"The general feeling is as if I'm continually shocked by a powerful current of electricity, starting in the head and shooting out into the limbs. The grinding, twisting of the bones and joints are too horrible and awful to describe. I sometimes wish the bones would break and relieve me. The most awful pain is at the head and in the right arm, whether the attack is grand mal or partial. When partial I hold the head and right arm to some extent by means of the left hand; this keeps down the pain somewhat. The force of my right hand as it twists up to the head is so great at times that a strong person is powerless to keep the member down. My mind is always clear in these attacks and is only bothered in keeping track of what is going on around me by the enormous pain which I suffer in my body. The head inside does not pain me until after. Usually I can talk out but a few words, cry for help and wait until some one comes and helps me hold the fit from destroying me. I dare say my fits are different than ordinary sufferers of epilepsy in that their attacks seem to affect their mind in such a way that they don't know they are having a fit. I have fits just like they do, but I am not unconscious. Twice I have had these fits for two weeks at a time on an average of 300 a day. At these periods I suffer the tortures of the damned. I would very willingly undergo an operation if necessary. I think I would survive; if not, I don't care. I am absolutely certain there is some pressure on my brain and if nothing is done soon I am positive I'll die soon in one of these awful attacks. The pain is so enormous. I fervently pray you can relieve me. Have pity on my awful fate and set me free by operation or death, or both."

All three cases I have given are genuine convulsive epilepsy in which either the cortical discharges are slow or incomplete. Consciousness is, therefore, more or less completely retained.

My first case is not unlike in some respects to Lemoine's case in which the crisis developed suddenly; the patient grew pale, became rigid and braced herself against the wall in her chair to avoid falling. While in this tonic stage, her jaws became set and she had great difficulty in talking. The tonic stage, which affected the muscles of the trunk and extremities, was succeeded by a classic clonic stage. During the entire period she conversed with Lemoine, her jaws still locked. She replied intelligently to a number of questions. In the wildest of her conscious convulsions Lemoine had to hold the patient, as in mine, to prevent injuries. As in my first case, there was no cry, no frothing at the mouth and no biting of the tongue. Restriction of respiration invited pallor, succeeded by cyanosis, which, in turn, disappeared as respiration was resumed normally. Convulsions were succeeded by profound physical and mental prostration, as in ordinary epilepsy. In an elaborate and convincing study Lemoine excluded hysteria. Le

moine, by constant tapping of knee-jerks, as in another of my cases, was able to induce occasional attacks.

In another of Lemoine's cases the man was able to give details of his feelings in the attacks. They were not unlike my third case just given. He felt, in his own words, " rigid and thrown violently on the ground." He felt himself "shaken" and felt an "indescribable malaise" during the seizure. Prolonged watch and study of the case proved the conscious nature of the convulsions. He conversed throughout most of the attacks, as in my case, with fragmentary speech. Hysteria was excluded. In one of his conscious fits he bit his tongue and passed urine.

In Lemoine's third case the attacks were major convulsive seizures with an epigastric aura, attended by a short tonic and prolonged clonic period. Again, as in my first case, this boy was able to converse during the convulsions only up to a certain point. When the convulsions became extremely violent and cyanosis was marked, consciousness was slowly but definitely lost. Stertor followed these latter attacks. [It may be interesting to state that I wrote this paper in the belief that such instances of classic genuine convulsive epilepsy were rare if not unique. A review of the literature has revealed the above cases just cited, which in very many respects are not at all unlike mine.]

It does not seem probable that the explanation of conscious epilepsy can be based on the topographical doctrine that the convulsive and conscious areas are not simultaneously affected, nor that the discharges are purely in the motor elements of the cortex. Nor are there good reasons in the parallel that retained consciousness in grand mal epilepsy is of the same nature as that occurring in psychic epilepsy. Time forbids our discussing this point.

To restate: A tentative explanation may be ventured for the presence of consciousness in genuine convulsive epilepsy. Consciousness is retained, as a rule, in genuine convulsive epilepsy just in proportion as the onset of attack is deliberate and focal. Consciousness is lost in direct ratio to the degree of completeness of these cortical discharges.

Finally, I wish to urge a more careful analysis of the disorders of consciousness, both in epileptic fits and in epileptic stupors. Such studies would not only be of forensic importance, but would throw not a little light on the nature of disturbance in consciousness in deliria, hysteric episodes and the stupors of the catatonic states.

METABOLISM IN GENERAL PARALYSIS: AN EXAMINATION OF THE URINE, BLOOD AND CEREBROSPINAL FLUID.

BY FRANCIS M. BARNES, JR.,

Assistant Physician and Director of the Clinical Laboratory of the Sheppard and Enoch Pratt Hospital, Towson, Md.

Among mental diseases the study of general paralysis has attracted a vast amount of attention-probably more than any one other condition. There is but slight doubt that this is so because of the fact that this pathologic state is evidenced by such a comparatively clearly-cut symptom complex that there has been an unanimity of opinion as to the diagnosis, an important element in explaining in part at least the concordance in the results of the various investigators.

