First, cases presenting excessive activity may be considered. It is always desirable that every patient should be treated individually; for instance if he be noisy he should not be stupefied with drugs because his noise disturbs others; unless, however, special provisions are at hand for his isolation, or perhaps more properly, insulation so far as any noise he may make is concerned, application of the principle of the greatest good to the greatest number may prevail and the individual suffer accordingly. Indeed I may now state that the main purpose of my remarks is first to call attention to the importance of having such provisions in institutions for the treatment of insanity as will permit the physician to refrain from administering sedative drugs except only when he believes they will benefit the patient to whom they are administered, with practical suggestions for the accomplishment of this object; and second, to emphasize the importance of the fresh-air treatment of acute insanity, with hints as to how this also may be carried out in practice. That fresh air is highly beneficial to persons suffering from tuberculosis has been clearly understood for many generations, and no doubt a few physicians have individually made some special provisions for having their patients kept much in the open air. But it has only been in the last decade or thereabout that a well-defined fresh-air method of treatment has been developed and come to be pretty generally understood and made use of; so, too, doubtless individuals have appreciated the value of the principles herein brought forward in reference to the insane and embodied them in practice. I think them so important, however, that I should like to see their value generally recognized and methods for their practical application perfected and adopted. Many cases of the active variety of acute insanity are very noisy and wakeful, especially in the early days or weeks of their attack. Certainly sometimes, if not generally, it happens at the expiration of any definite period, as, say, a week, the patient's physical condition will be far better if sedative drugs are withheld than it will be if the physiological effect of these be maintained. For such patients a room of ample size should be provided, with thick, deadened walls, double doors and windows; this room should be supplied with forced ventilation so as to keep the air strictly fresh even when one or more persons have to remain in it. In the country where there are no trees or adjacent tall buildings to deflect air currents, the rooms of an institution may be satisfactorily ventilated by the gravity system by using the basement as an air chamber and providing each room with an independent inlet and outlet flue. These rooms, however, which are devoted to the care of noisy patients and, therefore, have to be kept closed, especially in the summer months when a gravity system is inactive, should be supplied with noiseless electric fans in the outlet flue. In such a room, 15 x 12 x 11, so equipped, occupied by two nurses and a patient, the air remains perfectly fresh. I have had such rooms at my disposal now for nearly four years and have come to regard them as almost indispensable in the treatment of certain cases of acute insanity. Incidentally I would suggest that the plan here outlined of supplying an abundance of fresh air is equal or superior to the so-called outdoor treatment in cases of pneumonia, as it involves no increased liability to exposure either of patient or nurse. My experience happily is limited to one case which occurred in a woman of thirty-eight, who made a good recovery while suffering from a very severe attack of acute mania. The value of keeping a patient in the open air as a means of promoting his physical vigor, sleep, appetite and digestion has been amply demonstrated in the last ten years in the treatment of tuberculosis, and this is of course desirable in all cases of acute insanity, though some are so noisy and unmanageable that it is not practicable to keep them much out of doors. For those patients who are orderly enough to properly permit them to remain out of doors I have found open pavilions facing south, with concrete floors and concrete walks leading to them, well suited for this purpose. They are always dry and, therefore, always available. They may be supplied with comfortable lounges, and in the winter foot-warmers with a fuel cartridge may be used to supply necessary heat. It would, in my opinion, rarely be advisable to attempt to have cases of acute insanity sleep out of doors, as their co-operation could not be counted on to prevent dangerous exposure even if they were not noisy. While I believe the measures above outlined have a very wide application in the treatment of acute insanity, indeed are of cardinal importance, I do not wish to be understood as intending to maintain that sedatives, hypnotics and hydrotherapy are not useful. In regard to the latter I wish to say, however, that while some form of it may be employed in many cases with marked benefit, its value by no means justifies the advocacy it has received in some quarters