / THE NEGLECT OF THE AGED. By I. Li. NASCHER, M.D., NEW YORK. It needed the pen of a Dickens to rouse the public conscience to the neglect of the dependent child. In Oliver Twist, the child of the workhouse, he planted the germ of discontent with existing conditions, and this germ grew and multiplied and spread until the child today has the world for its guardian. Could some kind Dickens of our time with equally persuasive and forceful pen study and expose the conditions in our almshouses and asylums for the aged he might with equal success rouse the public conscience to the neglect of the aged. And as inter- est in the dependent child led to the scientific study of child welfare, so might an interest in the depend- ent aged lead to the scientific study of senility, of the needs and wants, the peculiarities and infirm- ities, the happiness and welfare of the aged. (There is not, so far as I know, any organization taking up the scientific study of the aged, not a journal de- voted to their welfare, no movement of any kind interested in their betterment. International con- gresses are held to discuss child conservation, while the aged receive but the scantiest attention. The aged in institutions are dealt with as they have been Copyright, William Wood & Company. dealt with for generations, though here and there some official who possessed the initiative and deter- mination, coupled with sympathy and common sense, has introduced innovations that tended to make his aged charges healthier and happier. The medical care of the aged has received but little consideration ; indeed, it is only a few months ago that the first modern American work on this subject appeared.* It is hardly necessary to discuss the causes for this neglect. I have referred to this matter repeat- edly. There are few so altruistic that they can com- pletely eliminate thoughts of economic value from their humanitarian spirit. In a former paper on this subject I said: "In this utilitarian age we gage the desirability of men and things by their practical value," and this applies as well in the work of phil- anthropy as in other fields of human endeavor. It applies with special force to the medical profession who have heretofore neglected the aged, using the term "old age" as a handy excuse for a diagnosis and a cloak for ignorance. \ We are only beginning to realize that old age is not a disease any more than childhood is a disease — that it is a period of life in which certain diseases prevail, while other diseases prevalent in earlier life do not occur; that the aged present many interesting medical prob- lems; that they require special study and special care. But the altruism of the physician is tinged with the spirit of commercialism, and it is influenced, consciously or subconsciously by the factor of eco- nomic value. The child has a prospective economic *Nascher: Geriatrics. The Diseases of Old Age and • Their Treatment. Philadelphia, 1914. P. Blakiston's. Son & Co. 2 value, the patient in the hospital may if he recovers have an economic value ; the aged are nearly, if not quite, economically worthless. In many cases the sense of uselessness is imposed upon the aged by those who do not know the mental and physical capacity of the aged individual. In a mistaken spirit of kindness the aged person is with- drawn from his accustomed routine of life and is made to feel that his usefulness to mankind is les- sened, and if he is at all sensitive he realizes that he is no longer a producer, but a consumer, and a bur- den. Not only in this, but in many other directions does the ignorance of senile mentality and the senile organism tend to the detriment of the aged, making them more unhappy, increasing their infirmities and shortening their lives. I have visited a number of institutions for the aged and found in every one, even in the best and most elaborately equipped, this lack of knowledge of the senile mind and body lead- ing to faults in the care of the aged which could be avoided. Much can be said in favor of institutional care of the aged; more can be said against it. Where ex- pense is the deciding factor the rending of home ties, the separation from the family and friends, the changing of lifelong habits, the loss of self-respect in the recognition that one is virtually a pauper de- pendent upon the bounty of the community or body maintaining the asylum, the inevitable mental de- pression that follows inactivity with gloomy retro- spection and dismal foreboding, all these count for nothing against the lower cost of maintenance in the institution. Dr. Paul Ritter, Minister of Switzerland, informs me that in several cantons — Zurich, Thiirgau, Ap- penzell, Uri, Basel-land and Lucerne — the poor and 3 aged are cared for in asylums and in private fam- ilies. Some place the dependents in different fam- ilies alternately, while Zurich places' its dependents with private families only in the country districts. He says this system has certain drawbacks and has 'not proved to be very satisfactory. *]From a purely humanitarian standpoint the family care of