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in April, 1907. She was seized with a violent screaming fit when she learned she was to be taken to the hospital, and the attempt to remove her had to be abandoned. A second attempt a few days later was successful. At the hospital she was visited by her sister from time to time, who reported that she would “become hysterical, crying very loud and hard."



The patient came under our care at the hospital, December 1, 1907, and the following notes were made of her condition. She lies on the sofa in careless fashion. Her dress is very untidy. She actively resents the physician's conversation with her and will make no reply to questions, or else a fretful, irritable one. When ordered to get up she will do so in a wilful, irritable manner and betake herself to a distant part of the ward. She lies about in this indifferent manner apparently taking no interest in anything, and apparently holding a strong resentment for all persons of the male sex. She treats the hospital sister very much better. In fact the sister reports that she can converse with the patient very readily and that her conversation is quite sensible, and that she behaves well. Lately (March, 1908) the patient is asking to go home, and she has from time to time promised to behave more civilly toward the physicians. But she forgets this promise when she sees any of them.

A point which has not been previously mentioned should be noted here, namely, that the patient submitted to a gynecological examination several months ago. She was naturally reserved and modest and this was a great ordeal for her. We mention this as it may explain the strong antipathy for the male sex which the patient holds.

The patient is visited by one or the other of her two sisters every two or three weeks. These sisters report that the patient talks to them very freely; and she asks for the latest news and gossip regarding her friends. She manifests a distinct interest in the wearing apparel of her sisters and sometimes asks that a hat be taken off for her inspection; or she will turn up a skirt to examine the embroidery, etc. When her sisters urge her to be more neat in her attire and upbraid her for her carelessness in dress, she replies that she cannot take any interest as long as she is in "a place like this.” She protests much against the horror of the asylum and the crazy actions of some of the patients there; but at 3

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.

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:

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"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.




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 severe 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.

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