ganic brain diseases make it seem improbable that in paretic dementia we have a definite mental entity directly related to the disease. The variability of the mental symptoms thus expressed has its analogy in other brain affections.

(3) In common with our knowledge of other organic brain diseases with attendant mental changes, we may regard the paretic syndrome as capable of being produced by numerous causes.

(4) Heredity of indirect type is probably a not infrequent predisposing element to the disease.

(5) The clinical differentiation of paretic dementia is often impossible. The late appearance of the so-called characteristic mental and physical signs may prohibit a concise diagnosis.

(6) The diagnosis of paretic dementia should only be made by a correlation of the mental and physical signs. There is no one pathognomonic clinical symptom.

(7) The differential diagnosis, clinically, is often a matter of extreme difficulty: the distinction from arterio-sclerosis of the nervous system, brain syphilis, chronic alcoholic insanity, with organic brain changes, cerebral tumors, and brain sclerosis may be impossible. Such a differentiation is particularly difficult in the early or incipient stages of these diseases.

(8) If we consider paretic dementia as an organic brain disease, the mental changes being secondary, we can more easily recognize and appreciate the vagaries of the malady. By comparing the mental symptoms observed to those occurring in other organic brain diseases we are more clearly impressed with the fact that in a case of paretic dementia there can be no well defined clinical picture. Of necessity we must have multiform mental and physical signs.

CONDITION OF THE HEART IN DEMENTS.

BY EDWARD FRENCH, M. D.,

Medical Superintendent Medfield Insane Asylum, Harding, Mass. Mr. President, Members of the Medico-Psychological Society: In every institution of considerable size there is bound to be an accumulation of human wrecks whom we class as dements. We latterly divide these into sub-divisions, such as precocious dements, terminal or secondary dements, epileptic, alcoholic, paretic dements, etc. The condition of dementia is not one of strict classification, and as Bianchi truly says, "Dementia has no place in classification, because it is not a morbid entity, but an issue of all acute and chronic mental affections not followed by recovery." Perhaps the largest percentage is due to primary attacks of dementia during or immediately following the adolescent period, and which we now call dementia præcox. The large number of such cases remaining in our public institutions constitutes quite a problem in their management. They vary considerably in condition. Some are apathetic, sluggish, and accumulating fat, with no disposition to move or do anything of their own volition. Other cases are more restless, mischievous, causing trouble both in their management and to other patients. The picture is a common one to all asylum physicians. Formerly our concern was to find the best means of caring for this class of patients. We had little faith in the cause of their improvement. The aspect of the case was entirely different from what it is to-day. Kraepelin had not then pointed out that the case of dementia præcox was liable to exaccerbations of violence, but lately it has been driven home to us by several homicides and our more careful observation. The ideas of the hospital superintendent regarding these cases has entirely changed in the past few years, and now instead of the question of care it is one of how to occupy these patients and in what way to re-educate them. Experiments have resulted in showing us that the dementia is not as profound as we for

merly thought it to be, and that the individual is capable of considerable development in an industrial and personal way. This applies, of course, to those cases where the functions are fairly well performed, even if somewhat imperfectly; for we have all noted from our practical experience the apparent failure of many of the physiological functions, most notably those of circulation, digestion, assimilation, and that delicate combination of physiological processes which we call metabolism. We have found out that these can all be vastly improved by proper exercise, and it is our modern problem to provide this in our public institutions. to-day.

What I am to consider to-day is first the circulation, and second the heart action in such cases. Some of our modern authors note changes in the circulation and heart action of dements, but it is almost entirely confined to contemporary writers. Among these, Berkeley says, "Vaso-motor pareses, shown by blueness of the extremities, low tension of the arteries, and oedematous conditions of the feet are equally frequent. Arterio-sclerosis is present in a large proportion of cases, even those occurring in earliest adult life." Kirchoff, speaks of "Brittle arteries and senile changes in the heart." Kellogg says, "The circulation is impaired. There is vaso paresis and enfeebled cardiac action."

My assistants have for some time past been making physical examinations of the hearts and the circulation of dements, preliminary to blood examinations. These examinations have so far only been confirmed in a few cases by autopsy. Over 700 cases were considered, and 550 odd cases were selected as proper ones for the collection of statistics along the lines mentioned. Certain doubts assailed us before this examination began. Among others, in certain cases it seemed possible that the demented condition might be due to senile changes of the heart and arteries. A study of the history of these cases showed that it was not possible except in a comparatively few cases, and these were accordingly thrown out. As a general proposition I believe that the condition of dementia is due only in a small number of cases to atheroma and senile changes. I also believe that these are confined to those cases where the psychosis appeared beyond middle life. The 550 cases from which I have drawn conclusions are

those of terminal dementia due to functional psychosis, and all cases of toxic insanity, paresis, epilepsy, and other psychoses which are not decidedly functional have been thrown out, so that the statistics apply solely to cases of terminal dementia or dementia præcox. A few were discarded because of difficulty in getting clear results in physical examinations, owing to excessive fat or the great restlessness of the person under examination.

I will first consider the observations made on pulse and circulation and analyze the results obtained. The lowest pulse observed in a male case was 50. The highest 120. It was noticed here that frequently patients with considerable atheroma did not have a pulse that was remarkable in any way. The highest pulse rates were found in those cases where it was expected and where a weak heart action seemed to be the cause, and also this weak action of the heart seemed to account for nearly all the rapid pulses in the whole number of cases. Many of the male cases showed nothing abnormal in the examination for heart symptoms, but the cyanosis and oedema of the extremities together with the high pulse which indicate a weak action of the heart. The average pulse rate for nearly 200 men was 781⁄2 per minute. There were 15 cases of marked tortuosity in the radial and temporal regions. There were 84 male cases in which atheroma of the arteries could be made out without any reasonable doubt in the radial and temporal arteries. There were 12 cases of irregularity, 8 of these 12 being intermissions.

The lowest pulse rate in a woman was 40. The highest was 140. The average pulse rate for 363 female dements was almost 86, being more than 8 beats higher than the average pulse rate for the male dements. The abnormalities among the women were not as great as among the men, that is, a weak pulse was found where it was to be expected and a high pulse where that would be looked for. Many of the cases of low pulse rate showed hypertrophy of the heart, some of them atheroma. There was marked tortuosity in the temporal and radial regions in 28 women. There was evident atheroma in the radial and temporal pulse in 40 female cases. This was very much less than among the men. There were 22 irregularities, 19 of these being intermissions.

Careful examinations of the heart's action, position, strength, etc., resulted in the following statistics. Among the 78 cases of