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sponsibility is his; will be act promptly and wisely, or will be wait for a suicide or a fully developed insanity before be wakes up? The difficult early recognition and its importance warrants this impertinence.

Contrary to the rule governing the conduct of insane cases, these patients know they are not well. A few do not seek a physician, but linger along in an indefinite state of healtb, frequently taunted and poked at for their inactivity, and may eventually get well without the psychosis being recognized. The majority, however, voluntarily ask medical aid but, in a very logical manner, misconstrue the cause or seat of their trouble. This is where they begin laying the foundation for false beliefs which eventually mature into delusions of an insane character; but even with tbe dawn of insane delusions they remain so clear in conversation that the mental phase is covered up. They may admit being somewhat depressed and unLappy, but in the presence of the physician they make special efforts at self-control even to the point of being under great internal stress; and thus the physician is kept making a misdirected search for some mysterious physical condition which exists only in the patient's mind. In this way the family and physician are alternately existing between excrementitious matter and perspiration till the actual diagnosis is revealed by some sudden insane impulsive act in a moment when mental inhibition (self.con. trol) for the first time is entirely lost.

Tbe following olinical illustration pictures the facts in mind:
A miss of 20 years of a neurotio but not insane beredity.

She was bright, active, but a sympathetic and sensitive girl. Two years previously she mourned the death of her father, her inseparable companion. She lived under great nerve pressure and forced cheerfulness that she might forget. She assumed unusual cares in the home and was never idle. Her ambition and will power forced the whole brain to work without rest and relaxation, beyond its inberent nutritive and dynamic support. The strain carried the exbaustion beyond physiological recuperation. This should not occur in a brain in which the active force giving centers are in normal co-ordination with each other. Such a brain will not allow the hyperenergy of one center to overwork its subordinate centers but, in. stead, it will equalize the fatigue and compel rest. And yet we boastfully pride ourselve on driving the brain energies to exceed the generating ca. pacity to meet the demands of so-called business circumstauces or the ego of an hypertrophic imaginitis. This is the pace that brings disaster to neurotics.

After eighteen nionths of latently active internal mental stress in externalizing the product of overdrafted energy, the smile began to fade, the facial sunlight grew less radiant, buoyant interests were less manifest and little blusters and temper irritations preceded the seemingly barm. Jess cloud on the mental horizon. In the home she was depressed, com. plained much, found fault and showed the disagreeableness of not being well. Even the favored lover no longer received encouragement, and with that sort of a "its no use, its not worth the while” inference, she dropped him out of her life without bis knowing why.

To the family physician she faintly smiled, was not well, but he grasped nothing in particular as being the matter. In the quandary of no diagnosis the digital examination remained to clear the mystery in an innocent virgin. Like the proverbial nose, never found without slight deviation from the median line of the face, the non-expert index finger advised correction of position of a uterus, reached with diffioulty, never reached before, bad never functionated beyond maturity and never had deviated from the moral or godly laws—but just that imaginary med. ian line. And so this virginal bloom was poked, gouged and insulted for six long months; and every treatment meant a degree of shock to her sensitive brain. At home she grew more restless, at times walked the floor, cried and was depressed; in the presence of the public, visitors and ber physician she smothered her morbid feeling, talked clearly and largely covered up an array of fears, anxieties, apprehensions and dreads. At little periods of relaxed self-possession, when a glimpse of the mental undercurrent was revealed, she was chided for "imagining things.

Her insomnia was persistent, and though she slept with her sister, a trained nurse, the latter was ignorant of the continued insomnia, the patient never moving all nigbt, but remaining in that nervous thinking, staring, wide-awake state. Sleeping together as usual, the sister was awakened one night just in time to see the patient at the medicine closet in the act of neutralizing ber meutal indigestion by flushing the stom. aob with a bottle of carbolic acid. Three months isolation and treatment at the sanitarium saw ber convalescent.

