makes up his mind that he is going to be friendly and forbearing rather than otherwise, things will be very much better. One can see in various towns very striking differences in the advantage of practice, depending on whether the doctors in the town are on good terms. I advise men who have asked me where to go never to go into a town where the doctors are not harmonious but if they know where they are so, to go there rather than to a place where they are always fighting. Quarreling makes the profession less looked up to. It lessens the legitimate return that one should expect from practice, as may be easily understood. The beginner can sometimes make himself useful by offering to do, on business lines, what the older and busier man has not time to do, although he never should intimate the other does not know how to do it. Nor should he overrate the importance of his part of the work, thinking that because he can count red corpuscles he is an expert in blood diseases, or because he can see hyaline casts that he knows more about the management of a case of uremia than the older man. Good but injudicious men have gone to offices of doctors in town or country and talked as if the other doctor did not know a blood counter from a microtome and very often have been introduced into better looking laboratories than they saw at school.

Other questions often asked about are in regard to cards, signs, et cetera. Those are all questions of local taste and custom. You should find out about them from the doctors in the locality. In some places it is customary to put a card in the newspapers; in others that is considered bad form, and even in little towns it makes a difference whether you do the right thing or not. In some places doctors have signs that look as if they might belong to a bath house; in other places they have a red light, that would in still other places invite a visitation from the police. Those details you should learn, and not have a big sign in a town where it is the proper thing to have a small one. That would make one appear as odd, and that is always a bad start for one to make in any walk of life, and dangerous unless one has great talents and the ability to make them known.

Practice. Let us consider next the getting of the patients. The things that govern the acquisition of a practice are too complicated to enumerate in a short time. The reasons for a patient going to a doctor are almost impossible to analyze, but a number of causes are sometimes. brought to my attention, and I shall try to explain them. The beginner has an idea he cannot get any patients because the patients belong to other people. That is by no means the case. It used to be so in many parts of the world, and still is so in some parts, that practices were bought and sold. It was formerly carried out most completely in England, where even now it is rather unusual for a man to get into a practice without having paid for it; but in other countries, as in Germany and this country, it has been decided by courts that medical practice cannot be a matter of sale in the ordinary sense. There is no exclusive

right about it. So if A buys B's practice, C has a perfect right to start in beside A and get all the practice he can. Whether it is a fair proceeding might be questioned, but the legality of it cannot be doubted at all. But the patient never belongs to anybody. The sick man has a right to go to anybody he pleases; in fact, he has a right not to go to anybody at all. Whether he is obliged to take his dependents to a doctor has not been settled. A man may go to a doctor, an osteopath or a Christian Scientist just as he chooses; but whether he has the right of taking his child with diphtheria to an osteopath or Christian Scientist has not been finally determined by the courts. It is sometimes said—and I am sometimes asked about this that one should not take a patient without being perfectly sure that the patient is no longer financially indebted to his previous doctor. That, however, I do not think can be considered as very good doctrine. In the first place when one is called to see a sick person it is not well to put the financial part first; not well to ask, "Are you able to pay your bill," or, “do you propose to pay your bill." You should find out what you can do for him and do it. If you put everything on the ground of payment in advance you certainly will not advance your practice very rapidly. On the other hand, the patient who easily changes from one doctor to another is not likely to do anybody much credit, so doctors should not encourage that sort of thing. Sometimes the new doctor knows or learns the patient already has a physician. In such cases patients should rather be encouraged not to change without good cause but keep on with anybody who is competent to treat them and willing to treat them. Then there are other reasons why one should not too quickly or too easily take up with a new patient,-geographical reasons or matter of convenience. As a general thing a doctor should not make his practice any more arduous than it has to be. To go ten or twelve miles out of your way in the district of another doctor is not a good thing to do, not because the patient has not a right to call you or you a right to go there, but because while you are going ten or twelve miles in someone else's territory you will lose time and perhaps practice in your own. So the best doctors in city and country try to limit their territory and remain on such terms of friendliness with their neighbors that if a patient calls. them up at a great distance they refer them to a neighbor, knowing very well that in the long run these matters will become equalized. Another point in regard to the selection of patients with reference to their financial ability. It strikes me sometimes that there is a greater tendency now on the part of young doctors to take that attitude than a few years ago. I think the difference is due to changes in methods of study. Up to a few years ago medical students saw more of the work of practicing physicians than they do now. They saw charity work done as a matter of course, and so carried out the same plan themselves. I have known of men starting out on the "no pay, no treatment" plan, who were soon obliged to migrate; but learning their lesson and begin

ning anew in other places, they were able to get along in a better way. There is one reason why a patient may change; that is the reason of dislike, with or without any cause, which is illustrated by the poem about Doctor Fell. It was said first not about a doctor of medicine, but of divinity, but illustrates the point very well. It runs:

I do not like thee, Doctor Fell,

The reason why I cannot tell;

But this I know and know full well,

I do not like thee, Doctor Fell.

Practice comes in very curious ways; not always from influential people in the ordinary sense. For example, it is more likely to come from a cook in a family than from the minister's wife or than from a lodge brother's wife. I do not mean to say that the church and the lodge should not be cultivated, but to cultivate them with the purpose of gaining practice is not only ethically wrong but will be a disappointment in the long run. But however the patient comes to you, with or without a discharge from his former doctor, no criticisms or comments should be made in regard to the doctor. So far as possible his treatment should not be criticized. Some men make a practice of disregarding both these rules, either by direct statement, by facial expression, or by the equally emphatic way of throwing medicine out of the window or into the fire, or by ostentatiously changing the line of treatment, as by giving one salt instead of another. In the case of a quack or pretender, no effort should be made to protect him, especially by continuing a faulty line of treatment, or you share his fault. On the other hand, it is a waste of time to condemn him. People understand only results in the treatment of disease, and cannot understand methods. This is well shown by the answer of the blind man healed (John, Chapter IX): "Whether he be a sinner I know not: one thing I know, that, whereas I was blind, now I see." The result in any case is not wholly in your own hands. If you get credit, accept it pleasantly. If blamed, accept the blame philosophically.

