It independent of the condition of the pupils, AN does not modify it, and is especially easy to note in those whose irides are dark in color. Gilles de la Tourctte (Jour. des Praticiens, Mar. 11, '99).
It is the physiviait's bounden duty to recognize this disease in the pre-ataxic stage. When these patients are seen in the beginning, one should not let them pass as instances of sciatica or rheuma tism. People who have rheumatic di atheses, as a rule, have attacks of in dammatory rheumatism in early life. They usually get rheumatism before they reach the age of forty-five or fifty years. Rheumatism is essentially a dis ease of early life, and. when patients complain of aches and pains which they hove diagnostieated as rheumatism, one will find in the great majority of eases they are not rheumatic at all. One sign which is not pathognomonic, but simply an aid in diagnosis, is tiluar analgesia, noted by rubbing the ulnar nerve in the idnar notch. Along with the ulnar an algesia is very frequently found marked diminution in pain-sense throughout the whole territory. Fraenkel's sign is also an aid in diagnosis. If the thigh is ex tended at right angles to the body, the leg can be brought up in a perfectly straight line. The usual angle that the leg makes in that position is not mani fest; the muscles are in a hypotonic con dition. In other words, there is a lack of muscular tone. In very many of these eases there is an exaggeration of the abdominal reflex. D. R. Brower (In terstate Med. Jour.. Aug.. 19011.
Among the diseases to be considered and which at times obscure the diagnosis, are ataxic paraplegia, disseminated scle rosis, brain-tumors, certain forms of mye litis; the syphilitic meningomyelitis of Oppenheim, Sachs, and others; multiple neuritis, and post-diphtheritic paralysis.
In the ataxic paraplegia of Gowers there is actual loss of motor function with spasticity, the knee-jerks being usu ally exaggerated with little if any pain, no crises, no arthropathies, and no in volvement of the muscles of the eye.
In multiple sclerosis there may be ocular palsies, pains (slight) in the lower extremities, defects of sensation, sphinc teric involvement, ataxia, and even abolished knee-jerks. The knee-jerks are usually exaggerated, however; the pains differ in degree and character, and in disseminated s.clerosis the peculiar
speech, intention-tremor, nystagmus, and special variety of optic atrophy (Gnauck) are distinctive.
Ataxia is common in tumor of the cerebellum, the frontal lobes, and the base of the brain. Optic atrophy and ocular palsies are also frequently encoun tered. Attacks of cerebral vomiting may simulate the gastric crises of tabes. The clinical picture and history of focal pal sies, headache, hebetude, etc., in brain tumors serve to distinguish the two con ditions quite readily. In myelitis the absence of optic atrophy, ocular palsies, and Argyll-Robertson pupil are sufficient to eliminate any element of temporary confusion. In multiple neuritis the deep reflexes are abolished or diminished, there may be much pain, and the ataxia may be decided. The rapid atrophy and true motor weakness, with altered elec trical reactions, together with absence of papillary changes, and preserved light reflex establish the diagnosis readily. Post-diphtheritic paralysis, when it sim ulates, through the ataxia and sensory symptoms present, true tabes dorsalis, is a multiple neuritis, and the differential data are the same. In syphilitic men ingomyelitis there is, at times, a close clinical resemblance to true locomotor ataxia. In such cases, however, motor as well as sensory defect is present, the symptoms are unilateral or at least un equal in degree on the two sides, the Argyll-Robertson pupil is not present, and prompt improvement nearly always follows the energetic use of potassium iodide and mercury.
Should the disease begin in the cer vical cord, is at times difficult to dif ferentiate locomotor ataxia from syringo tuella: a fact which has been especially emphasized by Marie. Cervical tabes is a rare form of the disease, Dejerine find ing only one such primarily in one hun dred and one cases at the Bicetre.
[Psychical disturbances during the course of tabes are rather rare, but not quite so rare as is usually believed. It is necessary, in such cases, to carefully guard against confounding these disturb ance,s with a condition of dementia para. lytica combined with ataxic symptoms.