Reprinted from the Journal of Nervous and MentAl Disease, June, 1896. Insanity in Young Women * BY CLARA BARRUS, M. D. Reprinted from the Journal of Nervous and Mental Disease, June, 1896. Isanity in Young Women BY CLARA BARRUS, M. D., Press of Raff & Co. 512 TO 516 WEST 41st STREET, NEW YORK. INSANITY IN YOUNG WOMEN. CLARA BARRUS, M. D. DURING nearly three years’ connection with the Middletown State Homoeopathic Hospital, 121 insane girls and young women have come to my notice. The ages of these patients range from 11 to 35. From the ages of 11 to 17 there were 6 cases; from 17 to 25, 58 cases, 23 of which had the earlier attacks, or the be- ginning of the present attack between 13 and 23. From 25 to 30 there were 27 cases, 21 of which had their initial attacks between 16 and 25. From 30 to 35 there were 30 cases ; 27 of these had the outbreak of insanity between the ages of 17 and 26. It will, therefore, be seen that by far the greater number of cases of insanity occurred be- tween the ages of 17 and 25. The nationalties represented are : American 88, Irish 10, Germans 7, Hebrews 4, English 4, Colored 3, French 2, Bohemians 2 and 1 Swede. Civil condition.—lo6 of the patients were unmarried, 15 married; 7of the unmarried had illegitimate children, and these 7 children, together with 19 others borne by the married patients, make a total of 26 children borne from these 121 insane young women. Social status.—71 middle class, 19 high class, and 31 pauper patients. These figures are, however, mislead- 4 ing, as many of the so classed middle and also high class patients have ultimately become public charges, owing to reverses, duration of insanity, etc. The attempt at classification refers rather to the original status in society of the patient. Education.—Those having a common school education number 63, an academic 36, a collegiate 7 ; 7 patients read and write only, and 8 are said to have had no edu- cation at all CLARA BARR US. Occupation.—Fifty out of the 121 patients had no oc- cupation, 18 were housewives, 17 domestics, 12 teachers, 8 students, 6 musicians, and the remaining few were divided up between stenographers, clerks, dressmakers, artists, elocutionists and nurse girls. Forms of Insanity.—An attempt to classify cases of insanity occurring during pubescence or adolescence meets with even more difficulty than we experience in the classification of insanity in adults. For, while some patients present well marked periods of excitement with the accompanying maniacal symptoms, and others show the profound depression and the distressing concomit- ants of melancholia, still each case is characterized by a peculiar contradictoriness and uncertainty belonging to adolescent insanity. Rapid alterations of mania and melancholia in the same individual, without the dis- tinctly marked cycle of folie circulaire, make it difficult to classify the individual case. Delusions of personal im- portance and of persecution, or extravagant notions of grandeur and power, make us doubtful how to class the cases which, had they the same delusions in adult life, we should class as cases of paranoia, or some even as gen- eral paresis. Nevertheless, an attempt at classification of the cases under consideration has been made. There were found to be 33 cases of acute mania, many of which are recurrent, and three or four are puerperal. Seventeen cases of sub-acute mania, 9 of chronic mania, 22 of acute melancholia, 6 of chronic melancholia, 5 of circular in- sanity, 14 of terminal dementia, 3 of primary dementia, 8 of epileptic insanity, and 4 of imbecility with mania. Many of the cases now classed as dementia terminal were admitted to the hospital as cases of mania or melancholia, but have drifted into dementia in later years. Alleged causes of insanity.—When patients are brought to the hospital the friends are asked to state, so far as they know, the cause of the outbreak of insanity. They generally give some one event or experience as though that were the only cause—the fact being, usually, that it was the culmination of a long train of pernicious in- fluences in a person already predisposed by heredity and environment to mental disease. In many cases three or more causes are given in one individual, namely, hered- ity, overwork and death of mother ; or, predisposition, masturbation, and religious excitement. Fifty nine of our 121 cases have acknowledged insane heredity; there are 26 cases attributed to overwork and worry, 10 to masturbation, 10 to domestic worries, 11 to child-birth, 7 of whom bore illegitimate children ; 9 to disappointment in love ; in 9 more the causes were un- known, 8 were attributed to over study, 6 to religious excitement, 7 to traumatism, 8 to epilepsy, 7 to physical disease, and 4 to fright from attempted rape. There were also assigned as causes intemperance, novel read- ing, infantile convulsions, chorea, sunstroke, “ mind cure,” powerful drugs, bicycle riding, the establishment of puberty, suppression of the menses; death of friends, lawsuits, &c. INSANITY IN YOUNG WOMEN. 5 Insane inheritance.