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INCIPIENT SYMPTOMS OF GENERAL PARALYSIS.
balance himself, and with difficulty saves himself from falling; he walks up a stair with comparative ease and comfort, because he has some object before his eyes to guide him ; but he goes down stairs with fear and difficulty, because there is nothing before him on which he can fix his eye. This is the most exaggerated or fullydevclopcd form of the paralytic condition ; but it is seldom seen, in the early stages at least, of the disease which I am describing, so strongly marked. Very often it is hardly observable, consisting merely of a slight widening of the limbs, and a rolling or shambling, and somewhat unsteady gait; in fact, the affection of the speech is not more truly like that of drunkenness than that of the locomotive powers ; they are both the result of the loss or impairment of that power by means of which we regulate and control the co-ordinate action of our voluntary muscles ; and may exist, in every varying degree, from the slightest appreciable thickness of speech or unsteadiness of walking, up to total loss of articulate speech or the power of walking.
“ In ordinary palsy, the nervous connexion between the muscles of the palsied part and the organ of volition is, as it were, cut off entirely, and the individual can no longer, by an effort of the will, make the palsied muscles act ; he cannot lift his arm, or close his hand, or draw up his limb. Or, it may be, he conveys a feeble and imperfect volition to the part (if the palsy is incomplete or passing off), and the hand is grasped feebly, or the limb is slowly and with difficulty drawn up. In the so-called paralysis of the general paralytic, on the other hand, there appears to be no sfoppaye of the nervous connexion or electric current between the organ of volition and the afl'ected parts; but the volition is irreyular/y conveyed and (Zislribuled. The person cannot control and direct his movements perfectly and consentaneously, just as a drunken man sees double, because he cannot make his eyes converge upon a given object; or walks unsteadily, because he cannot direct and regulate the harmonious movements of his limbs. In these movements of the general paralytic or drunken man, there is no palsy, in the ordinary sense of the term; the person affected will run, or dance, or kick, as actively and violently as ever, but his movements are irregular, and not always those desired or willed. In fact, they resemble in kind, although very much modified in degree, the movements of clzorca, in which the patient in vain attempts to steady his hand or carry it to his mouth. I am anxious to enforce these distinctions, because I think they have not hitherto been recognised, and because the name of this affection is apt to mislead as to their nature.
“Dr. Reynolds corroborates my statements, by pointing out as a means of diagnosis, between general paralysis and wasting palsy, that in general paralysis the muscles contract readily under the stimulus of galvanism, while in wasting palsy they do not. In wasting palsy, in fact, the contractility of the muscular fibre is impaired or lost, while in general paralysis it still remains unimpaired."
“ This impairment of the muscular movement gradually increases and extends, the speech becomes more and more inarticulate, the locomotion more and more unsteady, until at last scarcely a word can be distinguished, and the patient cannot rise or cross the room without being assisted.
“ The progress of these changes, however, varies very much in different cases; sometimes, for example, the speech is very little affected, hardly appreciably so, until a very advanced stage of the disease. In other cases it varies, being at times much more perceptible than at others. In the same way, the impairment of the loco
, On Wasting Palsy.
DIAGNOSIS or SOFTENING or THE BRAIN. 651
motive powers in some cases is far from being obvious, even towards the latter stages of the disease; and in others, it is at times more perceptible than it is in general. In all cases, however, I think there is enough evidence left, either from one of these sources or the other, taken in connexion with the state of the pupils, the expression of the face, and the action of the facial muscles, to make the physiognomy of the case diagnostic to an experienced observer)“
Although this disease very closely resembles, in its incipient manifestations as well as in its more mature stage of development, ordinary attacks of softening (such a disorganization of the cerebral matter being frequently found after death from general paralysis), it is, nevertheless, considered by pathologists as an affection sui yeneris, and distinct in its nature from that of ramollissement. The morbid changes, chronic in their character, discovered in the membranes of the brain, grey matter of its convolutions (indicated by changes of colour), as well as altera~ tions in the medullary or conducting portion of the encephalic structure, undoubtedly lead to this conclusion.