Concerning the freedom of patients in consulting their doctors, it might be well to point out some local facts at this time. As all of you know there is a good deal of opposition to the working of this hospital. The ground is taken that the hospital is a charity hospital but abused by rich people who come here and get their treatment at a nominal price. The matter of abuse of charity hospitals is a very extensive one; it happens everywhere, and every now and then a millionaire disguises himself, borrows somebody's old clothes and gets advice and treatment at some great city hospital for nothing. But this hospital was never built as a charity hospital, and any charity that comes out of it is purely casual and incidental, though the aggregate, as you know, is considerable. It was not built as a hospital in the beginning; it grew up in response to the need of a place for the care of people who came here for treatment and advice. They came before there was any special building and lived

in boarding houses and hotels and so a clinic grew up, but even now it is not a hospital where a perfectly penniless person can come and be taken in. This is undoubtedly unfortunate and should be remedied, but that it is improper or that there is any irregularity or any ethical failing about it, nobody can say; because just as a sick man has a right to go to a doctor in his own town or a distant town or to none at all or to a Christian Scientist, so he has a right to go to the hospital where he pays twenty-five dollars a week or to the one where he pays seven dollars a week and is examined by half a dozen doctors or half a hundred medical students. He sells his disability for a price, as he has the right. It is for him to decide whether to pay twenty-five dollars, or any sum, for service or to come here and get twenty-five dollars worth or more of service for seven dollars, and submit to a public examination; and if he wants to do that nobody can object on the ground of ethics or legality. In large cities there are men who make their living by serving in auscultation and percussion courses, just as there are others, with chronic diseases, who demonstrate the latter to classes for a price. Perhaps a patient will leave your district and come, but it does not follow that that represents a definite and actual loss to you. It is often the case that a patient who does that would be on the point of going to somebody else; if he did not come here he would go to one of your neighbors; probably the reason he did not is that he thinks the neighbor is not as good as you are, and that may be a consolation to you or may not. Now it undoubtedly is to the benefit of a practicing physician to have as many patients as he has time to treat, and the way to have them is to make your patients so comfortable that they would rather pay you any sum than go to a hospital for a smaller sum. And even after all that is done there will be plenty of patients who can conveniently or advantageously be sent to a place like this for treatment, and who can be sent without causing you any possible loss of income but actually, perhaps, aiding you by leaving you free for other practice.

THE CLINICAL ASPECTS OF PARETIC DEMENTIA,
WITH SPECIAL REFERENCE TO DIFFER-
ENTIAL DIAGNOSIS.*

IRWIN H. NEFF, M. D.

It is manifestly impossible to attempt more than a reference to facts pertinent to the subject-matter of this paper. Therefore I shall dwell for the most part with generalities, referring only to the more salient points bearing on the nature, pathogenesis, causation and differential diagnosis of paretic dementia. A reference to the recent and voluminous literature of paretic dementia is convincing

*Read at the annual meeting of the AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION, Boston, Massachusetts, June 12-15, 1906.

that although with reasonable certainty we can say that we have definite and characteristic pathologic lesions, we have not solved many questions concerning its nature, course, and clinical picture.

An unusual amount of labor has been expended in attempting to establish a pathognomonic clinical sign for this disease; but one must acknowledge that the clinical diagnosis is made on the correlation of symptoms. The advent of the atypical case-the arteriosclerotic case-and the frequent appearance of analogous symptoms in other cerebral organic diseases having a distinct pathology, has made apparently an endless degree of confusion. The idea that paretic dementia is an organic brain disease per se, with attendant changes in the mental attributes is an old one, but many of us today are again inclined to this belief. This theory is a plausible one when we remember that we have other brain conditions showing similar symptoms,-symptoms so closely resembling those found in paretic dementia that we are often unable to determine the differences. It has always seemed to me that we have attempted to surround paretic dementia with a veil of mystery, and have patiently and consistently endeavored to make all our cases conform to a certain type. Why should we not have a variation in the mental syndrome? Such a variation in symptoms may be found in cases of brain sclerosis, brain tumors, arteriosclerosis, and even old cases of softening and hemorrhages. If we recognize these inconsistencies occurring in the course of these diseases, why not consider paresis as a disease which can exhibit the same peculiarities.

F. W. Mott, seven years ago, advanced the theory, giving his reasons, for supposing that general paralysis of the insane was a primary degeneration of the neuron, with secondary inflammatory changes. His conception of the disease, briefly expressed, was as follows:

General paralysis is primarily a parenchymatous degeneration due to loss of durability of the nerve cells and a premature decay of tissue in which inherited and acquired conditions take part, with the result that progressive death of the last and most highly developed nervous structure ensues as soon as their initial energy is unable to cope with the antagonistic influences of environment.

While the acceptance of such a theory might seem to add to our confusion, I believe that a more general adoption of a theory comprehending Mott's main points might prove serviceable. By conforming to such an opinion many debatable points concerning the disease could be more easily explained.

Some years ago I accepted this theory of paretic dementia as a working basis, and have found that his conception of the disease has proved of considerable aid in the clinical interpretation of the mental and physical syndrome. The acceptance of such a theory might seem to prohibit an accurate diagnosis of the paretic syndrome and prevent a grouping of the disease as a psychosis. However, the classification