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Tabes Dorsalis and Perforated Duodenal Ulcer J i6o Postgrad Med J: first published as 10.1136/pgmj.37.425.160 on 1 March 1961. Downloaded from POSTGRAD. MED. J. (1961), 37, i60 TABES DORSALIS AND PERFORATED DUODENAL ULCER J. P. LAWSON, M.B., Ch.B. Late Senior House Officer in Medicine, Crumpsall Hospital, Manchester Senior House Oficer in Radiology, David Lewis Northern Hospital, Liverpool 3 IT is well recorded that tabes dorsalis can mask between the shoulder blades whilst standing in a bus serious visceral disease. Wilson mentions queue. This was shortly followed by a bout of vomiting (1954) and sweating. There was no dyspncea, pain in the chest that tabes can disrupt nervous pathways so as to or abdominal pain. The patient was able to make his produce a visceral analgesia capable of masking own way home on foot. serious abdominal disease. At home he took a Sedlitz powder, which was followed by three further attacks of vomiting and four Connor (I91o) published a case of a brakeman, loose bowel actions. There was no blood in either aged 42, who died in hospital following an acute vomitus or faeces. The pain spread to both shoulder febrile attack and vomiting. There had been no tips, where it persisted and was the cause of his attend- abdominal tenderness or to ance at the casualty department. pain, rigidity explain Four years previously he had developed a similar the condition but autopsy revealed a perforated attack of sweating and stated that he had also vomited appendix abscess and peritonitis. blood. At this time he was apparently found to be from and was trans- Hanser (I9I9) recorded the case of a tabetic suffering pulmonary tuberculosis, by copyright. him ferred to a sanatorium. Treatment was commenced with previously unknown to who although having streptomycin, PAS and INH. He was a difficult patient no abdominal signs or symptoms was found at and in all was admitted to, and took his own discharge autopsy to have a peritonitis caused by a per- from, four different sanatoria, finally taking his own forated duodenal ulcer. discharge before treatment was completed. He was quite emphatic that he had never suffered Sternberg (1929) described I2 cases of painless from any form of chest or abdominal pain, although pneumonia and pleurisy in tabetics. periodic attacks of nausea and vomiting had occurred. Grimble and Csonka a case of He had not noticed that they were related to food. (1952) published At the time he denied having had any 'venereal a 59-year-old man known to have tabes, who was infection. Later he admitted that he may have had an being treated for congestive heart failure due to infection whilst in Cyprus during the last war, but he http://pmj.bmj.com/ syphilitic aortitis. Death followed a sudden was not treated at the time and apparently had not had deterioration, and autopsy revealed a perforated any specific anti-syphilitic treatment for any stage since. chronic gastric ulcer and peritonitis, although at all times abdominal and had been Examination signs symptoms A well-built unkempt man. Skin: clammy, but no absent. pallor. Teeth: dirty and decayed. Throat: clear. Doyle and Campbell (1953) described the case of Tongue: notfurred. Noglandspalpable. Temperature: an obese male aged 68 who first attended the 98.6° F. At no stage in the examination did he complain of, or appear to be in, any pain. on September 27, 2021 by guest. Protected hospital with leukoplakia of the cheek and was C.V.S. Pulse I20/min., regular. B.P. 85/70. found to have clinical tabes. He was later R.S. Respiration regular, 20/min. Apical crepita- admitted with acute retention of urine, thought to tions present right and left. be due to a carcinoma of the and died the Abdomen. No distension, tenderness or guarding. prostate, Bowel sounds were present. The bladder was palpable following day. At all times he was quite free to the umbilicus and was not tender; urine could be from abdominal pain and abnormal abdominal expressed by manual pressure. Rectal examination was signs although post-mortem examination revealed normal. the of a B. coli C.N.S. Cranial nerves. Pupils: anisocoria was presence generalized peritonitis present. Both were irregular but not constricted. Both and a perforated chronic gastric ulcer. failed to react to light, but reacted to accommodation. Other cranial nerves intact. Spinal nerves. There was Case Report no obvious change in tone or power. Marked ataxia was History. J.S., an unemployed labourer aged 51, present on testing by the finger-nose and heel-knee was admitted to Crumpsall Hospital via the casualty tests. Reflexes: the lower limb and abdominal reflexes department on August 9, I959. Two hours before were absent. There was loss of position sense, vibration admission he had developed a sudden attack of pain sense and light touch below the level T 5-6. Sensation March x96 LAWSON: Tabes Dorsalis and Perforated Duodenal Ulcer i6r Postgrad Med J: first published as 10.1136/pgmj.37.425.160 on 1 March 1961. Downloaded from to pin-prick was greatly reduced below this level. The following investigational results support There was no pain on squeezing the Achilles tendon. the clinical diagnosis of tabes dorsalis. Marked Rombergism was present. C.S.F.: manometrically normal; clear colour- At this stage a clinical diagnosis of tabes dorsalis less fluid; cells 3 erythrocytes, 35 leucocytes pre- was made but there was nothing abnormal found dominantly lymphocytes; protein 32 mg.