Are there any pathognomonic or diagnostic symptoms by which we are able unerringly to detect in all cases the commencement of an attack of softening of the brain? I am, from a close observation of the phenomena of this disease, obliged to answer the question in the negative. In some cases where I felt justified in predicating a state of pulpy degeneration of the brain, no such pathological change was discovered after death. Nevertheless, in a vast number of instances, the indications of softening are clearly and unmistakeably manifested.
There are two principal forms of ramollissement of the brain, viz., red or inflammatory, white or non-inflammatory. This affection of the brain admits, however, of
' Vide “ Edinburgh Medical Journal," for April, 1860. No. 4. vol. iii.
other divisions and subdivisions, but it is my intention only to describe cursorily the symptoms of the two leading forms of softening. This important subject will be fully considered in all its details in the succeeding volume.
The premonitory stage of acute softening is not well or distinctly marked. Many of the symptoms manifested at this period of the disease closely resemble the incipient signs of cerebral hemorrhage and paralysis, such as headache, vertigo, muscular debility, loss of sensibility in some part of the body, tinnitus aurium, formications, a sensation of weight, or slight symptoms of hemiplegia’ 0:1, one side of the body, muscular tremors, tetanic spasm, occasionally resembling a stifi'ness or rigidity of one of the limbs, slight palsy of one of the eyelids, strabismus, defective articulation, misplacement of words, with marked changes in the physiognomy, the expression being that of “astonishment, stupor, indifference, or imbecility.” The eyes are sometimes brilliant and staring, and at other times dull and without expression. The face is occasionally suffused, indicating a state of cerebral sanguineous congestion.
Durand-Fardel says, that a remarkable and striking symptom, frequently observed in acute softening, is an increased secretion from the mouth and eye. This is especially remarked with old people, in whom this viscid secretion dries, and forms hard masses on the edge of the eyelids, which irritate the eyes, whilst an abundant glairy fluid drops from the mouth, or, when more viscid, adheres to the tongue and palate, forming a thick yellowish crust, which is reproduced as soon as removed. A remarkable fact connected with these increased secretions, says Fardel, is that, if a partial cerebral amendment takes place, the discharge of itself ceases, but reappears as soon as the acute softening progresses.
CEREBRAL ABSCESSES AND TUMOURS. 653
In acute softening the patient often complains of optical illusions, and of impaired powers of deglutition. But the principal diagnostic symptoms are undoubtedly cephalalgia, more or less persistent and acute in its character, vertigo, affections of the speech, marked symptoms of paralysis of the palpebrae, face, or one side of the body, associated with muscular debility, loss of memory, irritability of temper, occasional attacks of epilepsy, and a muddled and confused state of the intellect. The spirits are sometimes depressed, and occasionally excited. The pupils are often contracted, but as frequently dilated.
In chronic, white, or non-inflammatory conditions of softening, the premonitory symptoms very closely resemble those previously described as characteristic of acute types of this disease, but materially varying in severity. I have described in the chapters on Impairment of the Intelligence, including the Morbid Phenomena of Attention, Volition, Emotion, and Memory, the principal psychical symptoms indicative of the commencement of this form of cerebral degeneration or disorganization.
It will be unnecessary for me more than briefly to recapitulate what I have previously described as the psychical evidences of white softening. I refer principally, first, to a confusion and then to a gradual impairment of the intelligence, showing itself in defective powers of attention, enfeebled memory, infirmity of purpose, vacillation of will, and a general sluggishness, apathy, and subsequently imbecility of intellect. Associated with these mental symptoms, there are cephalalgia, obscure, but often obvious changes in the sensor and motor powers, (hyperaasthesia and often partial paralysis). I have described these insidious and subtle lesions when analyzing the morbid phenomena of motion, sensation, and speech.
In cerebral tumours and abscesses of the brain there are not generally detected in the early stage any well