The true madness, he is certain, came with a later change; after the Curwen portrait and the ancient papers had been unearthed; after a trip to strange foreign places had been made, and some terrible invocations chanted under strange and secret circumstances; after certain answers to these invocations had been plainly indicated, and a frantic letter penned under agonising and inexplicable conditions; after the wave of vampirism and the ominous Pawtuxet gossip; and after the patient's memory commenced to exclude contemporary images whilst his voice failed and his physical aspect underwent the subtle modification so many subsequently noticed.