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673

A NOTE ON TABES DORSALIS.

By CAPTAIN J. T. CLAPHAM. Royal Army Medical Oorps (half pay).

IN the classical monograph in which, in 1851, he sketched this disease, Romberg writes thus:-

"When the strength is taxed by continued standing in a bent posture, by forced marches, and the catarrhal influences of wet bivouacs, followed by drunkenness and debauchery, as is so often the case in campaigns, the malady is rife; this is the reason why tabes dorsalis was so frequent during the first decennia following the great wars of the present century." Twenty years later, Duchenne, who rediscovered the disease in France in 1858, and called it progressive locomotor ataxy, used these words: "those who have just (1871) suffered so cruelly in our unhappy country, afford me every day fresh proofs of this "-the effect of mental stress as a factor in the causation of this disease.

Whether or not an increased frequency of tabes was, noticed as a result of exertion and exposure in the war in South A frica, I am unable to say. In any case, the prevalence of syphilis in the Army must be my excuse for venturing some remarks on cases of the disease I have recently seen.

I say prevalence of syphilis, as the general trend of opinion seems now to be in favour of Fournier's view when he speaks of les afJect:ions para-syphilitiques, tabes et paralysie generale.

To start with, perhaps I may be excused for mentioningsoll1e views now held on the pathology of this disease, which are, doubt-hiss, well known to those whose attention has been directed to it of late, and to those who have recently left the hospitals. It 'm~st not be forgotten that tabes is a disease which attacks different parts of the nervous system simultaneously. Charcot divided its symptoms into spinal and cephalic, according as their starting point seemed to be in the cord or in the cerebral and bulbar nerves. Nowadays, many go further and consider that when the cerebral cortex is affected, and we get general paralysis of the insane, we are merely dealIng with another manifestation of the same disease. To deal, however, at first with the disease when its' symptoms are mainly spinal, the characteristic sclerosis of the neuroglia is secondary to the degeneration of the nerve elements proper. This degeneration is now held to be due to the failure

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674 A Note on 'Tabes Donalis

of the cells of the posterior root ganglia to maintain the full vitality of the fibres dependent on them. These fibres pass upwards in the postero-median columns, ultimately connecting with the cere-bellum, and downwards to the periphery as the sensory nerves, comprising fibres of various forms of sense, of which those con-cerned with muscle sense seem most vulnerable to the toxin of tabes, whatever it may be. Thus the sclerosis of the columns of Goll in tabes is identical in nature with any ascending degeneration in which the nerve fibres are cut off from their nutritive centres in the ganglia on the posterior roots. Through these ganglia, too, pass into the cord the various sympathetic fibres from the viscera, in which fibres degenerative changes have been demonstrated in tabes, as they have also ·been in the peripheral sensory nerves. But, whereas in the affections of the lower motor neurons, infantile paralysis and progressive muscular atrophy, due to lesions of the anterior cornua, vast changes are found in the cells there situated, such is not always the case where the nutritive centres of the lower sensory neurons are presumably concerned. In some cases, it is true, changes have been described, but in others it has so far been impossible to detect them. Sir ,V. Gowers says that too much stress must not be laid upon this, as molecular change must attain a relatively vast degree to be visible to the highest powers of the microscope. He adds that all causes of degeneration produce changes which are greatest at the distal parts, and lessen as we approach the centres. The neuronic unit may suffer in its farthest parts long before the centre undergoes conspicuous changes.

Assuming then that the spinal symptoms of tabes are due to changes in the lower sensory neurons dependent for their nutrition on the cells of the posterior ganglia, and that tabid atrophy of the optic nerve belongs to the same class, whilst a wider action of the same influence is shown in the involvement of the centres of the ocular muscles, what is this influence believed to be '? Most of the text-books still allow a varying margin for cases of tabes not of syphilitic origin, but otherwise the opinion seems prevalent that syphilis must be regarded as a necessary antecedent of tabes.

Fournier was the first to urge this view thirty years ago; and every year statistics support him more and more. The most im-portant are those of Erb, who in 1,100 cases finds a history of a primary sore in 89t per cent.

No greater percentage of cases, where there is a history 'of primary infection, will be found amongst those who undoubtedly show other late manifestations of syphilis. I have heard Sir W ..

