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Canadian Institute for Historical Microraproductions / Institut Canadian do microroproductions historiquas

1996

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D.B. WtMon Llbraiy
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A •APPLIED IM^OE Inc

^S 1653 Eo«t Uoin Sl'««l
r^g (716) *8i - D»0 • fhont

( Medical Journal, [muc rf

WHY Tl;!.: DKUW IN- liKCOCf NIZIXO
rj)(()M()TOI{ ATAXIA?*

e. F. np.i', jr. [).,

ri>fesHn.- 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<i at nieiting
July li. 11*15.

if .\Henists and XeiiruloKist^ Chicago,

treatment idtninwtered to interrupt or inhibit
the activity of the cauftative factors, the apiro-
diacte pallida or the tovic products of iti activity,
tlie better will be the reaulta of that treatment.
Mneting io frequently with patient* complaio-
ing of symptoma which point incontrovertibly to
the tabeiic condition, and who had complained of
them for j?ars and yet the probability, often not
even the poii'bility of the diaeaae conaidercd, one
iiaturally eeekk for lome explanation. Two fac-
tor) aeem to atind out predominantly: One ii
the statement uiually made by the attending
physician that kn.iwing the patient «o well he did
not believe a syphilitic infection possible, so did
not suspect it, or where suspected and inquiry
made, was given a positive denial either inten-
tionally or from ignorance thereof due to the
triviality of the manifestations at the time of in-
fection. The other factor seems to be the fault of
ufl neurologists and alienists in failing to empha-
size sufficiently the necessity of always having in
mind the possibility of a tabetic process where
one meets with manifestations well indicative of
it. With the means at our disposal jt the present
time, there is practically no excuse for failure to
recognize the tabetic condition until the process
has advanced to that stage where all who run may
read. The object of this paper, therefore, is not
to add anything new to our knowledge of the dis-
euse, but to eniphasite the necessity of recognis-
ing early the eharactc- ar.a nature of those con-
ditions which indicate the existence of the tabetic
process. In our eagerness and desire to win fame
and honor by discovering something new or start-
ling, something heretofore unknown or unthought

..f we ,m tou iijit tci ni.((lfit the more importnnl.
....rrimi. , n,ry\.n- pliwiomonn, at tho expcnie of
tlw |iiili..rit'« liealth ami happiiiw*. n [, „„( tho
mtijtii.ri to I'liui.'i.rntf uvpry nianir™tntion tliat
11 ni.i will, i„ tlic I'arlv .I,-,.;.., of the ..isoasf, nor
Im liiw 1.™ in .Mail indiviii'.. ,1 ,■;,«,, but a a.vnop-
tical oiillino of the early lii.tory of a few illus-
liative eases an aseertainwl l,y examination will
lie ^Mveii, pointin:; out tile unileccMarv ilela.v that
oe.iirre.l, „nil eallijiK attention .o tllo.e features
nhieh slioukl have direetcil the attention of thi'
phvsieian to the powihility of a tabetie process,
"itii a notation of the conditions eiistirg at tlii'
nrrie of cxamiDaton.

Cajc I. Male. aRcd fitly ytan. He gives a his-
tory of a posiibic infection at Ihirly-five, Ihe physi-
cian at thai lime calling a local penile ,ore merely
a so-called jofl rhancre. During the last ten to
twelve years he has complained of more or less pain
in Ihe legs, more about the knees, vaiying in severity
intcrmiltcnt in action dull and aching in character
Uiiially relieved by , course of hot baths or similar
treatment. I- our years ago following an attack of
gonorrhea w,-ich became chronic, he suffered from
what was called a nervous breakdown which was at-
tributed 10 the passage of sounds in the course of the
treatment. Alter four to five months he began to
notice a difficulty in going up and down stairs ; also
pain across Ihe arch of the foot and ankles, this being
attributed to Ihe condition of falling arch and lal-
f'^otedness. During the last two to three years , is
ccndilion has gradual'- grown worse. The pains
wer> 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-

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<l tcok up Christian Scienn- for severril
years, hut finding herself gradually growing worse
she later accepted the situuli.n more philosophically
and decided to secure what relief was possible by
appropriate treatment.

