INSANITY 305 tnit outrageous and immodest acts, such as ex- posure of person and foolish assaults upon women ; he is easily aroused into a passion, which often rises to uncontrollable fury ; he neglects his business, fails to keep appointments, and exhibits a general weakening of the mind simi- lar to that in the commencement of senile de- mentia. This, occurring in a vigorous man, cannot hut be regarded as a remarkable symp- tom, and of alarming import. These symptoms increase rapidly, so that the disease will have greatly advanced in a few weeks. He sleeps badly, eats and drinks irregularly and often voraciously, spilling his food on his dress, of which he takes but little care. He is for a tune sullen and morose, but as the disease ad- vances grows more and more excitable ; and it soon becomes evident that he needs restraint. A maniacal condition ensues, in which he as- sumes airs of great importance, imagines him- self possessed of unbounded riches, and the owner of studs of the fleetest horses. An or- dinary maniac may imagine himself a duke and the possessor of vast wealth, but he will show some consistency in adhering to the same delusion; while the general paralytic will style himself a duke, a prince, and a king al- most in the same sentence, and will announce his intention of doing a liundred impossible things on the next day. He has extravagant notions of his intellectual, and particularly of his physical strength, and when in the last stages of bodily weakness will maintain that he can perform the most wonderful feats. He nearly always says that he feels well, even when not able to feed himself. In consequence of these peculiar symptoms, the French have called the disease mania des grandeurs. His speech generally shows the first effects of pa- ralysis, although it sometimes commences in the lower extremities. The articulation be- comes obstructed, somewhat like that of a drunken man. It is not a true stammer, but shows, a want of power over the vocal organs. There is often a peculiar tremulousness of the lips, such as is seen in grief. The defect in speech varies from time to time, sometimes not being noticeable except to the practised physician, and at others rendering the patient unintelligible. The subjects of the disease are almost always men in the prime of life. It does not attack boys or old men, and rarely women. The violence of the mania attend- ing general paralysis is of the most danger- ous character; its subjects become possessed with a blind fnry, and know not what they are about. In this stage they are not paralyzed sufficiently in their limbs to prevent them from doing serious harm; therefore the restraints of an asylum are almost absolutely necessary. Other symptoms appear in time. Fits resem- bling apoplexy or epilepsy occur from time to time, dividing the disease into stages. They are called "congestive," or "paralytic," or " epileptiform " attacks, and resemble some- times the petit inal of epilepsy, at others the grand mal. Again, they may not be attended by any convulsion, but by sudden collapse and paralysis, which slowly passes away. The epi- leptiform attacks have not the definiteness of epileptic fits, but may last an hour or two, or pass off so rapidly that the patient may con- tinue standing. It is important to distinguish these fits from those of true epilepsy, as the latter are more benefited by treatment, even when accompanied by insanity. In fits of gen- eral paralysis patients seldom bite the tongue, while in epilepsy they almost always do. The pupils of the eyes will generally be found ir- regular, and when this symptom is present it is important. In 108 cases of general paralysis examined by Dr. Nasse of Siegburg, the irreg- ularity was present in all but three. Dr. Aus- tin found only two exceptions in 100 cases. Irregularity of the pupils may, however, exist in other forms of insanity, and also in the sane in other affections of the brain, but it is much more rare. When accompanied with the other symptoms of general paralysis, it may be considered pathognomonic. The course of general paralysis has an average duration of about two years ; some few cases last only a few weeks, and some may run on for five or six years. The maniacal or second period may last from a week to two months, and generally yields to treatment, the patient getting better, so that he is able to go about and appear like a sane man for a while ; or he passes into a state of dementia, and so on downward to extinction of mind and body. Sometimes after apparent recovery the subjects of this disease may at- tempt to reengage in business, but such attempts have always been found to fail. The last stage, that of dementia, is sad indeed, and it is fortu- nate that the disease is rapid in its progress. The patient can scarcely walk or feed himself, and there is constant tremor of the hands; a habit of grinding his teeth in a most horrible man- ner comes on at this time ; and his appetite remains good, but the power of swallowing is greatly diminished, and he will often go on cramming food into his mouth until he be- comes nearly suffocated. The cause of general paralysis is a subject of discussion. Some au- thorities have but little doubt that it is gen- erally produced by fast living, excess in wine and in sexual intercourse, particularly the lat- ter. Others deny this, saying that it may arise from extreme mental exertion, greatly pro- longed, and point to examples in men of a high order of intellect in which this was the only assignable cause. Whenever it attacks women, which is but rarely, it is nearly always those who have led irregular lives. Dr. Dickson has observed that its subjects are almost invariably men who have had no children. If this be a rule, it may point to a hereditary origin, and also to a tendency to die out. He also inclines to the opinion that the excesses of the patients are more to be regarded as evidences of the disease than as causes. The insanity which accompar nies true epilepsy, and which is known as epilep-
