at suicide or to make the family believe that the danger is as great as it is. I would personally never consent to the treatment of a case of acute melancholia at home, although I believed it would be short, because the danger of suicidal attempt is very great. I can recall numbers of instances of such cases that were apparently mild. The alcoholic is really committed as insane in this company, too frequently to institutions. The attempt to have inebriate institutions seems rather a failure. In New York State, at Binghampton, some years ago, there was a very prosperous institution for inebriates which went off with a great swing at the start, and it seems to have failed utterly, the institution being finally turned into an institution for the insane. I scarcely know why these places do not succeed, except that the man who is inebriate gets "sane" and "level-headed" so soon as his liquor is withdrawn, and there seems to be no way of retaining them in inebriate institutions long enough to "cure;" whereas in institutions for the insane they are retained long enough to do them some good, and that is one argument in favor of committing the recurrent drunkard as insane and letting him have a good long course of treatment where he is legally detained. But this is also considerably abused. There are committed now to the institutions for insane a good many "old rounders" who have been committed thirty times before perhaps for short terms; in other words, we have often heard the sentence, "Ten days or ten dollars."

DR. DELEHANTY-If you will permit me, I would like to refer to the case which Dr. Perkins mentioned in his last report, as the one in which I was interested. It was the case of an epileptic girl that was under my care at the Arapahoe County Hospital. She had some uterine trouble, for which she was referred to the gynaecological department. Later I found that an hysterectomy had been performed, and I should infer from the doctor's remarks that at the solicitation of her parents, it was done with a view of influencing the epilepsy. Speaking for myself, I would not advise the removal of either the uterus or ovaries in any case of epilepsy, unless there was sufficient local cause.

As to the home treatment for the insane, I think the great prejudice which exists is due to the treatment which insane patients formerly received in some state institutions. The great objection or feeling that people have of sending their insane to

an institution is the possibility of their being abused while there; and there is no doubt but what there were times in large institutions in which patients have been misused. We see in the papers occasionally exposures made of insane asylums where patients have been maltreated, and I think it is from this source more than anything else that friends do not care to have their people sent to institutions of that kind.

The great province of the physician is to improve upon the treatment in the care of insane in public institutions, to insist upon competent officials-officials not selected on political merit, for I feel as long as these institutions are under the control of political parties, the staff changing with each change of the party in power, necessitating new attendants.

DR. REED-Before closing the discussion, I desire to make a remark in reference to a point that was brought out by Dr. Delehanty, that of the change or rotation of the employees in the insane asylum, which I consider an objectionable feature. I am very thankful to say that in this state we have not been troubled in that direction. We have a competent man who is superintendent of the insane asylum, Dr. Solier, who has been there for ten or twelve years at least and has been kept there regardless of his political affiliations because of his worth to the state. I think it is a reprehensible thing to have this change because a man may be a Democrat, a Populist or a Republican, as the case may be. Although these institutions must of necessity be to a certain extent and for a long time to come political institutions. I think that those who manage them should be selected because of their worth and because of their experience in these matters. That has been the case in Ohio for a great many years. I have known Dr. Richardson for years, and he has passed through one political administration after another and retained his position as superintendent of the Columbus Insane Asylum until he was called to Washington, D. C., and I think those things should be encouraged by us all regardless of what we as politicians might be, we, as professional men, should stand by and urge the importance of keeping men in these positions who are competent and who have had experience. Now, as to the paper: As Dr. Solier well knows, I am probably a crank in the matter of sending patients to the insane asylum. I believe in regard to patients who are insane as I do in regard to patients with appendicitis. I believe

in early operation for appendicitis, and I believe that the hospital is the most desirable place to operate these cases. I believe that a party who is insane is better off in an insane asylum under competent treatment than he is under the care of an ordinary physician. Now, I do not make any pretensions as to insanity, and when I get hold of a patient that is insane I want him to go to Dr. Solier, because I know that he understands it. I am now speaking of our own state, and each physician in other states ought to feel the same way because they ought to have a competent man at the head of their institution, and I believe that the majority of states do have. It may be simply a mild attack. You have all, as surgeons, had patients with appendicitis sent to us (I simply speak of this because it is a common disease) that was not necessary to operate in the first attack, possibly you did not think it wise to operate them, possibly put them in the hospital a few days and then sent them out again. You did not criticise the party for sending those patients to you, for the reason that nobody knew when the case was sent but what it was possible that an operation was necessary. It is possible when we send a patient to the insane asylum to know to what extent that patient may be insane, and if they get well, so much the better. Now, we have had cases of this class frequently sent to the general hospitals of this state, and we have no facilities for taking care of them. We have no iron grates at our windows and we are not in a position to take care of these patients and feel that they are safer in the insane asylum than in our hands. We don't know the minute that one of these will jump out of the first story or the second story window and break his neck or commit a serious injury to himself, and for that reason we feel that they are safer placed in an asylum where every facility is at hand for their care and treatment, even if they get well in a week or ten days. If it is possible to treat these cases successfully at home, which it probably is in some instances, of course there is no objection to it. But at the same time who of us know what is going to take place in the mind or in the body of an insane person, and we feel a little uneasy when we have a case of that kind on our hands, and particularly if we have got a competent man in a good asylum to take care of them, and do not utilize his ability or the state's facilities for their care.