Another, a strong man of 30 years, weighing 180 or more pounds, had worked his way up from inexperience to manager of a large corporation department. Anxious to succeed, determined to win, be applied his brain energies continuously without rest. A brain hypertensioned, hyperstrained, hyperstressed, resulting in hyper-energized brain centers, incoordinately over-working auxillary brain centers till the degree of exhaustion, till the brain fag exceeded the interent power of the brain cell to meet recuperative demands. His quick, decisive mental alertness became hesitating and indecisive. His easy mental thought and calculations became labored and tardy; he found himself pondering over trivial common. place things. He could not make his “thinker" work up to the point of completing a thought and acting upon it. Fears and apprehensions and doubts and mental depression appeared in bis own consciousness, but he kept his feelings to himself and talked clearly and with exactness to others. Some vasomotor chill and beat Aushing appeared, and be was beavily dosed with quinine to overcome a malaria which existed only in the diag. nostician's mind; the quinine put the patient out of business but the vasomotor symptoms continued.

Dr. Geo. W. Lilly was now called in and at once requested my services also. We found a fine specimen of physical manhood enjoying a . nice bed, a cool room and much attention in being waited on. He received vs cheerfully and was clear in all bis mental processes, but bis facial expression occasionally cast a reflection resembling a mirror, the backing of which had been tainisbed and his enotions were too easily touched. These two features were most noticeable when we were departing; he was afraid to be alone. While this fear was only slightly manifested, was easily controlled and covered up by him, and therefore ordinarily not de. tected, it told me a volume and caused me to positively advise never leaving bim alone. In fact to isolate him from his family.

Acoordingly Dr. Lilly brought him to my sanitarium. The next day his wife took him home again. His absolute mental clearness to her con. vinced her tbat her busband was all right, mentally. No argument could convince her that any cloud dotted his mental horizon. She knew him better than any living being.” I told her be would get well if com. pelled to remain under treatment, but, madam, I added when you now go down my steps with him you start to his funeral; when you look on bis dead face, console yourself with the knowledge that you alone are respon. sible for his death-obe lost her temper, spluttered, made a scene of her. self and in departing ber silk skirts rustled a defiance that only belongs to woman. She was mad, mad clear through, because I tried to force her to see what she could not see-till a few days later when her husband walked into the house, tossed an empty carbolic acid bottle on the bed with tbe remark: "I have done it; its all over." First assistant police surgeon, Dr. R. E. Castelaw, was called but found him dead.

This patient was a young man of expert ability, his wife "knew bim better than any living being; he was just tired," sbe said; "be only needed a rest;" he got it in suicide, the end of a case of brain fag, the sane type of insanity.

The only excuse for his death was the utter impossibility to get bis family and friends to understand that anything seriously ailed him, there. fore, their failure to think for him and make a business of getting bim well. Had be possessed a sick liver, a sick lung, a sick kidney or even a nauseated stomach, he would have been overwhelmed with family anxiety and physician's care; but a sick brain was an unheard of thing, and the friends could not understand.

Again, on August 20, 1906, the family of a well-to-do farmer and stookman insisted on taking him bome from

my sanitarium. He resented their efforts with reasouable argument, Every excuse for taking bim home was met with the realization that he was not well, and that be could not get the mental and nerve comfort and rest and care at home or else. where; in bis isolation be was restful, mentally relaxed and at ease; out. side influences worried, fretted and tensioned him and caused him to have fears and apprebensions of his own self and his own acts toward himself. These subjective feelings filled him with alarm yet with bis clear reasoning and alert expressions, he was able to obscure bis undercurrent delusinal mental trend His friends could not see it. Even an assisting physician intrigued with them bebind my back, deprecating the seriousness of my views of the case and intimated that the patient would benefit by his home freedom and open air. My advice against his going bome and interrupting the quietude of his isolation and beginning convales. cence was, when urged on them, actually spurned and received with con. tempt.

They knew their father better than I did. I bowed them out with the assurance that they would have a funeral and hoped they would enjoy it - just nine days later they were entertaining him with a walk in the "freeopen air,” the century old cureall for minds diseased, and after the fast train had passed through the village the coroner arranged the human frag. ments for legal disposition.

And so endless clinical data could be cited from a list of over 12,000 cases observed in my life's practice, showing the inevitable trend of this so-called, sane type of insanity, namely, suicide before the mental illness is recognized and the continued recurrence of the suicidal idea and impulse and a long diawn out convalescence, or a chronic fixed insan. ity when early and successful treatment is not employed. However, if recognized in the incipienoy and properly treated every uncomplicated case should recover with no essential reason for a relapse.

