the same time, the patient's own conduct is such that she cannot be kept in the best ward of the hospital.

On several occasions the patient has danced with another patient in lively fashion; and she sometimes sings to the piano accompaniment when no men are present.

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Comments (made a short time before the patient's discharge).A very striking feature in this case is the marked difference in behavior in the patient toward the doctors and toward the sisters. Her indifference, refusal to converse and carelessness in dress are suggestive of dementia præcox. But, on the other hand, she is apparently much subject to suggestion; and her conduct appears rather as an active perversity rather than a kind of negativism. She can do some things very well sometimes which she persistently refuses to do at other times for other people. The mental phenomena strongly suggest mental perversion rather than mental reduction.

We have been much interested in studying this patient; but we have not yet been able to reach the conclusion as to whether her case should be labeled one of hysteria or dementia præcox; but we are inclined to the former diagnosis. Yet the carelessness, untidiness, loss of emotional feeling and the stereotyped positions of the patient, suggestive of dementia præcox, lead us to suspend judgment as to the diagnosis.

Subsequent Note, September 11, 1908. The patient's condition continued as previously noted; and in this state she was removed from the hospital on June 5, last, after a residence there of about 14 months. She went to live with a married sister in a small town several miles from her old home. Here she at once took an interest in dress and became tidy as had been her previous habit. On the second day after she left the hospital she took upon herself the duty of dusting the house; and ever since then she has shared with her sister the household duties and has appeared to her and the children to be her old normal self. She laughs and jokes; has a normal sense of humor; her dress is tidy; and in short, she appears to her sisters, as just stated, to be entirely restored to health. She makes no reference to the hospital, or to her stay there. But she evidently remembers much of her life in the hospital. She wrote the following letter to her sister two and a half weeks after she had left the hospital:

"DEAR T-: I suppose you think that I am never going to write. In fact I am not much in the humor for writing. Everything up here is just the same as ever. E- expects to come home Friday night, but I'm not positive. I received the tie and clasp and think both are very pretty. Well, I suppose this is all, will try to write more the next time. With love to mother and yourself. M.

"P. S.—In addressing letters don't address them any more as 'M.,' address them ‘Adelaide,' as I know some of the clerks at the Allegheny Post Office, and I don't care to have anyone know where I am at. Should anyone ask my address just give them the home address, as I don't care to be bothered with any letters from any person in Allegheny. The children nearly took a cat fit over their blue stockings. Little Louisa took the mirror and held her legs up and admired her blue legs in the mirror. C wants Charley to take either the three or the five train Saturday afternoon. The children want to come down to the station to meet him."

July 14, 1909.-The patient's sister reports that the patient continues to do well at home. She takes an interest in the household affairs and family life and is exact and particular as ever in her dress. She has now been home 13 months and the family consider her quite normal. She seldom refers to the hospital or her life there.

Additional Note.-This patient's immediate resumption of what appears to the family a normal attitude after a year's stay in the hospital is certainly a very striking feature of the case; and to our minds it appears as a response to suggestion and offers very strong evidence as to the character of the psychosis from which the patient suffered, which we now believe to have been hysterical in character.

THE NEURASTHENIC AND PSYCHASTHENIC

PSYCHOSES.*

BY HENRY P. FROST, M. D.,

First Assistant Physician, Buffalo State Hospital, Buffalo, N. Y.

The mental disorders which are discussed in this paper are of special interest to the asylum alienist, not because of their frequency, for in our experience at the Buffalo State Hospital they constitute only one per cent of the admissions (twenty cases in five years), but because of the relative lucidity and intelligence of the patients, the readiness with which they furnish a full account of their troubles, and their general amenability to treatment. Concerning the last mentioned point I venture the opinion that for

cases of neurasthenia and psychasthenia the definite authority and the more or less rigid routine of a State hospital are extremely valuable aids in the re-establishment of will power and self-control. The conditions certainly remove some of the difficulties inherent in the management of these cases in private practice and to a less extent in sanitariums. I do not purpose, however, to discuss the well-worn topic of treatment, either general or psychic, of these disorders, nor yet to repeat familiar theories concerning their nature, causes and symptoms, but merely to present and comment upon the records of a few cases illustrating various phases and types.

It is necessary, though, in the interest of clearness and for the more orderly presentation of my material, to take some account of the question whether we are considering under these heads a single disorder or two fairly distinct clinical forms. While admitting, as we all must, a close relationship between neurasthenia and psychasthenia and recognizing the occurrence of many cases with well-marked features of both, I believe that the subject is much befogged by regarding them as identical, except in the degree of the mental involvement. From a consideration of typical cases, which alone are of value in establishing clinical forms, espe

* Read at the sixty-fifth annual meeting of the American Medico-Psychological Association, Atlantic City, N. J., June 1-4, 1909.

cially in mental medicine, I hold with those who see in neurasthenia a state of bodily and mental fatigue, mostly acquired, dependent on a great variety of causes, manifesting itself psychically by such symptoms as failure of attention and application, indecision, emotional instability, lack of self-control and a feeling of general uneasiness and depression of spirits-together with a host of nervous symptoms comprised under the term "irritable weakness"; and regard psychasthenia as an expression of constitutional neuropathy, relatively independent of fatigue or exhaustion, having mental factors far more prominent in the etiology, and characterized by morbid anxieties, fears and impulses.

I avoid as far as possible going over ground already well covered by Blumer, Collins, Courtney, Schwab and many others in the easily accessible literature of this subject in our own country by restricting myself to a discussion of severer and more complicated cases, most of the contributions referred to having dealt with what I may term the sanitarium rather than the asylum types.

I shall cite first a few cases of the neurasthenic type and then several which I conceive to be instances of psychasthenia; and as these histories lose much of their interest if too briefly sketched, I desire to recite them in some detail.

The first case is that of a young woman in whom the principal cause of the trouble was a severe anemia of long duration. The onset was with hysteriform features, but a relapse during convalescence was characterized by typical symptoms of neurasthenia. An accidental inoculation with Christian Science thought at just the right time had a happy effect, and furnishes an interesting exhibit in the form of a letter written by the patient explaining its operation.

L. M., a single woman, age 33, admitted June 13, 1907.

Family History.-No insanity or neuroses. Mother an invalid from rheumatism for ten years. Patient was normal in infancy and childhood. At school she was bright; she graduated from high school. At the age of puberty she became anemic and has never been entirely well since. Her menses are irregular, often absent. She has been regarded as notional and peculiar and nervous, and has had a morbid fear of disease; was recently under treatment by an osteopath. She and her invalid mother lived alone and not very congenially, each jealous of the other's demands, apparently. Psychosis. Her present illness began in February. She complained of being nervous, did not want to be left alone, demanded a trained nurse.