Intestinal Cancer.-Professor Hochenegg, of Vienna (Interstate Medical Journal), has operated upon 282 cases of cancer of the large bowel, 237 of these being rectal in location. Among the latter excision was performed in 174 instances, and thirty patients are considered permanently cured.

The Effect of rest Upon the Progress of Septic Infection.O. J. Ochsner (American Medicine), reports 52 cases of severe infections of the hand, in which absolute rest was, he thinks, a valuable aid to the moist antiseptic dressings and general hygienic treatment. In the treatment of peritonitis complicating criminal abortion, he has abandoned the saline treatment, and keeps the abdominal viscera at rest by cleansing out the stomach by lavage and then placing the patients on rectal alimentation exclusively. In the severe local peritonitis accompanying some attacks of gallstone colic, he deems it important to inhibit peristalsis by abstaining from food by the mouth.

The Identity of Pathogenic Streptococci.-Marmorek (St. Louis Courier of Medicine), claims that all pathogenic streptococci are identical. He bases this claim on the three common characteristics which he has found present in all the bacteria taken. from 42 diseases—namely, the production in vivo of hemolysis in rabbit's blood, the inability to grow upon a filtrate of their own cultures, and the immunization of animals by Marmorek's antistreptococcic serum. The virulence of the micro-organisms varies. greatly, however.

Test For Albuminuria.-A very accurate test, suggested by Adler (St. Louis Courier of Medicine), is as follows: Place 5 to 10 c.c. of urine in a test-tube, add one to two drops of hydrochloric acid, then add phosphotungstic acid until no precipitate occurs. Centrifugate; pour off the fluid, shake the sediment with alcohol and then pour off the alcohol, repeating the process two or three times, then add concentrated sodium hydrate solution to the sediment. A blue color appears, which vanishes after shaking in the air. When dilute copper solution is now added, the pink biuret reaction is obtained.

Essential Hyperpyrexia.—In the Journal la France (quoted in St. Louis Courier of Medicine), the case of a young soldier is. mentioned who had frequent accessions of temperature to 111.2 degrees F., and even to 136.4 degrees F., without suffering the slightest discomfort.

VOLUME XXII.

DECEMBER, 1902.

NUMBER 6.

SOME OBSERVATIONS ON THE HOME TREATMENT OF INSANITY.*

By C. H. SOLIER, M.D.,
Evanston, Wyo.

It is the almost universal experience of every physician in general practice that but few things present such insurmountable and perplexing difficulties as do the management and treatment of insanity. Upon the one hand there is the immediate and pressing need of instituting an efficient and adequate course of treatment with the object not only of conserving the patient's chance of recovery, but also of preserving his own safety and perhaps that of others. There is, on the other hand, generally a natural reluctance on the part of relatives to fully appreciate and assume the great responsibilities that frequently result from this disease, and often a disposition to insist upon the trial of temporizing and dilatory expedients. In such dilemmas he is certainly a wise, tactful and courageous physician who can always determine what is the best course to pursue.

As soon as the diagnosis of insanity is made the question as to where the patient can best be treated should come up for immediate consideration. Certainly, except in the milder and least dangerous types, this is the most urgent and important problem imposed upon the attending physician. His opinion upon this subject will be solicited by friends and relatives, and he should therefore be fully advised as to the comparative advantages of home and institutional management. He will often be held responsible for the result of the plan of treatment he has recommended. If he has advised commitment to a hospital for one who makes a rapid recovery he may be censured thereafter because of the disgrace which the patient may feel attaches to residence in such an institution. Greater blame will of course result in the event that treatment at home should in any way terminate disastrously or even prove unsuccessful.

*Read before the Rocky Mountain Interstate Medical Society, Cheyenne, Wyo., Sept. 9th, 1902.

It is a fad with some to decry and disparage the hospital treatment of insanity. In glittering generalities they advocate treatment at home but preserve a discreet silence as to its peculiar difficulties and dangers. They dilate eloquently upon its manifest advantages and emphasize the avoidance of the stigma resulting from commitment to a hospital for the insane. From a somewhat limited personal experience with home treatment and an extended observation of its results in many cases, I have no hesitation in saying that except in a limited class of cases which I shall presently enumerate, or in the homes of the well-to-do, it is veritably an "iridescent dream." The very term itself is often a misnomer. For in the most prevalent forms of mental alienation such a complete revolution in the conduct of the household is demanded and the entire family is plunged into such a state of anxiety and gloom that there is at once abolished all those conditions that we associate with the term home. What can be more distressing to the impressionable mind of a child than to witness daily that almost indescribable mental anguish of a melancholic mother! What more terrifying than the noisy ravings and violent and destructive conduct of a maniacal father!

