The muscular sense is invariably im paired in some degree and in nearly all of its subdivisions — position, weight, pressure, etc. If the eyes are closed the patient may not be able to tell whether a given muscle or set of muscles is being flexed or extended, pronated or supinated, by the examiner. If two wooden globes, exactly alike in appearance and size, but differing materially in weight, are placed in the hands of the patient, he cannot distinguish the heavier from the lighter. Pressing unequally with the hands upon the patient's thighs or other symmetrical parts of the body, he is unable to dis tinguish the inequality. The tempera ture sense may be also affected so that variations in the degree of contact heat or cold are not appreciated. Finally, a condition of motor helplessness or paresis may be superadded to the sensory dis turbances.
Case of tabes in which peculiar vaso motor dilatations occurred, consisting of a cyanotic appearance of the face, neck, and fauces, occasional spontaneous ecchymoses and curious local swcatings. Audeoud (Revue MM. de la Suisse Rom., Sept., '90).
Of 22 tabetic patients, 2 found in which there was paralysis of the pos terior cricoarytenoid muscles; in the others no motor or sensory disturbances were found that could be due to tabes. Dreyfuss (Archly f. Mikros. Anat., B. 20, p. 154, '90).
Case of tabetic patient in which there was total paralysis of the soft palate, also bilateral paralysis of the abductors of the vocal cords. Some of the facial muscles, the masseters and the temporals, are much wasted; the mouth hangs w idely open, owing to the falling of the lower jaw. Semon (Clinical Jour., Jan. 14, '93).
Case of tabes in which there was tempo rarily present the rare symptom of labio glosso-laryngeal paralysis, resulting in aphonia; the impossibility of pronoun cing a syllable, even softly; and move ments of the tongue slow and restricted_ L6pine (Lyon Med., Feb. 18, '94).
Case of tabes with bilateral paralysis of the abductors in the larynx. Fr. Hawkins (Lancet, June 1, '95).
Case of bilateral abductor paralysis of the larynx accompanying tabes dorsalis. There is immobility of the vocal cords, which are closely approximated, leaving only a very narrow slit for respiration. The voice is well preserved; although somewhat monotonous, it is strong and clear. E. L. Vansant (Phila. Med. Jour., Feb. 19, '98).
Several variations in the picture de scribed, particularly as regards the order of precedence in symptoms, may occur.
The disease may begin with an initial ataxia; it may begin with an optic neu ritis or atrophy. In rare instances the earlier symptoms are referable to lesions in the cervical cord, the upper and not the lower extremities being affected first symptomatically. Such cases are known as cervical and sometimes as superior or descending tabes, though the two latter terms have also been applied to general paresis with secondary posterior spinal sclerosis. Painful sensory phenomena
are much more marked and persistent and wide-spread in some cases than in others. The shooting, stabbing, grind ing pains in the legs, the rectal pains, the trigeminal pains, the painful crises, may be all extreme and give rise when present to what has been termed the neuralgic type. If the disease develops within a year or two after primary syph ilis, the symptom-picture takes on more distinctly the bizarre characteristics of exudative nervous syphilis.
Under the term "acute ataxia" are g,rouped cases in which the onset of the ataxia is sudden, of rapid course, some times quickly fatal, though often ending in recovery, being mostly cases of ataxia occurring after some acute disease, rarely arising spontaneously. The central (cere bral) form is characterized by acute ataxia, without sensory disturbances, scanning speech, resembling the speech disturbances of multiple sclerosis. The intelligence may or may not be affected. Recovery occurs in some cases after a. few weeks; in others it becomes chronic and stationary, death occurring from some intercurrent disease. The second form— sensory ataxia—is due to multiple neu ritis. It is differentiated from the ataxia tabes by its acute or subacute onset, by frequent termination in recovery, and the return of the knee-jerk-s. The sensory symptoms usually present are: pain, numbness, hypermsthesia, and anmsthesia. Disturbances of speech are absent. It follows exposure to cold and moisture, acute fevers, alcoholism, lead and arsen ical poisoning, and possibly syphilis. Leyden (Zeit. f. klin. Med., B. 18, H. 5, 6, '91).
The following are the cardinal symp toms in the order of their importance: (1) failure of knee-jerks; (2) Romberg symptom; (3) Argyll-Robertson pupil; (4) lightning pains; (5) loss of func tions of the bladder or sexual organs. With the presence of any three of these symptoms the diagnosis may be made with certainty. And in the presence of any two with probability, when evidence pointing to multiple neuritis, paretic de mentia, or cerebro-spinal syphilis is ab sent. Among the important secondary symptoms or signs are: (a) parmsthesia, ansthesia, or analgesia of the legs, (b) loeomotor ataxia, (c) transient ocular palsies, (d) parmsthesia in the ulnar dis tribution, and (c) optie atrophy. With the presence of two of the cardinal sirrns and one of the secondary signs, the diagnosis may be made with certainty. With the presence of two of the second ary and only one of the primary, it may also be made, and even in the absence of all of the cardinal symptoms. Theodore Diller (Amer. .1Ied., June 1, 1901).