It eun scareoly be iiiH'stiiuicil tliiit the liilateral
zMstei follonofl by ji |H'i-ii.-;tinii fc-ciiii;; of lioavi-
iM'ss and jiinMe sensation was a direct result and
manifestation of the inci|iient tahotic process.
«nd it is pniltaide that liad a proper examination
I'cen made at that time tiio speeifie nature of tlio
trotihle wiinld have htn-n recofiriizod and all tlie.sc
years would not have elapsed hefore hein^ placed
niider proper treatment.

Case 4. Male, aged thirty-one years. History of
infection twelve to liftcen years before. Three years
ago the left eye turned inward, causing double vision,
lasting several days. Kight months ago he began to
notice a dimness of vision in the left eye, gradually
growing worse, and five months later also involving
the right eye. .About this time he began to notice
some difficulty in walking, especially at night; a teii-
d.ncy to fall and an inability to tell -^ the position
of the feet when the eyes were closed.

When the visual disturbance first began he con-
sulted an optometrist, who fitted him with glasses,
but receiving no benefit they were changed from time
lo time. Finally, he consulted an oculist who recog-

niaed the nature of the trouble and advised him to
consult a neurologist.

Examination disclosed an advanced optic atrophy
with practically complete blindness in the left eye and
almost complete bhndness in the right one; unequal
pupils not reacting to light, but reacting to accommo-
dation attempts, marked Romberg swaying; absent
tendon reflexes, delayed pain sensation; loss of sense
of position and of movement; impaired percepiion of
touch and temperature. Wassermann spinal fluid ex-
aminations were not made, as the patient was seen
before the advent of the Wassermann reaction.

Paresis or paralysis may occur early, involving
either a single muscle or part or all of a function-
ally associated group of muscles, or involving all
or only part of the distribution of a peripheral
nerve. These paralyses are usually transient in
duration, recovering in a few days, weeks or
months, and may be paroxysmal or periodic like
the pains (Pitres), assuming an apoplectiform
character. There may be a mere sense of fatigue,
■ a fatigue out of all proportion to the amount of
muscular exercise, this often preceding for
months the onset of a definite paralysis. Of these
paralyses those involving the ocular group of
muscles are probably the most frequently affected.
Impairment of the pupillary reflex, particularly
to light, sometimes also to accommodation, is one
of the earlier and most constant findings, the
time of disappearance of the pupillary response
being very difficult to fix, as it is usually absent
by the time examinations arc made.

Case 5 Male, aged fifty-two years. Denied syphi-
litic infection. About a year ago he began to suffer
from more or less stomach trouble and was treated
for the usual "indigestion." The following wmter
after the stomach trouble had existed about six

-9—

months lie contracted n severe attack of influenza, fol-
lowing whicli there developed urinary incontinetia-
which was subject to remissions. Two months later
he hcgan to notice a difficulty in walking and a feeling
of weakness or giving-way of the knees at times.
Examination disclosed the presence of the Argyll-
Robertsoti pupil, absent patellar and Achilles re-
flexes, incoordinate, atiixic gait, loss of control of the
vesical sphincter, a positive Wuscrmann of the blood
and spinal tluid; the latter also containing an excess
of protein content and a cell count of abottt ino per
c.mm.

Disturbance of the bladder control or of the
sexual function is not an infrefjuent early symp-
tom nnri shouM always arouse suspicion of a
possible lues. Difficulty in expulsion or in re-
tention of the urinary flow, abnormally active
erotic sensations, causelop^s erections and emis-
sions, sterility in fenifiles. etc., arc some of the
more common disturbances of these function:*.

It is not necessary to burden you with more
illustrations along this linr. Those that have
been given serve to illustrate' one of the most im-
portant points it is desired to make; namely, that
in practically all cases of locomotor atavia there
is an unnecessary and uncalled-for delay in the
recognition of the tabetic or syphilitic nature of
the earlv manifestations. I am satisfied that
this is the experience common to all of you, and
certainly calls fur greater effort on the part of
those teaching neurology and psychiatry and
those of us who are a.ssu(ning to be neurologists
and alienists, in directing attention to those con-
ditions which shouhl always lead one to bo on the
lookout tftr a luetic involvement of the nervous
6 Vetera.