—lt is generally conceded that heredity is the most potent etiological factor in the pro- duction of adolescent insanity There is, however, such a tendency on the part of the relatives to deny the pres- ence of insanity in their families, that alienists say we can safely multiply the acknowledged cases by two and thus reach a more nearly correct result than if we accept the statements of relatives concerning this matter. The more the insane temperament is apparent in the relative the more persistent is he in denying or concealing the existence of mental disease in the family. Patients are sometimes brought to the hospital by relatives who so evidently manifest the neuropathic constitution by their excitement and flightiness of manner that it is difficult to determine at a glance which is the patient and which the accompanying friend. In a few instances we are tempted to suggest to the patient that she take the ac- companying relative back home and get her duly exam- ined and committed, the patient herself being allowed to go “ scot free.” Of the 121 patients, in 50 the history of insanity in the family is denied ; concerning 7 it is unascertained ; 5 others come from distinctly neurotic, though not insane, families, and 59 are known to be heavily weighted with an insane inheritance from one or more relatives. Of the acknowledged insane inheritance in the cases 6 CLARA BARR US. under consideration, 16 had insane mothers, 13 had in- sane fathers, there were 23 cases showing insanity of paternal relatives, 18 maternal, and in many instances the records fail to show from which parent the taint was derived. In 8 cases there are recorded proofs of in- sanity from both maternal and paternal relatives. Aside from the direct connection of insanity in father or mother, brother or sister, there are grandparents and great grandparents, cousins and aunts and uncles galore. Patients come to us weighted with an inheritance from two, three, four and more insane relatives. “ I’m fairly saturated with insanity,” said one unfortunate girl during an attack of acute mania. Discouraging as such cases seem, some of these patients make good re- coveries, although, of course, the tendency to recurring attacks is great. Some instances of two or more insane relatives in the same individual have the added compli- cation of the transmission of insanity from both the paternal and maternal branches. One is led to inquire : What chances for recovery has a young girl weighted at the outset with an insane father and two maternal aunts ? Or another who has a father, brother and a paternal aunt and uncle insane ? Or still another who has an insane mother, a paternal grandfather and a maternal grand- mother ? One girl had a father insane, and five relatives had already committed suicide. Two of these 121 cases were twin sisters, who have been patients at the hospital for five years. A brother was also here for a time ; the three patients had attacks of acute mania grafted on to imbecility. These afflicted young people were brought here by parents, both of whom were imbeciles, and there was insanity in a pater- nal aunt as well. The twin sisters became terminal de- ments. Nature thus put a veto on the continuation of a stock which could have been discontinued one or two generations ago. Accompanying diseases.—The insane are subject to the same physical ailments as are the sane, although the manifestations of disease are altered in many instances. No mention is made here of physical troubles except those from which the patients were suffering on admis- sion. They are as follows: Epilepsy, 8; pregnancy, or the puerperal state, 5 ; cystitis, 4: dyspepsia, 5 ; anaemia, 3 ; phthisis, 2 ; tuberculous diathesis, 2; valvular heart disease, 2 : acne vulgaris, 2; psoriasis, 1; cerebral men- ingitis, 1 ; paralysis of arm, 1 ; neurasthenia, 3; chronic INSANITY IN YOUNG WOMEN. 7 laryngitis, i ; convalescent from typhoid fever, i ; facial neuralgia, i ; curvature of spine, i. Gynecological troubles.—Disorders of this kind are not conspicuous among these patients; 76 of these 121 patients were not examined owing to their youth and to the absence in most cases of symptoms demanding such investigations. Of the 45 examined there were found the following conditions : Sixteen cervical erosions, 8 retroversions, 3 anteversions, 1 anteflexion, 2 latero-ver- sions. Two patients had previously had ovariotomy performed, and one had had clitoridectomy. Two of the married ones had sub-involution and one had ruptured perineum. There was also one case of vaginismus, and one having uterine polypi. Menstruation.—The relation of menstruation to in- sanity, or of insanity to menstruation, is hard to deter- mine. In some of these cases the insanity was directly dependent on menstrual suppression ; in some the maniacal attacks appeared only at the time of menstrua- tion, there being a complete lucid interval between; In two of the cases, aged eleven and fourteen, puberty is not yet established. Several of the cases had a history of the establishment of puberty postponed till the eighteenth or twentieth years. Many of the patients have amenorrhoea for a time ; the majority of them show menstrual irregularity during acute attacks, although many preserve as much regularity as though they were sane. Most of them are more or less excited at the periods, although it is not uncommon to witness an abatement of the motor activity and