3. Most cases show a slight leuco cytosis, amounting on an average to about 22 per cent. above the normal. Early cases may have no leucocytosis . whatever.
4. In the differential count a decrease is found in the lymphocytes along with a marked increase in the large mononu clear cells. The cosinophiles in a few cases are very numerous. J. A. Capps (Amer. Jour. Med. Sci., June, '96).
Sometimes there are punctiform ex travasations of blood in the skin, and even actual haemorrhages from the mu cous surfaces, as from the bowel.
Consequent upon the defective inner vation, combined with external mechan ical influences (traumatisms, prolonged pressure, etc.), trophic changes occur.
Othiematoma and bed-sores are often noticed, the latter especially when the patients have become bedfast.
The course of general paresis is, as a rule, steadily progressive. Cases occur in which there are remissions, sometimes lasting for months, but, except in the earliest stages, when the diagnosis must be regarded as somewhat uncertain, no cases of permanent arrest of the disease have been recorded.
Changes that have appeared in the clinical picture of progressive paralysis of the insane in the last thirty years dis cussed. In 1SSO was found 55 typical eases and 37 of the form characterized by dementia. In 194 cases observed since, the typical form occurred in 37 cases and dementia in 70 cases. The greater fre quency of marked remissions also noted, many of the patients being able to re sume their occupation from time to time, even after the physical signs had been pronounced. The disease, in spite of its milder character, appears to have become much more frequent, particularly among the women; the present pro portion being about 4 men to 1 woman and, in eases developing early in life, the sexes are almost equally affected. Children are more frequently affected than formerly, and this appears to be due to the greater frequency of heredi tary syphilis. Mendel (Neurol. Centralb., Nov. 15, '93).
The average duration of the disease is between two and three years. In some cases it has been known to continue longer, and cases are on record in which the duration is said to have been twenty years. On the other hand, it sometimes runs an acute course, ending in death in a few months.
Diagnosis.—Cerebral syphilis, tabes, chronic alcoholism, and cerebral neuras thenia must be differentiated from gen eral paresis in its early stages. In syphi
lis there are more frequently symptoms referable to gross brain-lesions, ptosis, and other monoplegife, or more persistent heiniplegia than in paresis. At times the diagnosis is impossible during life. Tabes has strongly marked motor and sensory symptoms not usually present in general paresis, although they may com plicate the latter.
As regards paresis, syphilis produces a pseudoparesis which is very hard to distinguish from true general paralysis. True general paralysis, where syphilis is but a concomitant element, or at best but a secondary cause, is not in the least influenced by specific treatment, while in syphilitic pseudoparesis a recovery may be anticipated if organic structural changes have not been produced. A. Morel-Lavallec (Gaz. des Hop., Oct. 19, 'S9).
Study of 149 cases occurring at the Philadelphia Hospital. The old idea that the delusion of grandeur is the essential symptom of paresis seems con troverted, for paresis without delusion is extremely common (44 per cent. of the series). As to diagnosis, the forms of insanity most often confused with paresis of the simple form arc (1) the so-called organic dementias, chiefly those due to embolism, thrombosis, or Incmorrhage; (2) presenility ; (3) de mentia prfecox; (4) even epilepsy and alcoholic insanity. The prevalence of alcoholism among these patients de mands more recognition than was for merly ascribed to it as an etiological factor, and the hasty acceptance of syphilis as the sine qua non of paresis needs reservation. As regards the so called "crucial tests" of true paresis, the figures bear out the statement that any abnormality of the pupils not accounted for by a local lesion may serve as a sign of paresis. The consensual reflex was found as an independent sign in only a small number of cases. Atten tion is also directed to the confirmatory value of the paralytic attacks, the apo plectic form occurring more commonly early in the course of paresis, the epi leptiform prevailing later. After these points come, in order of scientific value for diagnosis: (1) tremors of face, lips, and tongue, with resultant hesitailey of speech, and (2) impairment of conscious ness and of judgment. Pickett (Phila. Med. Jour., March 29, 1902).