CIHM Microfiche Series (l\/lonographs) ICIVIH Collection de microfiches (monographies) m Canadian Institute for Historical Microraproductions / Institut Canadian do microroproductions historiquas 1996 Technical and Bibliographic Notes / Notes technique et bibllographlques The Institute has attempted to obtain the best original copy available for filming. Features of this copy which may be bibliographically unique, which may alter any of the images in the reproduction, or which may significantly change the usual method of filming are checked below. D D D D D D D Q D D D Coloured covers / Couverture de couleur Covers damaged / Couverture endommagee Covers restored and/or laminated / Couverture restauree et/ou pelliculee Cover title missing / Le titre de couverture manque Coloured maps / Cartes g^raphiques en couleur Coloured ink (i.e. other than blue or black) / Encre de couleur (i.e. autre que bleue ou noire) Coloured plates and/or illustrations / Planches et/ou illustrations en couleur Bound with other material / Rem avec d'autres documents Only editkjn available / Seule editk)n disponible Tight binding may cause shadows or distortion along interior margin / La reliure serrde peut causer de I'ombre ou de la distorsion le long de la marge interieure. Blank leaves added during festoratk>ns may appear within the text. Whenever possible, these have been omitted from filming / II se peut que certaines pages blanches ajoutees tors d'une restauration apparaissent dans le texte, mais, kxsque cela etait possible, ces pages n'ont pas ^ filmees. L'Institut a microfilm^ le meiiieur examplaire qu'il lui a 6te possible de se procurer. Les details de cet exem- plaire qui sont peut-6tre uniques du point de vue bibli- ographique, qui peuvent modifier une image reproduite, ou qui peuvent exiger une modifications dans la meth- ode nonmale de filmage sont indiquds ci-dessous. D D n 12 Coloured pages / Pages de couleur Pages damaged / Pages endommagdes Pages restored and/or laminated / Pages restaur^es et/ou pellicuiees Pages discoloured, stained or foxed / Pages decolorees, tachetees ou piquees I I Pages detached / Pages d^chees ("7] Showthrough/ Transparence □ Quality of print varies / Qualite inigale de I'impression I I Includes supplementary material / ' — ' Comprend du materiel supplementaire □ Pages wholly or partially obscured by errata slips, tissues, etc., have been refilmed to ensure the best possible image / Les pages totalement ou partiellement obscurcies par un feuillet d'errata, une pelure, etc., ont ete filmees a nouveau de fafon a obtenir la meiileure image possible. Opposing pages with varying colouration or discolourations are filmed twice to ensure the best possible image / Les pages s'opposant ayant des colorations variables ou des decol- orations sont filmees deux fois afin d'obtenir la meiiieur image possible. D D Addftional comments / Comment^res supp)enient£ures: This ittm is filmed at tht rtduction ratio checked below/ Ce document eii fitme eu taux de reduction indiqui ct-destous lOX 14X 18X 22X 26 X XX J tzx 2fesHn.- of N'civous I'nivtrsily Sehuii! n(i Mental Uiteascs, Indi.i ^f Mediiinc. It irmy scoin priwiirnplnoiis fur one to tnko up till' tiuir jin.l iittiMitioii of this mccthif; in morelv trying to liiy empliiisis upon oonclitions which are airoafly well known to all of us, ami which, too, niaiiy of us take for j;rniiteil, arc or should be known Ity every one ainiin;^ to practice rnedicine. hut judging from the frecpiency with which tlie early manifestations of locomotor ataxia aie at- tiibuteil to and treated for some entirely different ibseascd condition, it is evident that more atten- tion should be given to this disease and allied conditions, and greater stress placed upon the importance of the early recognition of such symptoms as are usually found in the early stages. Furthermore, since it is well known that •■■/hen once the destructive changes in the neurons of the central nervous system have taken place, no form of treatment can restore tlicm, and since the pathological-anatomical changes in this dis- eiiae are ultimately deiitructive in character, it is only too evident that tlie cailier the character of the disease-process is recognized and appropriate *Kea worse at night ai.d at changes of weather. He became more nervous, was olicn unable to sleep be- "■-use of the pains; noticed a loss of sexual power at ti-es difficulty in controlling the bladder, a numb^ ecsi n the fingers .-id hands, less so in the feet: a sense of early (atijiue after eiercise, of weakness in the knees and stiffness in Ihe feet, and a tendency tn «t;iKRfr when first RfttinR on hU feel !o wilk I'lider the influence o( alcoholic itimiilinti the diflfi- ciilty in gait and the tcnsqry ditturtnncei apparently ilitappearcd temporarily, or at leait he became un- cnscioui of their pretence. Txamination of thl« patient diictosed unequal pupil- inaniffiting the Ariiyll-Koliertion phenomenon absent tendon reflexes in both armi and Icgi; marked Rom- brrg swaying, marked ataxia and inco-ordination in the movements of the arms and le«»; a loss of the sense of movement in the toe and ankle joints; a marked delay in the perception of the pinprick, and a more or lets general hyperesthesia to heat and cold, the blood and spinal fluid each gave a foiir-|iIti* positive VVaasermann reaction. This patient duriiiR the last three to four years has passed through the hands of several phywcians. osteopaths and chiro- practors, and even at the time of examination hail been referred tn a surgeon for advice and treatment in regard to the falling arirhes, which we c regarded as the seat of the trouble. The loss of bladder con- trol and of sexual power was attributed to the in- discriminate use of the urethral soun**;. The pain* in the feet and legs and the difficulty in walking wrre attributed to the falling arches, and the general n- .usness due to the pain and the disturbance ( I sleep. The early paina in this patient were undoubt- t'llly tabetic in origin, since iHcy were not arthri- tic, had not the charttct*r of a peripheral neuritis, wiro transitory in duration, changeable in char- acter, not nfi.