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Gowers say that, if we except members of our own profession, he has never seen a case of true tabes in a man who had never run the risks of infection in the ordinary way. He added that there was no other disease of the nervous system of which the same assertion could be made. It must be remembered, too, that tabes occurs in children as the result of hereditary syphilis, and some have held that otherwise inexplicable cases of tabes in adults may be due to the late appearance of the congenital malady.

But this is not to say that tabes is the direct result of syphilis. " 'Ye are compelled to believe that the symptoms of tabes are due to the influence of a chemical toxin, which results from syphilis, and probably arises in a way 'similar to that by which the toxin which causes diphtheritic paralysis has been proved by Martin to be caused by the organisms of diphtheria" (Gowers).

The extraordinarily erratic behaviour of tabes, with its long intervals and acute exacerbations, needs still further explanation. To meet this difficulty it has been suggested that some other unknown agent is needed. In short, many hold that tabes is the result of a syphilitic toxin plus an- unknown intensifying agent.

There is no classical sign which may not be absent in this disease and yet the diagnosis of tabes be absolutely admissible.

Here is a case, which I saw at Dr. Risien Russell's clinic in Queen's Square, in which the knee-jerks were present and there was no ataxy. A woman of 34, six years married, with three children, came complaining of severe attacks of vomiting during the past fifteen months; also of pain in the back and shooting pai:gs in the legs. She had had syphilis ten years ago and was treated for more than a year. She had no ocular palsy. Her pupils were rather large, did not react to light and but slowly to accommodation. There was a little nystagmus. Her discs were normal. She had no ataxy in her arms and the supinator-jerks were good. Her knee-jerks were active on both sides, as were the Achilles-jerks, which are usually the first to disappear. She had no ataxy of the legs at all. She could stand with her eyes shut, and also on one leg. The left knee was in an early stage of Charcot's arthritis. She had analgesia ,o,f the legs and ulnar side of the forearms. No sphincter trouble.

This is an instance of the necessity of always investigating the nervous system most thoroughly in cases of apparent stomach trouble which do not yield to treatment. Sir 'V. Gowers describes a series of cases of tabes which he calls "tabetic neuralgia," where the knee· jerk is not lost and where there is no ataxy. He does not

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regard th~se as merely a stage in the development of tabes, but as a special variety. In these the pains dominated the aspect, though in almost all there were pupillary changes and in one gastric crises, as in this case. To account for such cases he assumes a difference, possibly very minute, in the chemical nature of the causal agent, as he does in cases where the toxin seems to pick out the fibres of the optic nerve and ataxy is often absent. In addition to her other troubles this woman's left knee had some fluid in it, and the tissues round were swollen. It is noteworthy that ataxy had not yet set in; the old idea used to be that such joints were the results of Rccident from the nature of the disease. Charcot regarded arthro-pathy as always an early phenomenon, and placed it between the period of pain and that of inco-ordination, as is the case here. He calls such the early or benign form, which often clears up; whereas the malignant one runs on to rapid disorganisation of the joint. Dr. Mott says that the poor women he met with in the infirmaries suffering from Charcot's knee joints nearly always gave a history of being widows who had to earn their living by charing or scrubbing, or the use of the sewing machine. This bears out Edinger's theory of stress, mentioned later.

An even more striking instance of the insidious nature of tabes is the following: R. K., aged 42, came into hospital complaining of sickness and abdominal pain. He stated that for ten years he had attacks of pain every three months in the umbilical region, which came on about an hour after food; after this vomiting occurred. It was ascertained that two years ago he had had gastro-jejunostomy performed by a well-known surgeon, but his attacks had continued just the same. In addition to gastric symptoms he now had commencing optic atrophy, his pupils did not react to light and his knee~jerks, though still present, were diminished. No other signs of tabes were present. Probably two years ago there were no symptoms except those referred to the stomach. The periodicity of the pains, every three or six months, is noted by Marie as being characteristic of tabes.

In the next case there was no alteration in the reaction of the pupils and no marked pain. A man of 27 came with the story that he had had some difficulty in walking for the last eight or ten months, especially at night, and on enquiry it was found that for the last four or five months he had had occasional pains in his calves and at the back of .his knees, but he said very little about them. He admitted having had a sore six years before. He com-plained of no eye symptoms or bladder trouble. His pupils were

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found to be large and still reacted to light. Ataxy was very acute. Knee-jerks were absent. There was some analgesia of legs, but tactile sensation was good. It was pointed. out that the Argyll-Robertson pupil is no more necessarily present in tabes than is nystagmus in disseminated sclerosis. It will be noticed that his pupils were large. This condition is not uncommon in young cases of tabes, but in those over forty the pupils are generally small. It is also noticeable that he did not complain of pains until direct enquiry was made. This sign is less frequently absent than any other. "As a rule, pains are more common than ataxy; they begin earlier in the course of the disease, and often make life almost unendurable, in cases in which there is no other objective symptom" (Gowers). Patients will often deny pain and explain that they have only had "rheumatism."

