As the disease progresses, dementia becomes more and more marked. The destruction of the intellectual faculties is so complete that toward the last even the delusions disappear. This progressive dementia goes hand in hand with the physical deterioration of the powers, so that when at last death comes to end the scene, the vital machine may be said to go to pieces like the "deacon's one-boss shay." One of the earliest physical symptoms is persistent insomnia, not yielding to hygienic or medicinal agencies. It is often accompanied by intense and fre quently-recurring hemicrania. The sleeplessness and pain are believed by many to indicate intracranial pressure; but this is not absolutely certain. Ophthalmoscopic examination fails to show intracranial pressure. In other cases there is an uncontrollable desire 'to sleep. The patient falls asleep in the midst of his occupation or in company.
Early symptoms also are losses of con sciousness varying in degree from mo mentary dizziness to apparently true apoplectic attacks. They are present in nearly every case and are important diag nostic signs. While they are frequent and severe in the advanced stages, they are often the first indication of serious cerebral disease. After severe attacks there may be hemiplegia, which, how ever, usually disappears in a few hours or days. These attacks are evidently not due to rupture or thrombus of the cerebral vessels, but probably to circum scribed cedema of the brain, which rapidly passes away.
[I have seen cases of general paresis in advanced stages with apoplectic at tacks, sometimes with convulsions, fol lowed by profound coma, contracted pupils. and Cheyne-Stokes respiration, and after predicting a fatal termination of the case within two hours have had the patients still in hospital three months later. GEORGE H. Convulsions cpileptiform in character, may also be present as early symptoms, but are usually met with in the later stages.
Sometimes the apoplectic attacks are due to internal hxmorrhagic pacify meningitis, and in these cases death often follows soon after the stroke.
Ordinary cerebral haemorrhage consti tutes the gross lesion in the majority of eases of paralytic insanity. It is also very common in senile insanity.
Multiple minute recent blood-extrava sations are to be observed with consider able frequency in microscopical sections of the brain from the insane. Most of such hemorrhages are capillary ruptures of very small size. When they take place from larger vessels, the blood is often merely poured into the adventitial lymph-space. W. F. Robertson (Edin burgh Med. Jour., Mar., '96).
Frequent among the early symptoms are those connected with the innervation of the iris. The pupil is usually
lar, mostly dilated, more rarely con tracted, in the fewest cases normal in diameter. The pupils of the two sides often vary in size and reaction. The re action to light and sensation may be tarded or entirely abolished. The Argyll Robertson 'pupil, so characteristic of tabes, is also a frequent symptom of gen eral paresis. It probably depends upon similar degenerative processes as in the former disease. It is said that the ocular symptoms,—inequality of pupils, myosin, and Argyll-Robertson pupil have been noted several years before the outbreak of the mental disturbances.
Two per cent, of all insane persons have lost the color-sense. The sense for violet is lost in about 10 per cent. of the cases, being almost exclusively limited to various forms of dementia (general paresis, senile dementia, organic de mentia). This loss of color-sense is gen erally accompanied by a diminution of acuteness of vision and the sense of light. L. Cronstcl (These de Paris, '93).
Inequality of the pupils is at times met with in healthy individuals, and it occurs in general diseases of the most diverse nature. In 3010 cases of dementia para lytica the pupillary reaction to light was lost or diminished in 6S per cent. The Argyll-Robertson pupil of great diagnos tic importance in general paralysis, and is one of the very early manifestations of the disease. It is usually bilateral; a continuous unilateral loss of the light reflex is very rare. The first change is generally a diminution of the reaction to light, then a total loss, followed by paresis and paralysis of reaction to ac commodation. Siemerling (Berl. klin. Woch., No. 44, '96).
Early diagnosis of general paralysis: 1. In the great majority of cases of in sanity in which reflex immobility of the pupil is present (92 per cent.) the diagno sis of general paralysis is justified. 2. In the great majority of eases of general paralysis (70 per cent.) isolated reflex immobility of the pupils is found. 3. Isolated double-sided pupillary immobil ity is characteristic of general paralysis. Still, in the earliest stages a limitation of the pupillary reaction may have a similar significance as above (1). 4. Immobility of the pupils combined with failure of the convergence reaction does not nega tive the diagnosis of general paralysis. 5. Isolated double-sided pupillary immo bility may exist for years without the development of general paralysis or loco motor ataxia. 0. It is an early symptom of general paralysis, and has been seen for years before the ensuing general paralysis has developed. Schwarz (St. Petersburger med. Woch., No. 4, '99).