Initial symptoms in 111 cases of tabes: l'ain, 57 times; ataxia, 21 times; numb ness, extremities, 6 times; eye-symptoms, 20 times; nausea and vomiting (gastric crises), 4 times; paralysis of bladder, 5 times; loss of sexual power, 1 time; paralytic attacks, 2 times; mental symp toms, 1 time; nenrasthenia, 1 time.
Among the subjective sensations pain was prominent; girdle-pain was present in 27; gastric crises in 9; laryngeal in 2; rectal (and penile) in 1; optic atrophy as found in 11; eye-musele paralyses in 33; Argyll-Robertson pupils in 70; in S slight reaction to light was present, and in 21 tbe pupillary reflexes were normal. Ataxia 1) as present in 91, ab sent in S. The knec-jerks were normal in 4 eases.
Objective sensory disturbances were present in 78 of 90 eases; typical arthrop athies occurred in 5, and perforating ulcer in 5. Mental symptoms were pres ent in 7; in 1. epilepsy had lasted from the fourteenth year up to the time of onset of tabes, at 44. H. M. Thomas (Phila. Med. Jour., from Bull. Johns Hopkins Hosp., Apr., '99).
Fatigue from exercise, as in walking, dancing, or the ordinary occupation, is greater in degree and occurs more quickly than before.
Case in which there was absence of a sense of fatigue in a tabetie patient. This patient was able to hold both arms in an horizontal position for twenty-five min utes without experiencing the slightest feeling of fatigue. Frenkel (Centralb. f. Nervenh., Psych., IL gerich. Psychop., July 1, '93).
Transient attacks of double vision may be noted with or without ptosis. The normal action of the bladder and some times of the rectum may be disturbed. Severe attacks of rectal neuralgia some times occur quite early in the disease. Examination at this time will develop the fact that the knee-jerks are either decidedly diminished in activity or even abolished (Westphal's symptom). Tests of sensation may reveal an impaired tactile perception in the distribution of the ulnar nerve (Diernacki), the peroneal (Sarbo) or the popliteal space (Bech terew), or over the plantar surfaces of the feet. The eyes, on examination, will present what is known as the Argyll Robertson pupil, which consists in a loss of the reflex to light, although accom modation to distance is preserved. The pupils are often quite early found ab normally contracted, sometimes to a de gree which has given origin to the term "pin-point" pupil. The pupils may be unequal.
The disease may l'emain practically stationary at this stage for some time, even for years (Gray), but sooner or later symptoms of ataxia supervene. Ordi narily the ataxia is first noticed by the patient in walking at night or along a narrow pathway or in circumventing obstructions. More effort is required. llitherto-automatic action in walking, in standing, in dancing, and in other efforts demands more and more con scious attention in order to effect proper co-ordination. Quite early in the devel opment of the ataxic stage the patient will present the Romberg symptom. by
which is meant an inability to stand without swaying or falling if the feet are placed close together. Minor degrees of this variety of ataxia can sometimes be demonstrated only with the patient's eyes closed or by having the patient at tempt to stand on one foot. In walking the ataxia is manifest in the increasing difficulty with which the patient follows, heel and toe, a chalk line or a carpet seam or crack along the floor. Here, again, deprivation of the co-ordinating assistance of vision greatly intensifies the difficulty.
[It astonishes me that, in the majority of text-books, a pronounced, and also well-known, initial symptom of tabes is not mentioned,--i.e., the inability to walk backward. OBERSTEINER, Assoc. Ed., Annual, '931 The gait becomes characteristic; the feet are kept wide apart and are lifted unnecessarily high, are brought down to the floor with an appearance of unusual and unnecessary force, the heel striking first. Charcot is quoted as stating that he often made the diagnosis of locomotor ataxia from hearing the patient's foot falls as he approached the examination room and before having seen him at all. The patient will often state, in explana tion of his defective gait, that he is losing power in the legs. Attempts at forced flexion or extension, the patient resisting, will show, however, that mus cular power is intact. The ataxia may extend—in the cervical cases it begins— into the upper extremities. The pianist loses his delicate technique, the machin ist his dexterity. Fastening a button, especially when not in the field of vision, becomes a serious problem. If asked to touch the top of his nose with the tip of his finger or to bring his outstretched arms together so as to touch the tips of the right and left forefingers, the eyes being closed, the patient will almost in variably fail. As the disease progresses all these symptoms become intensified and others are added, chiefly sensory. The patient complains of a feeling of pressure or constriction or band of numbness around the waist or chest or throat. Various disturbances of the viscera may develop. Attacks of ap parently causeless vomiting, of gastric pain, of dyspncea, of palpitation, of yes ical or rectal tenesmus occur which are known as crises. Certain trophic altera tions in the skin, hair, and nails may be present or the teeth may fall out gradually and painlessly. The joints, especially the knees and elbows, some times enlarge suddenly, as a rule, with out pain, constituting the so-called ta betic arthropathies of Charcot. The bones become easily friable. Abnormali ties in the visual apparatus again become conspicuous. The transient strabismus or ptosis of the earlier stage may recur and become permanent. The optic nerve presents the symptoms of atrophy, and total blindness may result. The optic nerve may be—and, indeed, often is— affected quite early in the disease.