into close relationship pathologically with paralytic ins with which it has many common features. They are the clinical forms of insanity most allied. Senile insanity becomes paralytic insanity. Paralytic insanity always has of the mental symptoms of senile insanity. There was distinct meningitis in three cases, one of wh was the case of L. E., with "pachymeningitis hæmorrhag externa," referred to on page 516. Of the other organs of body, the heart was found most frequently affected, there b marked cardiac disease in ten cases. The lungs came next, .. bronchitis and broncho-pneumonia in nine cases; and next kidneys in two cases. In many of the patients several of t above morbid conditions were combined. With regard to the microscopic appearances in senile bra I must refer to the careful and correct descriptions and drawt. of Dr Major. We have all been able to confirm those obser tions, and perhaps to see some special points in addition, have not been able to add much to them. The various stag in the degeneration of the large cells, the atrophy of t smaller cells and nuclei, the enlargement of the vascular cana and the débris of granules and hæmatin crystals, are all described by Dr Major. I have met with such general atroph as is represented in Plate VIII. fig. 3, in several cases where t nerve cells and fibres were gradually disappearing, leaving or an irregular loose reticulation of cell walls, neuroglia, and at phied vessels. The weak point in the pathology of senile insanity is, that have no means of comparing those lesions and changes I have described with the appearances of the brains of old persons w were not insane. Beyond a doubt, some of them, both nake eye and microscopic, are present in persons whose mental or dition never got beyond normal senility; but there is less dos that in the brains of fifty-two persons from the average populati over 60, there would not have been found so many softenings au! atrophies, &c. What we have to ask ourselves, in order to for 1 West Riding Reports, vol. iv. p. 223; and ibid., vol. v. p. 161. anything like a proper conception of these cases of senile insanity, is, what was the relationship between the purely dynamical phenomena of morbid mental exaltation or depression, loss of memory, and constant purposeless motor excitement, during life, and the atrophied convolutions, the degenerated cells, the diseased vascular system, and the starved areas of brain found after death? Did these pathological changes, when they advanced to a certain point, simply allow old hereditary convolutional weaknesses to come out that had been so slight that by nothing but slow death of brain tissue could they have become actualities instead of mere potentialities? Or had the advancing brain degeneration simply weakened and destroyed all the higher inhibitory faculties and "centres" in the brain? Is the constant motor restlessness referable to the progress of the manifest changes in the larger "motor" cells of the convolutions? Is the loss of memory a mere paralysis of the power of attention and mental concentration on sense impressions-a result of the loss of inhibitory power, in fact? Or is it, in addition, an absolute paralysis of receptive capacity on the part of the cells in the convolutions, the impressions-from the senses being "writ in water"? Or do the impressions not reach the convolutions through degeneration of the white conducting fibres? As to the memory of old events, which is the last to go, is that just the result of destruction and atrophy of the cells as organised activities? What light does the whole known pathology throw on the constant connection of the mental and motor symptoms? It seems to me that that connection in senile insanity is another proof of the motor functions of some of the brain convolutions. I can How can senile insanity best be treated and managed? only lay down the principles that I have found useful, and can scarcely enter into the details of individual cases or requirements. The thing of first importance is undoubtedly to get a good nurse, a responsible, skilled, patient, experienced person. Women make by far the best nurses for old people of either sex, but for male patients they are sometimes not physically strong enough. After a good nurse (and a daughter or relative will sometimes make the best of all) comes the routine of manage ment, diet, exercise, and regimen. Excitement, and new things or ways, or places or persons, should be avoided. Old peopl take best with what they have been accustomed to. Warmth by night and day is most important, combined with airiness of the apartments. The clothing should be warm by night as well as by day. Cold aggravates excitement and causes dirty habits The night management is the most important and the most troublesome. It is better not to attempt to keep the patients in bed all the time if they will not stay there quietly. Struggling with them causes irritation and resistance. A suite of airy, not over-furnished apartments down stairs are the best. As t exercise in the fresh air, it is most important. It makes all the difference between being able to manage a case at home at all or to manage it well in an asylum. It should not be given up to the point of exhaustion, like exercise in young acutely maniacal cases. The walks should be short and often; and, when the weather admits, sitting in the open air should be practised Senile patients have a provoking habit of sleeping during the day and waking at night. Better sleep by day than not at al The diet is also most important. I find the first food of man t be the best at the opposite end of life. There is nothing like milk, given warm and in small quantities at a time, and ofte Fatten your patient and you will improve him in mind. T much flesh and beef-tea are often too stimulating and ind gestible; cod-liver oil often works wonders, and so does maltine. Fresh vegetables, or their juice in soups, should always be give All the solid food should be minced or pounded for a large numbe of the cases. Sometimes it is necessary to fit up a special room in a privat house for night use, without furniture, warmed, and that car be cleansed daily. Night feeding as well as day feeding often needed. Often a big stomachful of hot porridge bread and milk will give a night's sleep far better than a hypnotic medicine. It diminishes the But by means of mild The purely medical treatment is, in senile insanity, the least important, but we can do something in that way. My experience of opium is unfavourable as a sedative. appetite, and often kills the patient. doses of the bromides, with or without small doses of cannabis Indica, used occasionally as required, we can tide over bad nights comfortably. Tonics are useful, and iron and the phosphates often work wonders. Alcoholic stimulants are often useful, but not so often as is commonly supposed. The bowels should be regulated by the simplest laxatives, some treacle or syrup given with the evening meal of porridge being often all that is needed. The great aim, in most patients, is to get into comfortable normal senility as soon and quietly as possible. In some the restlessness and noise are so pathological that nothing seems to have any effect in controlling or abating them. The patient and his brain simply wear themselves out, and everyone about him is thankful when all is over without accident. Few questions are so difficult to determine as the one of sending a very old person to an asylum or not. The feelings of everyone go against it if there is a good home, dutiful relatives, and sufficient means. The best way is to try all other means first. In good asylums we give the poor suffering from senile insanity a sort of treatment that the richest often cannot get at home for any price, and in many instances with remarkable success. If, therefore, there is poverty and no conveniences for treatment, one cannot hesitate about the course to adopt. I am well aware of the imperfect view of the whole senile condition, bodily and mental, that a physician to an asylum is apt to get from seeing the very worst cases only. His picture is filled in with very black shadows. To keep himself right, he must take all the opportunities he has of seeing and studying senility outside of an asylum, which I habitually do, trying to look at it with a medico-psychological and pathological eye. I never see an old man who fails to interest me from that point of view. I wish physicians in general practice |