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was removed from the hall to another, and where she could pass out and into a large yard. She used to like to have her food, while here, in one of the summer houses, and was gratified in this respect by the attendant. The second day, while at dinner, she managed to climb over a fence some ten feet in height, and disappeared. Notice was given within a very few minutes, and search was made in all directions, but without avail. The next day (Sunday) a telephonic message was received from a neighboring town, inquiring if any one of our patients was missing. It appears that she had passed directly through the city, and had walked all the way up the railroad and through the town to the small house of a laborer, arriving there about sunset, and inquired if she could remain all night; was made welcome, and at once began to make herself useful by caring for a baby in the house. She carefully avoided saying anything to indicate where she had come from, and appeared to be very well; but the scanty amount of clothing she had on and her reticence led them to suspect that she might be from the Retreat. When called for, she stipulated certain conditions on which she would return, which were entirely reasonable, and at once acceded to. Within one day after her return she again began the round of excitement, destruction, denudation, and unnatural conduct. This continued for several weeks, when she rather suddenly began to improve, and at the end of a month returned home, where she has remained well since. She at no time gave indications of delusions, hallucinations, or dementia; her mind seemed to be remarkably active, easily excited, though the periods of excitement were not long protracted.

It will be observed that in the female patients there has existed an absence or irregularity of the catamenia, and in

two of the males a tendency toward the habit of masturbation. A similar statement could be made in regard to a majority of the cases of pubescent insanity which have been under my care. The question is suggested as to how far, if at all, the mental derangement is dependent upon the abnormal condition of the sexual system, or whether the latter is the result of the former? Probably in a large majority of cases the derangement of the sexual system exists as simply a concomitant, and not a cause, of the mental condition.

It may be admitted that the mental function in the case of females may become clouded and imperfect in its expression in consequence of a circulation of blood from which certain products of secondary metamorphosis have not been eliminated by the function of menstruation; and also that a disorder of the central nervous system may cause an insufficient nervous energy in the sexual system to perfectly establish the function of menstruation; but these must be regarded as merely attendant conditions, or expressions of the disease. The fons et origo exists in the abnormal evolution of the several great nerve centres at the most critical period of life by reason of inheritance or faulty education.

Allusion has already been made to the tendency toward relapses in adolescent insanity. There exists such a tendency during convalescence from mania and melancholia, and for a considerable period afterward, making it unadvisable to suddenly terminate asylum residence after the cessation of the acute symptoms; but this tendency is more decided during convalescence from adolescent insanity which has its basis in an inherited neurosis. In brain so burdened the inhibitory centres appear to regain their stability of action much more slowly. The whole nervous

system is more sensitive to the effects of experiences of an unfavorable nature. The inhibitory centres are those which come into maturity of strength latest, and when they once become weakened and disordered in their activities the stamp of instability becomes greatly intensified and may continue for years.

Hence the danger of a too early removal from the asylum. The friends are only too ready to yield to the importunities of the patient as soon as he is able to realize that he is better and expresses a wish to go home. The frictions incident to every-day life outside are quite sure to exhaust the little store of inhibitory energy which has been acquired very soon, and a relapse occurs.

Such cases cannot be regarded as recoveries. The unstable condition of brain centres continues to exist and relapses may occur from two to three years before the brain becomes fully restored. Indeed, this habit of brain may become permanently established, as it does in the case of epilepsy, so that it rarely or never again attains a permanent state of equilibrium.

During these seasons of convalescence and while the cells of the cortex are still in a morbidly sensitive condition, there are two sexual activities which are very likely to act as exciting causes toward a relapse, even if they were not factors in the causation of the original attack. These are masturbation in the male and menstruation in the female. The occurrence of menstruation, which is usually absent during the acute stage, though a favorable indication of approaching recovery, yet necessarily entails a large drain for the time being upon the stock of nervous energy; but the practice of masturbation acts much more efficiently through its effects upon the nerve centres, rendering them unstable and easily excited. The blood also becomes

greatly impoverished through the occurrence of both these experiences and this reacts upon the brain centres, causing sudden and irregular liberations of energy.

The degree of mental excitement which may appear will depend largely upon the stage of recovery previously attained. Some patients will become talkative, boisterous, mischievous, and exhibit a tendency to injure those who may thwart their purposes; while others will become sullen, suspicious, morose, apathetic, and dull. It becomes. impossible to predict from any present condition of mind. which may exist what will be that of an hour or day hence. Such cases contribute largely to the number, who in after life have frequent admissions to asylums, or when not discharged are recorded as stationary.

It should be stated that cases of adolescent insanity which make favorable recoveries are those who constitute the larger portion of persons who experience attacks of insanity at the other great epochs of life, viz. the climacteric and old age.

Treatment. One of the first and most important measures in the treatment of pubescent insanity is removal from home and its associations to some institution. The moral effect of such a change is greater than in most other forms of insanity. It is the only means by which the patient's will may become supplemented by that of the physician's, to the end that a regular system of daily habits and experiences may be secured.

Again: Regularity and a considerable amount of daily exercise or employment, if practicable, out-of-doors, should be secured, unless there exist contrary indications in the physical condition. This should be extended to producing physical fatigue. Restriction of general physical activities, and exercise in the open air, and confinement to seden

tary habits and employments at this period of life, have a tendency to awaken into activity any hitherto dormant tendency in the system toward any neurosis which may have been inherited. Such habits of life also tend to develop and bring into activity any tendency which may exist toward an excitement of the sexual organs, and the consequent habit of masturbation.

These measures will prove sufficient in the majority of cases to secure sleep without the use of medicines for this purpose, which should be avoided if possible.

In cases presenting an anæmic state, the system must be strengthened by the use of a sufficient amount of easily digested food used with regularity, tonic bitters, cod-liver oil, and some preparation of iron. These remedies will also be in order in those cases attended with menstrual deficiency or irregularities. Pills of iron and aloes may also be used at night as the patient approaches near to the monthly period, together with hot applications to the lower spine.

What I have to add further in relation to the treatment of pubescent insanity will relate to its prophylaxis. Indeed, this may be regarded as of the highest importance in relation to all children who inherit a predisposition to insanity or any of the neuroses, and relates to such a course of education, using this word in its broadest sense, as will tend to carry the child through this important period of physical and mental development with the least possible strain upon the nervous system.

In the first place, the education of such children should be individual rather than general. Whatever may be said as to the efficiency and desirableness of the system of public schools for educating children who have sound, vigorous constitutions, cannot be regarded as true in the case of

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