These pains vary much in nature and degree. In one· class of cases typical lightning pains come on early and are the principal feature of the picture. In another they are not of so severe a type. They are mistaken for muscular rheumatism or neuralgia, especially as they foretell, like a glass, changes of weather; and patients may be treated for years before ataxy, or some other objective sign, points to the real condition. In the last case of this series, a very acute one, the pains were entirely absent. In this present case there was a definite history [of a primary sore less than six years before the first symptoms of tabes were noticed. This is early. Erb gives six to fifteen years as the usual time, and says that 37 per cent. of his cases ca]TIe on at nine or ten years after infection, while others give a longer average interval. As in this case the ataxy was very acute, it was considered that Fraenkel's exercises would be of use in re-educating his muscles. In view of the history:of recent syphilis, Dr. Russell ordered vigorous mercurial treatment by inunction, as he agrees with the French physicians, who advocate . the Aix treatment in such cases. .

Now comes a woman of 47, who has been married twenty-six years, but has had no children. She has complained of "rheuma-tism" for five years, but has only noticed difficulty in walking for the last six weeks. She says that she used to see double at times, and has had drooping of the right eyelid. She has difficulty in hold-ing her water. On examination, her pupils were found to he very large, as in the last case, but unlike it, they' did not react to light. No ocular palsy is present now; no nystagmus and no optic atrophy. Considerable tremor, but no notable ataxy of the upper extremi-ties. Supinator-jerks absent. Knee-jerks absent; Romberg'S sign

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present and slight ataxy of legs. The transitory character of the ocular paralysis is worthy of note; this is very characteristic of tabes. The tremor of the hands is functional in origin. It must be remembered that organic disease of the nervous system is con-stantly masked by functional symptoms, indeed, in women, their presence is rather the rule than the exception. As to her pre-cipitancy of micturition, partial incontinence, as well as inability to completely empty the bladder, are common symptoms in tabes. This did not escape the notice of Romberg half a century ago. He writes" Diuresis alternates with ischuria-the urine is not dis-charged in an arched jet as in health, but falls more perpendicu-larly; nor is the bladder completely emptied." Marie says of the bladder that, at the onset of tabes, though not paralysed, it is, as it were, an instrument upon which the patient cannot play with the necessary precision; and Fournier, that these patients "only pass water in several acts"; adding that his tabid patients in the lower classes complained to him of being roughly handled at the public urinals by those whom they kept waiting for several minutes.

When tabes is suspected a patient should always be asked if anything unusual happens when he passes water. Sir W. Gowers lays great stress on the very insidious manner in which this trouble develops, often unnoticed by the patient. A little residual urine is left, which increases more and more. Should it be as much as two ounces, the bladder should be emptied once a day with the catheter, and may recover its tone. Charcot says that ergot is most useful in this complication. Too much stress cannot be laid on the ever present danger of cystitis and pyonephrosis in tabes. Indeed, the prognosis as regards life in this disease is largely influenced by the care with which the bladder is treated.

Here is a case of cervical tabes. A man. of 45 complains of " pains," of the uselessness of his hands and inability to hold his water. His pupils are unequal aud do not react to light, he also has convergent strabismus. With his eyes shut he cannot touch the tip of his nose or approximate the tips of his forefingers, and has great difficulty in writing or picking up small objects. His supinator-jerks are present, whereas in the last case it may be remembered they were absent, without there being inco-ordination. So you may have extreme ataxy of the lower limbs and yet exag-gerated knee-jerks. In his case ataxy of the lower limbs is hardly noticeable. His knee-jerks are absent. The loss of tone of the muscles, so characteristic of tabes, is marked. His extended leg can be flexed on the pelvis till the foot is over his shoulder. Such

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patients, from hypotonicity of their adductors, can readily do " splits" which it takes acrobats years to acquire.