%; in the abdomen to the condition. globulin no excess; Lange zero in all dilutions; explain patient's W.R. positive. Blood Wasserman, Reiter protein Investigations complement fixation, treponemal immobilization Hb on admission .. 12.0 g./Ioo ml. tests all positive. Four hours later.... 1.4 g./Ioo ml. He was referred to the Manchester Chest clinic Serum urea .... 38 mg./ioo ml. for assessment of his pulmonary tuberculosis, Na .... 129 mEq./l. where it was found that his was free from K .. .. 5 mEq./l. sputum C1 .... 96 mEq./l. A.F.B. and his clinical and radiographic condition Amylase .. .. 60 Street-Close units unchanged from his previous attendances. He is (normal 9-35 units/Ioo ml.) at present being kept under observation as an ECG showed a sinus rhythm with occasional ven- out-patient. tricular premature beats and was otherwise normal. He also attended Ancoats for his neuro- X-ray chest showed a marked infiltration of both hospital apices. There was no evidence ofmediastinal emphysema syphilis. He was given Procaine Penicillin, and no evidence of pneumothorax. 600,000 units daily for ten days and then three- Unfortunately, at this stage he was not fit enough to weekly injections each of 1.2 m.u. Penidural. He radiograph in the upright position to determine whether then defaulted. or not gas was present under the diaphragm and radio- Barium studies were not graphs in the lateral recumbent position using a hori- Post-operative per- zontal tube were not taken. formed as he failed to keep his appointment at Crumpsall hospital. Management Discussion The was admitted to the ward for patient The of cases of tabes dorsalis with symptomatic treatment of his shocked state. percentage by copyright. Throughout the following hours his clinical co-existent gastric or duodenal ulcer is very condition did not improve despite intravenous difficult to estimate and great variation is found in blood transfusion. Early the following morning the series of various authors. his blood pressure had fallen to 70/50 and there Bockus (1950) maintained the incidence of had been an increase in his sweating. At this peptic ulcer in neurosyphilis is no greater than the stage his abdomen was found to be free from all population as a whole and puts the figure at 8% tenderness and guarding. He was seen on this but he did not define the population studied. occasion by the Senior Surgical Registrar who Crohn (I921), although not giving any figure for could find in the abdomen to the the association, called attention to the fact that nothing explain ' http://pmj.bmj.com/ condition. coexistent with the easily recognized and familiar picture of tabes we may be and possibly Although the symptomatic treatment was often are treating a fully developed gastric or continued, there was little improvement in the duodenal ulcer ... and it is possible that peptic patient's condition, and when next examined, it was ulcer is a frequent concurrent of tabes'. He observed that his abdomen was becoming dis- suggested that the gastric ulcers are 'trophic' in tended, the liver dullness was diminished and there origin and that the involvement of the nervous was shifting dullness present in the abdomen. to ulcer formation system might predispose by on September 27, 2021 by guest. Protected There was no abdominal tenderness or rigidity. giving rise to hypersecretion, quoting that 33% The bowel sounds were diminished. of cases of continuous hypersecretion are ac- At this stage it was decided that a laparotomy companied by ulcers. Most authoritative articles should be performed. This was performed by now show that duodenal ulcers are accompanied Mr. M. A. Brennan. The patient was considered by hypersecretion and gastric ulcers by normal well enough for a general anaesthetic. levels of secretion (Levin, Kirshner and Palmer The peritoneal cavity contained over two pints I948). In addition Crohn and Wilensky (1917) of fibrinous exudate and there was an obvious called attention to the frequent disturbance of peritonitis. In the anterior wall of the first part gastricmotility associated with gastric crises. That of the duodenum there was a perforated ulcer, delayed emptying predisposes to ulcer and causes over i cm. in diameter. The perforation was retarded healing in experimental dogs has been repaired by omental grafting.
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