in the last few years as a sort of cure-all, nor the expenditure of huge sums for the installation of elaborate plumbing which has been made in various public institutions throughout the country. Nevertheless, I maintain anyone who studies his cases closely and has at his disposal such provisions as I have described will, I believe, carry some of them at least through to convalescence without the employment of any medicinal sedative, hypnotic or even tonic, or at any rate he is likely to become more and more abstemious in the matter of prescribing medicinal sedatives and hypnotics. A pretty wide experience with both methods has convinced me, as I have said before, that in most cases of acute insanity when insomnia is pronounced the patient's condition is likely to be far more satisfactory, at the end of a stated period, if medicinal hypnotics and sedatives are entirely withheld than if they are freely administered. The disease generally runs a course of several months, and the secretions and consequently the metabolic processes are often profoundly deranged by an attempt to maintain medicinal sedation over so long a period. Indeed it is not difficult to conceive how occasionally such medication might determine a fatal issue or, worse, permanent mental impairment in a case otherwise curable. Finally I wish to remark emphatically that an establishment adapted to the treatment of acute insanity should have rooms measurably impervious to noise and equipped with efficient forced ventilation. It should also be supplied with open pavilions or porches so as to enable certain patients to spend their days wholly in the open air. I believe the medical profession should advocate the installation of accommodations and appliances suitable to the practical application of the principles above described in public institutions devoted to the treatment of acute insanity. ANATOMICAL FINDINGS IN SENILE DEMENTIA: A DIAGNOSTIC STUDY BEARING ESPECIALLY ON THE GROUP OF CEREBRAL ATROPHIES.* By E. E. SOUTHARD, M. D. (From the Laboratory of the Danvers State Hospital, Hathorne, Massachusetts; and the Department of Neuropathology, Harvard Medical School.) CONTENTS. The daily clinics of the Danvers State Hospital.... Accuracy of diagnosis in General paresis Senile dementia Proportion of senile dements with and without 1) cerebral atrophy PAGE. 674 674 675 ៩៩ ៩៩៩៩ ៩ 676 676 677 678 Incidence of focal lesions, Nötzli, Meyer, Appeldorn, the writer...... 678 Clinical and anatomical summaries in eight relatively pure atrophic cases General clinical analysis of the eight atrophic cases as to Sex Heredity and antecedent factors.. Social factors .... Defects of vision and hearing.. Relation to manic-depressive insanity. General and visceral arteriosclerosis.. General clinical features... Neurological Psychiatric Age, onset, and duration (table). General anatomical analysis as to Gross anatomy of the brain... Nötzli's hypothesis Meyer's data 679 685 685 687 687 688 689 690 691 693 693 695 697 * Read in part at the Annual Session of the American Medico-Psycho logical Association, Atlantic City, N. J., June, 1909. Appeldorn's data Ratios of actual to calculated weights of brain and of heart, liver, kidneys (combined)..... Comments of Alzheimer..... Chronic non-nervous conditions Arteriosclerosis Heart disease Kidney disease Other chronic conditions. The cause of death....... Discussion and microscopic analysis.. "Neuronophagia" and Metchnikoff's hypothesis... Positions assumed by satellite cells....... Relation of vascular to atrophic changes.. Conclusions I have lately possessed the unusual advantage of reviewing a considerable collection of autopsies (247) upon cases of mental disease introduced at various times in the years 1904-1908 at the daily clinics of the Danvers State Hospital, Massachusetts. The cases introduced in these clinics are of particular value, because the often divergent opinions of several diagnosticians, from three to eight or more, are recorded in each instance. The staff has varied from time to time, but has at all times contained members familiar in our recent American psychiatric literature, such as Prof. A. M. Barrett (now of Ann Arbor), Dr. H. A. Cotton (now of Trenton, New Jersey), Dr. H. W. Mitchell (now of the Eastern Maine Hospital for the Insane), Dr. H. M. Swift, and Dr. Charles Ricksher, as well as the moderator, Superintendent Charles W. Page. The clinical diagnoses which I have considered have not been those chosen for the statistical records required for the Board of Insanity, but all the diagnoses rendered for each case. For more minute examination I have naturally resorted to those cases in which all the staff agreed, holding the opinion that uniformity in diagnosis by several men is of more value than that induced by a single chief of clinic. To establish the degree of accuracy in diagnosis at these clinics, I may mention (what I have dealt with more specifically before the American Neurological Association) the 85 per cent accurate diagnoses where all agreed to general paresis. Only 6 out of 41 cases unanimously diagnosed general paresis turned out to be cases of |