the cerebral rest- lessness in maniacal cases, during the menstrual flow, and a disappearance of the gloom and apathy in the cases of melancholia. Physical degenerative signs. Among these insane pa- tients may be noted certain stigmata which show them to be descendants from degenerated stock. Six of them have pronounced twitching of facial muscles, tics, etc.; eight present varying grades of imbecility with defec- tive or tardy development of physical structures ; four are deaf, and two are deaf mutes ; eleven have the high- arched, V-shaped palates which characterize them as de- generates; four have the peculiar, wavering, restless eyes characterized as neurotic eyes; four lisp; three stammer; three are prematurely grey ; six have marked asymmetry of features ; eight have irregular ears ; two are left-handed; one has defective sexual organs; one stra- 8 bismus ; one had premature loss of teeth and one had chorea. CLARA BARR US. A large number of the cases of chronic insanity pre- sent unsymmetrical contraction of the facial muscles, giving their countenances a peculiar distorted appear- ance. Perversions. Among the perversions noted in these cases, the one which occurs the most often is that of masturbation, there being forty-two cases, but it must be remembered that while it may be the cause in some instances, it is the concomitant and the result of the ex- isting insanity in many more. Twenty-seven of the cases were suicidal, twenty-two homicidal, and twenty- two others both suicidal and homicidal. Thirty-seven of the cases were profane and obscene, these deplorable symptoms being observed in girls who have had the most cultured antecedents. Most of the maniacal cases are filthy during a part of their illness, and the demented ones are almost invariably so unless carefully watched. Their filthiness concerning excretions and saliva is some- thing incredible to all except those who have the care of them. A large number of them aside from suicidal tenden- cies attempt to mutilate themselves in various ways; the self-worrying disposition which manifests itself in biting the nails to the quick, is often carried further, and the skin is picked and mutilated till it is rendered un- sightly with ineradicable marks. They also pinch and bite themselves, and pull out their hair and their eye- brows. Many of them have a pronounced aversion to their nearest friends, which manifests itself in suspicion, abuse, gross accusations, and even homicidal attacks. A few have an insane fear of men. The majority of these patients are vain and hysterical, untruthful, mis- chievous, crafty, and given to pilferings and multitud- inous kinds of misconduct. In some of these girls only one or more of the above-mentioned perversions exist, but in most of them nearly the entire list is observed during the course of the insanity. Delusions. “ Their name is legion.” The acute mania cases have unsystematized, rapidly changing ones—“l’m a Russian princess—l’m a Jew—I’m your husband—l’m the Valkyrie, no, I’m the Vigilant,” and a dozen other things one girl will say in one minute’s talk. INSANITY IN YOUNG WOMEN. But in other cases we find more or less fixed delu- sions. Below are some of the delusions noted in the cases which form the basis of this paper: 9 Believes she can’t swallow food because her stomach is grown together. Thinks we feed her poison. Thinks we give her “love powders” to make her like the doctors. Thinks we beat her, insult her, and make her swear. Thinks she is possessed of the devil (and certainly acts so). Thinks she is Jehovah, the Virgin, the Church, The Bride of Christ, the Saviour, or God’s wife. Thinks she is married and has had several children. Thinks she has had a rooster for a child. Thinks she is pregnant. Thinks she has had a baby which was conceived by the Holy Ghost. Thinks she is a crazy alligator. Thinks she is a snake, an i wriggles and hisses like one. Thinks she is a dog, a cat, a chicken, or a horse. Thinks she is a little colored girl. Says she is a boy. Says she is dead and must be buried. Says she has committed the unpardonable sin. Says God is dead. Says she is Adam and Eve. Says she is persecuted by her family. Says her body is immortal. Says her hands are being bitten by horses. Says this is a brothel. Says her ovaries have been removed. Thinks she is violated in the night. Thinks she is engaged, and waits daily by the win dow for her lover. Keeps handkerchief rolled in palm of hand and says it is God. Thinks snakes are crawling on her and are in bed with her. Says there is a white elephant in her bed. Says she is an electric bell. Asks to have her uterus removed as she is married to the devil and doesn’t wish to have devilish children. Says she is a black snake with a false face. Imagines she is covered with dust and dirt and can CLARA BARR US. never get elean, washes hands all day if allowed water in the room. Premonitory symptoms of adolescent insanity.