flannel surface next the skin. The limb is elevated and held in the position which it is desired to retain, the plastic splint moulded accurately to it. and fixed in place by circular turns of a plain muslin or gauze bandage. The limb is lowered and held in proper position on a pillow for a few minutes till the plaster 'sets.' With good plaster this occurs in fifteen to thirty minutes. This splint can be easily removed by cutting the circular turns of the plain gauze bandage, should the limb swell or shrink. The application of a fresh circular bandage renders the splint as firm as before." The advantages of this splint over the more common way of applying plaster of Paris are readily perceived and may thus be enumerated:

(1) Its removable character.

(2) Its adjustability.

(3) The cleanliness of application.

(4) Its safeness as regards circular constriction.

(5) The facility and thoroughness with which antiseptic treatment can be carried out with it.

(6) The non-necessity of interposing any protective between skin and splint. (Buchanan.)

My individual experience in the use of this splint includes 37 cases, and my personal observation extends over a still larger number. Simple and compound fractures of the leg constituted by far the largest class in the list; in the latter variety the splint proved to be particularly valuable. The skinopening, if a compound fracture of the leg, being generally, as is wellknown, on the anterior surface, since it is here that the tibia lies subcutane ously, the wound, after having been thoroughly disinfected, may be dressed with perfect antiseptic precautions, the plastic splint applied to the posterior half of the limb, and subsequent change in the dressing be made without disturbing the relation of the fragments in the slightest degree. Its superiority over the fracture-box in this instance consists in its greater cleanliness and closer apposition of the fragments. Indeed, it has been frequently seen that this apposition is too perfect, not giving that limited freedom which sometimes materially aids union. This latter point is still under consideration.

COCAINE IN CHLOROFORM NARCOSIS.-Rosenberg, at a recent meeting of the Berlin Medical Society, advised the anesthetizing of the mucous membrane of the nose with a spray of cocaine solution before the administration of chloroform. By this means anæsthesia is more readily induced, and reflex action on the heart is prevented. Cocaine is an antidote to chloroform, and, therefore, its absorption would probably lessen the danger of the latter. -Canadian Practitioner.

REPORT OF A CASE OF INTESTINAL PERFORATION.

By R. H. WHITEHEAD, M.D., Chapel Hill, N. C.

The case which I am about to report to you is so different from anything that I have ever seen in my practice, that I have thought it not unworthy of being recorded. Moreover, I do not feel certain as to its nature, and shall welcome expressions of your opinior. on that subject.

The patient was a young man, about 18 yaars old, who entered the University last September. He gave a history of severe suffering from dyspepsia during the past summer, and had found it necessary to live almost solely on milk and crackers much of that time. He had recently improved, and' being a very ambitious fellow, had insisted upon entering the University. He stated that he had almost constant pain in the abdomen. This pain was often severe and was not limited to any particular part of the abdomen, which was flat and not tender to pressure. He had no diarrhœa, and was positive that he had passed no blood, mucus or pus from the bowels.

There was no objective symptom that I could detect except anæmia, which was striking.

He was so anxious to pursue his studies that I consented to his entering college on the conditions of light study and withdrawal in case he did not improve. He did improve, to some extent, for about a month, when he was suddenly taken sick with what seemed to be an attack of cholera morbus. These symptoms rapidly passed away, and on the following day I permitted him to sit up. A few hours after leaving his bed he was seized with violent pain in the epigastric region, tympanitis rapidly developed to such an extent as to obscure the liver dulness, and the temperature rose to 103° F. He lived five days, and died with all the symptoms of severe septic peritonitis.

I had suspected a perforation of the appendix, or, perhaps, of the duodenum; so that I was much astonished when I opened the abdomen post-mortem to find, not one, but a great many perforations of the small intestine extending from the duodenum to the colon. The appendix was apparently not diseased. The perforations varied in size from that of a pin-head to that of a garden pea. Some were situated on indurated bases, others had ragged, gangrenous margins. In several places the wall of the intestine was much thickened, hard and contracted, as if by cicatricial tissue. The mesenteric glands were somewhat enlarged. There were a few soft recent adhesions. The abdomen contained no pus, but its entire contents presented that livid hue which we see in the worst cases of septic peritonitis. I regret to say that no microscopical or bacteriological examination was made.

This is certainly not the usual history of any of the forms of intestinal perforation with which I am acquainted. The supposition which best explains the case to my mind is this: that the patient had chronic intestinal tuberculosis, as evidenced by the indurated bases of some of the ulcers and the cicatricial remains of others, that from some cause or another an acute inflammation was lighted up, leading to perforation of one or more of the ulcers, thus causing a septic peritonitis, which, in its turn, may have produced the perforations which had thin gangrenous margins.

*Read before the North Carolina Medical Society, May 15, 1895.

THE CARE OF THE INSANE AND THE TREATMENT AND PROĠNOSIS OF INSANITY.

BY P. L. MURPHY, M.D., Superintendent of the North Carolina Hospital, Morganton, N. C.

The subjects mentioned as the title of this paper can only be briefly dwelt on in the time allowed. They will be dealt with in a general way, and in such a manner, it is hoped, that will be interesting, if not instructive, to the general practitioner. The subjects will be treated separately, as far as possible.

All civilized States or communities make some kind of provision for the care of their insane, usually in hospitals and asylums. These terms mean in America very much the same thing, the tendency being to use hospital in preference, for the reason that insanity is now universally believed to be a disease, and is to be treated by physicians, whether by drugs or other means. The old, and at one time common, idea that an insane asylum was merely a place for the detention of persons who are dangerous or otherwise objectionable, to be at large, is fast giving way to the more modern belief that insanity requires, as other diseases, medical treatment.

