ment is past, and hundreds of cases thus become chronic and swell the great number of those cared for by the state and counties, who might have recovered if treated early.

Every insane person is an egotist, and many imagine all to be leagued against them. They suspect and accuse their relatives and dearest friends of abusing them, and their statements cannot always be relied upon.

In

The question of home or hospital treatment is one that the physician and relatives, must decide, and the decision must come early that the treatment may be prompt and thereby more effective. patients with whose history you are familiar, you may sometimes abort an attack before it becomes serious, by close attention, and in some cases, where the family have means sufficient to provide skilled and experienced nurses and everything you may deem necessary for the care of the case, home treatment may be tried, but as a rule patients should be entirely removed from the home influences and relatives, whose anxiety to benefit the patient many times has a contrary effect.

The following pertinent remarks made by Dr. Evarts, supt. of the Cincinnati Sanitarium, in a paper entitled "Treatment of the Insane," read as a committee report at the meeting of the superintendents of American institutions for the insane, at Philadelphia in May 1884, bear upon this point.

"That the greater success of hospital treatment of the insane as contrasted with home treatment, is attributable to any superiority of skill or learning upon the part of such hospital physicians as usually intrusted with the medication of the insane, is not to be presumed, because, while it is to be presumed that all hospital physicians are learned and skilful, it is known that they are not as a class, in possession of secret knowledge of any kind pertaining to the healing art. Excluding our medication from our estimate of values then, in considering hospital treatment of the insane, what other treatment is there of sufficient importance to attract attention, and justify the inference of superiority?

"The most prominent of all-restraint. Not this, that, or the other method or appliance for restraining the insane-some one or more of which may be objectionable per se-but restraint in a general or comprehensive sense. Restraint that falls upon the patient as he approaches the hospital as the shadows fall from its facade and tower

upon the lawn beneath. Restraint, that becomes more appreciable, when expressed by the attitude of persons in authority, superintendent and subordinates, physicians, attendants, nurses and others acting under orders, whereby the patient is placed at once, and unequivocally, upon a footing of a person laboring under some disabil ity as requiring care and treatment, as an invalid--as insane. A whole system of restraint making it possible to secure for the benefit of the insane, more or less perfectly, by general and special means, persuasive or coercive, 1st, regularity of habits, including eating, drinking, bathing, exercise and rest; and, 2d, an abandonment of pernicious practices. All of which to an intelligent observer familiar with the homes and habits of our people—the assumptions, intolerance of environments, insubordination towards authority, and indıfference to consequences of conduct characteristic of the insane; and the attitude of concession, evasion and downright lying generally practiced by relatives, friends and others toward the patient, justifies the presumption in favor of hospital over home treatment."

If it is decided that the patient should be sent to the hospital, then the sooner the better, and I beg of you that you impressively warn friends that no deception be used. Let the patients understand that they are to be removed to the hospital for treatment, and that their friends are cognizant of and approve the plan. I cannot tell you how often patients are brought to the hospital under the false impression, given by those having them in charge, that they are coming to a hotel, or some other falsehood is told them to induce them to come quietly. Better by far that the patients be fully informed where they are to be taken, and if they object send them with the proper officers. A woman should always accompany female cases. When patients are decoyed into the hospital by deception it can only result in one of two ways; either they will insist that they have been kidnapped by the officers of the institution without their friends being cognizant of it, and refuse to give the physicians their confidence and submit to proper treatment, or else they become bitterly angry towards the friends they have so implicitly trusted for so deceiving them as to the character of the institution, and the fact they were to be detained therein. I always insist upon two things before admitting patients. First, that all restraint be removed, and second. that those bringing patients shall tell them fully where they are and why they are brought there.

