ranks of life. These initial changes, especially the physical ones, are so obscure that they have not been noticed, and in consequence of the character of occupations, could not be by non-professional observers. Only the more pronounced and easily recognizable ones which occur later on in the progress of the disorder can be recalled by friends and physician. It will be in those cases which occur among professional men, and those engaged in large business enterprises, that such a medical history as has been described may be observed, while in the larger majority of cases the friends will declare that nothing whatever unusual has been noticed in the mental or physical condition of the patient until within a very short period. When, however, inquiries are made, not infrequently it will be remembered that some of these obscure symptoms have appeared at times, for months or years, in the history of the individual.

The recuperation of brain energy which ordinarily occurs during the periods of rest, diversion, and sleep is in partial abeyance; the vaso-motor system is disturbed in its functions, causing a more or less irregular circulation in the brain cortex, and hence the mental functions common to it become irregular and in some degree abnormal.

Symptoms Become More Pronounced in Character-Increase of Irritability and Excitability Egotism—Self-confidence — Extravagance of Projects— Sexual Excitement-Change in Moral Character-Failure in Memory-Mental Obtuseness-Insomnia-Depression not Unfrequently Present -Physical Symptoms -Vertigo-Incoördination of Gait-Tongue— Articulation-Spinal Symptoms-Disturbances of Circulation-Importance of Recognizing Early Symptoms-Symptoms of Pronounced Period -Excitement-Impairment of Judgment—Dementia—Memory—Attention-Inability to Combine Concepts-Delusions of Great Wealth and Importance-Hallucinations-Emotional States.

We now approach another stage in the development of what are usually described as the prodromatous symptoms of general paresis. In this period a process of evolution in the changed conditions of mind and body which have been hitherto obscure appears to have taken place; they all become more or less pronounced in character, and others arise in connection with them.

While it is difficult to present a description or picture of the symptoms which will hold true as to the patient. from day to day, for the reason that they are constantly changing in degree of intensity, and, in some measure, in character, yet certain characteristics may be indicated which will be found existing more or less in all cases if not at all times.

The tendency to increase of irritability and excita

bility, has been already alluded to as existing among the primary indications of change in mental character. This excitability becomes more marked as the disorder advances; the patient walks with greater energy and for long distances without definite purpose or appreciation of what he is doing; he becomes impatient of dictation or control, and assumes to give orders to others; becomes excited if he cannot compass his desires; punishes his children with brutality, and sometimes threatens violence to others.

In connection with this state of irritability there often exists an unusual egotism and self-confidence which leads to new enterprises and large undertakings. In the case of a patient brought to the Retreat several years since, the friends stated that the first act which really aroused attention to the patient's altered condition of mind was the ordering a carload of potatoes, when he went to the market in the morning, instead of a bushel, as was his usual custom. When remonstrated with he became violent and threatening in language, talked loud, and declared that he was not to be dictated to in providing for his family, which, by the way, consisted of himself and wife only. There can be no doubt that this very marked change had been preceded by many others of a less pronounced character during months and possibly for years.

Another patient recently brought to the Retreat had been regarded as well until within a few days; during this short period he had managed to squander the larger portion of a moderate fortune by unwise trades, and had undertaken to contract for the building of a hundred houses in the little village where he resided, with the view of a fabulous income from their rental. He was also negotiating for a steamer with which he intended to make a voyage to India (he had formerly been engaged in trade in China,

and owned ships, or an interest in some) with one thousand of his friends as invited guests, all expenses to be paid by him.

These extravagant projects, which are connected with delusions of self-importance and grandeur, often lead to loss of property, excessive brutality, and boastful conduct, while there still exists an appearance of sanity, and before the condition of the patient is appreciated by friends.

This exaggerated egotism, self-confidence, and excitability, which doubtless arises as a reaction from a former state of dullness attended with a diminution of functional activity of the cortex, or from impairment in the inhibitory centres, may manifest itself in other ways. The patient indulges in alcoholic excesses, invites friends or strangers irrespectively to indulge with him, and insists upon settling the expenses in the most lavish manner. In other cases the sexual centres become abnormally excited, and the patient begins to make love to the servant girls in his own house, and almost in the presence of his wife; or, again, may leave his family and make proposals for new alliances or marriage with the street girls of the city, and in case he is unmarried, elope with one of them, while in conversation he becomes coarse in language and manners. A change in the moral character sometimes appears several years prior to the more marked and definite symptoms. Friends not infrequently infer that such a course of conduct in relation to alcohol and venery is the cause of the subsequent disorder, when in reality it is only an indication of a modification in the normal activities of the brain which has been going on for a considerable period.

On the other hand, there may exist a partial or entire loss of sexual ability. This state had existed in a case which is under my care at the present writing during some

months prior to his admission, and was among the earliest indications of disease as afterward recalled.

The change in moral character may manifest itself in other ways, as in deception and motiveless lying, or in the purloining of articles of little value. A patient formerly under my care, at an early period in the disease, was detected in taking some small articles from the counter of a store where he was calling and placing them in his pockets; this tendency became more pronounced at a later stage in the progress of the disease, and no occasion to indulge it. was omitted by him. The articles could be removed from his pockets or the drawers of his room where he had placed them, and he apparently never missed them. He always affirmed in the most positive and imperturbable manner that he had paid for them, or that the articles had been presented to him by friends and had been in his possession for years. This patient, who was a physician, had married a mulatto woman two or three years before his friends instituted measures for his being placed under legal restraint.

The failure in memory, already alluded to, becomes more pronounced. This more often relates to recent occurences or appointments, and is generally regarded by friends as mere forgetfulness or carelessness. The physician forgets his appointment with patients; the business man with his customers; the clergyman the day of the week and the hour he has assigned for a particular service. The failure in memory may be observed especially in relation to dates and numbers. The adding of columns of figures or making mathematical calculations becomes very difficult, as does the committing to memory anything heard or read. In consequence of this impairment, most serious mistakes. regarding agreements and property not infrequently happen, which serve to call attention to the approach of disease.