{198} The early mental symptoms may simulate those of cerebral neurasthenia, in which the patient thinks that there is decided mental impairment, although there is no progressive dementia. The tremor in neurasthenia is greater and more universal than in the stage of general paralysis with which it might be confounded, and the subjective symptoms are much more prominent. Muscular malaise and pains throughout the body give rise to the diagnosis of malaria or rheumatism, in which there may be loss of power, but no ataxia or dementia. The sclerosis may be predominating or pronounced in the basal ganglia and bulbar nuclei, giving occasion for a hasty diagnosis of labio-glosso-pharyngeal paralysis, until it is found that the clinical history of that disease is not followed. In the same way, any motor or sensory ganglia or nerve-roots may be so early implicated in the degenerative process as to mislead the physician into giving attention to only the local symptoms. Once I have known the early convulsions of general paralysis in a very self-conscious woman mistaken for hysteria, the mental impairment and physical weakness having been overlooked on account of the prominence of the convulsive attacks and the hysterical symptoms, which may be a complication of any form of insanity in young and middle-aged people, particularly women. It is not uncommon for the attacks to so thoroughly resemble epilepsy as to be mistaken for it, the dementia not being observed or being supposed to be the ordinary mental deterioration generally following epilepsy. In such cases the progressive dementia, ataxia, and muscular weakness may advance so slowly as to entirely escape observation for a long time, and give rise to the confident diagnosis of epilepsy for five or six years. Epilepsy, however, arising in a vigorous, middle-aged person without evident cause, should always suggest the suspicion of syphilis, cerebral tumor, or general paralysis, when careful scrutiny of all the symptoms will show where it belongs. Embolisms, hemorrhages, cerebral effusions, more or less diffuse encephalitis from an injury to the head, sometimes give rise to the suspicion of general paralysis, until it is found that its characteristic progressive symptoms do not appear, but chiefly when the history of the case has not been definitely ascertained, or when the usual symptoms of those conditions are not well marked. Chronic endarteritis, arterio-sclerosis, atheroma of the cerebral arteries may be so diffused as to simulate general paralysis, especially in drunkards and syphilitics, but the symptoms do not advance in the manner characteristic of that disease. Multiple cerebro-spinal sclerosis of the descending form may be confounded with general paralysis while the symptoms are obscure and consist in change of character, when, indeed, organic disease can only be suspected to be present.