SYMPTOMS. The onset is gradual. It is first noticed by friends that the patient does not seem in his usual frame of mind. He is irritable, either depressed o• excitable, is growing inat tentive to business, is laying unusual plans and schemes. These are often of great magnitude and involve expense entirely out of proportion to the man's means. The patient feels well, often say ing that he never felt better in his life. A marked egotism usually develops. He boasts of his wealth, power, and abilities. Soon he be comes forgetful, careless, inattentive, linable to concentrate his mind upon any definite train of thoughts or to carry on a logical argument. This becomes noticeable in his conversation, which is disconnected. Headache and sleepless ness are common and there is a marked loss in weight and in strength. Even though previously a man of exemplary habits, the patient becomes neglectful of the ordinary proprieties of life, uses bad language, ignores family obligations, loses his temper, and indulges in sexual and al coholic excesses. This condition lasts from one to three years and passes over gradually into a fully developed dementia. This condition is marked by an increase in the symptoms above described. Egotism is usually a marked feature and delusions of grandeur are the rule. Instead of exaltation there may be depression and melan cholia, or melancholia and elation may alternate. Illusions, delusions, and hallucinations are com mon, but there are no fixed systematic delusions as is the case in paranoia. The emotions are in a state of unstable equilibrium. The patient is easily moved to laughter or tears. Slight causes produce intense excitement, which may take the form of rage or frenzy, rendering the patient dangerous to his fellows. There is rarely any
suicidal tendency. Self-control is weakened, and consequently voluntary actions are weak, irre sponsible, and impulsive. Self-consciousness is impaired, the patient failing to appreciate his changed mental condition. Ile is contented wherever he is, is not concerned about the anx iety of his friends, loss of money or business, or even asylum confinement. Of motor symptoms tremor of the tongue and face muscles appears first. Later almost any motion is attended with trembling. This results iu thickness of speech and in clumsiness in the finer coordinate move ments, such as writing. ,These motor symptoms gradually pass over into a paralysis, which be comes increasingly widespread and increasingly complete. There is also marked increase or marked decrease in the reflexes, with less reten tion of urine and of control of the rectum. Sen sory symptoms, anesthesia and analgesia, are late manifestations. Bed-sores and cystitis are very common. The average duration of the dis ease is from three to four years. In the early stage of the disease there may be transient pa ralysis of one arm or one leg. There may be convulsions occurring at intervals of a few days, which may be mistaken for epilepsy. In the last stages convulsions are usual and severe. Death results from exhaustion, frequently from con vulsions, or from some intereurrent complication, such as pneumonia, cystitis, or obstruction of the bowels.