ankylosis of knees, heart's action very feeble, appetite poor, toothless, skin dry and loose.

Mental Examination.-Quiet, but keeps up a constant muttering in French, disoriented, does not know her age, confined to bed, takes little nourishment, died April 19, 1904.

Autopsy Report.-Mammary glands atrophied, abdominal aorta much sclerosed and calcareous, small cysts on surface of kidneys, pleuritic adhesions, pus points on section of left lung, many pericardial adhesions, tricuspid valve thickened, mitral and aortic valves calcareous.

Brain. Much softened all over cortex, vessels at base present much atheroma, slight general cerebral atrophy.

Assigned Cause of Death.-Arteriosclerosis and senile dementia.

CASE X.-1561, J. W., female (17,156). Patient was admitted January 10, 1906, from Edgartown, aged 75.

Physical Examination.-Very feeble, skin harsh and dry, prolonged rasping murmur replacing first sound of heart, circulation poor, some arterial hardening, gait feeble, tremor of tongue and extended fingers.

Mental Examination.-Quiet, but restless especially at night, memory defective for recent events, orientation imperfect, delusions of a persecutory nature, irritable, pseudo-reminiscences, suffered from a shock on morning of January 21, 1907, and died January 22, 1907.

Autopsy Report.-Mitral valves much thickened, coronaries sclerosed, lungs negative, strong adhesions throughout abdomen, capsule of kidney strips with difficulty leaving rough surface, numerous cysts just beneath capsule.

Cerebral vessels show marked sclerosis, fresh hemorrhage in right occipital lobe, atrophic patches around the vessels in both hemispheres, slight frontal atrophy.

Assigned Cause of Death.-Cerebral hemorrhage and valvular heart disease.

CASE XI.-1407, T. H. T., male (16,504). Patient was admitted August 8, 1904, from New Bedford.

Physical Examination.—Feeble old man, face asymmetrical, small inguinal hernia, urine normal, lungs negative, soft blowing systolic murmurs heard at apex, arteries somewhat hardened, gait tremulous and unsteady, hands too tremulous to write.

Mental Examination.-Quiet, but restless, constantly arranging his bed clothes, much confused, motor restlessness, disoriented, no change in mental condition, but a gradual physical weakening resulted in death May 7, 1905.

Autopsy Report.-Sacral decubitus, tricuspid valve thickened, also mitral; aorta sclerotic, pleuritic adhesions and streptococcus exudate covering lower lobe left lung, which on section shows much congestion, smears from

the exudate in bronchioles of right lung show pneumococci. Many peritoneal adhesions, slight increase of fibrous tissue in liver, numerous small cysts on surface of both kidneys.

Head.-Grooves for meningeal vessels well marked, dura thickened and adherent externally, brain tissue is fairly soft, a very large cyst in the left choroid plexus; no atrophy.

Assigned Cause of Death.-Lobar pneumonia.

Basal sclerosis was noted in 30 cases and probably that is a small percentage if the microscopic pictures could have been obtained, but that was impossible. In most instances, however, a distinct note was made to the effect that the sclerosis was confined to the large basal vessels and did not penetrate into the brain substance. Four of the 44 brain weights showed distinct loss in weight without any cerebral or basal sclerosis being noted macroscopically, and in only one case of these four did the microscope reveal any thickening of the vessel walls and that was very slight.

Eleven cases showed distinct atheromatous change, no atrophy of the cortex was noted and the brain weights were above the average or only slightly below it.

Six brains macroscopically showed no arteriosclerosis and no atrophy. Of this number one showed a slight thickening of the cortical vessels under the microscope and one distinct cell infiltration around the vessels with the presence of plasma cells, so this case can probably be thrown out altogether.

CONCLUSIONS.

I. That the frontal convolutions undergo the most atrophy and that general atrophy is uncommon.

II. That the female brain loses more often in weight and that the loss is greater.

III. That men are attacked by the disease much earlier than women, but live somewhat longer after it is established.

IV. That atrophy does not go hand-in-hand with atheromatous change.

V. That some cases with symptoms pointing to senile dementia show neither arteriosclerosis nor atrophy at autopsy.

IMPRESSIONS OF SOME ASYLUMS IN SCOTLAND.*

BY C. A. DREW, M. D.,

Superintendent City Hospital, Worcester, Mass.