This generally well-defined disease, running a comparatively rapid course, during which definitely known organic changes tending to parallel the progress of the mental disorder occur, would seem to offer the greatest opportunity for the occurrence of some particular or widespread disturbance of metabolism which might manifest itself in a variation from the normal in certain of the fluids and excretions. The work of Folin' has shown, however, that in this as well as in other mental diseases no particular definitely marked deviation from the normal' is to be detected. As he has pointed out, here, as in many other mental disorders, the daily amounts of the different urinary constituents vary within wider limits than do similar substances in the urine of a normal individual. Folin considered that the most definite tendency toward abnormality in the metabolism of cases of general paralysis was shown in a rather slight though distinct alteration of the relative amounts of nitrogen and sulphur excreted. There will be occasion to mention this point in more detail at a later time.

'Folin: American Journal of Insanity, 1904, LX, p. 699.

"By "normal" wherever used is understood the figures as are given as such by Folin in the American Journal of Insanity, 1904, LX, p. 301.

Previously to the work of Dr. Folin above mentioned there were no complete studies of the metabolism in paresis recorded and a rather careful perusal of the literature has revealed no such investigations of a similarly comprehensive nature since then. The present study is based upon the observation of five cases of paresis. The work has become largely but a repetition of that done by Folin and has been carried out, as far as methods and general plans are concerned, in a manner entirely similar to that formerly described as used in this laboratory. It is only necessary to remark that the collection of the urine began on the fourth morning after beginning the diet (Folin's "milk and egg diet ") and that the patients were constantly watched by special nurses detailed for that purpose only. The subjects of the experiment were kept in bed during the entire period of observation. During the second twenty-four-hour period recorded in the tables lumbar puncture was done and during the third blood was taken for cultures, etc., while every day an ordinary leucocyte count was made. In order that the first two procedures might be carried out a subcutaneous injection of hyoscin-morphin mixture was made shortly beforehand. It was not necessary to use this in the third case. Although the drugs exerted some influence upon the excretions it was not so much but that it can be largely allowed for in considering the results of the experiment. As the effect of the drugs has more of a pharmacologic interest than psychiatric it will be treated in detail elsewhere, and only such comment as is necessary in consideration

The American Journal of Insanity, 1909, LXV, p. 592. It might be said at this point that the observations here recorded were made more or less incidentally in connection with other investigations which have not been satisfactorily completed. As these results are independent in part of those obtained by more extensive unfinished investigations in these same cases it was deemed advisable to publish them at this time.

The lumbar punctures, together with a cytologic examination of the fluid and a determination of the presence and increase of proteins was made by Dr. William B. Cornell, Assistant Physician at this hospital. The blood cultures and the determination of the Wasserman reaction in both the blood serum and in the spinal fluid were made by Dr. P. W. Clough, of the Medical Service of the Johns Hopkins Hospital. As both of these will publish their results in connection with larger series of cases and will there give the details of the technique employed, only the findings will be given here.

of the metabolic condition will be made here. The results obtained as arranged in the accompanying tables show quite well the state of metabolism as found in these patients. Some especial features will be mentioned along with the separate case records which follow. No patient had a seizure during the period while under observation.

R. N. H.-Case No. 1527. Table I. Male, age 53. Luetic history positive. Physical condition fair, although there is a lowering of about nine kilos under the usual weight. Pupils unequal and irregular, spastic. Knee jerks are exaggerated; there are definite speech defect, marked tremor, poor memory, want of insight and judgment; euphoria and pressure of activity present. Duration of the disease about three years; diagnosis, paresis; Hyoscin-morphin given on the 20th and 21st. The spinal fluid shows an increase in the number of lymphocytes and in the amount of protein. The Noguchi test was negative. The Wasserman reaction gave negative results with spinal fluid, but positive with the blood serum. Blood cultures showed no growth. Referring to the table it is seen that the total nitrogen is lower than might be expected; the undetermined rest is too high (in part due to the inaccurate urea estimates); the ammonia is high; and on the last day duplicate determinations showed an entire absence of ethereal sulphates. The latter substance and the indican decreased from the first day. Among the ratios it is interesting to note the slightly raised N1: SO2.

P. L. F.-Case No. 1269. Table II. Male, age 37, definite history of syphilis. General physical condition fair; at the present time has several small cutaneous infections over the back. Early in course of the disease and till quite recently seizures have been frequent and severe. Pupils are irregular and inactive, knee jerks are absent; poor memory, no insight or judgment, generally complacent and euphoric, but occasionally irritable; a case of well-advanced dementia. Duration, about four years; diagnosis, paresis. Hyoscin-morphin given daily to reduce restlessness. The spinal fluid shows an increase in lymphocytes and protein; the Noguchi test was positive. Wasserman reaction positive with both spinal fluid and blood serum. Blood cultures sterile. The tabulation of the results does not reveal any very marked deviation, although several minor points are noticeable; low nitrogen and urea with increased uric acid and rest; low total sulphur with high neutral and low ethereal sulphates. Slight increase in nitrogensulphur ratio.

H. S. W.-Case No. 1846. Table III. Male, aged 36.5, probable history of lues. General physical condition somewhat below par; particularly is there evident a loss in weight. No seizures have been known to have occurred. Pupils are equal, irregular and react poorly. Affect changeable; insight and memory partial. Tremor of the hands and facial muscles present. Duration, about six months; diagnosis, paresis. No narcosis for puncture or blood cul