In Napa for the second time, Earle Nelson was immediately diagnosed by his psychiatrist as a "constitutional psychopath with outbreaks of psychosis." Alert to his desire to escape -- he suffered from what doctors called "nomadic dementia" -- hospital officials would not let Earle roam the grounds without restraints. In the first two weeks of his incarceration, Earle tried twice to flee but never managed to get outside.

At first, thanks apparently to a treatment with anti-syphilis drug Salversan, Earle managed to improve slightly. His record for the first year of his stay at Napa showed he was cooperative and capable of performing menial tasks and carrying on normal conversation. He continued to show a religious mania; on Christmas 1921 Earle told his doctor he felt "a blessing on him." He also made a few half-hearted attempts to escape, but gradually the staff became more trusting of Nelson and he was allowed in certain areas without restraint.

However, the progress was short-lived. His case file shows that at around 18 months into his hospitalization he began to get agitated and melancholy. "Increasingly, the word quiet, which appears so frequently in the preceding entries, is supplanted by the more ominous word, restless," Schechter wrote. He began to refuse the necessary Salversan treatments and warned his doctors that he was getting ready to escape.

On November 2, 1923, he made good on his threat and fled Napa only to turn up at his aunt's house in the middle of the night. Lillian told the papers what her first encounter with Earle was like: "He had his face right against the glass with a horrible crazy hat on, and I let out one terrible scream because he looked so awfully insane," she said. "His eyes were just black, glaring at me, and the children rushed up to me and of course I opened the door because he was my own flesh and kin, and I loved him."

Lillian said she was scared to death and gave Nelson a set of her husband's clothes and urged him to run away. She convinced her nephew that it was unsafe for him to stay there, and he agreed, fleeing into the night. As soon as he was gone, Lillian called the police and the Napa Hospital to let them know Earle had been by.

He remained on the lam for two days before he was apprehended wandering the streets of San Francisco.

Taken back to Napa, Earle remained there for another 16 months, during which time no further entries were made into his record. Whether or not he improved was unknown, but four years almost to the day that he assaulted Mary Summers, Earle Nelson was released from the hospital. The only note in his file read "Discharged as improved."

Earle managed to convince his wife Mary to take him back, but it was only a matter of weeks before his "nomadic dementia" took over and he began to wander the Northwest. He also began to kill.