(B) Motor Disorders

The most frequent are phenomena of paralysis and of paresis, which may assume the most varied types: monoplegia, hemiplegia, facial paralysis. The latter, generally slight, constitutes a very frequent and often an early symptom.

The paralysis is either flaccid or associated with contractures.

A certain degree of motor aphasia is often observed.

Paralysis in many cases follows a seizure and is usually transitory.

Convulsions will be considered in connection with epileptiform seizures.

Sometimes choreiform movements are observed in general paralysis (Vallon and Marie), also tremors analogous to those of multiple sclerosis and of athetosis.

(C) Disorders Of The Reflexes

The best known and the most important are the changes in the patellar reflex.

There is nothing constant about these, as they vary not only in different patients but also in the same patient at different times.

The patellar reflexes may be normal, exaggerated, diminished, or abolished. Sometimes they are unequal on the two sides: one may be exaggerated, the other abolished.

Complete abolition is seen in the tabetic form, exaggeration in the spastic form.

Other tendon reflexes have been but little studied. It has been noted that exaggeration of deep reflexes is generally more marked in the upper extremities.

• As to cutaneous reflexes, they are sometimes exaggerated, more often abolished. The Babinski sign is present only in cases with lesions of the pyramidal tracts, especially in those with combined sclerosis.

(D) Disorders Of Sensation

These have been well described by Marandon de Montyel, from whom the following facts have been borrowed:

(a) Sensibility to pain is often diminished, less frequently abolished, rarely exaggerated. Some patients present retardation of the perception of pain. Disorders of pain sensibility often persist during remissions.

(6) Tactile sensibility is usually normal. However, there may be hyperesthesia, hyposesthesia, and even complete anaesthesia. These disorders disappear during remissions.

(c) Special senses: disorders of hearing (more or less marked deafness, tinnitus, etc.) are not infrequent, but by reason of their common occurrence in other mental disorders and in normal individuals they are of but slight importance.

In some cases, however, the deafness is of central origin and seems to be directly due to the meningo-encephalitis. Recently I had under my observation a paretic who developed bilateral deafness following an apoplectiform attack. At first his deafness was remittent; on some days the patient could hear fairly well, while on other days he understood what was said to him only by the movements of the lips and, of course, but very imperfectly. Now his deafness is complete.

Amblyopia or even complete amaurosis is sometimes encountered. In certain cases it depends upon atrophy of the optic nerve.

The senses of taste and smell are often greatly impaired.

Disorders of the generative function are quite frequent and vary with the stage of the disease.

The onset is often marked by genital excitation, which, associated with the mental deterioration, may lead to indecent or criminal acts: exhibitionism, rape, etc. Later this excitation is replaced by absolute impotence.

(E) Trophic Disorders

These affect all the tissues.

Osseous tissue: abnormal fragility of the bones, fractures caused by slight traumatisms or even occurring spontaneously.

Connective and cartilaginous tissues: the trophic disorders are here chiefly manifested by hematoma auris,1 which consists in an extravasation of blood into the tissues of the auricle.

The exact seat of the extravasation in hematoma auris is still a disputed question. Some are of the opinion that it is in the subcutaneous tissues, others believe that it is between the cartilage and the perichondrium, and still others think that it is within the cartilage itself.

Manifestations of trophic_ disorders are usually favored by traumatisms. It must not be forgotten that the great majority of hcematomata auris are on the left side and that when one receives a blow it is usually on that side. It is possible to reduce considerably the number of hcematomata in institutions by holding the attendants directly responsible for their occurrence.

1 Gatian de Clerambault. Contribution & I'etude de l'othimalome. These de Paris, 1899.

Skin

Deformity and grooving of the nails,1 diverse eruptions, herpes. The latter lesion indicates involvement of the cord in the pathological process; it may constitute one of the first symptoms of the disease.

The most frequent and most grave cutaneous disturbances are pressure-sores.

Whether bilateral or unilateral they develop chiefly at the points bearing the weight of the body while the patient is in bed; hence the sacral, gluteal, and trochanteric bedsores. The sacral bed-sore is very often median.

In their dimensions they vary from small sores of the size of a dime to those exceeding the size of the palm of the hand.

Their depth also varies in different cases. Some remain superficial, while others destroy the skin, subcutaneous tissue, and muscles, and expose the bone.

Their course is often progressive; that is to say, they increase in extent and in depth. Sometimes they heal under the influence of appropriate treatment.

Muscles

Localized muscular atrophy is rare. It affects different groups of muscles and may have one of two origins, resulting either from degeneration of the white columns of the cord, which, in its turn, is caused by cerebral lesions (Grelliere),2 or from primary degeneration of the cells in the anterior horns (Joffroy).3

1 Treves. Su alcani alteretzioni distrophiche delle unghi. Rivist. di clin. medic, 1899, No. 6.

2 Grelliere. Atrophie musculaire dans la paralysie generate des alienes. Paris, 1875.

3 Joffroy. Contribution a l'anatomie pathologique de la paralysie generate. Congres de Medecine mentale, 1892.

(F) Visceral Disorders

These are dependent either upon the disease itself or upon a complication. It is unfortunately difficult to determine in any given case what the real cause is.

(a) Digestive apparatus: Its functions become disturbed chiefly in the terminal stage of all forms, and early in the depressed and excited forms: anorexia, vomiting, constipation, or intractable diarrhoea. In the expansive form one often notes a veritable boulimia.

(6) Cardio-vascular apparatus: Evidences of atheroma, myocarditis, rapid and feeble pulse in the terminal cachexia. Aortic insufficiency is not rare and is probably due to syphilis.

(c) Kidneys: Slight albuminuria is frequent. This with the low specific gravity of the urine is an indication of a certain degree of renal insufficiency.

(d) Liver: Sometimes hypertrophied, more rarely atrophied with phenomena of cirrhosis. The ascites that usually accompanies atrophic cirrhosis of the liver is generally absent in the cirrhosis of general paralysis (Klippel).

(e) Respiratory apparatus: Congestion, broncho-pneumonia, and splenization are frequent complications of the last stage. Pulmonary tuberculosis is, on the contrary, quite rare and usually runs a slow course (Bergoni6, Klippel.)

(G) Seizures

These are frequent, occurring at all periods of the disease and often marking the onset. They may be fatal. According to Arnaud death from a seizure is the natural mode of termination of general paralysis. They are often accompanied by elevation of temperature which is at times considerable. In some cases more or less marked albuminuria is observed, which disappears several hours or several days after the seizure.

On recovery from these seizures, which is most usual, symptoms of apoplexy (paralysis, aphasia) often appear; they are almost always transitory, there being no gross lesions of the corresponding projection-centers. The seizures are generally followed by an aggravation of the fundamental psychic and physical symptoms.

1 Pierret. Les attaqties 6pileptiformes et apoplectiformes dans la paralysie generate. Progres medical, 1897. - Arnaud. Arch, de neurol., 1897. - Bonnat. These de Paris, 1900.

The seizures are of two kinds: apoplectiform and epileptiform.

The former are characterized by more or less complete loss of consciousness associated with complete flaccidity of the limbs.

The latter consist in general or localized convulsions. The general convulsions sometimes so closely simulate epilepsy as to be mistaken for it. The localized convulsions assume the aspect of Jacksonian epilepsy (monocrural, mono-brachial, facial). The loss of consciousness accompanying the partial convulsions is either complete or reduced to a slight degree of confusion, as in the case of convulsions due to focal lesions, such as cerebral tumor and the like.