«iK-iated with any local dirtturbances, and showed a tendency to be worse at night and during changes of weather. Tliese featnres taken individually may not mean much, but taken rolleetively arc almost pathognomonic of tabetic pains. It is quiie probable that had a proper ex- amination been made when these pains first ap- .J pfun'J iIhtp wotilil liiiv.> I ti t'*uu*\ other i*vi- lUucfn (t( till' [inwni'c of e(. tdlM-tic iim.'sn. Ca« U', Male, aitnl foriy-fivc yttra. IU«tnry ..f luetic iiifrction clcvrn years ago. Three year* aifo In- iHljati to have aHaik-. of pain in the upper abdominal regirm, located mo«' between the median line, th« level i»f the utntiili. , and the rinht cntlal mariiin. The paini were sudden in on«t, upavmodic, (jrininK in character, were aivocialed with naii«ea and vomitiiiK. were relieved only oy opiatet, were not followed I>y any Ir -al loreneis ur teniI(Tiie!i!i and recurud at nr»t at ii> lir intcrvalt. hut ..f hite they have wen mnre (requen . occurring alnmt every week or ten daj* This patient wa^ treated by neveral physician* fur gastric and for gall-bladder discaic. He had als.. cnniiutled several siirReons, who also diagnosed gall- bladder Hiseaie. probably calculus, and had advistil nperation. At the time of exap .ition there was found the Argyll-Robertson pupi slight Romberg swayipg. absence of the patella ^nd Achilles tendon reflexes, anesthesia over the outer =de of both legs, retarda- tion of pain and pressure &ense in both feet and legs. The abdominal examination was negative r - at Ica^l •'oubtful. From these clinical data the diagnosis - tabetic crisis was midc. As this was before the ent «f the Wassermann reaction, or before much attention was given to the spinal fluid for luetic states, no data are at hand in this regard. The family physician disagreed with the diagnoisi^, and when the surgeon who had referred the patient for a neurolugical examination declined to operate he persuaded the patient to submit to an operation, but failed to find any evidence of a surgical patholog- ical process in the abdominal cavity. Also the sub- sequent history of the patient'^, illness proved it to lie wholly tabetic in origin. It is not iinrommmi to meet with cases of locomotor ataxic in whidi acute pains of this type an.l character are tiie first manifestations tiiat lead the patient to sook modical advice, al- though close interrogation will usually disclose the presence of other disturbances wliich had ex- isted for a variable length of time, but were not dufRcicntly prominent to attract much attention or cause much disconifurt or distress. When such iievere pains are more or less constantly located in one or other of the special organs they consti- tute the more common form of the so-called tabetic crisis. But it must be borne in mind that pain is not the only way in which such a crisis luay manifest itself. The pain may be entirely wanting, and in its place there may appear an un- controllable vomiting, an unexplainable diarrhea, a profuse polyuria, an unsiratifiable erotic sensa- tion, etc., any one of wluch may be the only prominent manifestation in the earlier stage of the disease. Case 3. Female, aged forty-five years. W^dow of an army officer. Ten years before the time of ex- amination she suffered from an attack of herpes zoster completely encircling the body at the watst- Iti-.e, following which there persisted a feeling of hi-aviness and of a band-like constriction. About a yi^ar later she began to have pains in both heels, sud- den in onset, transitory in duration, and stabbing in character. Later these extended up the inner side of the legs. Two years later she began to notice a difficulty ill walking, particularly at night, describing it as a feeling or sensation as if on skates, also a numbness in the whole lower extremities. Various physicians were consulted and she spent several years in various sanitarias, her condition bt- ing regarded as a nervous breakdown incident to the approaching menopause. Exami.iation disclosed unequal pupils, the Argyll- Robertson phenomenon, absent patellar and Achilles ti'iidon refltxes, paresthesia of the lower extrcmitifs. a marked RomhcrK, marked ataxia and incoordina- tion, and the hlood gave a four-plus pi>sitivc Uasser- Pinnn reaction. The patient gave a neRative history and bitterly risented any suRgestion of it being syphilitic in origin after having insisted that she be told deriiiitely and specilically the nature and origin of her trouble. In this idea that the di.scased condition could not pos- sibly be syphilitic in origin she was supported by stiveral physicians who had previously treated Ikt, .''is a result of this disagreement she discarded medi- cal advice an