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identical in appearance and behavior with those which I have often seen in wounded soldiers during the late War of the Rebellion, who had been long confined in hospitals and had become scorbutic.

In my own experience epileptiform seizures, of one form or other, have proved more frequently the cause of death than any other. It may occur directly from the severity of the convulsion, which exhausts the vital energies of the system, or it may come indirectly from disease of the lungs, which has developed from the congested state that was a result of the spasm; or, again, from the development of a comatose state, from which the patient never recovers, and which is probably due to ruptures of the capillaries of the brain and consequent effusions.

Bone fractures are more common in general paresis than in other forms of insanity. This may be due to impairment of nerve energy, which prevents the patient from responding to the necessity of guarding himself when in danger. He is certainly less sensitive to the effects of blows, bruises, and falls, and yet is much more liable to receive them, especially during periods of excitement. There may also in some cases exist an abnormal brittleness of the bone texture, due to absorption of the organic constituents. Fractures of the ribs are more frequent than of other bones. Cases are reported in which post-mortems have revealed the fractures of several ribs.

The following case, which I take from my record, will illustrate the ending of the third stage of general paresis. J. E. J., age forty-four. This has been one of the typical cases of the disease, and was brought to the Retreat in the initial stage, has passed through the general conditions of that and the pronounced stage, and now presents those of the final one. He is no longer able to walk or even to

stand, but lies in bed in the position in which he may be placed, being barely able to turn his body unassisted. Two months since he could walk about the halls and grounds, though with difficulty, and with a very staggering gait, stammering out that he had a large farm in Maryland with three hundred and sixty-five acres, and five hundred horses, and promised another paralytic, who was with him, a pair of splendid black horses with harness and corn to feed them, also that he would raise his father who had been dead many years, to life; said he had invented a steamer which would steam to Germany and back in four days, and another which would go around the world in a week; that he was the strongest man in the world, and could lift 175,000 pounds, was six feet and nine inches high, etc., etc.; but now he is unable to articulate more than a word or two at a time, his flesh is fast wasting, he swallows with difficulty, and is fed chiefly with liquid food; he defecates and urinates unconsciously in bed, but the expression of good feeling still lingers on his face, and he makes no sign of complaint and has no want to utter; when addressed he sometimes tries to reply, and even to smile a recognition, but does not succeed, and the semi-flaccid muscles of the mouth and face fail in their effort of movement. Only by the most careful attention can we prevent the formation of bed-sores. The system will assimilate less and less of nourishment, and become even thinner than at present, unless the drama shall soon end by a paralysis of the muscles of deglutition.



Remissions—Duration of—Relapses-A Case—Duration of Disease; Average

from Three to Four Years-Diagnosis-Characteristic Symptoms --Im-
portance of Physical Symptoms in Determining Doubtful Cases — These
May Precede or Follow Mental Symptoms — Maniacal State of Alcoholism
--Chronic Lead Poisoning—Morbid Anatomy—The Whole Cerebro-Spinal
and Sympathetic Systems Affected-Diminution in Volume of Brain-
Adhesion of the Pia to the Gyri-Disease of Vessels and Nerve-cells-
“Spider-like” Cells—Ventricles-Spinal Cord— Treatment Prognosis-
Importance of Early Treatment and of Removal from Home to an Insti-
tution - Medication --- Bromides — Tonics-Laxatives-Hypnotics-Lo.
tions— Water-bed, etc.

Remissions. We have now traced the more pronounced symptoms of general paresis, both mental and physical, in the order of sequence, which is more often observed. There are, however, some cases which are exceptions to this course. The involution of the more active form of mental symptoms occurs and the motor signs also largely disappear. Whatever indications of the disease still remain consist in a less degree of mental vigor than is normal to the individual, rather than a dementia, and some traces of incoördination in muscles or groups of muscles. The patient regards himself as entirely recovered and quite able to undertake the execution of any plan or project which his friends have suggested or proposed for him. The memory and power of attention during longer periods have improved; he converses more intelligently and pointedly upon subjects introduced, and seems to have regained in some degree, at least, the ability to appreciate the force of any objections to plans suggested. The friends, therefore, insist that the patient has recovered, when it is perfectly manifest to the expert that such a condition would not continue a single month, or perhaps a single week, outside of an asylum.

There are other cases, however, in which the remissions become quite perfect, and all, or nearly all, the symptoms are in abeyance. Dr. Henry M. Hurd has reported a case of such remission after the patient had passed through the experience of a large carbuncle located over the cervical vertebræ. Dr. Sankey has reported a case of apparent recovery in which the patient remained well about sixteen months. Many others have reported similar cases. They occur more frequently after the patient has experienced a fracture, had boils or a carbuncle, or some form of intercurrent disease.

It would be a mistake to speedily remove such patients, whether the remission be partial or entire, from the care and supervision which can be had only in some asylum or home especially arranged for them. The friction incident to everyday life, with the attending necessity of self-control, even in the most favorable circumstances, entails a vastly greater strain upon the mind than a life wholly: freed from care and responsibility. Besides, it is of the first importance that such cases should be constantly under medical observation, and in the majority of cases receive medical treatment for a long period after the advent of a remission. The more favorable the environments and care, other conditions being auspicious, the longer we may expect the remission to continue.

Still, the progress of the disease will again appear sooner or later, in the vast majority of such cases, even aster the lapse of years, and not unfrequently is ushered in by an epileptiform seizure or an outburst of maniacal excitement, after which the course of the disease is generally more rapid than before. I say generally, because cases are on record in which there have occurred several such remissions. Cases also sometimes occur in which remissions relate chiefly to the motor symptoms, while the mental symptoms remain unmodified

Only one such case has been under my observation. The physical symptoms, when again they appear, develop rapidly and follow the usual order of sequence.

In 1879 a case was under my care in which the symptoms were characterized by expansive ideas and projects, great restlessness, and some excitement, with moral defect, while the physical symptoms were quite obscure. After three months there occurred so far an abatement of the conditions that some of the friends insisted that a mistake had been made in the diagnosis, and that he did not longer require the seclusion and care of an asylum. He was accordingly removed and set at liberty. I am unable to report how long he remained unrestrained, but he very soon plunged into a life of speculation, became indecent in language, and most lascivious in conduct, and died in less than three years, of general paresis.

Duration.—One of the questions which are always, or nearly always, addressed, to the physician is, “How long is the patient likely to live?” A reply can be given only in a very general manner. One can be based upon the experience of the physician, or upon that of institutions. The experience of physicians and even that of different institutions will differ quite largely as to length of time.

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