A woman of 45 says that for two years she has had difficulty in walking, with some weakness of the legs, also of the arms. She also complains of pains, but of nothing else. Her ocular movements are good, but her pupils do not react to light. There is no optic atrophy. She has loss of sense of position in the muscles of the hand, but not of the shoulder. There is marked analgesia down the ulnar side of the forearm, and on the thorax at level of third costal cartilage. Also analgesia of the legs, where painful sensa-tion is delayed for two seconds. Her knee-jerks are absent and gait is moderately ataxic. Also there is lack of full control over the bladder.

The analgesic area in the upper limb and thorax is that of the skin area corresponding to the first dorsal spinal segment, for the perversions of sensation in tabes do not correspond to the areas supplied by nerve trunks, but to those representing the various spinal segments. A very common situation for analgesia is at the level of the thorax where the fourth cervical and first dorsal areas meet; this sign is often present here when absent elsewhere. It is said that the areas affected in stomach affections are those from the sixth to the ninth dorsal; and that gastric crises may be asso-ciated with girdle pains. The sole of the foot, so often affected, corresponds to the first sacral, whereas, when the third sacral segment is involved, it affects the gluteal region and the patient feels as if he were sitting on an air cushion.

B. Y., aged 54, complains of pains in the legs and difficulty in walking for the last eight years; for three or four years he has had impaired vision, and ulcers on the soles for the last three years. Like a previous case, he has loss of light reflex in one pupil only. Fine tremor in his hands, gait ataxic, knee-jerks absent. Ulcers under the ball of both great toes and a corn under the little toe, which, if cut, will very probably become a sore; continued irritation of an insensitive part is commonly said to be the cause of such ulcers, but the physician under whose care the man was said that he was coming back to the idea of special trophic nerves in which he had previously disbelieved, especially in view

680 A N ate an Tabes Dorsalis

or two, so that the loss and return of sensation may be only an index of other changes. However that may be, such ulcers will sometimes heal if the patient is put in bed and the wound kept aseptic. As soon as the patient walks. about again they are liable to reopen; he needs to be continually putting pressure on a different part of his foot. The problem is much the same as that of the prevention of bed sores.

M. K., aged 43, lost her only child ten years ago. She says she can see nothing with her left eye. Two years ago pains began in her head, and since then she has had gradually increasing weakness in the legs. At the onset of symptoms she had diplopia, but it passed off in a month. Her pupils are small, the left especially so. It does not react to light, whereas the right one does so. Ocular movements are good. Complete white atrophy of the left disc and commencing changes in the right. On the tongue there is a typical patch of syphilitic glossitis. She has no ataxy of the upper limbs. Typical ataxic gait. Knee-jerk absent on left side only. No sphincter trouble.

Optic atrophy is said to occur in about 10 per cent. of cases of tabes. She is an exception 'to the rule that in these cases ataxy generally i~ late in developing. Such patients usually go first to the ophthalmic hospitals, and it may be many years before other symptoms appear. Thus, Charcot speaks of a woman of 55 who had been blind for twenty-nine years, lightning pains and crises had appeared ten years ago,. but so far there was no inco-ordination. Marie says that optic atrophy is most frequent in those who have had ocular palsy, and that the average interval between the first appearance of eye symptoms and blindness is three years. Unlike optic atrophy in disseminated sclerosis, that in 'tabes goes on to complete blindness. She might be called a case of hemi-tabes, as there is loss of knee-jerk and iridoplegia on one side only.

A smart-looking man of 45 complains of difficulty in walking. He says, as is not infrequently the case, tbat he first noticed his unsteadiness by falling into his basin when washing his face. He has had some kind of fit with unconsciousness. Twenty-three years ago he had syphilis. There is loss of light reflex and he sways on closing his eyes, though his gait is not noticeably ataxic. Apoplectiform or epileptiform attacks, varying from complete uncon-sciousness to simple vertigo, are not uncommon at the onset or during the course of tabes, though not nearly so frequent as in the closely-allied disease, general paralysis, for further signs of which '" close look out should be kept wheri they occur. Hemiplegia

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accompanying such attacks may be very transitory, or it may be of a more permanent nature, in which case it would appear to be an ordinary sequel of syphilitic arteritis and not necessarily due to the existence of tabes. As to the relationship between tabes and general paralysis, Fournier says that they are different expressions of one and the same morbid entity, and will some day be grouped under one head; and M6bius that "we call it tabes when especially the centripetal nerve fibres are diseased, and general paralysis when especially the cerebral cortex is affected."