the aged is incomparably better than institutional care. The child brought up in an institution is accustomed to institutional life. The aged find in institutional life a constant, galling restraint, a severance of their past freedom; family relations and ties are dis- rupted; domesticity, privacy, independence, the love of home, even interest in life are lessened, sup- pressed or entirely abolished. ..Life becomes one dreary, monotonous routine, the mind becomes apa- thetic, the body becomes weak, existence becomes ) automatic; a helpless, hopeless, purposeless exist- ence dragging along to its dismal end. How differ- : f ent in lands where reverence is done to the aged, where sympathy is not measured by cost, where old age pensions enable the aged to maintain their little homes or aid the family to support them, and not \^ force them to the dreary, soul-destroying life of the poorhouse. It is not my purpose here to appeal to the heart (though I hope this may touch the conscience), but to show faults in the care of the aged in some insti- tutions that I visited, and how some of the faults may be remedied with little or no expense. We must remember that the asylum is usually the last resort, that the inmates enter when they can no longer earn a livelihood, when they have no means or family ties or when the family cannot or will not look after them. The separation from home, family and friends is itself depressing, and this depression 4 4 is increased by the sense of lost independence, in enforced obedience to rules which ignore personal wishes and lifelong habits, and the sense of depend- ence upon public or private bounty. Other depress- ing influences are the unavoidable association with undesirable companions in misery, the segregation of the sexes and lack of mental occupation, permit- ting the mind to look back with regret or forward in despair. I know of no more senseless, heartless rule than the segregation of the sexes. In the few institu- tions in which the men and women are permitted to associate they take better care of their personal appearance and they take an interest in life. The effect of segregation as compared with free asso- ciation of the sexes is clearly observable in the New York City Farm Colony. Married couples are housed in cottages, where each couple occupies a separate room. The inmates meet each other, take an inter- est in each other's welfare; they take a pride in their personal appearance and in the appearance of the cottage and their rooms. In other parts of the institution the sexes are segregated, the inmates become indifferent to their appearance, slouching in their attitude, apathetic or morose. The superin- tendent occasionally secures the services of an or- chestra or a dramatic company which give a concert or performance in the open, the inmates sitting on a terrace which they constructed for this purpose. On these occasions the men and women sit together and both men and women fix up to look neat and clean. In the Home of the Actors' Fund, which is con- ducted like a good family hotel, the inmates are called permanent guests and they associate as freely as they would at any other hotel. They take pride in their appearance and in the appearance of their Home and of their rooms, some of which are elab- orately decorated by the inmates occupying them. The inmates belong to the theatrical profession, and, being accustomed to hotel life, find here as close a semblance to their home life as is possible in an institution, with the advantage of a beautiful situa- tion and beautiful grounds, marred only by the proximity of an adjoining cemetery, a constant re- minder of death. The dining room has small tables seating four to six guests. Aside from the necessary restrictions as to rising, meal and closing hours, the inmates are free to come and go at will. They have a w T ell-stocked library, smoking room, billiard room, parlor, sewing room, etc. This institution, now holding thirty-five guests, and which can hold one hundred, is the model institution of its kind. The principal fault here is lack of occupation for the men, for, while they are not accustomed to man- ual labor, the routine becomes monotonous and they become apathetic. Being considered guests, they are not urged to do anything, and they lead lazy, purposeless lives, and mind and body become "stale" from inactivity. There is no infirmary ward, and an inmate becoming ill remains in his room while a neighboring physician is called in. If the illness is serious the patient is removed to a hospital sev- eral miles away. The superintendent is a graduate pharmacist, well able to take care of minor ailments and to give emergency relief. While most of the aged in institutions are more or less ailing or complaining, few institutions have a resident physician. In the New York City Farm Colony, with 1,000 inmates, nearly 100 were in the hospital wards, in charge of a single nurse and one visiting physician. There is nearby the Sea View 6 i Hospital for Tuberculosis, from which a physician could be summoned in an emergency, but the