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twenty out of 194 cases. * This is a considerably lower percentage than I have found in cases at the Retreat.

And here it may be noted as characteristic of the emotional general paretic, that his conduct is at entire variance with the delusions which have occupied so large a place in his mental operations. All the grand offices he has occupied or is about to possess; the billions of golden sovereigns he has on his person; the lovely children he is the fortunate father of; the visions of charming faces with which he has held converse; the horrible scenes of his night-waking hours, in which he has seen his home burglarized, his wife taken away and ravished in his very presence, and his children orphaned or dead,—all these pleasing or horrible visions, with kaleidoscopic movement, vanish, and he will be as happy or miserable as if he had never experienced such delusions and seen such visions.

*Journal of Insanity, p. 392.

Depression-Much Less Common During the Pronounced Period than Exaltation and Elation-Melancholic Symptoms May be Present-Periods of Excitement-Illustration-In Some Cases Neither Excitement nor Depression Exist-States of Elation May become Changed by Suggestions-Extravagance of Delusions-Physical Symptoms of the Pronounced PeriodTongue-Lips-Muscles of the Face-Handwriting-Epileptiform Seizures-Corpulence-Gait-Eye Symptoms-Period of Boasting-Increase of Dementia-Paralysis-Sphincters-Convulsive Seizures-Bed-sores— Bone Fractures-Case.

Depression. In my own experience the symptoins of depression and melancholia have been comparatively rare in the pronounced period of general paresis, and yet, at the time of this writing, there are two such cases in the Retreat. According to the statements of friends, one of them had never presented symptoms of excitement or exhilaration prior to his admission, and since then the mental state has been one of depression. The hallucinations and delusions partake of this character, and render him exceedingly suspicious. He says that he sees persons entering his room at night, sometimes by the windows, and at others. by the doors, and he is confident that they are his enemies, that at times they take a camera into the room for the purpose of securing a photograph of him. At other times they pound his feet and legs until they become black and blue, and in evidence of this he begs you to examine them

for yourself. At other times he hears them shouting at him and defying him to come out and defend himself if he is able. During the day he believes that these persons are the attendants of the hall, who have been in the habit of disguising themselves at night for the purpose of annoying and injuring him. On many occasions, under the influence of this suspicion, he has endeavored to be avenged by stealthily approaching them with a chair in hand, while they were engaged, with the purpose of striking them. When remonstrated with, he freely says that he would like to kill them, that they have haunted his rooms, persecuted and insulted him long enough, and he is unwilling to endure it longer. This patient experienced an epileptoid seizure soon after his admission, and remained in a partial hemiplegic condition for nearly three weeks.

General paretics sometimes present symptoms which are characteristic of melancholia. They refuse to take food lest it shall never pass from their bowels, or they refuse to go to the water closet lest they may contaminate it, or somebody who may be near it; they urinate in their rooms at night or out of the open window; they are silent, dejected, and mutter to themselves in some manner expressive of regret or remorse, and apparently suffer more or less physical discomfort in the epigastric region. Such conditions, however, are generally confined to the initial period, rather than to the pronounced stage, and when present alternate with a state of mild exaltation.

The passage from the initial to the pronounced period occurs in many cases by an explosion of excitement. The patient leaves his home, makes contracts for immense business undertakings, insults females in open day on the street, orders a cloak for his wife which is to be covered with diamonds, or purchases the entire contents of a

jewelry store, and when arrested or interfered with, he bursts forth in a torrent of denunciation and abuse of every one who seeks to restrain him. Neither wife, children, nor friends produce the slightest effect in their efforts to reason with him. The subject of his talk is nearly always burdened with expansive delusions, which relate to himself and what he is about to do for others, and yet, as in conditions of mind already referred to, the element of change is always observed. There exists no logical sequence of ideas; any one has no immediate connection with that which has immediately preceded it, nor does it suggest what will follow, and, indeed, may be entirely, contradictory. It is true that all considered together may appear to be the outcome of a semi-realized delusion of great wealth and of vast importance, but the individual concepts used to express this delusion have very little, if any, relation to each other.

These attacks of maniacal excitement are seldom of long continuance, rarely extending longer than a few days or weeks, and sometimes only during a few hours. But while they continue they constitute some of the most anxious periods which ever occur in any form of insanity. Patients sometimes do an incredible amount of injury in a very short time, which may relate to property or persons. Houses are burned, windows and doors are smashed, furniture destroyed, and wife or children may be killed. If in an institution they will attack attendants if sharply or suddenly contradicted or interfered with. They are without appreciation of their surroundings, and hence are without fear, and will struggle and fight with ten men as readily as with one when once aroused to a conflict. And yet in the midst of the highest excitement the skillful attendant will often succeed in changing the current of delirium and

modifying the excitement by suggesting some other subject of thought.

As illustrating this point I may mention an occurrence which took place in one of the halls of the Retreat. On the occasion of a visit to the hall, in which there was a general paretic in the early stage of the pronounced period, I found him striding from one end of the hall to the other in the wildest condition, and shouting forth a storm of oaths, denunciations, and incoherent language. All indications of physical impairment had left him, and words of one kind and another poured forth in a continuous stream. After a short time he saw me observing him, and at the same time seized a settee so heavy that he could with difficulty have lifted it while in his ordinary condition, raised it in the air, apparently with perfect ease, and with the intention of dashing it through the guard of the window. His attendant, who had been near him, observing every movement and waiting for the storm to pass by, immediately stepped to his side, put his hand on his arm, and in a quiet voice, and in a perfectly self-possessed manner, said something to him which seemed to act with the magic of a charm by distracting his attention. Within thirty seconds he was assisting his patient in placing the settee on the floor, upon which they immediately sat down, while the attendant became a profoundly interested listener to the recital of some train of delusional talk.

Such attacks have rarely occurred in my experience except during the pronounced period of the disease, though they may be present at a later period. They, however, become modified and limited in intensity as the disease progresses.

There are other cases which are neither excited, depressed, nor emotional. They are perfectly calm, make no