DR. SOLIER-I am very glad that this paper had such a full

discussion because there were points brought up in it that I wanted to impress upon the minds of the gentlemen present, not that they were facts that they were not already familiar with, but sometimes recalling these facts is productive of a great deal of good. Since commencing this paper I have called to mind quite a number of instances that have occurred in this state-I speak of this state because I am more familiar with what is going on in Wyoming-in the past year where accidents, such as suicides. and homicides have occurred where the person was insane and had been insane for some time. I know of a number of cases where the physicians were slow to act upon the evidence that they had as to the existence of insanity and failed to institute proper treatment. I remember once hearing the statement that almost every case of melancholia would get well if suicide did not terminate it. I think that this is rather an exaggerated statement, and yet it is in very many cases true. I believe that every physician ought to bear in mind that if he attempts to take care of a case of insanity at the patient's home that he ought to do so only under proper precautions and with proper attendance. Now as to the prejudice against state institutions that one gentleman referred to, on account of the periodical exposures through the newspapers. I know there is a great deal of truth in the statement. It is a subject that I am pretty familiar with because I have been exposed a number of times myself, but I want to say this, that I think the prejudice is against all kinds of institutions for the insane, whether public or private, and as long as we have such hospitals there will be exposures, I think, from the very circumstances surrounding them whether there are politics in the matter or not. I believe very few people, unless they have had actual experience in the management of a public institution of this sort, really understand the great difficulty experienced in always securing competent, humane and merciful help, and anyone who has had experience in this line of work must be aware of the fact that we don't have to go to institutions to find cruelty to the insane. Some of the grossest acts of cruelty that I have ever heard of have occurred in the homes of the patients themselves, and often at the hands of relatives. Now, it is not to be supposed for a moment that relatives deliberately intended to perpetuate any act of cruelty, but under the excitement and under the strain of the care of violently insane persons they have been

driven to extremes. These are the very things that happen in the best regulated institutions. They will happen, but of course every superintendent who has the welfare of his charges at heart does all that he can to prevent them. But occasionally it will happen that incompetent, cruel, hard-hearted help is employed, and a man can show his ability, I think, in scarcely any way better than in detecting such an employee promptly and in discharging him. Very likely as soon as such a person is discharged you will hear a great outcry of neglect and cruelty at such and such an institution, and it often happens you will hear described the very acts that he himself has been guilty of.

SOME THOUGHTS ON SYPHILIS.*

By MELVILLE BLACK, M.D.,

Prof. Optholmology Denver-Gross Medical College: Optholmologist and Otologist to St. Anthony's Hospital, and the National Jewish Hospital, Etc.

Denver.

Those of us working in the limited field of the eye, ear, nose and throat see a surprisingly large number of cases of syphilitic disease in both the secondary and tertiary stage.

It is remarkable how often we have the opportunity of diagnosticating syphilis in the early secondary stage from the presence of mucous patches in the throat. It is often the case that patients are up to this time unaware of syphilitic infection. A chancre in the usual situation and of typical appearance usually causes the patient to consult his physician at once. It is, therefore, the patient who has the initial sore in some unusual situation, or who has a sore that appears to be non-specific that is made acquainted for the first time of his specific condition upon consulting us.

I remember the case of a woman who consulted me some years ago. She was suffering from an acute iritis, which was to every appearance syphilitic. This diagnosis was strengthened by a maculo-papular skin eruption and mucous patches in her throat. I felt sure the whole process was specific, but could get absolutely no history of an initial sore. I felt sure from the girl's manner that she was not deceiving me intentionally. I sent her to a gynecologist for a vaginal examination, which was reported upon as negative. She was placed upon antisyphilitic treatment with the usual rapid clearing up of symptoms. Some two months later she told me that some two or three months before consulting me she had used the syringe of a married woman friend to give herself a rectal injection, and that only recently had she learned that *Read before the Rocky Mountain Interstate Medical Society, Cheyenne, Wyo., Sept.

9th, 1002.