— Before the friends of these patients recognize them to be of un- sound mind, hysterical manifestations, countless in num- ber and variety characterize most of them. They are for the most part girls who have been given up to will- fulness, caprice, passion and self-indulgence, the parents having yielded to their whims till the girls became veritable tyrants. A certain shrewdness characterizes these misguided girls; finding they can get their own way by so doing, they indulge, upon occasion, in fits of hysterics when their friends are inclined to oppose them. There is a changeability about them which makes them very uncertain elements in the family life; they are un- stable as weather vanes. They will not brook any inter- ference and are intolerant of restraint, giving way to tumultuous emotions when attempts are made to control their conduct, their aversion to such control being in direct proportion to the necessity for it. '‘Was your daughter willful and passionate as a child, or are these exhibitions the result of her disease ?” And for some unaccountable reason the mother attempts to conceal or actually deludes herself concerning the truth, and tells us that the girl has always been sweet tempered and do- cile. Later we learn from some disinterested relative that the child has often been seen to become furious at any opposition, stamping her feet and even spitting in her mother’s face. Thus the daughter who is said to have been a model of propriety is found to have been, like Carlyle, “gey ill to live with.” These girls cannot be made to reason, “ I can’t help it,” or “ because I want to ” are their only attempts to justify their wayward conduct. They are moody, self- absorbed, and consequently depressed. Or, they evince an exaggerated self-assertion and undue elation. Their exaggerated impressionability renders them very sensi- tive to supposed sleights and keeps them “ in hot water ” most of the time. They are imbued with the idea that they are “ not appreciated.” The protean forms of hysteria which develop during the incipiency of the disease make us ready to expect the unexpected from them always. They may be mor- bidly conscientious and aim at extreme circumspection of speech and conduct, or they may become cat like and crafty, and disposed to take a ghoulish delight in all INSANITY IN YOUNG WOMEN. sorts of mischief and wrong—their conduct being merely an exaggeration of their individual impulses and ten- dencies. Many of them show a propensity for prevari eating for no other motive than an inherent desire to deceive. They may be “ light fingered,” often being de- tected in petty thefts. They are prone to run away from home, using the fire-escape and other extraordinary means of escape, if the ordinary ones fail. Or they may show extravagance, ordering large bills of goods sent C. O. D. and in other ways attempting to carry things with a high hand. Some of them become very slangy and “ tomboyish,” aping the tone, gait, and conduct of a boy. Some of them belong to the order of whistling girls, and shout and whistle in a very boisterous manner. Further inanife stations. After the actual outbreak of insanity, the condition is only an exaggeration and pro- longation of these wayward tendencies, they become im- perious, arrogant, and dramatic, or taciturn, moody and despondent. The destructive tendency becomes very strong, they especially delight in breaking glass, smash- ing things generally, in tearing clothing, and in destroy- ing everything of value. Many of them show wonder- ful facility in the making of rhymes and puns, and they recite poetry, sing songs, or sing their conversation for hours at a time. It is during the acute attacks that the various perversions appear. The suicidal cases make repeated attempts to carry out their -purpose, the homi- cidal are persistent in their efforts and show a malicious delight whenever they accomplish even a part of their intent. The depressed and morbidly conscientious patients are prone to self-accusations, sometimes reverting to childhood and girlhood and recalling petty wrong-do ings, all of which increase their self-denunciatory states. Some even accuse themselves of horrible perversions in childhood, which we can hardly credit. Some maintain a quasi cataleptic state and remain that way for weeks and even months, evidently compre- hending all that is going on about them—a blush and a quivering of the eyelids betraying their consciousness of what is said to them. Some persist in talking baby talk for days or weeks at a time. Epileptics are especially homicidal and dangerous. After attacks they are quite prone to talk familiarly with God, addressing Him as though He and they were 12 boon companions. One young girl, on admission, being asked by the nurse if she were not going to say her prayers, quickly replied, “ Good-night, God,” and crept into bed with a consciousness of duty done. This is, however, far preferable to the midnight vigils of those who wrestle with the Lord after the Jacobian fashion. Duration and Recoveries. The duration of insanity in these cases cannot be accurately determined, many of them being insane for varying lengths of time previous to admission, and no accurate means of determining the time being at our disposal. Of the acute cases that have recovered, most recoveries were made in from six to twelve months. Some of the chronic cases though young on admission, have been here six, eight, ten years and even longer, and for that reason patients now over thirty years have been included in this study. The acute cases which fail to recover, gradually slide into chronic mania and chronic melancholia, and from these conditions to the still lower step in the scale of degen- eracy—terminal dementia. Of these 121 young women, 68 are still here. Con- cerning the recovery of these 68, 23 give us reason to hope; in 25 the prognosis is doubtful, and 20 give little or no promise of recovery ; 53 have been discharged. Of these 53, 40 were recovered, 7 died, 5 were transferred unimproved, and 1 was discharged as improved, but not cured. CLARA BARR US. Treatment.