He omits and reduplicates letters and misspells words. Cannot write even his own name so that it is legible. His speech is affected to a very gross degree and is typically paretic in type. Is utterly unable to pronounce such words as "parallelogram," "capital L," etc. The pupils are small in diameter but react normally.

It was noted that his comprehension was greatly diminished; unable to understand and carry out the simplest possible orders. His remarks were irrelevant, often absolutely incoherent. Exhibited a marked tendency toward echolalia. Delusions of a grandiose nature; owns millions, is going to give away fortunes, etc. Repeats these statements over and over. Memory extremely defective, especially for recent events. Practically no power of voluntary attention. He was elated to a certain degree, but there was also an apathy. Says that he is the best man on earth, is happy and contented; that he has been kindly treated, etc., but was seldom seen to laugh and only occasionally smiled. In behavior he was restless, wandered from one room to another, but was quite manageable. His lack of discrimination and of comprehension were beautifully shown in his attempt to dress himself after the examination. Thus, he picked up his shirt, endeavored to push his feet through the sleeves; failing in this he pushed both legs through the neck of his shirt and wound the lower part of it about his waist, then picked up his drawers and tried to put them on over his head, pushing his arms through the drawers' legs. He did not express the slightest surprise when this ludicrous state of affairs was pointed out to him.

An attempt was made to do a lumbar puncture but this failed.

Diagnosis.-The fact that his symptoms came on within a short time after the acquirement of his syphilis and the absence of morbid pupillary changes, might lead one to suspect this to have been a case of cerebral syphilis. His whole appearance and clinical symptoms otherwise were characteristic of paresis. Moreover, antisyphilitic treatment had no apparent effect upon him. He was removed from the hospital one and one-half months after admission, absolutely unimproved. The probabilites are that this was a genuine case of general paresis, but this diagnosis could not have been made with certainty at the time of admission and must even now remain somewhat in doubt.

There is not space for other cases, but those already given, although so briefly described, may suffice to place the student upon his guard against accepting too readily the statements of the textbooks as to the ease with which cerebral syphilis and paretic dementia are to be differentiated from each other at sight. There are numberless cases in which the age of the patient, the length of time intervening between the syphilitic infection and the appearance of the symptoms under consideration, the course of the dis

ease and particularly the effect of antisyphilitic treatment are absolutely essential in distinguishing between these two conditions and in which, these factors being unknown, it would be impossible to make a sure diagnosis from observation of the patient alone. Finally there are a certain number of cases in which prolonged antisyphilitic treatment alone can solve the difficulty. Certainly

the pupillary signs, the character of the speech and the presence or absence (especially the latter) of somatic signs, such as ocular paralysis, hemiplegia, etc., will in many cases be quite insufficient testimony on which to establish the diagnosis.

Proceedings of Societies.

THE NEW YORK PSYCHIATRICAL SOCIETY.

STATED MEETING, JANUARY 2, 1907.

The President, Dr. Adolf Meyer, in the chair.

THE SYMPTOMATIC-PROGNOSTIC COMPLEX OF MANIC-DEPRESSIVE

INSANITY.

This paper was read by Dr. George H. Kirby, of the Pathological Institute of the State of New York. Dr. Kirby said: "The field of psychiatry is too complex for us to expect absolute or clean-cut distinctions either in disease types or nosological groups. Kraepelin did a great service by showing that most of the previously made distinctions of types could be replaced by far more valuable nosological groups if one considered the whole course and outcome of mental disorders. From this point of view the great bulk of the acute psychoses can be brought under two divisions, viz., those that pass into deterioration and those that end in recovery. It was found that in cases which terminated in either of the above mentioned ways, one was able to identify certain characteristic symptoms present from the beginning and which thus acquired a distinct prognostic value. Two large symptomatic-prognostic groups were thus created-Dementia Præcox and Manic-Depressive Insanity. At present it seems best to consider the manic-depressive complex merely as a reaction type and not a disease entity as Kraepelin proposes. It is rather a type of response which may be elicited in various ways. In some cases the constitutional disposition may be most important, but in others the exogenous causes are of great importance and give valuable hints as to prophylaxis and probability of recurrence. This peculiar kind of reaction in its pure form has the characteristics of a benign disorder and thus a favorable prognosis is implied. Vari

ous additional elements may enter to confuse the picture and the symptomatic and prognostic features may seem to diverge at various times. There are many equivalents difficult to recognize. In a few cases the principle seems to fail through transitions to other forms."