interne of a tuberculosis hospital is as little prepared to treat senile cases as the ophthalmologist would be to perform a cesarean section. With a growing in- terest in geriatrics in medical schools, it should not be difficult to secure internes for homes for the aged. Surely the aged invalid, who has sense and sensi- bilities, who feels the physical pain of disease and the mental anguish of neglect, who has been of some service to mankind while he was able to be of serv- ice, deserves at least the attention that is given to the idiot and imbecile, who have a resident physi- cian in their institution. The National Home for Disabled Volunteer Sol- diers and the various state homes for soldiers and sailors generally make suitable provision for the ill and ailing. Let me quote here an extract from a letter from Dr. James E. Miller, Inspector General and Chief Surgeon of the National Home for Dis- abled Volunteer Soldiers: "There are ten branches of the National Home for Disabled Volunteer Soldiers. Each branch has a hospital with bed capacity sufficient to care for one- fourth of the members present; comfortably fur- nished, amply equipped with modern instruments, appliances and apparatus necessary for the proper care of the sick. At four branches there are spe- cial facilities for treatment of tuberculous patients. The hospitals of the Home are equal in points of efficiency and equipment to the best in the country. There are sixty-five efficient surgeons on the med- ical staff of the Home." I have not visited any of these homes, and base conclusions solely upon the published reports. The inmates are well supplied with amusements and 7 recreations, but not with occupations which would keep their minds occupied. This probably accounts for the large number of cases of drunkenness re- ported. At one branch 680 out of 968 minor of- fenses were drunkenness out of an average number present and absent of 2,626 (1913 report). The food is plentiful, but some articles are clearly un- suitable for aged ailing individuals. The City Farm Colony is a branch of the New York City Homes for the Aged and Infirm, the in- stitutions formerly called the Almshouse and the Poorhouse. Of its 1,000 inmates about 100 were in the hospital building and nearly 700 were employed in the fields and shops and on construction work. This institution can serve as the model for the sys- tematic employment of aged dependents. The in- mates are mostly from the lowest and poorest stratum of society, many are ailing, others com- plaining, others lazy, but the able superintendent has succeeded in instilling in his charges a sense of usefulness, and they work cheerfully, many without supervision. They are urged but not forced to work, they are not hurried, and they rest when tired. The men work at trades with which they are familiar, those having no trade working in the fields, on construction work or in the broom factory or other shop where skilled labor is not required, working eight hours a day. Those least able to work set and clear away the dishes on the tables in the dining hall, while a few of the more able-bodied and better-educated men are made overseers at nom- inal wages. The women look after their dormi- tories, sewing and laundry. The work is so thoroughly systematized that there is employment for all, nearly everything about the institution, on the fields and in the shops is done by 8 inmates, and the products of the fields and shops are disposed of, so that the cost of maintenance is reduced to about 31 cents a day per inmate, said to be the lowest cost per inmate in any public institu- tion for adults. The great advantage is, however, that the inmates have their minds occupied with their tasks, they feel that they are not entirely use- less and their thoughts are not fixed on self and death. This institution is conducted along strict institu- tional lines, with rigid rules, clearly defined duties and absolute restrictions. These rules and restric- tions are probably necessary to control so large a body of paupers who are unaccustomed to cleanliness and order, yet much could be done to make their lives brighter and make them more comfortable without impairing discipline. In all my writings I have urged mental stimulation as the most effect- ive means of warding off the mental depression which leads to melancholia and dementia. The frightfully monotonous life in the institution leads to a lethargy in which the individual becomes an automaton, acting mechanically through force of habit. It is a simple matter to stimulate interest in life while the individual still has some interest; it is difficult to rouse him out of his lethargy when he has once reached that condition. One of the most potent measures to keep up interest in life is through newspapers and the discussion of the af- fairs of the day. Newspapers and other reading matter could probably be obtained at little or no ex- pense, but the aged generally have presbyopia, and they cannot read without proper glasses. The mental impression produced when we read a paper is much more powerful