patient. I recall visits to institutions where patients work in long lines, being driven along just like oxen or mules, and it always gives me a feeling of very great discomfort. I believe this has been very much overdone and it is time attention should be called to it. I see a paper is to be read on the cardiac conditions of the insane and I expect to learn something from it. I am-satisfied disturbances are caused from labor in this way that contribute to the bad condition of the patient. I think the patient should be carefully examined as to the heart and the blood pressure and a clinical record should be kept. A sphygmographic report should be made. Very often those patients would then be relieved from labor that is injurious to them. Some time ago I had a patient in an acute maniacal attack which ceased soon. I put him on his back in bed and required him to remain there for a week and then I permitted him to get up. Gradually he improved until he pronounced himself well. I explained to his friends that the trouble was peculiar and that when he resumed his occupation it would bring back a return of the mania. He went back to work and later came again to the institution. After the second time, when he was convalescing and ready to return, he joined in chasing an escaping patient and he was again brought back.

DR. WISE: There was one point I think Dr Runge brought out very well. In fact it was the keynote of his paper; and that is psychic treatment as it concerns the individual patient. One patient may be benefited by a given amusement, and another may not. It may not be prescribed, but if they want it and need it they should get it. Their pills should be sugar coated. Whether it will do a patient good must be determined in each instance.

DR. RUNGE: It was stated that my paper did not bring anything new before the Association, and that is true, for it deals only with what is commonplace and self-evident. My intention was only to fill the gap in our textbooks, where the subject of psychic treatment is condensed to about a page, often with the excuse that little can be said about psychic treatment. That is absurd, for I am sure I could write a book on it. I think Dr. Burr takes his position too lightly. The question is a very important one. Any of us who are capable of self-analysis, who are not steeped with self-satisfaction, may well go home and think over what we are doing for our patients. Have I the means to reach all of my patients? No. Have you? No. I say this without knowing your conditions definitely. We cannot reach all cases. When I pass a patient who can barely understand my greeting, I do not fail to speak to him, for even that much may give him a spark of pleasure. It is unjust to treat such an important subject in the manner of Dr. Burr in this discussion; it simply lulls us into security. It is after all only a question how to get the money to carry on such treatment. For that purpose we should have at least one or two medical men and women as psychic agents. I personally would be willing to give them fully as large a salary as I get, for I believe their services would be worth even more than mine.

OPERATIVE WORK AMONG THE INSANE.

Anne Burnet, M. D.,
Clarinda, Ia.

It is not with the expectation of saying something new on operative work among the insane that that subject has been chosen for discussion in this paper. The influence of surgical operations in possibly causing and perhaps curing some cases of mental disease has been ably discussed before this Association by those of wide experience in the care of the insane. This title, however, will cover as well as any other could some experiences which have come to me in my hospital service among the insane women, especially with reference to operative work for the relief of pelvic disease.

Alienists were long severely criticized by the other members of the profession for paying no attention to the necessity of examining insane women for possible disease of the pelvic organs requiring treatment. But surely of late years such criticism is unfounded. Yet in a paper published in the March number of a medical journal such criticisms are renewed and the claims for the cure of insanity in women by operations on the organs of generation as strenuously asserted as ever. The plea is made by the writer of that paper after citing several cases of recovery from mental disease as a result of such operations at his hands that alienists and gynecologists should get together on this subject. He says: "I am free to admit that alienists have gone to one extreme and gynecologists may have gone to the other. We should get together. There is such a thing as curing these cases by gynæcological work." In a general way we may agree with that statement, but it is far too sweeping. There is a wide difference between operating in all such cases and operating in none of them. And it would seem fair under the circumstances to suppose that the alienist would be the better

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judge as to the propriety of operating in any given case. And when the question comes up of removing normal organs with the expectation of preventing or curing mental disease it is a serious matter.

That disease of the pelvic organs does of itself cause insanity I do not believe; and that the removal of normal organs normally discharging their functions can cure mental disease I can not conceive. That this has been done is matter of record. If one were to concede that diseased pelvic organs might cause insanity the question would remain with reference to perfectly healthy organs having such an effect.