In preparing this paper I did not aim at making it scientific. I have endeavored in a somewhat crude and superficial way to give you a few points that I trust may prove of some practical importance to you and your patients and aid in increasing the accuracy of hospital statistics. To many of you some of the points dwelt upon may seem trivial, yet in a matter of so much importance as the committal of a patient to a hospital for the insane, you cannot be too careful. One of the European superintendents reports that in over 500 commitments to the hospitals of which he has charge, 91 per cent. of the papers were defective in one particular, that of giving the proper name and address of the patient, and though at first glance this may seem a trifling omission, yet it was legally decided that it invalidated all these papers as it did not admit of a full and complete identification of the patient.

ARTICLE X.

OUR DUTY TO OUR INSANE.

BY J. SANDERSON CHRISTISON, M. D., MADISON, WIS.

I take it to be a duty as well as a privilege to call the attention of this the most representative society of the medical profession in the state-to a question of great importance, though I fear of comparatively little interest to most of you. As my time is so limited, I can but briefly outline what I consider to be the best practical measures in the main, that will satisfy the sane as being in the line of progress in the matter of meeting the needs of our unfortunate relatives-the insane.

When a physician is called to a case of insanity probably the leading question with him is, can the case be treated successfully at home, or must it be sent away? In reply I would say that most cases from acute blood poisoning, or recent injury, or of sudden onset can be treated at home, i. e., there is nothing in the mere environment of home to preclude a speedy and successful result. But as a rule the case will be a source of great discomfort and perhaps unbearable expense to the relatives or friends of the patient if the proper skill and attention are to be secured. In the great majority of cases, neither the proper medical or nurse skill can be had and thus it is desirable, even in most of the acute cases, to at once remove them to a place where all the requisites are provided. This will also be a relief to those at home, both as regards cost and care.

As regards cases of more gradual evolution, especially those partaking more or less of hereditary taint, there should be no question about their leaving home at once, for even their best friends and nearest relatives are usually sources of irritation in one way or another and their familiar environment, if not in some degree causative, is at least a fostering agency of their morbid mental state. There is nothing to afford mental diversion. A skilled medical attendant and travel may be all that are required. But comparatively few can

have these and thus a special institution is needed for perhaps ninetenths of all cases whether sharp or insidious in growth.

Now, notwithstanding that we have special institutions for the insane, a large number of cases are detained at home for a long time after first symptoms are positively evinced. This is due I think to two facts: Ist, the remoteness of the institutions, and 2nd, the uncertainty of the fitness of the institutions; thus the cases are withheld until the friends are worn out with care and the patients have only become less amenable to scientific treatment. I propose to briefly outline what I most emphatically consider the right step for ward in the matter of obviating these evils.

There are thus two points to be considered, viz.: 1st, the ingathering of the patients, and 2nd, the means for their cure.

As I have remarked the remoteness of our present institutions and prejudice against them, or at least, uncertainty of their fitness, have much to do with the late detention of patients at home. Usually both patient and friends share these feelings, for, with the insane, the essential trouble is volitional. The dullest are not so dead to facts as they appear to the common eye. Now to remove these objections as much as possible, a reception hospital ought to exist in at least every town of 10,000 or over. Indeed, every town of 10,000 population ought to have a general hospital with provision for the insane. There can be no objection to this, for where tact will not reduce a noisy case to quietness there is a medicament that will, it only being a matter of skill in its selection and administration. Of course, all

the insane cases should be kept apart from the rest. The hospital should have a physician in charge and resident in it or near by, but the friends or relatives of the patient should be at liberty to employ such consultants as they wish. Some of the rooms should be private and pay. For the insane this could only be regarded as a reception hospital and yet it would be as far as many acute cases need to go. If a case should prove hopeless from age and complications, it could either be returned home, sent to the county hospital, or elsewhere provided for. The cases of a chronic character would be retained only for a reasonable diagnosis and then forwarded to a larger and special hospital for such. To this city reception hospital patients should be admitted either with or without commitment papers. It should have in addition to a lay board of trustees, a medical board composed of some of the most prominent and trusted physicians of