The onset of infantile tabes, as may be inferred from the sy-mptoms described, is even more indefinite than in adults. The patients are hardly inconvenienced by- the initial symptoms; lancinating pains are interpreted as rheumatism, atrophy of the optic nerve as beginning myopia and the incontinence of urine as enuresis. Only when some more striking symptom such as headache or increasing visual disturb ances develops, a physician is consulted, and the history and physical examination reveal a tabes of long standing. The course is extremely tedious and may extend over several decades. As the first visible signs usually develop during the latter part of childhood (in exceptional eases between the fifth and sixth y-eara, Dyclyski, Iclelsolin and v. Rad), tabes due to hereditary syphilis usually runs its manifest course after the age of childhood. So far as I know, there are as yet no post-mortem reports of juvenile tabes (quite recently Koster described a case with changes in the posterior columns). Treatment with the iodides and biehloride of mercury is followed by no better results than in the adult form.
(b) Progressive Paralysis.—Our knowledge of progressive paralysis in childhood being of less recent date than our knowledge of tabes, the number of cases is correspondingly greater. In 1S'9S Thiry col lected 69 cases, and since then a considerable number of additional cases have been contributed to the literature. I myself have had the opportunity of seeing from 6 to S cases of this disease.
Progressive paralysis usually begins between the 12th and 16th years of life, the lowest limit being about S (or, according to Zappert, five years), the upper limit twenty years. Patients in whom the disease makes its appearance toward the end of childhood or even later very frequently exhibit an infantile habit and delayed puberty, as is so often observed in cases of hereditary sy-philis.
The symptoms of the disease are partly psychic and partly somatic. Dementia, which is of sudden onset, occupies the most prominent place in the picture. In contradistinction to progressive paralysis in adults, the mental disturbance in children manifests itself in steadily increasing mental decay without fixed idea.s or hallucinations. The children become apathetic, lose interest in their surroundings and in their toys, become undemonstrative and give no sign of affection for their parents. forget all they had learned either in school or at a simple trade, are sluggish in their movements and, when left to thems.elves, idle their time an-ay aimlessly, taking up and looking at any object that comes in their reach without betraying any knoN-s-ledge of its proper use. They arc subjeet to occasional outbreaks of passion, crying fits,
uncontrollable rage, with or without adequate reason; but these at tacks never degenerate into tnania. Such children are never seen to indulge in hearty laughter.
These psychic changes are accompanied by disturbances of speech. Letters and syllables are confused; there is bradylalia, babbling speech (lallatio); the child's vocabulary rapidly diminishes, and finally it ceases to talk altogether and its utterances are limited to a few almost unintelligible words.
Along with these marked psychic disturbances certain somatic symptoms are observed. The face becomes expressionless and the child develops a tendency to indulge in sucking and chewing movements, humming and puckering the lips. Tremor of the lips and tongue is often observed. Pupillary rigidity is usually present early in the disease. The patellar reflexes are almost never absent and frequently exagger ated; paralysis of the extremities is never observed, at least (luring the initial period of the disease.
A special peculiarity of infantile paralysis is the early occurrence of paralytic attacks. These manifest themselves in the sudden onset of vertigo and loss of the power of speech, temporary unconsciousness, paroxysmal headache and epileptiform seizures. In rare cases the paralytic attack is preceded by hemierania. paralysis of the extremities and ptosis. All the above-described symptoms may be regarded as the initial indications of progressive paralysis and sometimes persist from 1 to 2 years without exhibiting any change or, at most, a slow progressiveness. Gradually the somatic symptoms become more pro nounced. The patients exhibit tremor and intention tremor and con tractions of the extremities; they lose the power of walking, become bedridden and rapidly emaciate. The terminal stage is often marked by bedsores and consequent fever. The patient finally dies of general sepsis, pneumonia, or in a paralytic attack. Remissions such as are so frequently observed in the paralysis of adults are very rare in the juve nile form. The duration of the disease according to Hirschl and Thiry is 31 years, according to Alzheimer -11 years, or in other words longer than in adults, in whom the average duration is two years.
Tabetic symptoms, especially atrophy of the optic absence of the patellar reflex and lancinating pains, may be superadded to those of progressive paralysis. According to Alzheimer cases of this kind have a longer duration than cases of simple paralysis.