vived eleven days. Both were in the terminal stage of dementia, and neither could have survived long even in the absence of these supposed injuries.

The suspicion of pellagra as the condition to which all of these circumstances might be attributed did not arise until last year. When attention was directed to this disease it was found after consultation with the experts of the State Board of Health and the U. S. Public Health and Marine Hospital Service that over one hundred cases of this disease were present in the institution last summer, and that all of these mysterious cases of the last five or six years were not due to wrong administration and abuses, but to the prevalence of this disease. Dr. Zeller further says:

One of the annoying features of our death rate was the constantly recurring cases of summer diarrhea. It rapidly changed to entero-colitis with collapse and death. These I considered preventable deaths, and in the face of assurances that they were an accompaniment of dementia, I felt that they were a reflection upon my administration.

I secured the ablest dietist that the Lewis Institute of Chicago had graduated, and placed her in charge of the food supply. I ordered a crusade against flies, and while every door and window of this institution is protected by fly screens, we covered every table and every garbage can and all food supplies with mosquito netting.

The dietist was given a graduate nurse to assist her, and later a woman physician was detailed to supervise the preparation of the food and to look out for the domestic hygiene. While these precautions had some effect in reducing the amount of intestinal disorder, we found ourselves confronted with another annoyance.

As far back as 1905 we noticed a number of extensive sunburns. The attendants usually attributed them to the fact that the patients would lie on the grass in the shade and go to sleep while the shadows would move and leave them exposed to the sunlight, resulting very often in burns about the face and neck and especially the back of the hands. These sunburns became so prevalent in 1908 that we were greatly embarrassed in case such a patient died, and my correspondence will show many instances where I wrote to the friends and made the best explanation that I could of the presence of these sunburns.

In no case were the burns sufficient in themselves to cause death, but occurring as they did in patients who died after a diarrhea of five or six days, they were still visible in the corpse and it was very difficult to convince the friends that the patient's arms and hands had not been dipped in boiling water, or that concentrated lye or full strength carbolic acid had not been spread over the face and neck. These deaths caused considerable distress when they followed four or five days after we may have written a letter stating that the patient was in excellent physical condition.

In the case of a body shipped to Canada it required the utmost assurance on my part to convince a most excellent family that there had been no accident.

A devoted Swede family came to bury one of its members, and we called attention to extensive sunburns on the back of the hands. They were suspicious because of the unexpectedness of the death. They had visited the patient a week before and walked about the grounds with her and declared that there were no sunburns then, and they accepted our explanation with mental reservation.

A consumptive in the tent colony died, and the friends at home insisted that he was burned in a lamp explosion, although there is not an oil lamp in the institution.

In the winter these sunburns ceased, but it was not an unusual occurrence to have a case transferred to the hospital from the wards with extensive sloughs involving the genital parts.

Early in the present year I called the thirty head attendants into the library and gave them a strong admonition that sunburns must not occur in 1909. I cited their unusual number in the previous year and showed that while most of the patients recovered, and were returned to the cottages, in a number the burns were sufficiently severe to have contributed in a measure to a fatal termination of the disease, which was usually entero-colitis or general paralysis of the insane. I warned them that dismissal would follow a repetition of last year's conditions, and showed them how difficult it was to explain away such appearances even if death from some other cause intervened.

Later the daily inspections showed that the lecture was having its effect. Most carefully and considerately the attendants moved the patients from the sunny to the shady side, but it seemed that all precautions were without avail.

This record of Dr. Zeller's is a most unique contribution to the possibilities of clinical misconceptions, and reveals incidentally the mental pressure under which asylum physicians carry on their work. Over-conscientiousness is not a universal fault, and in a hospital where the helplessness of the patients does not constitute a daily appeal to the sympathies of the physician, a different viewpoint would probably reach more quickly the significance of the unexpected and curious groups of symptoms.

THE MUNICH CLINIC AND DEMENTIA PRÆCOX.-A suggestion of the difficulties attending the use of the term dementia præcox is conveyed in an interesting communication to the Edinburgh Medical Journal of January of the current year. Under the title

"The Study of Psychiatry in Munich," Dr. J. Mackie Whyte describes a visit to the Royal Psychiatric Clinic, and gives his impressions not only of the general administration of Professor Kraepelin and his staff, but also of the methods of study of the patients. Perhaps no phrase in modern medicine has aroused such interest and excited so many doubts as the term " dementia præcox." This diagnosis has been applied in a wide variety of cases and has been seized with avidity in America, although the English have been much slower to accept it, and the more conservative practitioners may find some comfort now in an expression of doubt from Professor Kraepelin himself. Dr. Whyte states that the cases of dementia præcox occupied second place in frequency in the statistical tables of the Munich clinic in 1905, whereas in 1907 the number had dropped to the fifth place. On the other hand, the manic-depressive group has risen from the seventh to the second place. Dr. Whyte states that Professor Kraepelin acknowledges that many of the cases were formerly wrongly diagnosed as dementia præcox. With his further experience he is much more chary than he was about this diagnosis with its much less hopeful prognosis. It is evident from this that Professor Kraepelin intends to group under this phrase a class of incurable cases passing on to irretrievable degeneracy, and has had in mind the desirability of a knowledge of the early symptoms which predicate "no recovery." The mass of literature upon the topic reveals that these cases are not universally assumed to be adolescents. It would almost appear that Professor Kraepelin has not been entirely successful in the assumption early in an attack of mental disease of incurability based on some symptom or group of symptoms. Alienists may agree upon a term to be applied to certain manifestations, but should not be expected to stake the correctness of the diagnosis upon the outcome of the case. In the general practice of internal medicine a great many cases are recognized as serious, and often fatal, but no practitioner would take it upon himself to predict the outcome of an acute disease, such as pneumonia for instance, on other than general principles.

