Visceral crises represent another interesting manifestation of this disease, now rarely seen. The gastric ones are the best known. The patient is seized abruptly with epigastric pain that spreads around the body or up over the chest. There may be a sense of thoracic constriction as well as nausea and vomiting—the latter repeated until nothing but blood-tinged mucus and bile are raised. The symptoms may last for several days; a barium swallow sometimes demonstrates pylorospasm. The attack subsides as quickly as it came, leaving the patient exhausted, with a soreness of the epigastric skin. Intestinal crises with colic and diarrhea, pharyngeal and laryngeal crises with gulping movements and dyspneic attacks, rectal crises with painful tenesmus, and genitourinary crises with strangury and dysuria are all less frequent but well-documented types.
In most cases now seen, the CSF is normal when the patient is first examined (so-called burned-out tabes). It is abnormal less often than in general paresis.
Pathology Pathologic study reveals a striking thinness and grayness of the posterior roots, principally lumbosacral, and thinning of the spinal cord mainly as a result of wallerian degeneration of the posterior columns. Only a slight outfall of neurons is observed in the dorsal root ganglia; the peripheral nerves are essentially normal. For many years, there was an argument as to whether the spirochete first attacked the posterior columns of the spinal cord, the posterior root as it pierced the pia, the more distal part of the radicular nerve where it acquires its arachnoid and dural sheaths, or the dorsal root ganglion cell. The observations of our colleagues of rare active cases have shown the inflammation to be all along the posterior root; the slight dorsal ganglion cell loss and posterior column degeneration were considered to be secondary.
The hypotonia, areflexia, and ataxia relate to destruction of proprioceptive fibers in the sensory roots. The hypotonia and insensitivity of the bladder are caused by deafferentation at the S2 and S3 levels; the same is true of the impotence and obstipation. Lightning pains and visceral crises cannot be fully explained but are probably attributable to incomplete posterior root lesions at different levels. Analgesia and joint insensitivity that lead to Charcot joints relate to the partial loss of A and C fibers in the roots.
Treatment If the CSF serology is positive and the patient has not been treated before, the patient should be treated with penicillin, as described below. (The CSF VDRL may remain positive for many years after treatment.) If, however, CSF serology is negative, there is no pleocytosis, the CSF protein content is normal, and there is no evidence of cardiovascular or other types of syphilis, antisyphilitic treatment may not be necessary. We are uncertain of the proper course of treatment in patients with tabes who have survived many decades with HIV. Residual symptoms in the form of lightning pains, gastric crises, Charcot joints, or urinary incontinence frequently continue long after all signs of active neurosyphilitic infection have disappeared. These should be treated symptomatically rather than by antisyphilitic drugs.