Some years ago a member of this Association, who had visited many of the asylums and hospitals for insane in Great Britain and on the Continent, said to the writer: "If you wish to study laboratory methods principally, I advise you to put in all the time you can in Germany, but if I were to be insane I think I would rather take chances in a Scottish Asylum than in any hospital for the insane I know of outside of Scotland and certain small hospitals in our own country." We did not then realize the personal need of asylum treatment but were confident our medical friend had a good eye for the comforts of this world and the thought grew, nourished by reports from other sources, that the asylums of Scotland might be among the most interesting from the clinical viewpoint of all the hospitals for the insane across the seas. So it happened that we found ourselves in the land of "Robbie" Burns for the first time about the middle of September, 1907. The summer had been a rainy one-even for Scotland-as the uncut grass and unharvested grain bore eloquent witness. But September was making amends. Not even the early autumn days of northern New England, nor the late autumn days of our own middle west could have been more delightful than the two weeks in which we were leisurely approaching the Scottish asylums through Westmoreland and Cumberland,—the "lake district of England," and the lakes and highlands north of the Forth and Clyde.

We were first introduced to a Scottish asylum at Dumfries, in one of the garden districts of Scotland, a short ride from England's northern boundary. Crichton Royal Asylum is one of the best endowed and most favored of all the Scottish asylums, and for a good first impression one could hardly do better than to visit Dumfries on a fair summer's day. The soft reddish stone buildings sufficiently detached to avoid a crowded appearance, the

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

gently rolling garden and pasture land, like the surface of northern England or our own southern Iowa, with a fertile soil and frequent showers or misty rains, all combined to favor this Royal institution. We were assured that for twenty-five years or more this asylum has had in Dr. Rutherford one of the ablest administrative superintendents of Great Britain.

We did not learn that any effort had been made to make this,— the richest of Scotland's asylums,-a teaching center or a leader in laboratory research work.

In 1907 there were in round numbers 18,000 insane and feebleminded persons under the General Board of Commissioners in Lunacy for Scotland, about 3000 of whom were boarded out in private dwellings.

The Crichton Asylum is one of the seven Royal asylums all of which, we understand, were financed by legacies, subscriptions and donations prior to the Scottish Lunacy Act of 1857, which marked the beginning of the building of so-called "district asylums" for pauper insane, supported by public taxation.

From 1857 to 1907 Scotland had erected nineteen district asylums, in which, at the latter date, were cared for 9000 of her 18,000 insane. This low average of less than 500 patients per district asylum is in rather marked contrast to the many very large public asylums in England and to a smaller number of very large hospitals for the insane in the United States. It seems to be not unlikely that the smaller asylums in Scotland have made less difficult there the progress in practical psychiatry, so marked during the last two decades.

In addition to the seven Royal asylums, accommodating nearly 4000 patients, and the nineteen district asylums, accommodating upward of 9000 patients, and the 3000 patients boarded out in private dwellings, the report of the Commissioners of Lunacy shows that in 1907 there were 104 patients in private asylums and over 1300 patients in insane wards of poorhouses with restricted or unrestricted licenses.

Scotland has no separate asylum for her criminal insane and had only 51 inmates in the criminal lunatic department of H. M. prison at Perth, January 1, 1907.

The custom in Great Britain is to transfer patients to the Broadmoor Criminal Lunatic Asylum in England and return

them from this asylum to the district asylums in Scotland or the county and borough asylums in England so soon as their sentences have expired. This is in contrast to the practice in Massachusetts, but is in harmony with the practice in New York state, if I am correctly informed.

Partly because the Broadmoor Asylum is a long distance from the prisons and asylums in Scotland, and partly because the insane convict is held in the asylum for the criminal insane only till the expiration of his sentence, it has been found expedient to send to Broadmoor only those convicts serving long sentences and those held "during His Majesty's pleasure," which latter form of commitment gives the patient about the same status as the "court case" has in Massachusetts and New York. As a matter of fact, the influence of English law and the geographical location of institutions, working with other forces, have so eliminated the insane convict from the Broadmoor Criminal Asylum that on January 1, 1907, with a population of 780 (574 men and 206 women) there were less than 50 patients of the convict class in the asylum,—732 patients being held “during His Majesty's pleasure" or the order of the Secretary of State.

On Duke Street in Glasgow are the observation wards for mental cases of the Eastern District Hospital, widely known as "Dr. Carswell's Observation Hospital." This hospital was of peculiar interest because it is the Scottish representative of the much talked of psychopathic hospital of our own land. From the opening of this hospital in June, 1904, with about fifty beds, to May 15, 1907, nearly 1100 patients had been received and treated, with 475 discharged as recovered and 188 discharged as improved. It is interesting to note in this connection that there were 22 times as many discharged "recovered" as were discharged "improved," and that both combined (663) equalled 61 per cent of the number admitted.

In "Pavalion F" of the Albany (N. Y.) Hospital there were admitted 784 mental cases from February 18, 1902, to February 28, 1906, of whom 211 were discharged recovered and 244 discharged improved. Here we may note that those discharged as " improved " exceeded those discharged as "recovered," in marked contrast to the statistics of the Scotland observation hospital, while the sum of those discharged recovered and those discharged im