and lasting than when we hear it read. If these poor people were 9 supplied with glasses and newspapers they would take a greater interest in life and in them- selves. Here is a fruitful field for public and pri- vate philanthropy. I was informed that no pro- vision was made for recreation or amusement, that the superintendent upon his own initiative secured the orchestras and dramatic talent which gave the occasional performances to the inmates. On rainy days, when the inmates cannot go to the shops or work in the fields they remain indoors and do noth- ing — nothing but think with regret of the past, in despair of the future. There is no piano or phono- graph to chase sad thoughts away, no games like checkers or chess to while away dreary hours. True, they are paupers, they may have been improvident ; now they are unfortunates and look for sympathy and kindness. In one institution near Vienna there are enough inmates able to play musical instruments to form a good-sized band, and they give occasional public concerts. The income from these concerts supplies the inmates with little luxuries which they procure at a canteen on the grounds. It would probably not be possible to recruit an orchestra from the inmates of the Farm Colony, but out of a thousand inmates one or several would be found who could play the piano. A universal fault in institutions for the aged is improper feeding. The falling out of the teeth is nature's signal that food which must be masticated is to be avoided. The principal article of diet which requires chewing is meat. Almost all other foods can be crushed between the tongue and hard palate, either dry or when moistened or soaked. Fats and insipid articles of food are distasteful and they should be avoided on physiological grounds. While it is not practicable in a large institution to furnish 10 meals suitable to each individual, it is possible to so arrange the dietary that those unable to chew can get sufficient food without meat. In the New York City Home a pious Jew would not eat proscribed dishes and almost starved until he was transferred to a Jewish home for the aged. In one institution the superintendent introduced a cathartic in the food one day each week, a pernicious practice, heart- less as well as ignorant. Drugs should never be given indiscriminately, never without a physician's order, or so as to incommode other inmates. A fault which prevails in many institutions is inadequate bathing facilities. The aged find it dif- ficult to enter a bath tub and more difficult to get up after the bath. Stout women are often unable to get up without assistance, and for this reason they dread the bath tub. This trouble can be avoid- ed by using a shower bath and allowing the bather to sit upon a chair. In one institution there were no carpets on the floor, the inmates were not permitted to go barefoot, but several had bladder and prostatic troubles which compelled them to go to the toilet at night. When this happened they awoke the whole dormitory. A strip of carpet removed this source of insomnia. In ■ another institution the windows were opened during the day even in winter. At night they were closed and the heat was turned on. The bedding during the day was folded over the foot of the bed and the bed was still cold when the inmates retirea. They could not fall asleep until the heat from their bodies warmed the bed sufficiently to make them comfortable, and those who had bronchitis began coughing as soon as they entered the cold bed. As there were a lot of empty mineral water jugs in the cellar, I suggested that the inmates fill these with 11 hot water and each one put a jug in his bed as soon as he went to the dormitory after supper, and when he entered the bed he could push the hot jug to the foot of the bed and keep his feet warm. Many aged persons have bromidrosis, and where a large number congregate in a room the odor soon becomes exceedingly offensive. In one institution there is no infirmary w 7 ard, and there are several bedridden cases in the dormitories. During a cold spell the windows could not be opened for a few days, as the bedridden patients could not be shifted and the atmosphere became nauseating. In one in- stitution the inmates are paired off c o that each one has a companion. The companion of an inmate who had hemiplegia acquired through mimicry a similar gait, and in another case an inmate acquired a senile tremor in like manner. Separation and disciplinary measures were necessary before it was possible to overcome these habits. In another case association with a garrulous dement resulted in a quarrel in which the dement was injured and the other devel- oped delusions of persecution. Other faults frequently met with in institutions are neglect of the petty ailments, such as broken down arches, corns and bunions, pruritus, pains in the joints (arthrosclerosis), etc.; lack of canes, the presence of curiosity seekers and professional sym- pathizers, inadequate facilities for holding religious services, mingling of nervous and mental defectives with impressionable, healthy