Dr. Mott says, that all gradations between the two diseases can be detected, not only clinically, but pathologically. He considers that in their etiology and pathogenesis the two diseases are identical, and says that, though this idea has not found its way into the text-books, most of the leading neurologii'lts of the day agreed with him in this view when the sub.iect was under discussion at the Pathological Society.

In the ordinary cases, however, of the two diseases the mental powers differ as widely as does the prognosis. Speaking of tabes, Duchenne says, "I have been struck by the integrity of the intellectual powers, which, like that of the muscular force, is retained to the end."

I mentioned in a previous case that symptoms of organic and functional mischief are very often strangely mixed up, especially in women. Here a man is the sufferer. Competent authorities say that when we use the term" functional" with reference to nervous diseases, it is largely a confession of ignorance, merely meaning that we are as yet unable to refer the symptoms to their cause. This seemsto have been Trousseau's view. He says, "I have stated to you .on numerous occasions that I cannot conceive a functional disturbance without a corresponding modification of the organ which discharges that function. This may be more or less transi-tory, and it frequently does not alter the structure of the organ which discharges that function, any more than an overcharge of electricity alters the structure of the gl~ss or metal of a Leyden jar, and it therefore remains perfectly unknown to us."

This man is a bricklayer of 45. Eight months ago he was a good deal shaken by a train accident, but went back to work; five weeks afterwards he had a very s


(Jf field of VISIon. He has very marked intention tremor of the upper limbs, and even more so of the lower. vVhen attempting a movement with the hands he starts inco-ordinately, but comes straight at the finish, whereas in tabes the reverse is usual. Similarly, though he walks with extreme difficulty, his gait is not typical of tabes, and when his eyes are shut he falls backwards, but not with the swaying movement generally associated with Romberg's sign. His knee-jerks are absent and he has no ankle clonus. No sphincter troubles, pains or alterations of sensation. The plantar response is flexor. His pupil reaction and absence of knee-jerks undoubtedly point to organic disease, whilst the other symptoms are apparently of functional origin. '1'he diagnosis is tabes, the onset of the symptoms of which had been precipitated by the accident or subsequent influenza. A very difficult case medico-legally, if compensation were involved. With reference to the plantar reflex, on which such very great importance is now laid in separating organic lesions of the pyramidal tract from functional disease, I might digress for a moment to say that some time may be taken to elicit Babinski's sign if the feet are cold. I have seen two or three minutes elapse before the typical slow extension of the great toe took place; the feet were rubbed with a rough towel, and the external border of the sole was stroked in preference to the Inner.

Some cases of tabes and functional paraplegia are said to be the (Jnly cases in which absolutely no plantar reflex at all can be obtained.

Here is a case where there is even more direct relation between an accident and the apparent onset of the disease. A man, aged 45, who admits to venereal disease when a youth, was in the fire brigade. Four years ago a mass of brickwork fell on his back. He was in bed for six weeks and dates his trouble from that period, before which he had been perfectly well. On examination he pre-sented all the cardinal signs of tabes.

Of course it is a very common thing for patients to date symptoms from a fall, which was the result, and not the cause, of. the disease. On the other hand, there is no doubt that in some cases, such as the above, an injury may start the symptoms, which would otherwise have taken a long time to develop. There is a pre-symptomatic stage of the 'disease in which an accident, shock, ()r intercurrent disease will precipitate matters. Thus, I have heard of an officer's groom who, whilst exercising a restive horse, was crushed against some railings. The immediate result was a severe

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attack of vomiting, which persisted at intervals for years as the gastric crises of tabes.

My last case is a curious one, of the very rapid onset of the disease in an elderly man. P. F., carpenter, aged 55, states that six weeks ago he was at work and well. He had not had a day's illness for thirty years. Five weeks ago he began to lose power in his legs, which have rapidly got worse. He had no diplopia, nor, which is worthy of note, does he complain of pain in his limbs. For the past month he has felt as if a belt were round his chest. He is constipated, and is unable to hold his water. On examination his ocular movements are good. His pupils are small and do not rea:ct to light. There is no ataxy in his upper limbs, but in his legs it is so marked that he can hardly stand. He has no sense of position in his lower limbs at all; when lying on a couch with his eyes shut he has no idea whether his knee or ankle is flexed or straight. He has no knee-jerks; tactile pain, and thermal sense is apparently normal, except in first dorsal area, where it is somewhat impaired. The fact that he could go up and down ladders till five weeks ago is evidence of the truth of the sudden onset of the disease. This case of a carpenter, whose arms were not affected, does not bear out Edinger's theory that the susceptibility of various groups of muscles to ataxy is increased by over-exertion. Thus, in time of war prolonged marches would render the foot soldier more liable to the ordinary form of inco-ordination than the cavalry man. Dr. Mott quotes many cases in favour of this view; clerks, packers, &c., in whom the upper limbs were affected; whereas he states that those who suffered from the more usual variety were almost all labourers, whose work involved a great deal of use of their legs.