A series of cases was reported which had offered difficulties for various reasons. Some patients were also presented. A recurrent depression with retardation and prominent auditory hallucinations; another case of depression with sensory-somatic complex and only slight signs of difficulty in thinking. A third case illustrating the mixed forms of manic-depressive insanity, the so-called "manicstupor," showing inhibition and mutism with an exhilarated mood.

DISCUSSION.

Dr. Charles L. Dana was inclined to think "prognostic principle" a rather unfortunate term, inasmuch as this was not all that was used in attempting to establish types. The consideration of the whole life history was the great principle to be used in making classifications, and he did not think there could be any objection found to basing groups of insanity upon this method. It was not new but the rational and accepted one in other forms of disease. The case presented by Dr. Kirby in which there was melancholia without retardation of thought was interesting, but was a type not infrequently seen outside of asylums at least, and often in connection with intense suicidal feelings. This suicidal impulse was not always due to somatic feeling of inadequacy, but was sometimes also a well reasoned out point of view. A woman of intelligence, for example, realizing that she had had melancholia now for three times, that she would have it again, that she would be a burden to her family, that she would never be right permanently, schemes to kill herself, obeying in a way a logical conclusion as well as a morbid impulse. Such patients did not have always retardation of thought, but they often could not do their work easily or effectively. He did not believe the first patient presented by Dr. Kirby would be able to do her work. Such patients could not play games of skill as formerly, becoming tired quickly. Dr. Kirby had neglected to touch upon chronic melancholia, melancholia of involution, a group which Dr. Dana believed to be represented in early life. He had records of cases

of melancholia at the climacteric who gave a history of depression earlier very much like that of later life, so that there was melancholia of early life which did not belong to manicdepressive insanity.

Dr. L. Pierce Clark thought the symptom complex of manicdepressive insanity would be easier of analysis if the idea were borne in mind that the complex was likely to partake of the nature of the physiological epochs at which it occurred. The suicidal impulse to which Dr. Dana referred was well-known to most alienists. Even in convalescence this tendency was most marked.

Dr. August Hoch said it was usually claimed that it was impossible to formulate any laws of prognosis about the different forms of manic-depressive insanity. This was not quite correct. Dr. Kirby had shown that a careful reasoning might do much in formulating a special prognosis. Dr. Hoch wished to mention a few more general points of view from which a prognosis might be made. The first referred to the depressions. The symptoms of the entire depressive complex were retardation, sadness, and the anxiety-unreality complex. In the typical manic-depressive states there were only sadness and retardation. In such cases the outlook was good. In the typical involution melancholias there was, from the beginning, uneasiness, anxiety, to which were often added later in the course symptoms of the anxiety-unreality complex. In such cases the outlook was bad; such patients got into a state of deterioration, characterized by a narrowing of the mental horizon. But the anxiety-unreality complex might also be reached by way of the manic-depressive states. This happened not infrequently in the manic-depressive depressions, which occur at the involution period, sometimes in those occurring earlier in life. These cases might, therefore, begin with a typical retardation or feeling of inadequacy and then develop an anxietyunreality complex. In such cases the prognosis was not so bad as in the typical involution melancholias, but decidedly worse than in the simple manic-depressive depressions.

The second point of view referred to the prognosis of the manic states. All alienists knew that those cases which present the best prognosis are cases of clean-cut manias of considerable intensity, manias in which the exhilaration, the general excitement, and the flight of ideas are all of about the same degree. The hypomanic