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having become excited, and left home as before. He again passed through a similar experience in the form of disease and treatment, though he remained about seven months the second time before going home. He was at home only about one year, when he again passed into his former condition, and he was brought back a third time. At the time of this writing he has been in the Retreat nearly fifteen months, never acutely excited long at a time, but frequently passing three and four hours of the day in a stupid condition on the lounge, and always sleeping enough at night. He is now making his third recovery, and will soon be ready to try the experiences of home-life again. During his third period of treatment, the state of hebetude has been more profound at times, and we have had much difficulty in preventing the habit of masturbation. To prevent this he has been kept in a condition of vesication for weeks at a time. It will be observed that each succeeding stay has been longer, the characteristics of the disease more marked, and a recovery seems less probable. There have also been more indications of dementia during his last attack than in either of the others, though the mental symptoms, so far as they relate to degrees of excitement and dullness, have been quite similar. Since convalescence has become established this third time his brain has been more free in its activities than after his former recoveries. He seems more cheerful, rides and walks with pleasure, joins in the dances, writes short, connected, and intelligent letters to his father, and appears to be interested in reading during some portion of every day.

The above case illustrates another peculiarity of this form of insanity, which is its tendency to recurrence. In the large majority of cases more than one attack occurs.



Case 2—As Age Advances the Tendency to a More Protracted Period of

Excitement Increases—The Catamenia—Cases 3 and 4-Absence of Acute, Prolonged Excitement or Great Depression, also of Fixed De. lusions and Hallucinations-Condition one of Partial Dementia-Cases Occurring at a More Advanced Age-Symptoms More PronouncedIn Females Absence or Irregularity of the Catamenia— Probability of Relapses— Importance of Avoiding a Too Farly Removal from Asylum Life-Danger of Masturbation – Treatment — Importance of Restraints and Regularity of Lise-Medication-Educational Influences,Occupation.

CASE 2.-R. R. (female), aged sixteen, but appears younger; a person of good habits; had scarlet fever several years ago and diphtheria four years since. About a year prior to admission she had been sent to school in a convent; was very ambitious, over studious, and much chagrined because she could not dress as finely as some of the other girls in the school. Before leaving home had been much indulged by her father, her mother having died when she was an infant. She had also received unusual attention from others, and became vain of her personal appearance. For some reason, probably inability to go on with her class, she left school and returned home after a short trial in study.

The development of insanity came on quite suddenly, after taking a long ride in the winter, soon after leaving school. She became incoherent, hysterical, wildly talkative. This state passed away after a few days, and she became dull and inclined to wander about in an aimless manner, and endeavored to leave home, saying she wanted to get a situation in some family, thought there was not much the matter with her, and became so persistent and determined to leave home, threatening to commit suicide if she was not permitted to do so, that it became necessary to restrain her by mechanical means.

When admitted she was anæmic; had a dry skin, a pale and slightly coated tongue, and feeble pulse. The memory and mental action were much impaired, the thoughts confused, and replies irrelevant. She had not menstruated for several months. She remained during several weeks in a listless and confused state of mind, with very little interest in what was going on around her; was inclined to lie on the lounge in the hall during the larger part of the day, in a condition of semi-stupor ; when aroused would reply in a vague, abstracted manner, and talked sometimes incoherently about medicine, the convent, and staying all night. At other times would pay little attention to what was said to her; kept her eyes closed, was dull of apprehension and apathetic, requiring to be led to the dining-room to take food, and even to have it placed in her mouth, and then often left it unmasticated. During one period she required to be dressed and undressed like any child. At the present time she has recovered a considerable degree of her mental activity; has become interested in reading, converses with the physicians and others; has written a letter to her father, requesting to be taken home. She takes food more freely, and is willing to take more physical exercise.

The immediate cause of the disorder in this case was, doubtless, over-study, anxiety, and chagrin that she was not able to achieve as high a stand in her class and appear as well as her schoolmates. These experiences, acting upon a neurotic temperament at that period of life when the normal forces of the system were being largely called into requisition to fully establish the reproductive function, proved sufficient to cause derangement of the mental function.

In my experience this tendency to stupor has been present in cases occurring before sixteen or seventeen years of age, and in females before the catamenia had become fully established. The regular appearance of this function is one of the most auspicious indications of an approaching recovery. In case it is long deferred the stupor may become very profound, the circulation of the extremities cold, the breath very offensive, all the secretions very deficient, and for the time being patients have the symptoms of primary dementia.

In the .cases already detailed, there existed enough excitement of the motor centres to lead to wandering (or an effort to do so) from home. While this condition continued there was little mental excitement, but a confused state of mind, attended with inability to comprehend or appreciate the true relation of the environment.

CASE 3.-J. K., age sixteen, and small for his age, weighing only ninety-two pounds, and with a scar on his forehead from the kick of a horse, was admitted in July, 188–. His father and mother are separated; his father has a violent temper and bad disposition. A few months previous to admission, he had become absent-minded; lost interest in all employment; showed a disposition to be ugly; on several occasions struck his mother and threatened to kill her. He could, however, conceal his vicious propensities when in the presence of strangers or persons


not living with him. When admitted he was depressed, and at times inclined to shed tears. He confessed that he had masturbated, and said he had a “bad disease." He did not sleep well, and was often out of bed in the night; refused his medicine, saying it was poison. He had an elongated prepuce, which was circumcised after considerable resistance.

At one time he was inclined to stand on the floor of the halls during long periods, and refused to sit down when requested, and in various other ways, such as refusing to take food until he was fed with a stomach tube, exhibited a disposition to be contrary. Afterward he became capricious, mischievous, and disorderly, and when required to take food would swear and cry and shout for a long time. He became destructive of books, plants, and furniture in the hall, and required to be vesicated on account of the habit of masturbation. During the month of June, 188-, there occurred a profuse discharge of pus from his left ear, which was attended with considerable pain and constitutional disturbance, and continued during several days. He remained in a decidedly improved condition after this for about two months, but then relapsed into his former condition. During the last year he has alternated between a condition of apathy and stupidity, in which he is very reserved and moody, never engaging in games or conversation, and replies to questions only by saying, “Don't know!” and a state in which he is mischievous and unruly, and inclined to annoy everybody with whom he comes in contact. During this time he has grown in stature considerably, but has not improved mentally. His mother visited him, but he would scarcely recognize her, and throughout the interview preserved an apathetic and stupid attitude. The

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