children, but had left none to the children of a former wife. Having got off so much with tolerable clearness, he became confused in thought and utterance and unintelligible, began to shed tears, and soon to mutter about something else, and since then has never referred to the subject, or clearly to any other. The disposal of his property in this manner had evidently caused him some anxiety when he made his will, and now for a moment the subject came again into consciousness, but soon vanished in the confusion and weakness of his mental activity.

There is another case, F. H., on the same hall as T. A., whose condition is somewhat different. During the larger portion of the time he will sit in his chair from morning to night, except as he is taken to his room or to the dining table, saying little or nothing. But during the two years since his admission to the Retreat there have been several occasions during which he has been quite excited. At these times his leading delusion is that some one is being killed; he then shouts at the windows and begs to be taken home; is thoroughly confused in his mental operations, and is constantly appropriating articles belonging to other patients.

This excited state continues only two or three days, when he relapses again into his state of dementia and mental inactivity. These periods of excitement probably arise from changes in the circulation in certain areas of the cortex or the central ganglia, or from the irritation which results from pathological changes which are frequently taking place in these portions of the brain; and as the senile brain soon becomes tolerant of the changed conditions if they are not too great, the irritation becomes less, and the outward expression of it in the form of increased motor activity, restlessness, and shouting also subsides.

The fourth case had an attack of melancholia with delu

sions, which passed through a more or less definite course with an ending in recovery, but with conditions usually present in senile decay.

C. A. A., aged sixty-eight, was admitted with the statement that he had been failing in strength and activity for some years past, but had never been able to realize it; has thought that he could do just as much as in former years, and became greatly annoyed by any insinuations to the contrary; has persisted in trying to dictate how the men on the farm should do the work, and in showing them how to do it himself. A few months ago he lost his self-confidence, began to fear that his property was all gone, and that he was to go to the poorhouse; that persons were trying to rob him; threatened to kill his wife, and recently wished himself dead, and made one or two attempts at suicide, which led to his being brought to the Retreat. He is now restless and uneasy, walks the hall, often sheds tears, and wishes to be returned home; is very suspicious; has hallucinations of hearing; says the poorhouse is the place for him; that he can never pay for being here, etc., etc.

Under the influence of the treatment and regularity of the Retreat life, he began to improve; his despondency became less; the hallucinations ceased; he took an abundance of nourishing food, and in a few months returned home quite happy, but still with the enfeebled mind of an old man. This case, so widely different from the cases of S. T. and C. A., is simply one in which there came on an attack of acute melancholia in an old brain. While there existed an enfeebled and imperfect mental condition both before and subsequently to the attack, yet there was not such a state as is implied by the term senile dementia, which is the sequel of irreparable loss of nerve energy or more pronounced pathological changes in the brain with atrophy.

The fifth case to be mentioned is in the Retreat at the present time of writing. It illustrates a senile form of melancholia, connected with brain atrophy, from which patients do not recover.

He has been under observation six years, and during that time has passed more than five years in a condition of mental and physical depression. He is now seventy-four years of age, of light, sandy complexion, thin in flesh, unstable in gait, somewhat anæmic, with feeble action of the heart. He experienced one or more periods of depression several years ago, but was never placed in an institution for treatment.

During his residence at the Retreat, he has never, on any occasion, been especially exhilarated or happy, but, on the contrary, all the while self-accusatory, and reproaching himself for past delinquencies, for which he says he has never been forgiven, and for which he fears he will be eternally punished. The secretions are rather scanty, and he rarely takes any satisfaction in the use of food, which he takes only as a duty.

He has often told me he would like to die, and the suicidal intent is evidently frequently present, but he has not the courage to execute it, and says he is really afraid to die, but would do so if he dared. Sometimes he confidentially asks me if I am willing he should longer remain at the Retreat, and when asked what reason he has for supposing that I do not desire him to do so, replies that he has been such a hypocrite and sham all his life that he cannot believe that I wish to see him about.

At the present time the mind acts very slowly, and there is little if any ability to associate ideas together so as to form a definite opinion about any subject. He can refer with some accuracy to events which occurred years ago,

but has little capacity for registering the events of yesterday. The action of the mind is largely automatic, and he lacks the ability to reason about any plan or question which may be suggested to him for decision.

There is no history of alcoholism, but, on the contrary, one of great regularity as to habits of life. He is becoming more and more insensible to passing events, which seem to become blended with former experiences, which he sometimes refers to as if they had only just now occurred. The process of involution is steadily and slowly going forward, and he will, if he lives long enough, ultimately become as feeble in mind and body as the first case described.

During the last two years he has had epileptiform seizures of a mild character, three or four times a year. He generally remains in bed, however, only a few days, and appears less despondent after recovering from the immediate effects of an attack than before. While he has had short periods of being almost free from depression, yet he has never been entirely so, and never confident that he could with safety to himself leave the Retreat.

The suicidal tendency is present at times in a large proportion of such cases.

It will be observed from the study of the senile cases in almost any institution, of which those above outlined may be regarded as specimens, that the symptoms of senile insanity present a large diversity. They may prove to be those of dementia which is the result of slow and longcontinued degenerative changes in the system, with consequent diminution or loss of nerve energy, in which case the patient finally dies in a state of fatuity.

Or, again, the symptoms may consist in simple excitement, increased motor activity, loquacity, and self-confidence, all of which may subside after a few weeks; or, on

the other hand, may become greatly exaggerated, until the patient is noisy, incoherent, and rambling in thought and speech, and unable to sleep or remain quiet for any length of time. Such patients often refuse to take food and are likely to die of exhaustion unless the acuteness of the symptoms becomes less pronounced. All these mental states may subside and the patient recover a considerable degree of mental soundness, or he may pass into a state of confirmed senile dementia.

Finally, the symptoms may from the first assume a depressive or melancholic type, and the patient, so far as he is fully conscious, becomes absorbed in reflections which are of a painful nature, and often has impulsive tendencies. At a later stage the mind may pass into a condition of reverie or be lost in a state of torpidity with little indication of volition, or of attempts to recall the past, or to initiate any course of action or thought, unless it may be one of self-injury or destruction. Not unfrequently the general condition of melancholia is attended with short periods of maniacal excitement and destructive tendencies.

The treatment, or rather the course to be adopted in the management of some cases of senile insanity, may become one of much delicacy. If the person is one who is likely to be benefited or cured by treatment in a Hospital for the insane, the duty of an early removal, as in cases of other forms of insanity, is evident, but in the majority of these cases there exists little prospect of recovery. The question, therefore, resolves itself into one of care; and it is one often presenting a good deal of embarrassment. It is no light thing to remove an old man or woman from the scenes and surroundings of a home, where long years have been spent, and which, in many cases, is the result of years of labor, to any public institution, and from the presence of