rule, with healthy regularity, and the appetite is good. The patient is disposed to eat voluminously, and often in this stage becomes fat. Sexual feelings are said by authors to be usually annihilated. Evidence on this subject is obviously not readily to be obtained. I have never met with any erotic manifestations, and menstruation is not interrupted.

In this middle stage, therefore, there are distinctive symptoms of a state of paresis or relaxation of power extending over the motor functions, the intellect and the emotions of the patient; and some indications of extension to the excito-motory system, which becomes distinctly involved at last. I will proceed to trace the further progress of the disease at our next meeting.

LECTURE VIII.

Argument. The symptomatology of the second stage of general paresis continued -Occurrence of distinct remissions in this stage-The phenomena of the third stage-The phenomena of the first stage and mode of invasion-Three modes of attack-The diagnosis of the disease-Its pathology and anatomical changes.

THE second or middle stage of general paresis, with which we were occupied in the preceding lecture, lasts in the largest number of cases from seven to ten months, but the disease is subject to great variation in this respect.

In this period of the disease, there occurs occasionally a distinct remission of the symptoms. This part of the subject has been specially studied by Dr. A. Sauze, who has collected the opinions of the best French writers upon it, in a paper in the Annales Médico-Psychologique' (October, 1858). He makes the following summary of the facts he gathered.

That the remissions occur under three principal forms.

In the first, the motor paresis remits, but the state of dementia continues.

The second form of M. Sauze is characterised by the persistence of the signs of motor paresis, and the absence or apparent disappearance of the intellectual symptoms. This is not an uncommon form; the most frequent instances of this kind of remission, however, occur, perhaps, in cases in which there is a degree of remission the whole of the morbid phenomena. The mental symptoms, in fact, as observed by M. Baillarger, do not regain their pristine power or energy. If closely scrutinised, there will be found to remain a feebleness of intellect, evidenced by peevishness, fickleness of purpose, puerility, or irresolution; contrary to the former character of the patient. He may be capable of reasoning, but he exhibits a feebleness or want of power in his mental faculties.

The patient, perhaps, would be considered sane by some, though the motor paresis continued and showed itself in the gait, in the facial expression, and in the peculiar imperfection of the articulation. The relapse of such a patient is almost inevitable.

The third form which Dr. Sauze mentions, presents even greater difficulties with respect to the question of the patient's sanity. In this variety of remission, the mental and motor. symptoms undergo amelioration simultaneously. The same remark, however, holds good with this kind of case also, on close scrutiny there may be detected, some indications of feebleness of both mental and muscular powers; there is not the same vigour in the patient, even at his best condition, as prior to his attack.

There are cases in which these variations in the mode of remission are mixed. The second and third form of remission merge into each other; that is, there may be remission in both the mental and motor symptoms; but in the progress of the case, there may be, besides the liability to remission, some inequality, in the completeness of the cessation of the one or other faculty.

In the middle stage of the malady another not uncommon occurrence is a sudden seizure resembling apoplexy or epilepsy; in other words, the attack is attended in some cases with comatose symptoms, and in others with epileptiform or convulsive symptoms. The patient is seized suddenly and falls, or becomes unconscious, or drowsy, and has stertorous breathing; the limbs if lifted fall heavily, and one limb or even side appears to be paralysed. This condition is transient, and yields usually to purgatives, and especially to purgative enemata. I have known cases, however, to terminate fatally in a seizure of this kind. I have known, also, the convulsive attack to recur at short intervals, and then prove fatal. It must, however, be observed, that the disease is often associated with true epilepsy; and all the symptoms of paresis are occasionally met with in patients who have been epileptic for their whole life.

I pass now to the third stage of the disease; there is, of course, no line of demarcation between these artificial divisions. The characteristics of the third epoch are-dementia as regards intellect, and inability to stand with respect to motility; not that these conditions take place simultaneously; one may be

established before the other. When the patient is no longer able to stand without support, the mind will be at best much enfeebled. At first the patient is unable to rise in the morning, for the muscular feebleness is particularly marked at this period of the day. He usually, for a time, gains power as the day advances, and is able to sit up in the afternoon, for a few hours; then this degree of strength is lost. Again an improvement may occur, and the patient may rise for a period every day, but at each remission the disease gains, till prostration is complete. The total or final annihilation of the ability to stand is sometimes brought about by the gradual accession of contraction of the limbs. As the patient lies on the back, a propensity is shown at first, to lie with the knees up; then this position becomes a pretty constant one. At last, it will be found, that he cannot straighten his legs, but if extended by the nurse, the limbs at first will remain so. The knees then, one or both, generally one more than the other, become more and more contracted, and the thighs become permanently flexed on the pelvis.

With regard to the mental condition, at times the dementia is complete, but not always. The power of utterance is often nearly extinguished. The expression of the face is heavy and stupid; the muscular twitchings are increased; there is still a degree of restlessness in the patient, even while lying prostrated on the back. In nearly every case, there is a propensity to gather up the bed-clothes, tumbling them over and over in great confusion, with a slow and torpid movement of the arms. The patients gradually become more and more unconscious of their evacuations, and besmear themselves, if not closely watched, in an apparently heedless manner. The sense or instinct of decency is obliterated. The power of smell and taste, are probably, also deadened; for not only do they seem undisturbed by their own filthy condition, but they cram their food sapid or insipid alike into their mouths, as though no longer able to distinguish it by the sense of taste. The mental and instinctive faculties are thus shown much impaired, and the motor power nearly annihilated.

It is in this the third stage that paresis of the excito-motory system becomes apparent; its advent is slow and gradual, like the rest of the symptoms, but its phenomena are not the less readily recognisable. One of the first symptoms to force itself upon the

attention, is an imperfection in the act of deglutition. The patient also has a propensity to fill the mouth and to hold the food there, and roll it from one side to the other; and from these combined causes it often happens that food gets impacted in the pharynx, and frequent accidents occur in consequence. Another sign is derived from the condition of the conjunctiva, which becomes covered with secretion, and there is a turgescent state of the vessels of the conjunctiva, due probably to the imperfection of the lubrication of it by excited action. In tickling the soles of the feet of these patients, there is, according to my own observation, less excited movement produced in paresis than normal. But on this subject there is some discrepancy in the accounts given by different authors. The effect of electricity and that of tickling appears to be the same. Dr. Bucknill says, "In ordinary paralysis, there is no loss of excito-motory sensibility, while in general paralysis there is great loss of this power." He adds that, "the experiment may be more conveniently tried, by tickling the soles of the feet; in common paralysis, muscular contraction is caused, in general paralysis it is not caused." These experiments were published by Dr. Bucknill in 1852. He made no allusion to similar experiments by MM. Brierre de Boismont and Duchenne de Boulogne, which were published in 1851. M. Jules Falret in his 'Thesis' published in 1853, to whom I am indebted, gives the result of their experiments in these words: "MM. Brierre de Boismont and Duchenne de Boulogne, believe that they have found in electricity, a practical means for distinguishing the general paralysis unconnected with insanity, from paralysis with insanity. They say that in the former, that the electric irritability of the muscles diminishes or disappears, while it remains intact in the paralysis of the insane."

My own observation agrees with that of Dr. Bucknill with regard to the effect of an excitant applied to the soles of the feet, and the symptoms connected with the deglutition appear to corroborate his experiments.

Frequently some intercurrent disease will carry off the patient before the whole of the paretic phenomena are consummated. Patients are, especially, liable to certain accidents on account of their condition, among which must be enumerated choking from impaction of food in the gullet. They also expose themselves to cold and its consequences. Epileptiform seizures