There are many other facts of interest in the short communication of Dr. Whyte, and particularly the description of the scientific work done by the staff associated with Professor Kraepelin.

SUMMER SCHOOL FOR ATTENDANTS IN INSTITUTIONS FOR THE INSANE IN ILLINOIS.-A recent circular from the Chicago School of Civics and Philanthropy informs the public that a summer school to give training in occupations for attendants and nurses in institutions for the insane has been established, the sessions of which will extend from June 21 to July 29, 1910. The appended. extract will give some idea of the purpose and scope of the instruction thus promised:

A great movement forward in the care of the insane has taken place in the introduction of the nurse trained in the general hospital and in the emphasis placed on the need of hospital care for the acute patient, but this movement, by its very importance, leaves the so-called chronic patients more neglected than before unless at the same time a wise and systematic effort is made to re-educate and stimulate them. Far the greater portion of the patients in the great state hospitals, numbering in all nearly 200,000 persons, are day and night in charge of attendants. The physician may spend a few moments daily in each ward, the nurse some hours; attendants must be constantly present, day and night. In most institutions it is still, unfortunately, true that the hours are about 15 per day, that the attendants eat with their patients and sleep near them on the same wards, while their pay is most inadequate in view of their exacting responsibilities. Laborious and thankless as this service may appear, and difficult as it is to secure suitable attendants, yet when intelligently regarded it offers much that is interesting and attractive. Its fundamental importance in improving the care of the largest class of public wards is very great, and its appeal to humanitarian and educational interest is so strong that, when rightly understood, there is certain to be an improved type of attendant, better pay, and more reasonable conditions of labor. The work of the attendant is plainly educational and the true methods are those employed by the best teachers of little children-teaching the use of the muscles and mind together in games, exercises and handicraft. Doubtless the games and exercises are the most effective stimuli for certain patients, for others the making of objects. Such work is far different in curative and remedial value from the routine work which, of course, must be done by patients in every institu tion, but which soon becomes a mere mechanical process.

Upon this point we may quote Dr. Adolf Meyer, late head of the Psychiatric Institute of New York and recently appointed head of the Johns Hopkins University psychiatric wards in Baltimore.

Dr. Meyer says: "During the last decade we have come to realize more than ever that, while some mental disorders are due to toxic conditions, others are rather due to conflicts through poor adaptation. In these conditions a training in normal activities and a cultivation of fruitful interests are the sanest and only efficient point of attack. Occupation in our hospitals has so far been limited largely to housekeeping and sewing and

carpet making, but only few things adapted to rouse a constructive interest which may be carried into the home as a recreation and a relief from routine. It stands to reason that an hour or two spent on some interesting work may relieve a brain from the perpetual and fruitless grind of worry or of day-dreaming; it brings contact with a sane teacher and new outlooks.

"Occupation is a matter of prescription comparable to the plan of work in the gymnasium. Last summer the Chicago School of Civics and Philanthropy gave a course to attendants in the methods of play and entertainment of patients, to my mind one of the most useful steps taken by philanthropy in our field."

This course is frankly, therefore, another effort in the direction of securing greater efficiency through the training of persons now engaged in what cannot be reckoned yet as a skilled occupation-that of the ward attendant. Although the number of students has been limited, and only six states and sixteen institutions for the insane have been represented in the classes, yet there are many indications that the influence and stimulus of the school have been of more considerable extent than would be indicated by the comparatively small beginning.

During the first year's session of the school the class was taken to the Cook County Asylum and was given normal practice with a large circle of patients of this stupid chronic type. One of the students was teaching an awkward man patient to twist a rough basket, and as he sat struggling she said to him, "Do you like this?" To which he responded with the sudden abruptness which characterizes patients usually silent, "My God, yes! Anything is better than sitting idle all day on the wards." This man was typical. The attendant who is tactless, untrained in ways of occupying and amusing, can only get the routine ward work done and then leave the rows "idle" and dull, content if the patients are "quiet."

A significant item is the following history of a patient in a Wisconsin county asylum. The matron was a student of the school last summer, but because of many cares had not taught any of the handicraft learned by her until she was asked for illustrative material, when she at once set to work teaching patients who had no previous knowledge of such work and who were chronic cases. In a week she sent down several examples with photographs and descriptions of the patients as employed. These are of special interest as illustrating the mental stimulus which can be imparted through individual attention. The perfection of the objects made is of slight importance; the awakening of the patient's interest in some orderly process is all-important. J. R. and his work are thus described: "A pierced brass tray and raffia basket were made by J. R. during the week ending February 18, 1910. He has had no previous experience or knowledge of this work. History: Age, 27; first symptoms of insanity at age of 23; committed to State Hospital, July 17, 1907; transferred here, September 25, 1909; chronic melancholia. Patient usualy remains quietly seated in one position with his eyes closed, takes no interest in his sur