In most if not in all cases in which pelvic disease seems to have been an active factor in causing mental disorders a history of strong neurotic tendency or predisposition will be found,—a susceptibility, an instability of the nervous system which should be taken into account. Keeping this in mind one can understand more readily why a condition which in one woman may produce marked nervous symptoms will be borne by one of less irritable nervous make-up without her knowledge often times, at any rate without undue disturbance. If this neurotic element is ignored no treatment can effect a permanent cure. Such persons are continually on the borderland of possibilities, requiring only some condition or circumstance to destroy the delicate balance between mental health and disease.

Several reasons might be stated for objecting to so great stress being placed upon the influence of the pelvic organs in causing mental disease.

First: The most severe cases of pelvic disease in my experience have not been among the insane but in general and dispensary practice among the sane.

Second: The most severe cases of mental disturbance have presented no pelvic lesions.

Third: Several cases having severe pelvic lesions have made excellent recoveries from intense mental disturbance without operative interference. One case at present in the hospital has complete laceration of the perineum with all the accompanying displacements which occur in that condition in its most severe forms. When admitted she was very maniacal and nothing could be done in the way of treatment for local conditions. She has made an excellent recovery without operation, but will prob

ably be given the benefit of an operation to promote her comfort in the future. This patient has a marked neurotic history and had an attack of insanity before she was married.

A fourth reason for objecting to this theory is that cases presenting pelvic disease and whose delusions are connected with the sexual functions were worse rather than better after the operation for the removal of the offending organs-in some cases drifting into a rapidly deepening dementia.

Insanity is a disease of the mind and the brain is the organ at fault. It is manifested in the same forms, presenting the same symptoms in both sexes. Like causes produce like effects and surely the converse is equally true. In no classification of insanity that I have seen has any distinction been made with reference to sex, with the exception perhaps of puerperal insanity.

- That diseased organs,-pelvic, abdominal, thoracic, may and frequently do affect the general health, and in that way the health of the brain, no one would disbelieve; and that all such conditions should receive necessary treatment, medical or surgical, no one would question. In fact such treatment as will restore physical health should be insisted upon so far as practicable. But the recommending of operative treatment for any and all such cases is greatly to be deprecated.

A patient recently admitted to the hospital at Clarinda stated that the physician had told her husband that she would have insanity of the womb unless she were operated on. Her pelvic organs were removed and to their dismay her mind became deranged.

Since beginning service in the hospital at Clarinda, eleven cases of insanity following operations for the removal of all or a part of the internal organs of generation have been under my care. In nine of these cases the operation was done because the patients were nervous and complained of some pelvic pain which failed to yield to the usual treatment for such cases. One of these patients was an epileptic who may truly be said to have suffered many things of many physicians,-the oophorectomy being the last. Her seizures had grown steadily worse and after the last operation her mind deteriorated rapidly. Fortunately for her she passed into status epilepticus shortly after coming to the hospital and was soon released from her unhappy condition.

Two of these patients were rather above the average in intelligence and could give a fairly good history of their respective cases. Both of them had been very nervous and stated that the operation had been done to relieve that condition rather than because of existing disease in the organs removed. There was a neurotic heredity in both cases. One had been operated on

five and the other two years previous to admission, and in both the nervous symptoms had grown progressively worse until the one became very delusional and attempted suicide several times before being committed to the hospital. She was discharged recovered after five months but was returned within one week in a condition of deep depression, having attempted suicide again. She remained in the hospital about eighteen months and was then again discharged and has remained well up to date. The second of these two cases recovered after several months and was discharged. She remained at home a year and a half and was at the end of that time returned very much disturbed mentally. After six months she was again discharged and at last report was doing well. This patient suffered greatly from a peculiar sensation of something impending over her head -something about to fall upon and injure her seriously. She would start back as though dodging this object and became so harassed by the constant dread of it that she ran away from home to get free from it. This gradually disappeared as she improved in health.

It is unfortunate that the actual conditions found at the time of operation in these several cases were not included in the histories given on their admission to the hospital. An effort has been made to secure more definite information but without success except in a few cases. In some of these cases the organs were found to be free from disease. One is said to have had a tumor of the broad ligament which seems rather an indefinite reason for removal of both ovaries. In one- a young girl of sixteen years-the ovaries were removed with the expectation of curing pernicious habits. When admitted to the hospital this girl was suffering from chorea and marked hysteria and had delusions of persecution. She was a mere skeleton but soon began to improve and in time made an excellent recovery and has remained well for nearly a year.