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Related post: the single and essential exception that the sleep did not improve,
or was wor.se. This was a valuable indication in the prognosis
of permanent return to reason. To the cardinal signs of con-
valescence should often be added the disappearance of decided
fear of a return of the attack and dread of the stigma to follow.
It was iinportatit to he informed regarding the normal and usual
physical troubles of the patient, as their reappearance was an-
other and valuable indication of recovery ; also in regard to a
knowledge of the secquence of immediate prodromata of an at-
tack. They were often repeated in reverse order while the pa-
tient was getting well. Complete mental rest during menstrual
epochs, so highly important at this time, was often disregarded,
and application of the mind, even to a slight degree, in study or
other work, was equally to be deprecated. Early discharge
from the asylum, or from special care away from home, was to
be advised against, as a rule, especially in cases of melancholia
with a history of suicidal attempts, and after acute mania, the
most exhausting form of ins.mity, and one which left the patient
particularly susceptible to slight influences for a long time. On
the other hand, we should frequently advise early removal in
other cases convalescing from melancholia, particularly when
home.sickne3S was a marked feature and occasionally when there
was refusal of food. Certain patients with mild mania, also
paranoiacs who were independent in the asylum and actively
opposed treatment, were steadied by outside life. A change
also worked well until its novelty had worn off. The first year
or so after recovery was a very critical time. The reader gave
a number of indii'ations in special cases, and suggestions for
prevention of relapse.
These remarks ai)plied chiefly to well-to-do patients. An
important branch of this subject was the means for the after-
care of the pauper insane. There was practically no pro-
vision outside of asylums for this class, and practically little
advice or other help was given these unfortunates on leaving
asylums; while for the physically sick, on the other hand, there
was abundant provision for their care during convalescence,
and the discharged convict was greatly helped and encouraged
by charitable societies for the purpose. Asylum physicians
often hesitated to set certain patients, whoso menial condition
seemed to have so far im|iroved as to make it useless to keep
this class longer under care (and even some who had fully re-
covered), at lil)erty, for fear that, thus suddenly thrown on
their own resources, without oversight or perhaps means of sup-
port, they would fall back into their old habits of life which
had given rise to their insanity. This fact, and their delicate
mental condition, often rendered them easy victims to designing
people.
These and other reasons had led to the formation in France
of protective societies, called Societies of Patronage^ under
official auspices. Their duties were to .aid convalescent or re-
covered pauper patients by gifts of money, clothing, tools, re-
demption of articles in pawn, payment of rent, admission to
convalescent homes in cottages intermediate between confine-
ment and complete freedom, or in hospitals or houses of refuge ;
securing situations for them, and finally their supervision wher-
ever employed. This work continued during the first month
or two after the patient's discharge. iSimilar societies or means
of relief had been adopted in England and Scotland. They were
described in detail. There was no better work on the score of
both humanity and public economy than the adoption in this
country of similar means for the prevention of insanity.
Dr. E. D. Fisher was of the opinion that patients left the
asylum too early. In cases where they were oversensitive re-
garding their previous incarceration, something must he done
to care for them and obviate a relapse. He was in favor of
establishing convalescent homes for such patients, and spoke at
length in confirmation of the views of the author of the paper.
Dr. Dercdm thought this matter a very important pha~o in
the care of the insane. It was, however, quite difficult to deal
with individual cases. Where the element of exhaustion had
been a prominent causative factor, the patient required deten-
tion and care much longer.
Dr. Stare was glad to know that Dr. Stedman favored the
earlier removal of nielanchohcs from asylums. One of the chief
difficulties was in controlliug the families who did not know
how to manage the patient alter his return.
Dr. .Jones, of Minnesota, said that Ticlid 250 Mg in Minnesota, since the
word asylum had been changed to that of hospital, it had tend-
ed to remove any of the supposed stigma that had been usu-
ally attached to people who had been in institutions for the in-
sane.
Dr. Knapp and the President concurred in the views ex-
pressed by the reader of the paper.
Dr. Dana said that the subject was of great economic as
well as medical importance, and he would suggest that a com-
mittee be appointed to investigate the matter. This suggestion
was then presented in the form of a motion, which was carried.
The President then appointed as a committee Dr. Stedman, Dr.
Dana, and Dr. Dercum.
A Suicids's Erain with Two Pistol-bail Wov.nds.— Dr.
Burt G. Wilder, of Ithaca, exhibited a specimen and showed
a dozen photographs of various aspects, and blackboard diagrams
of the left side, and of a transverse section at the level of the
fatal wound. W. I. B., a dentist, thirty five years old, of llliaea,
N. Y., was found dead in his office on the 7th of April, 1894.
A 0*22 revolver was clasped in his right hand. There were two
bullet holes, one in the middle of the forehead and the other in
the right temple, neither ball having emerged. In accordance
with his written directions, the brain had been preserved in
the museum of Cornell University as specimen 3,129. The
first ball, presumably deflected by the skull, had passed caudo-
ventrad to the cranial floor, and had been reflected dorso-
caudad at nearly the same angle to a point just cephalad of the
2H
PROCEEDINnS OF SOCJETJES.
[N. Y. Med. Jocr.,
precominissiire, where it Ijad lodged, having merely ahnided tlie
niesiiil surface of llie left Irontal lobe. The second ball had en-
tered at the rij;ht subfrontal fryrus, passed obliquely siiiistro-
caudo-dorsad, hail toru the callosum and intervening: stnictuixs,
and emerged in the central seeimd left central fissure. As there
had been no suspicion of foul play, and documents in the de-
ceased's handwriting had declared his intention to commit sui-
cide, the ease exemplified the possibility of two self infiisted
bullet wounds of one brain. The fissures presented many pe-
culiarities. The most perplexinf; was the apparent coexistence
of two central fissures on each side. The only two similar cases
hitherto observed had been recorded by Giacomini and C^lori.
Suicide had been committed by a grandfather ai-d one ancle, and
attempted by another uncle.
Dr. Dercum had examined a large number of brains of the
insane, but he had never seen such an instance as that presented
by Dr. Wilder.
Dr. Dana said that he bad no doubt tliat the anterior of ihe
two fissures was the fissure of Rolando. The interruption of
this Buy Ticlid fissure on one side by a bridging convolution was extreme-
ly rare and very interesting. The brain had presented a uniipie
fissuration. He could not understand how a primary fissure
like the Rolandic could be doubled in any event, and was skep-
tical of the genuineness of reported cases.

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