With the failure in memory comes also obtuseness and dullness in mental activity. The mind no longer initiates or enters upon new lines of thought, study, or business. The power of attention becomes impaired, and what is addressed to the person is only partially apprehended and soon fades from the mind, all of which is indicative of the approaching confusion of ideas and dementia, which will ultimately be one of the most marked indicia of the disease.

Insomnia is very common as the early symptoms progress in their development. This is not attended with any anxiety on the part of the patient in consequence of its experience, but, on the contrary, he pays little attention to it, rarely complains of any disagreeable feeling, and refers to it, if at all, as of no importance. In some cases in which the sleep is broken and scanty at night there may be drowsiness during the day.

In contrast with the state of self-importance and excitement, there may exist in a certain proportion of cases, mental depression attended with loss of self-confidence. Patients become sad, unhopeful, inclined to shed tears, and experience a foreboding of something terrible about to happen to them. These conditions may increase until a true melancholia appears to be the leading feature in the mental state. This depression appears to be quite identical with that of ordinary melancholia, and the diagnosis of such cases will depend upon the history, as presented by friends, together with physical symptoms. It is not unfrequently attended with more or less uneasiness or positive pain about the epigastric region, indicating some lesion of the great sympathetic nerve.

Dr. James S. Kiernan* presents a table of thirty-four cases

* Alienist and Neurologist, January, 1885, pages 65 and 66.

in which depression existed as an "early mental symptom" in thirty-two. This is certainly a higher proportion than has existed in my own experience, though according to the statement of friends it has existed in from 50 to 60 per cent. As the disorder progresses so as to attract the daily attention of friends, the leading characteristic becomes one of irritability and excitement in the great majority of cases.

Physical Symptoms of this Stage.-The late Dr. W. B. Goldsmith* says that epileptoid seizures in some form had existed in twenty of the one hundred cases which had been under his observation as one of the earlier indications of approaching general paresis. This is a much higher per cent. than has existed in my experience, such seizures being confined almost entirely to the third period of the disease.

Vertigo. There is a case under my care at the time of this writing, in which the first indication recognized by the patient himself or his friends consisted in an attack which was described as “vertigo and slight faintness,” requiring the patient, who, at the time was engaged in his store, to sit down for a few minutes. He, however, did not lose consciousness, soon arose, and going immediately to his physician explained the character of the attack. He experienced no other of any kind, and appeared to his friends to be in his usual state of health during several months. Being somewhat over-heated and fatigued at his place of business, in the month of June, he laid down for a sleep in mid-day. After a short time he awoke in a delirious condition, in which he continued, a part of the time greatly excited, during three or four weeks. The delirium and excitement then gradually passed away, leaving the mind at times

* Archives of Medicine, August, 1883, page 50-57.

confused and with delusions of importance. He has had no attacks approaching the nature of an epileptic form of seizure, or loss of consciousness, or even vertigo, to the present time, a period of nine months, though other symptoms are well marked.

Dr. Mickle says that "vertigo, whether slight or severe, and occurring independently of gastric disorder, is not at all rare at this preliminary stage.

An impairment in coördination of gait appears so plainly as to be readily observed in a small proportion of cases before the mental symptoms are pronounced. In a case under my care several years since, the wife told me that this had existed to such a degree that when walking upon the sidewalk with her he would at times require her support to prevent his staggering against those whom he met. When alone he generally went near the fence, so as to support himself if necessary, as it often was. This character of gait had existed several months before any change in his mental condition was observed and he was brought to the Retreat. Tabes dorsalis was not a prior condition in this case, and the disease was in no other wise exceptional in its course or symptoms.

In a much larger per cent. of cases there is observed a failure in the finer movements of the tongue, in articulation, and also in the manner of its protrusion. This is done by a sudden movement, and then it is almost as quickly withdrawn. An unusual effort to keep the tongue extended appears to be necessary, and the patient requires several invitations before he will keep it out long enough to be carefully examined. When it is fully protruded, there will often be seen a twitching of the muscular fibrillæ of the surface. Such a movement on the surface may, how

* Mickle on "General Paralysis of the Insane," p. 9.

ever, exist in other conditions than that of general paresis. The difficulty in articulation will be observed more particularly in the effort to enunciate words beginning or ending with consonants and those containing a number of con

sonants.

When spinal symptoms appear first in the course of the disease, patients often complain of neuralgic pains in the head and neck, and about the loins, and in the legs, attended with cramps of the muscles of the soles of the feet and calves of the legs. In the case of a female patient at the Retreat, such pains, according to the statement of her husband, had existed at times for six years before the mental symptoms appeared. Whenever these pains subsided, as they frequently did, there occurred numbness, and at times loss of sensation in feet and ankles. The ataxic

gait had been present during several years. It does not appear that the anesthesia in this case preceded the motor disturbance as a primary symptom. It certainly remained a prominent one for months after the mental symptoms were pronounced, and a pin could be inserted without causing the slightest pain

In other cases there may occur disturbance of the circulation, palpitations, heat in the head, a congested state of the capillaries of the face, or ringing in the ears. I infer from my own experience that these symptoms are less common than many others in the earlier stage, though they often appear later.

The character of the initiatory symptoms will depend, at least to some extent, upon the etiology of each case. This will be true especially in those cases resulting from injuries to the brain and nervous system, sunstroke, and poisoning by lead, and also when the disease is preceded by tabes dorsalis.

It will be observed that so far in our enumeration of primary mental symptoms none have been described which appear in the classical literature of general paresis as pathognomonic. Moreover, nearly all cases in which the law interferes and restricts the liberty of the individual have progressed to another stage and exhibited symptoms of a much more pronounced character. The general practitioner, therefore, who searches for those conditions. only which constitute its typical character, as described by Skae, Calmeil, and the earlier French authors, will utterly fail in forming a correct diagnosis. Yet the importance of a recognition of these early indications, both from a medico-legal as well as a social point of view, can hardly be over-estimated. Fortunes have been squandered, public trusts betrayed, positions of influence, which have been secured as the reward of years of faithful service, have been lost, morals have been outraged, and family ties sundered, all before the true cause has been understood.

Pronounced Period. The initial period varies greatly in duration in different cases, in some covering several years, and in others a few months, or even weeks. This will depend largely upon the exciting causes and the inheritance of the individual. Whatever has been the length of time, however, since a change may have been observed, it seldom happens that the patients are placed under asylum supervision until the occurrence of some act, or a series of acts, which are manifestly so abnormal and foreign to the previous character as to make this step necessary.

In some cases this will consist in an outburst of excitement or the undertaking of some great financial scheme; in others an inability to be longer interested or occupied in former pursuits and a consequent vagrancy; in others still, the commission of some moral delinquency, such as a theft,