In spite of the grave condition of this man the prognosis was not regarded as hopeless. He was ordered mercury and iodide of potassmm, and it was thought that with rest and exercises he might greatly improve. 'l'he fact of his age was considered rather in his favour, as, if it could be checked, the disease might not again progress for years, whereas in the young it would· probably be less amenable to treatment.

These twelve cases include most of the manifestations of a disease which, in these days of short service, would not appear, at first sight, to come often under the notice of the Army surgeon. ]'or, with a few exceptions, beyond both age limits, the first symptoms of tabes occur, in 25 per cent. of the cases, between the ages of 20 and 30, in 50 per cent. in the next decade, alld in the remaining 25 per cent. between 40 and 50. But it must

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be remembered that it is rather the rule than the exception < for tabes to be overlooked in its early stages. No mistake is more common than for its pains to be mistaken for muscular rheumatism, or for neuralgia of various forms .. Forty years ago Trousseau drew attention to the fact that many patients were sent to the various baths of Europe for rheumatic and neuralgic pains who were really suffering from those of tabes. Neurologists will tell you that it is just the same to-day. People go about being treated for dyspepsia or cystitis, the general cause being overlooked. They have their stomachs or bladders washed out, and may even get as far as the operating table. Again, failing sight from optic atrophy sends a considerable number first to the ophthalmic surgeon; so that, allowing for the rarity of tabes as compared with the frequency of its presumed cause, syphilis, and also for the fact that in two-thirds or more of affected soldiers the symptoms do not appeal' till they have left the Service, there must remain a sufficiently large proportion of cases, amongst the vast number of syphilitics which pass before us, to oblige us to be very much on the alert to detect, by thorough and systematic examination, this protean disease in its early stages.

The second reason for tabes being of special interest to us lies in the fact that it is now generally believed to be a sequel of syphilis. It is true that patients with this disease rarely present evidences of a severe attack of syphilis. But it is just these mild cases who would not trouble about treatment in the early stages. Fournier has recently published some statistics of the allied disease, general paralysis, which occurred in his private practice, in which he states that 80 per cent. of the sufferers were those who had been treated for syphilis, but for less than a year. On the other hand, cases of tabes undoubtedly occur where the patient is known to have under-gone the most thorough course of anti-syphilitic treatment, so that it cannot be said that the latter confers certain immunity. But until the life history of the Spirochr:ete pallida, or some other organism, throws more light on the nature of syphilis, it would seem sound policy to assume that this terrible sequel of syphilis may, in most cases, be prevented by a prolonged treatment of the primary disease; I say prolonged, because in reading the Second Report on the Treat-ment of Venereal Diseases ill the Army, nothing struck me more than the difference between military and civil opinion, as to the length of time during which mercury should be given to obtain the best results.

Most of the Army surgeons who were questioned considered one

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year's treatment sufficient; whereas of fifteen civilians six preferred that it should extend over three years, seven considered that two should be the minimum, and the two who considered a shorter period enough qualified their remarks. Now when one goes round civil hospitals one cannot help being struck with the frequency of the later manifestations of syphilis, especially in the nervous and vascular systems, many of the patients being ex-soldiers. Such cases are comparatively rare in military practice. May not the reason for the divergent opinions above stated lie here? The civilian sees all stages of the disease and is impressed accordingly with the necessity· for more prolonged treatment. Doubtless, in most cases, a year's treatment will prevent other symptoms re-appearing during a man's service with the colours, but will it protect him from the grave sequelffi of later life '? I see by Major Pollock's last Report that in the French Army treatment is insisted on for four years, should a man remain with the colours so long. and that mercury is continued into the third year at long intervals. Professor Fournier'splan of spreading treatment over eight years or more, with years of intermission, is rarely possible; but his opinion is worthy of note when he says that the older he grows in the society of syphilis and mercury the more he is convinced that it is with mercury as with vaccine: it is preventive, but pro-visionally, and the patient must be remercurialised to be protected from the subsequent assaults of his syphilis.