—The treatment adopted in these cases is not easily defined, being based on the needs of the indi- vidual cases so far as possible. The removal from home and from the environments which are aggravating the condition, is the first step toward helping the patient to recover her mental health. Physical disorders are sought after and remedied by hygienic and therapeutic measures. Rest for the overworked and worried patients—en- forced rest in bed, is one of the means employed toward rebuilding the shattered physical structure. Abund- ance of plain, nourishing food, with a liberal allowance of raw eggs and hot milk are important allies in our efforts at reconstruction. When we have attended to the physical ailments of our patient, there still remain the “ thick coming fancies which keep her from her rest,” and we have before us the difficult task of ministering to a mind diseased. We are often forced to say with conviction : “Therein the INSANITY IN YOUNG WOMEN. 13 patient must minister to herself.” We can only stand by observantly and wait, with here and there a sugges- tion or a word of encouragement, while the work of re- construction is going on. We can do much, however, in the way of directing the work, exercise, amusement and reading of many of the patients. A judicious selection of the fellow patients with whom they associate is also important, as patients are helpful or harmful to each other to a great degree. The regular life, the salutary discipliiie of conform- ing to the rules of the Institution, the example of so many others conforming to the same rules, the encour- agement of self-control, the discouragement of self-re- gard, the observant neglect of those inclined to be hys- terical or hypochondrical—these are some of the means employed in the restoration of the mental health of our patients. Prophylaxis—Our study of these cases, from the records and from what the friends have told us, and more especially from the girls themselves during the development of the disease, and while convalescence has been going on, has led us to conclude that the alleged causes are by no means invariably the real ones in the development of insanity. An investigation of the formative influences of child- hood and girlhood has shown us that many contributing causes have been not a little responsible for the mental disorders of these young people. Little more than an enumeration of these causes will be given here, but the mere enumeration suggests the prophylactic measures necessary to be considered by those who have the training of neurotic girls and young women. The evolution of puberty and the period of adoles- cence are in themselves trying times for those having the most fortunate endowments and environments. It is, therefore, not at all strange that these periods should be marked by the development of mental disease in neuropathic individuals. It is during adolescence that the inherited tendencies crop out, giving the girl a multiple personality to deal with, with all its conflicting impulses, instead of her own individual personality. This in itself is sufficient reason why girls at this period should be under the most intelli- gent, sympathetic and judicious supervision as regards their physical, intellectual and moral environments. 14 CLARA BARR US. That the neurotic girl should shun marriage would seem to need no proof other than that obtained by a care- ful observation of her tendencies and her conduct, but all physicians do not agree in this particular. Many of them cite the excess of the reproductive instinct as a reason why these young people should marry early in life. That this excess exists there is no doubt, neither is there any doubt in my mind that marriage should be interdicted, at least till the period of adolescence is safely passed, thus prohibiting the girl from adding the bur- dens of marriage and motherhood to those of adolescence, when nature is already having all she can well do to pre- serve the mental equilibrium. At the start the greater number of these patients were handicapped by an insane inheritance, and as though that were not enough, many of them were subjected to daily association with their insane or neurotic relatives, thus living in a mental atmosphere eminently fitted to favor the growth and development of insanity. Some of these young people had slight bodily de- formities, such as lisping, stammering, asymetry of fea- tures, deafness, &c. These in themselves, to the casual observer, might not seem of enough importance to men- tion, but when we reflect that scientists consider them the outward accompaniments of inherent abnormal men- tality, they have a new significance for us. Further than that, they are constant