The popular opinion that asylums are places of dark cells, of chains, of cruel and inhuman treatment, is slowly but surely giving way to the hospital idea, where the unfortunate inmates have the kindest attention and the best treatment. The former keeper is now an attendant, or, what is better, a nurse. Training schools for nurses are being established in most of the best hospitals; in short, everything is being done that can be to foster the idea. that persons inflicted with the disease (insanity) ought to have, and do have, the most careful and skillful medical treatment.

Other modes for caring for the insane are in use, namely, private institutions, in colonies, the Scotch or boarding-out system, alms-houses and jails, or outside of an asylum, technically called "single treatment."

A mere mention of these different modes of caring for the insane, except the last, will be sufficient to answer the purposes of this paper.

Private institutions were established to care for a certain class of patients, principally the wealthy, who wish to have better or more expensive apartments than State institutions furnish, or who, for a variety of reasons, do not desire to mix with the class who are sent to public hospitals. They are almost universally under the care of physicians.

The colony of Gheel, which may be taken as the type of all other colonies, has been known since the 17th century. "The legend of St. Dymphna attracted lunatics to Gheel from time immemorial with a view to cure by

*Read before the North Carolina Medical Society, May 15, 1895.

miraculous agency.

The lunatics who arrived in the colony were dependent on the church called in Flemish 'Zie ken kamer' (infirmary) and were present at the religious services which should deliver them from their malady through the intercession of the Virgin Mary. When the patients did not recover their reason after a lapse of nine weeks, they were often left with the inhabitants to wait for the next festival of St. Dymphna."

This custom seems to have been the origin of the system of family treatment which has continued at Gheel for several centuries. This system has undergone modifications since the colony has been subjected to lunacy laws, principally the establishment of a hospital thirty-five or forty years ago. But long before this the lunatics were regarded as patients.

Persons who become greatly excited, or prove unmanageable in the families, or have grave inter-current maladies, are sent to the hospital.

The "boarding-out," or the Scotch system of caring for the insane was, as its name indicates, first established in Scotland. The Scotchman, with his usual thrift and yet humane spirit, undertook to care for the insane in a cheaper manner than in hospitals, which are so expensive to build. The law requires every lunatic to be sent to the proper asylum, unless his removal has been dispensed with by the General Board of Lunacy, who have charge of all these cases in Scotland. Such cases as, in the opinion of the Lunacy Board, do not require hospital treatment, are boarded out in private families. If any of these should become violent, or need hospital treatment, the Board orders his return to the hospital. The patients are visited four times a year (oftener in case of sickness) by the parochial medical officer and twice a year by an inspector of the poor.

This plan has been adopted by the Massachusetts law in 1885 and partially so by Wisconsin, perhaps at a later date. I know of no other State using this system.

Care for the insane in alms-houses is almost universally condemned, especially in such alms-houses as are common in our States. The system has nothing to recommend it except the lessened cost, which is conclusive evidence of improper care.

Jails are used for the temporary custody of dangerous lunatics awaiting proper commitment to the hospitals, which course, while objectionable, seems to be unavoidable in many instances. It is to our credit in North Carolina

that nothing but necessity compels it.

In the Western Hospital district I

know of but one case confined in jail, and that is a criminal case.

Home care, or the treatment of single patients outside of an institution, is for the general practitioner the only practical point under this head of the subject. What cases should be treated at home, or outside of an asylum, is oftentimes a very perplexing question, and, it may be added, a very important one, for, rightly or wrongly, there is a stigma attached to a person who

has been an inmate of an asylum. That this odium is rapidly on the decline is true, but as long as such an opinion does exist, it is clearly our duty as physicians to save our patients from it if possible. It is, of course, proper to consider the damage likely to occur by such a step, and act accordingly. Young men and women often have their lives blighted and their future prospects injured by being sent to an asylum when they might have been restored by "single treatment."

Many young mothers break down in their first confinement and rapidly recover if properly treated. We will surely confer a great blessing on them. if they can be relieved outside of an institution.

It

To properly arrive at the answer to the question, What cases can be treated as "single patients," I will first attempt to show those whom we cannot hope to care for at home-in other words, make our diagnosis by exclusion. will be found that the number whom we are able to give "single treatment" is exceedingly limited.

In our own State one of the first difficulties that, in the vast majority of cases confronts us, is the want of sufficient money to give our patients such care and treatment as he needs, for we will find that single treatment means travelling, in some cases, with an attendant; and even at home the most assiduous watching by the physician and nurses. Few of our people are able to bear this expense, even if the patient has everything else in his favor for private treatment. It is plain that dangerous homicidal or suicidal persons need sequestration, that noisy and destructive ones-those disposed to burn, to steal or commit depredations of any kind, must be restrained. Acute mania, delirious melancholia and even melancholia of less acute form, does better when sent to an asylum; indeed, a cure is hardly to be expected outGeneral paralytics, because of their tendency to steal and to

squander their means, require sequestration.

“The

Persons who have hallucinations of hearing are always dangerous. mystics, besides their practices of fasting, asceticism and self-inflicted violence, even to the extent of more or less serious mutilations, often attempt the lives of others in obedience to the sense of duty that inspires them. Those persons who believe they have received from heaven missions to destroy great or prominent persons, others with the view of pleasing God by sacrificing children in imitation of Abraham, still others who have delusions that they are persecuted, those suffering with subacute mania, with acute and subacute alcoholic insanity, those with delusions of grandeur, paranoiacs (primary delusional insanity), all these should be confined.

There are many patients whom we cannot pronounce dangerous, but who seem unable to exercise self-control enough to recover outside of an asylum. The following case will fully illustrate this class of cases: A short time ago a gentleman visited me with his medical adviser with a view to putting himself in the hospital. He was a shrewd business man, one who had accumu