It has been said that ten to thirty years may be consumed in the history of tabes, or it may unroll its panorama of symptoms in two or three. Complete recovery is impossible, but complete arrest may take place. Dr. Starr records a case of a man, aged 65, who for thirty-five years had had slight ataxy, though not enough to prevent his walking at night, slight bladder trouble, loss of knee-jerks, and iridoplegia. Yet during all that time the disease had made no progress. Trousseau speaks of a Polish cavalry officer whose first symptoms dated from 1846; he fought with distinction in the Hungarian War of 1848, and in 1865 he still had a firm seat on a horse, though he could no longer feel his stirrups. Another patient of his was an old man, aged 80, whose doctor believed him paralysed; he demonstrated he was not, when, supported by Trous-seau, he carried his adviser on his shoulders round the room.

On the other hand, Duchenne speaks of a rare, almost acute, form of the disease, reaching the third stage in six months or a year. It is a disease that progresses in jerks, with long periods during which the symptoms are stationary; and this may occur

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at almost any point in the disease. Fortunately, lightning pains and visceral crises are not, as a rule, experienced whell the disease is advanced or has been arrested.

As to treatment, Romberg '~'Tote: "If, in any case, the busy activity of the physician increases the suffering of the patient, it is in tabes dorsalis. When one of these unfortunate individuals presents himself to us we generally find his back seamed with cicatrices, he brings us a heap of prescriptions, and gives a long list of the watering-places he has visited in search of health." A more hopeful view is taken nowadays. They will tell you at the National Hospital in Queen's Square that there is no chronic disease of the nervous system for the alleviation of whose symptoms more can be done. A majority of cases derive a great deal of benefit from treat-ment. This consists in rest, attention to the malnutrition, which often accompanies the disease, and the re-education of muscles by exercises. In this way some patients, unable to stand, have been enabled, after a year or two, to walk some miles.

Bladder troubles should never be overlooked; they are a con-stant menace to life in this disease. For the excruciating pains of tabes there is nothing like the coal tar preparations, of which Sir W. Gowers gives the palm to acetanilide (anti-febrin), using it in doses of 10 grains. To prevent their reCurrence he speaks highly of chloride of aluminium, 10 grains thrice a day; or of aspirin, so useful in all forms of neuritis and muscular rheumatism, in similar doses. But the point which interests us most in the Army, where we may see the start of the disease, is the question of anti-syphilitic treatment on its first appearance. Writing in 1895, Marie does not seem to think much of mercury, though he says he does not hesitate to employ it to make the patient secure from other lesions of a syphilitic nature, which otherwise may attend the early stages of tabes. When not contra-indicated, Erb prescribes an active anti-syphilitic treatment to clear the air. Dr. Risien Russell thus sums up the matter: "Opinions differ as to the question of anti-syphilitic treatment, some advocate it, while others consider that it not only does no good, but that it even does harm. rfhe shorter the interval that has elapsed bet ween the primary affection and the time that the symptoms of tabes commence, the more justification there is for anti-syphilitic treatment. Cases in which the symptoms come on rapidly should also be subjected to this plan of treatment before other measures are tried. A thorough and systematic course of mercurial inunction should be followed by the administration of iodide of potassium in large doses."

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J. T. Olapham 687

Better still is prevention. Whether by the efficient treatment of syphilis in its early stages, or by avoiding stress in those who have acquired it, if this be possible, by placing them in conditions favourable to their temperament.

To those in whose hands this duty lies the saying of Duchenne will appeal: "The motto of all those who treat this disease should be 'principiis obsta.' "

REFERENCES.

Sir \"1. Gowers. "The Pains of Tabes," British Medical Journal, January 7th, 1905.

Sir W. Gowers. "The Nature of Tabes," British Medical J07~rnal, July 8th, 1905.

Sir W. Gowers. "Diseases of Nervous System," vol. i. Dr. F. W. Mott. "Archives of Neurology," vol. ii. Dr. Risien Russell's article in Bain's "Medicine." Dr. Starr. "Organic Diseases of Nervous System." The works of Romberg,

Duchenne, Charcot and Marie, in" New Sydenham Society Series." Prof. Fournier's "Les maladies para-syphilitiques." Also in British Medical Jo~~rnal, March 11th, 1905. Mobin's" Ueber die Tabes." by copyright.

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