Tabes Dorsalis. A Boenninghausen case.

We present for your information and education the following case from the notes of Dr Boenninghausen. This case singularly, demonstrated a number of case management issues that will be discussed in full at a later date.   we would advise that you, the practitioner simply read the case and make notes, follow the protocol and ask questions or post your comments on Tabes Dorsalis. A Boenninghausen case.

Miss Francisca v. W., belonging to one of the most honored families in Münster, now nearly nineteen years of age, and living here with her relatives for ten years, had often suffered from various ailments (even before her coming here) which bear the most manifest indication of a chronic (psoric) dyscrasy. She had, therefore, in her former place of residence, besides the inevitable codliver oil, also received from a homoeopathic physician now deceased several homoeopathic remedies, namely, Puls., Sulph., Calcar. carb., Carbo veg., Silic. and Lycop. with only partial and insufficient success.

In my Journal (Vol. LXXI., p. 89), I find first enumerated under her name, and dated Dec. 27, 1848, the following:

  • Since four weeks she has had a moist eruption on the head, especially behind both the ears and above both the external ears, which aches most of all and most violently in the evening and in the morning.
  • The abdomen thick and hard.
  • Aversion to meat.
  • Desire for milk, bread and butter and all vegetables of the cabbage and kale kind.
  • She sleeps altogether too long and even till late in the day.
  • Pretty strong curvature of the spine and protuberance of one shoulder-blade.
  • Chilblains on the toes (not on the hands).
  • She feels worse early in the morning; better in the evening.

It would lead too far from my purpose and lead to useless diffusiveness to relate in detail the former treatment of this child, who was manifestly scrofulous, and it will be enough to observe here that these ailments were very stubborn, and that the eruption at first extended further, not only over the head and neck, but even down to the sexual parts, and only after the course of two years it was brought to a cure, together with the curvature of the spine, so that nothing abnormal could any more be found.

Still, in the years following, i. e., 1851 and 1852, there again appeared ailments from time to time, which were not very considerable and were soon removed, but which caused it to be plainly seen that the scrofulosis which was manifestly deeply inrooted was not yet completely exterminated.

In the spring of 1853 she was taken sick with a pretty violent gastric fever, while she had an unconquerable longing for ink, while every time after taking milk she would vomit. Nevertheless, her cure soon followed and she remained well until the winter 1853 to 1854, when the old eruption together with the chilblains on the feet again appeared, which were only fully removed with the beginning of March.

In the beginning of 1855 the same eruption reappeared, but lasted this time only till about the middle of February. The menses now also appeared and, indeed, with unusual violence. In the summer of this year she was seized with a violent case of grippe, which was removed in a few days, and soon afterward by a violent, convulsive colic with excessive menses (quickly cured by a dose of Zincum) followed by a lengthy period of apparently complete health.

In the meanwhile, she had been removed to an educational institution, twenty miles from here, where about the middle of September, 1857, she was taken ill again, and, indeed, first with violent headache with bleeding of the nose and much too copious a flow of blood with the menses, appearing prematurely; all these symptoms were aggravated: in the evening from motion, and from every mental or bodily exertion. Bellad., Bryonia and Phosphor., each in a high potency and in a single dose, relieved this, all excepting a few symptoms, which appeared in the evening, while sitting in the warm room, and which also yielded to a similar dose of Pulsatilla. About the middle of January, 1858, quite a new ailment appeared, concerning which a teacher of the institution gave only a very sparing and incomplete account.

According to her account the patient suffered from violent pains in the back, aggravated by every motion, disappearing at night, and which had once caused a real tonic spasm. Nothing further could be deduced from the written report.

Nux vom. 200, dissolved in water, taken three times a day for three days, produced “considerable and still progressing improvement;” but the patient now complained of “pains in the pit of the neck and inability to swallow,” without any further description. I directed the repetition of Nux vom. a dose dissolved in water taken for six days, twice a day, morning and evening, every time a spoonful.

This second dose of Nux vom. not only remained without any effect, but the (quite undefined) pains in the back had again returned, and a new symptom was announced, namely, an “aphony,” which is most decided in the morning and evening, and which “made it impossible to utter any loud word.” At the same time and only now I was informed that even while using the former remedy speech had become daily more difficult and more of a strain, as “from a paralysis of the tongue,” so that the patient was obliged “to catch a breath with every word, and that she was inordinately wearied by even a little talking.”

Caust. did not affect these ailments, but Sepia, given a week later, caused the voice to return for hours, as was stated, but always soft and subdued. But all the rest remained almost unchanged, only, according to the description of the patient herself, “somewhat better.”

A dose of Sulphur 200, sent on February 3d, had the effect that every night after midnight she had headache (without any further description) with epistaxis, only improved by sitting up in bed. All the rest was merely described with the stereotyped phrase, “somewhat better,” showing that it was still present; but not a syllable was added which could have secured a proper selection of the remedy.

Under such circumstances, sufficient to lead to despair, I sent on February 17, a dose of Belladonna 200, to be taken as the preceding medicine, but then I demanded with decision, that the patient should be brought here, so that I might see her, which might be done without danger, considering the short distance and the nature of the disease, manifestly chronic. It is noteworthy, that especially among the higher classes and, especially in veryous diseases, the stereotype euphemism is always “somewhat better,” while the improvement makes no essential progress, but on the contrary, new symptoms are continually added, which complicate the matter without offering any hold for the selection of the remedy. According to my decidedly pronounced desire, the patient was brought here on February 24 and in the evening I called on her. Great was my astonishment at recognizing at once the most decided image of a genuine tabes dorsalis, to which nothing reported so far had pointed at all. Especially the aphony which was always emphasized as the chief characteristic and which is only exceptionally observed in this disease had caused no suspicion of the real state of the case, since the paralysis of the lower extremities, which was already far advanced, had not been mentioned in any one of the letters.