sources of annoyance and unhap- piness to those thus afflicted; their infirmaties make them envy their more fortunate playmates; envy gives rise to suspicion, and an unhealthy moral nature is the result. It is not only unwise, but cruel, for parents, brothers and sisters to keep these infirmities before the minds of the unfortunate possessors of them, even by good natured teasing, or by repeated allusions to them. If they are defects which can be remedied, do so by all means ; if not, train the girls to ignore them, or to rise above them Some of these patients have been girls who all their lives believed themselves to have been foundlings, and, brooding over this feeling, they have interpreted chance remarks or acts of their parents as confirmation of this belief. Such a girl feels herself out of harmony with her environments. She is actuated by contending im- pulses, which lead her to eccentricities of speech and action which are clearly disapproved by wiser members of the family, and their very disapproval gives her the feeling of alienation that easily develops into a fixed delusion of her being a foundling. From this feeling to extreme aversion for her nearest friend is but a step. An inharmonious home life has been a very common cause given by the girls themselves on recovery as the reason for their mental outbreak. Bickerings and wrang- lings between the parents created daily sources of irrita- tion which, to sensitive, growing girls, had a peculiarly deleterious influence. INSANITY IN YOUNG WOMEN. 15 The natural romanticism of girls at this period leads them to the perusal of the most romantic fiction they can find. Their dawning hopes and high ideals make them eagerly seek for satisfaction in books, being denied it in the prose of every day life. It would be cruel to deprive them of this mental pabulum they crave, but parents or teachers should stand ready to keep them supplied with wholesome romances, thus creating a taste for good novels, and supplying that taste, so as to leave no room for trashy fiction. The tendency of the romantic girl to find a hero in every one she meets should not be lost sight of in her relations with her pastor, her physician, or her teacher. These men come into a girl’s life very closely. If they are the right minded, high souled men they should be, and usually are, they can keep this natural romanticism on a healthful basis, and thus be instrumental in direct- ing the girl’s career to no small degree ; but if they are vain or unprincipled, or inclined to experiment on her susceptibilities; the amount of harm they can effect is unmeasurable. Idleness and aimlessness are, we believe, responsible for much of the dissatisfaction and mental unrest which are the forerunners of mental disease. Girls have dawn- ing hopes, vague aspirations and thrills of ambition as well as their brothers, yet too often they are forced to stifle these aspirations and remain at home, leading a mere humdrum life, or, on the other hand, a butterfly existence, and in either case they drift into discontent and despondency, simply for the lack of some occupa- tion, pursuit, or study which would furnish them a zest to existence, and would give them a wholesome feeling that they have their place of usefulness and responsi- bility in this busy world. Overwork has, however, been found to have been the exciting cause in many of these cases of insanity. Too serious views of life, neglect to relax and yield to the 16 CLARA BARR US. sportive tendencies of youth are easily found to be quite as productive of evil as no work and no aim in life. Hard work and no play is as bad for “ Jill ” as it is for “ Jack.” Therefore, a life of temperance (using the word in its broadest significance), is one of the best prophyl- actics for these neuropathic patients. Religious excitement is one of the etiological factors which we cannot overlook in the study of these cases. We believe that some of our religious customs are largely responsible for the outbreak of insanity in girls of neu- rotic temperament. Reference is made more particularly to the religious revival, with its series of meetings, pos- sessing such an absorbing interest for girls of the sensi- tive, emotional type. The young should be taught the principles of right thinking and right living, but customs which appeal to their emotions alone not only fail to accomplish the good that is desired, but they actually serve to arouse an un- healthful excitability which furnishes the soil for per- versions, and the manifestation of these perversions, which are wholly inconsistent with their religious pro- fessions. These inconsistencies make us wish to urge parents and pastors to keep the religious training of the young on a rational rather than an emotional basis. In conclusion, we would say that the above list of contributing causes could, we believe, be largely supple- mented by still further investigations of the environ- ments of these neuropathic girls, and that it is only by such investigations, and an intelligent supervision and direction concerning the tendencies and environments, that other neurotic young women can be prevented from having attacks of adolescent insanity. Press of Raff & Co. 512 TO 518 WEST 41st STREET, NEWYORK.