A Hint to the Surgeon.-I advise against major operations where there is an under current question of the mental status. Wait a wbile and study the case closely, if in doubt, unless waiting jeopardizes life. In my practice 67% of post operative insanities have died witbin a few days to four weeks. * My experience in many cases of acute insanity, precipitated by surgical operations, therefore embarrassing to the surgeon, is that the operation was only the last straw flying in the face of an unsuspected but previously existing sane type of insanity; the mental illness existed and only needed the depletion of the operation to overthrow the already overstrained inhibition.

At this writing I have two such cases under observation and a third case recently died in the fourtb week after the operation. Such a dilema is not easy for the surgeon to explain away, yet it occurs with greater frequency than is suspected.

This sane type of insanity is a depressive psychosis. It is exceed. ingly common in a mild, recurring form in the lives of some women at nearly every menstrual flow. It is well known that inherent neuroses like migraine, bysteria, epilepsy and neuralgia come and go with the rise and fall of the repletion and depletion, dependent upon the systemic menstrual cbanges. And so it is not strange that extreme blueness, causeless sadness, fears, mental depression, apprehensions, suspicious and perversions of instincts should result from depletion of the organ of the mind, the brain cortex, inherently weak, or, weakened from other causes. The per cent of women who experience this in some degree, between the alpha and omega of the catamenia is alarming and the obeerful consolation is that in only a few does the psychic pendulum swing over the borderline. In the past twenty years I bave been consulted by a small army of husbands who would relate the emotional suspicious, delusional and depressive mental states of the wife around this period. Frequently the seemingly causeless mental attitude disrupted the home tranquillity and still, in the midst of the mental perversion, the presence of a visi. tor would stimulate the patient to the point of mental self-control. ·

Such brains are unstable and are in danger of doing many insane acts during the menstrual depletion, especially if subject to more than the ordinary mental stress and strain. It is this class of mothers who frequently kill their children and then commit suicide, leaving a mystery wbioh only meddlesome or ignorant people can fully explain.

I have seen many of these women swing from the morbid monthly kabit psychosis to an acute insanity after a provoked abortion-the socalled early and barmless abortion. My clinical observation classes these abortions as pernicious in precipitating an acute insanity in this class of women.

*NOTE: of 48 cases, 32 died from a few days to four weeks after operation.

Scientifically computed the encouragement of the marriage of these people is the most aggravating form of race suicide.

The more stable members of this mentally unstable class do, many of them, rear a passing average offspring, when fortunate in marrying a strong, healthy companion; but wise nature has a quiet way, as in the first case cited, of Tricking and side tracking many of them into old bachelor or old maidenhood where they do our race the least possible harm by spilling the seed on the chip and wasting their sweetness on the desert air.



R. J. Midgley, M. D., Omaha Neb.

Lecturer on Therapeutics, Nebraska State University.
ERE it possible to go back in the bistory of evolution to the time

when the maternal instinct prompted the first mother to apply
the sympathetically soothing influence of its lingual muscles to

the bruises or wounds of its young, it would be possible to conjecture with some reasonable degree of certainty as to the era in which psychotherapy was first used and thu practice of the healing art had its beginning. This desideratum, however, is no more possible of achievement than is that of ascertaining at what time in the development of the genus bomo the first mother kissed away the pain which her infant experienced from the first forceful impact of its head on mother earth.

That the practice of the most noble of professions bad its origin in some such manner as this, is attested by facts within the memory of his. tory. Developing as it did in primitive man, at a time when the emo. tions were most readily played upon because of a misconception of natural phenomena, the practice of medicine was practically, a comparatively so re. cent a time, nothing more nor less than the practice of psychotherapy; the whole stock in trade of that worthy ancestor of ours, the medicine man. That even now in this our enlightened twentieth century mankind, which can no longer be desiguated as primitive, is incapable of interpreting nat. ural phenomena is proved as well by the number of votaries at the shrine of that misnomer, Christian Science, as by the neglect which the most ancient, the most powerful, and the most widely employed of therapeutic measures receives at the hands of those who owe their very exist. ence as physicians to its potency.

It is probably to that trait of human nature wbich causes it to seek always after Gods strange and new, that we owe both the search for new remedies which are no sooner discovered than forgotten, and the overlooking of this common, this omniscient and omnipresent measure. Certain it is, however, that so long as mankind lives psychotherapy will continue

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