These muscular defects and mental inefficiencies, when slight, may be hardly detected after the patient has had a prolonged rest and is quiet and calm. After some emotional irritation, weariness, sleeplessness, vaso-motor disturbances, or congestive attacks they become very pronounced. After several weeks of absolute rest, with the patient still at rest, it may be impossible for a time to find any trace of mental defect or muscular deficiency until the patient has again been put to the strain following some effort. They are very much increased after epileptiform or apoplectiform attacks, which, however, are uncommon so early in the case. In the progress of the disease, as the mental impairment increases, the reaction of the nervous system to external conditions becomes less active, the mind weakens, the loss of flesh may be, at least in part, regained, a great portion of the irritability and active symptoms disappears, and as the patient grows worse he may seem for a while to his friends to improve. The leading symptoms of general paralysis of the insane are—(1) vaso-motor, (2) mental, (3) physical. The vaso-motor symptoms consist in a progressive paresis or lessened power, which in the progress of the disease advances to complete arterial paralysis—at first a functional disorder of impaired innervation, and finally organic. They are marked early by rapid changes in the cerebral circulation, a diminished arterial tension, with occasional or frequent attacks of vertigo, dizziness, or faintness, confusion and incoherence that may amount to a transient dementia, localized and general elevation or {190} depression of the bodily temperature; frequent attacks of congestion or at long intervals, with a flushed face or transient cerebral anæmia, may be marked by sharp emotional disturbances, fits of temper, irritability, maniacal excitement, loss of self-control, etc., or by epileptiform and apoplectiform seizures of various degrees of severity, with or without temporary or transient loss of muscular power, local or of the monoplegic, hemiplegic, or paraplegic nature, of a much less severe character than similar attacks later in the disease, due in part also to organic changes. The circumscribed loss of power of the vessels of the skin leads to various functional disturbances, and finally to paralysis, involving bed-sores, etc. Cyanosis, neuroparalytic hyperæmia of the lungs, bladder, and intestines, cold feet, œdema of the skin, local sweatings, etc. are final evidences of vaso-motor paralysis. Throughout the disease, at least nearly to the end, this vaso-motor paresis and paralysis causes marked variations in the mental state which are too rapid to be accounted for by organic changes.