cases, irrational amusements and recreations, uniform costumes, sometimes lack of sympathy and interest on the part of the superintendent in his charges, more often failure to encourage interest of the inmates in their institution. Not alone should the inmates of asylums for the 12 aged be urged to keep their minds and bodies em- ployed, they should be permitted to dispose of their products or abilities and use their earnings for the general betterment of their institution. The object should always be to instil a sense of usefulness, even if it be only the ability to go on errands. Segregation of the sexes should be prohibited, and as the association of the sexes will rouse pride in appearance they should have the facilities to enable them to make a good appearance. This is not so important in soldiers' and sailors' homes, but in other homes this separation from the opposite sex is a hardship for which no good reason can be given. Such association will arouse interest in others and in the surroundings. A distinctive pauper costume is as humiliating as are the prison stripes. In the course of this paper I have touched upon some other factors applicable to the institutional and communal care of the aged which should receive careful study. Such are the cottage system of housing, the distribution of aged dependents among families, the earning capacity as a contribution to the cost of maintenance, systematic employment, the canteen, stimulation of interest in the institution and in self, etc. The City Farm Colony has a well- equipped printing office manned by inmates, which could publish a weekly or monthly journal dealing with the institution and department and to which inmates could contribute. These matters deserve attention and study, far more study than one individual working without assistance can possibly give to them. But to re- ceive attention it will require the forceful and per- suasive pen of a Dickens to rouse the public con- science to the neglect of the aged. -6- 01 HA3T One Hundred and Gut 'i' i m u ii ' m Street. A COMPOSITE FAC-SIMILE MEDICAL RECORD A Weekly Journal of Medicine and Surgery WILLIAM WOOD AND COMPANY PuMhMrar*. 81 ftflh toum. N*v* Twt $5.00 Per Annurr/. Published at New York Every Saturday Stofle Copies. 15c ORIGINAL ARTICLE* Th* Occupational Neuroees A Clin- ical Study of One Hundred Cases. Br Charie* U Dana. M.D., New Tor* Failure of tha Colon to Rotate. By Charlaa H Mayo, M.D., Rochester. Minn. y.< On* Taar'a Experience with Salyar- aen. Being a Report of lit IiTJee- tlona with Special Raftranca to Eye and Ear Complications. Br B. C Corbua. M.D.. Chicago. Ill Tha Quantitative Analyala of Human and of Cows' Milk. Br Arthur V Meigs. M D.. and Howard L> Marah. B S. Philadelphia Not** on the Neurology of Voluntary Movement. By George Van Neaa Dearborn. M.D.. Boston, Mass Notes Upon a So-Called Parasite of Yellow Fever (Seldelln) By Arls- tides Agramonte. A.B.. M.D., Ha- vana, Cuba Chorloeplthelloma Mallgnum: Report of a Case Following Abortion; Ova- ries Retained. Complete Recovery; With Detailed Report of the Path- ologtat. By Wra. H. Dukemaa. M.D.. Los Angeles. Cal Hysteria and Psychotherapy By Eugene D BoaduranL M.D., Mo feUe. 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Christian Bclenc* In th Zone Our London Letter , Our Letter from Paris ✓ Our Berlin Letter , Our Letter from the Philippine* Our Canadian Letter <• PROGRESS OF MEDICAL SCIENCE, End Result* of Surgery In Neurax- tltenles and on Neurasthenia Primary Turner* of th* Spleen — Urinary infection — The Prevention •f Eclampsia — ChVloue Ascites — Relation of Intestinal Toxemia to Chronic Arthritis— Creative 8urgery Combined Infestation with ~ Ascarle and Hookworm — Extradural Hemor- rhage — Anesthesia In Tonsil Enu- cleation— Antityphoid Vaccination— Convalescent Carrier* of Typhoid— Streptococcus Vaccina* In Scarlet Fever Prophylaxis .-. INSURANCE MEDICINE. Suggestions to Medical Examiner*. By th* Insurance Editor Th* Physical Examination . Wessermann Reaction lit Judging a Claim for Indemnity — A Case *f Multiple Sclerosis from Chrerrle Oaa Poisoning The Mortality of Alcohol— Medical Section of th* American Life Con- vention — Pleurisy and Insurance . BOOK REVIEWS. A Practical Medical Dictionary *f Words Used In Medicine. With Their Derivation and Pronunciation. Including Dental. Veterinary. Chemical. Botanical, Electrical. Ufa Insurance and Other Special Term*. By Thomaa Lathrop Stedman. M.D Illustrated American Practice of Burgery A Complete System of the Solence and Art of Surgery by Representative Surgeon* of the United State* and Jilete In Eight Volume*. Profusely llustrated. Volume VIII Utle Palate. By John B, Roberta. A. M. M. D. Illustrated with 171 engraving* SOCIETY REPORTS. Mississippi Valley Medical Association American Aaaociatlon of Medical Ex- aminers , American Medical Association Southern Surgical and Gynecological Association New York Academy of Medicine The Western Surgical Association;.. Connecticut State Medical Society. t . 'MEDICOLEGAL NOTES. 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