A system of practical medicine. By American authors. Vol. 5

by Unknown

The bladder disturbance,²⁰ which in some forms is usually found among the initial symptoms, is always a marked feature in the ataxic period. Usually, there is a frequent desire for micturition, with more or less after-dribbling; sometimes there is retention, alternating with involuntary discharge; complete incontinence may close the scene through the channel of an ensuing cystitis and pyelitis. With the incontinence of urine there is usually found obstinate constipation, which may be varied by occasional spells of incontinence of feces. The crises of tabes often complicate these visceral symptoms.

²⁰ Contrary to what might be anticipated from the topographical nearness of the vesical and genital centres in the cord, the disturbances of bladder function and virile power do not go hand in hand.

The reflex disturbances are among the most continuous evidences of the disease. Of two of these, the disappearance of the patellar jerk or knee-phenomenon and the inability of the pupil to react to light, we have already spoken when discussing the initial period. Practically, it may be claimed that both are always found in typical tabes. It has been claimed that the patellar jerk may be exaggerated, or even that its disappearance is preceded by exaggeration. As this disappearance usually occurs extremely early in the pre-ataxic period, it is difficult to follow the deductions of those who claim to have watched an alleged earlier phase of exaggeration. It is more than probable that cases of combined sclerosis, in which the lateral columns were affected together with or earlier than the anterior, have been mistaken for typical tabes. Here, it is true, the jerk is first exaggerated through the disease of the lateral column, and later abolished as the lesion in the posterior reflex arch progresses and becomes absolute.

Other tendinous reflexes²¹ suffer with the knee-jerk in the peripheries corresponding to and below the involved level of the cord. The cutaneous reflexes are usually abolished, but may be retained in advanced stages of the disease. The same is true of the cremaster reflex.

²¹ Whether the tendon phenomena are true reflexes or not is a question still agitating physiologists. Opinion inclines in favor of their reflex nature, and, pathologically considered, it is difficult to regard them in any other light.

Opinion is divided as to the electrical reactions in tabes dorsalis. That qualitative changes never occur in uncomplicated cases all authorities are agreed, but while Strümpell and other modern writers claim there is no change of any kind, a number of careful investigators have found an increased irritability in the initial period, particularly marked in the peroneal group of muscles (Erb). In my own experience this is frequently the case, where lightning-like pains are the only subjectively distressing symptoms complained of.

While the symptoms thus far considered as marking the origin and progress of tabes dorsalis are more or less constant, and although some of them show remarkable remissions and exacerbations, yet may in their entity be regarded as a continuous condition slowly and surely increasing in severity, there are others which constitute episodes of the disease, appearing only to disappear after a brief duration varying from a few hours to a few days: they have been termed the crises of tabes dorsalis. These crises consist in disturbances of the functions of one or several viscera, and are undoubtedly due to an error in innervation provoked by the progressing affection of the spinal marrow and oblongata. The most frequent and important are the gastric crises. In the midst of apparent somatic health, without any assignable cause, the patient is seized with a terrible distress in the epigastric region, accompanied by pain which may rival in severity the fulgurating pains of another phase of the disease, and by uncontrollable vomiting. Usually, these symptoms are accompanied by disturbances of some other of the organs under the influence of the pneumogastric and sympathetic nerves. The heart is agitated by violent palpitations, a cold sweat breaks out, and a vertigo may accompany it, which, but for the fact that it is not relieved by the vomiting and from its other associations, might mislead the physician into regarding it as a reflex symptom. In other cases the symptoms of disturbed cardiac innervation or those of respiration are in the foreground, constituting respectively the cardiac and bronchial crises. Laryngeal crises are marked by a tickling and strangling sensation in the throat, and in their severer form, which is associated with spasm of the glottis, a crowing cough is added.²² Enteric crises, which sometimes coexist with gastric crises, at others follow them, and occasionally occur independently, consist in sudden diarrhœal movements, with or without pain, and may continue for several days. Renal or nephritic crises are described²³ as resembling an attack of renal colic. The sudden disturbances of bladder function have been described as vesical crises, and recent French observers have observed so-called crises clitoridiennes in female tabic patients which were characterized by voluptuous sensations. All of these symptoms have these in common: that they last but a short time, that their disappearance is as rapid as their advent, and that they depend for their distribution on the attitude of the disease in the cord. The vesical crises are more apt to occur early than late in the disease and where the belt sensation is in the hypogastric region. The gastric and enteric crises are usually found when the belt is in the epigastric level, and the bronchial, cardiac, and laryngeal crises when it is in the thorax and neck. Some connection has been observed between the occurrence of the lightning-like pains and these crises. Thus, a sudden cessation of the former is sometimes the forerunner of the latter. It is also found that one variety of these crises disappears to give way to another: this is particularly noticed with the bronchial crises, which often cease suddenly, to be followed by vomiting.

²² Krause, in a paper read before the Society of Neurologists at Berlin (Neurologisches Centralblatt, 1885, p. 543), found either laryngeal crises or other laryngeal symptoms, such as demonstrable ataxia of movement of the vocal cords, in 13 out of 38 cases. This proportion would be far too high for tabes in general; his cases were probably advanced ones. He established the interesting fact that the laryngeal crisis may sometimes be provoked by pressure with a probe on the superior laryngeal nerve at its laryngeal entry-point. Jastrowitz claims to have determined the existence of actual paralysis of the vocal cords with the crises, but Krause concludes from the experimental inductibility of the crisis that it cannot be due to a posticus paralysis. In a discussion on the subject Remak affirms that a unilateral paralysis of the crico-arytenoideus posticus may be an early or the earliest symptom of tabes. It seems, however, that in all cases where he determined such paralysis there had been disturbances of function of other cranial nerves in unusual severity at about the same time.

²³ They must be extremely rare: they have not occurred in a single one of my 81 private cases, nor do I recall one in clinic or dispensary experience.

There is some analogy between the exceptionally-occurring mental disturbance of tabic patients and the crises. Like them, it resembles a disturbance of innervation, in this instance the centres regulating the cerebral circulation appearing to be at fault. It also seems as if in cases of this character the direction of the mental disturbance were determined in some sense by the emotional relations of the oblongata, for the insane outbreak usually consists in a brief but extreme outburst either of a depressed and melancholiac or an expansive maniacal or delirious outburst. It is a very rare occurrence, and usually limited to the latest stages. Much more common is the development of paretic dementia, but this is to be regarded rather as a complication than an integral feature of tabes. Most tabic patients retain their mental equilibrium to the last moment; some develop truly heroic resignation to their terrible sufferings and gloomy prospects; and a few, becoming irritable, petulant, and abnormally selfish, show the effect of invalidism manifested equally with other chronic diseases.