When I saw the patient, the aphony was indeed, so great and the pronunciation so indistinct that I had to incline my ear close to her mouth to understand her whispers. But all the other symptoms spoke too plainly to allow the real character of the disease to be mistaken and the last-named symptom could only permit the supposition that the affection of the spinal marrow had reached an unusual extent.

What I discovered at once at my first visit and immediately noted down more carefully and circumstantially than usual was the following:

  • The patient had for a long time noticed an ever increasing weakness of the lower extremities, connected with which she had always felt a more or less pronounced pain in the back.
  • The sensation in the back was a sort of burning, as if a hot iron had been pushed up from the small of the back up through the spine. In the beginning this had often only been a disagreeable formication extending upward.
  • At the same time the soles of her feet had appeared as if soft or padded, as if the feet were resting on a soft woolen cover or on a pillow.
  • Gradually all sensation in the soles of her feet had been more and more lost, so much even that she did not feel the ground under her feet any more, nor did she know whether her feet rested on it unless her sight assured her of it.
  • So long as she still was able to walk, which she had not, however, been able to do for several weeks, she had only been able to do this by day in a bright light and with her eyes open. When her eyes were closed, or in the dark, she had tottered and staggered so much that she had immediately had to take hold of something to keep from falling.
  • Now she was quite unable to stand in the dark and had even to lean against something in bright daylight. When she was lying in bed she had no sensation at all of the position and situation of her feet and legs, which, often unknown to her, occupied the most varied positions.
  • During the beginning of the disease, if she made the attempt to walk a few steps in the dark, even in rooms well-known to her, she would always unconsciously and involuntarily turn to the left and thus miss her aim.
  • Very frequently she had a sensation of contraction in the abdomen, as if it was drawn together with a band; this sensation as well as the pains in the back were always worse when beginning to move after a long rest.
  • The aphony mentioned above still continues, but it is painless, but it is conjoined with a striking and excessive weariness if she speaks at all, so that she assured me that she was frequently compelled to rest herself.
  • As for the rest, I found the patient well-nourished, with a blooming complexion, complaining but little, and not in the least disquieted about her condition; yea, even with the clearly pronounced inclination to consider her ailment as by no means dangerous or serious. Appetite and digestion good. Stool somewhat hard and inert. The menstruals appear at the right time, but pretty copious. In the evening the condition is worse than in the morning.

These symptoms, which were at once and completely written out, and which had for me a double importance because they were the first that I had an opportunity of investigating with respect to this disease after my particular study of XXXXX, left no room for the least doubt that the case was a pronounced case of tabes dorsalis, and on the basis of my earlier experience I did not hesitate to give her at once a dose of XXXXX. 200, from the pharmacy of druggist Lehrmann, in Schoeningen. This was to be dissolved in six tablespoonfuls of water, and three times a day for two days a tablespoonful was to be taken.

On the 26th of February, when I again visited my patient, the improvement was already so manifest and decided that I did not wish as yet to disturb the after-effects. A second dose of XXXXX 200, taken in the same manner on March 1st, continued the improvement, and since in the meanwhile the menses had appeared without any concomitant trouble I followed it up with a third dose of the same remedy, given in the same way on March 5th.

According to my journal the improvement progressed steadily and regularly. The patient is already able to stay up all day, and she walks about all over the house in the bright daylight. She can even go up and down stairs without any particular trouble. Only when she closes her eyes she cannot as yet walk straight, but she still constantly turns to the left, as I found out on making the trial; nor can she walk as yet in the dark without holding on to something.

March 10. Again XXXXX. 200 as before.

The lower limbs do very well, but the voice is still often lost in the evenings, and talking is difficult and wearisome. Thus it seems that too frequent a repetition of this remedy without intervening remedies does not advance the cure quickly enough.

This is a result which not infrequently appears in chronic ailments, where the symptoms only become milder, without any essential change. Accordingly, on March 15 I gave Natrum mur. 200, to be taken in the same way. The action was good, still not as favorable as that of the prior remedy.

Perhaps the similarity between the effects of Natrum mur. and of XXXXX. is too great, a fact which is occasionally seen when two remedies too closely related immediately follow on each other (compare Ignat., Nux vom. and Puls). Nevertheless, the improvement had again progressed so much that the patient on March 21 could without any strain come to see me, and called on me. She now received Alumina 3000 (Jenichen’s), when the improvement again advanced more manifestly. Only the pains in the back and in the small of the back increased again. Thus the action was not as specific as that of XXXXX.

On March 28 she received Caust. 200, which caused all these pains to vanish, while her voice and speech improved. On the other hand, the soft feeling in the soles of the feet and the weakness of the legs increased, showing that this remedy does not sufficiently correspond to the proper essential character of tabes dorsalis.

On April 11 I returned again to XXXXX.

Now, also, the last considerable remnants of the disease vanished almost completely, and even her speech became again as sonorous and unobstructed as in her days of health. Only on account of a rarely-occurring formication, appearing especially in the evening, with a transitory insensibility in the soles of the feet, On April 20 I gave another dose of XXXXX, and On April 28 one dose of Pulsatilla 200, and, finally, On May 7 a dose of Sulphur 200. The three medicines were taken as the former ones, when the last traces of the disease completely disappeared and nothing of the kind has since been seen.

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