Yet it will sometimes happen that the family entertain such insurmountable objections to any kind of a hospital, either public or private, that nothing remains but to devise some plan of home treatment. However ill founded and groundless these objections may be, they are deserving of respectful consideration, for it is generally admitted that much of the opprobcium or stigma attaching to insanity is due to methods of commitment that resemble and suggest criminal proceedings and, to a somewhat greater extent, to confinement to a hospital devoted to the exclusive treatment of mental disorders. The necessity of commitment to a hospital is regarded as primà facie evidence that the disease is undoubted insanity. While if the attack is so transitory in duration. or so mild in its manifestations that treatment at home soon effects mental restoration, the patient will be spared much anguish and mortification that would certainly have attended even a brief residence in an institution. Thus there is also afforded an opportunity which few are disposed to reject, of ascribing the illness to a purely nervous derangement. Even a mild attack of insanity is in itself assuredly a serious enough misfortune without adding any to the stigma which the world has in every age attached to it.

While much has been said and written in denunciation of this attitude of the public toward the insane, nevertheless, the feeling still remains and will probably continue for ages to come. It is largely but the effect of the belief that insanity is the outcome of an inherited or acquired unstable mental organization, that it is seldom completely and permanently recovered from, that at any time there is serious possibility that the patient may become a menance to himself or to others and that the taint may be transmitted from one generation to another. The physician ought never to ignore or miminize the force and influence of these sentiments when advising relatives as to the most suitable method of managing a given case of insanity. Yet, after due allowance has been made for these facts, the truth is that, except where the matter of expense needs no serious consideration, there are not many forms of insanity for treatment at home.

Without attempting to lay down a general rule, it may be said that only such cases as promise to run a brief course or such as are not characterized by dangerous tendencies should be treated outside of an institution. Among these may be mentioned the temporary insanity occurring in the course of fevers and other infections.

Perpetual insanity when of the maniacal type may be satisfactorily managed at home, as these outbreaks are usually of brief duration. Here the homicidal impulse is often directed toward the child and must be especially guarded against. However, when these attacks show a tendency to become protracted or when they take the melancholic form, which are always more chronic than the maniacal type, institutional treatment offers obvious advantages.

Acute transitory manias and acute delirious insanities may also be treated at home. The latter are usually characterized by such extreme exhaustion of the vital forces that they do not bear transportation well, especially for any great distance.

Maniacal outbreaks in which there is a clear history of alcoholism, almost invariably run a brief course and can be readily managed outside of a hospital, especially if proper mechanical restraints are provided. Many such cases are received every year at our public institutions, especially in states where commitments are hastily and easily made. Since beginning this paper I have had under my care a lady who had become violently maniacal

while en route across the state. This attack was presumably due to alcoholic or drug addiction, and, as might have been expected, subsided within forty-eight hours. If the place where she was treated had been provided with a restraint sheet or even the time honored camisole, she could have avoided the mortification of a commitment to a hospital for the insane.

Another class of cases often needlessly committed to public institutions are the simple dementias of old age. I often think that these patients present some of the saddest scenes to be witnessed in our state hospitals. Many of them can and should be cared for at home. To discourage such commitments is a duty that often devolves upon the family physician. Of course, if in these cases there are depressive ideas, suicidal tendencies, groundless hatred and suspicion with outbreaks of violent anger, their management at home is extremely difficult and dangerous.

For almost all other types of insanity, institutional treatment ought to be preferred. Comparatively few physicians unless they have had some hospital experience with the insane, can ever acquire sufficient familiarity with the symptomatology and management of insanity to successfully undertake its home treatment. And certainly no one who has not had such experience can really appreciate the comparatively greater difficulty of instituting at home proper precautions against suicides and accidents, and of surrounding the patient with such influences as will conduce to his speedy recovery. My own experience in attempting the treatment of several cases at their own homes, has so profoundly convinced me of these difficulties that I am now most unwilling to assume such responsibility.

One must constantly bear in mind the saying of Maudsley, that if there is one thing which a large experience with the insane teaches, it is how impossible it is to foreknow the impulses which may suddenly arise in their minds, and to trust them from hour to hour. Of course, at home the risks are far greater from stairs, open windows, razors, knives, etc., and, therefore, the first thing that the attendant must do is to carefully guard against such risks by taking possession of keys, knives, razors, etc. To do this successfully without the employment of a trained nurse is next to impossible. An attendant experienced in the management of the insane, almost intuitively takes all necessary precautions. He can also render valuable services in the way of keeping