Other motor symptoms are changes in the deep reflexes. The patellar reflex is most often increased, but may be normal, diminished, or absent. It has no diag nostic significance except in connection with other physical or mental symptoms.
The facial muscles often show signs of involvement. A fibrillary tremor or twitching of the muscles about the mouth, sometimes a spastic condition of single muscles or groups of muscles about the face, loss of expression from paresis of certain muscle-groups may be present. On protruding the tongue the organ is tremulous or protruded in a spastic or jerky manner. Tremor of the hands is also present as a symptom of the advanced stage. The writing becomes irregular and "shaky." The speech is jerky, slow, or "scan ning." In advanced cases it becomes slurring. Syllables are dropped or re peated. Certain words are pronounced with difficulty, the test phrase "truly rural" usually running into "toory looral." Later the speech becomes indis tinct and finally degenerates into an in articulate sound, in which no words can be distinguished. The early speech defects are probably due to fibrillary tremor or twitchings of the tongue and lips. The later ones are paretic in origin.
In the earlier stages of general paresis, the physical signs are the most marked. Chief among them are: (1) the stam mering or tremulous speech; (2) the tremor of the facial muscles and of the tongue; (3) the pupillary symptoms; (4) the change in the handwriting; (5) the exaggeration or the absence of the reflexes. The diagnosis, however, can only be established if some one or more of these signs are associated with mental symptoms. Any departure from the standard of thought and action that the individual has established for himself should always be regarded with sus picion, as should also any changes in his bearing that are not in keeping with his position in life. Defective judgment and especially defective memory are common changes. The early stages of the disease may be readily confounded with other conditions. The most common is cerebral neurasthenia. B. Sachs (N. Y. Med. Jour., July 2, '93).
The lines of expression in the face be come obliterated in the later stages of paresis, but this sign can at times be noticed among the early symptoms on careful examination.
An early symptom is retention of the urine, which is due to loss of contractile power, or of reflex sensibility in the ves ical walls. The overdistended bladder dribbles urine. This may be mistaken for a paralytic condition. In the ad vanced cases there is dribbling of urine and involuntary escape of faeces from relaxation of the sphincters.
An annoying symptom of cortical irri tation is a constant grinding of the teeth. This is so often present in general pare sis that it is considered by some authors as pathognomonic, but it also occurs in some cases of simple dementia.
The gait in the early stages is spastic or ataxic. In advanced cases it becomes slouching or dragging.
In the advanced stages, coincident with the progressive dementia, is in creased motor debility. Tremors or twitchings give place to paresis and these again to complete paralytic condi tions. The patient is no longer able to keep on his feet, and after a time he becomes bedfast. The power of articu lation is lost and the voice becomes an inarticulate moan, extremely distressing to the hearer.
Mastication of food is forgotten and masses too large to pass down the oesoph agus are partly swallowed and often cause asphyxia by compressing the trachea.
Vasomotor disturbances are frequent. The innervation of the vessels is dimin ished and there follows dilatation of the superficial vessels, redness or blueness of the skin, oedema and cyanosis of the peripheral members, and diminution of blood-pressure.
The hmmoglobin and red corpuscles in general paralysis vary with the body weight, the hmmoglobin, however, dimin ishing more than the red cells. They both decrease in the early stage, are sta tionary in the so-called second stage, and fall again in the third. Winckler (Inaug. Dissect., '91).
In general paralysis: 1. The hemo globin and red corpuscles are always diminished.
2. The specific gravity falls slightly below the normal.