Journal o f Neurology. NeurosurgerY, t U l PsYchiatriy 1988;51:1097-1099 Short report Tabes dorsalis: electrodiagnostic features PETER D DONOFRIO, FRANCIS 0 WALKER From h e Department o f Neurology, Wake Forest University, Bowman Gray School of Medicine, Winston Salem, North Carolina, U SA SUMMARY Electrodiagnostic data have n o t been previously reported i n tabes dorsalis. A patient with tabes dorsalis i s described whose nerve conduction studies a n d median nerve somatosensory evoked responses (SEPs) were normal. H-reflexes were absent. SEPs o f t h e tibial nerve suggested posterior column dysfunction. These electrodiagnostic findings correlate precisely with the known pathology o f tabes dorsalis. Although tabes dorsalis i t h e most common neu- rological expression o f tertiary syphilis,' n o reports exist of i t s clinical electrophysiology. Since t h e symp- toms a n d signs o f tabes dorsalis mimic those o f severe peripheral neuropathy or myelopathy, patients with tabes dorsalis m a y b e referred f o r electrodiagn6sis. W e describe t he electrodiagnosticfindings i n this dis- order. Case presentation A 5 4 year o l d woman w a s referred f or poor balance, l e g weakness a n d pain, recurrent left knee effusions, a n d a pre- vious history o f "polio". S h e developed weakness o f both legs a t a g e 7 years, diagnosed as "polio". Several years later, s h e began t o experience diminished lower extremity sensa- tion a n d gait deterioration. Several years after onset o f t h e disease, bladder distension an d overflow incontinence further complicated h er illness. Additional disabilities included lower extremity lightning pains, recurrent knee effusions, a n d chronic t o e infections necessitating amputation. Examination revealed a n enlarged left knee, p e s cavus an d hammer t o e deformities, an d amputation ofboth small toes. Pupils were large a n d unreactive to light and accommo- dation. Dilute pilocarpine did n o t constrict them. Reflexes were normal in upper extremities a n d absent in th e legs. Light touch, pinprick, a n d cold sensation were markedly reduced i n t he legs from 5 c m above the patella distally. Vibration sensation w a s absent distalto the pelvis. Proprio- ception w as absent a t t h e great t o e an d ankle, a n d markedly Address f o r reprint requests: Peter D Donofrio, MD., Department o f Neurology, Bowman Gray School o f Medicine, 3 0 0 S . Hawthorne Road, Winston-Salem, NC 27103, USA. Received 5 January 1988 a n d i n revised form 1 1 March 1988. 1 5 March 1988 reduced a t t h e knee. Coordination w a s severely impaired i n h er legs. H e r gait was wide-based an d unsteady; s h e w a s unable t o tandem walk. Romberg manoeuvre demonstrated profound instability. Routine blood a n d urine studies were normal. Serum folate level wasnormal as w a s Schilling's Test, Part 1 . Serum VDRL w a s non-reactive reactive a previous hospitalisation). Serum microhaemagglutination- Treponema pallidum (MHA-TP) w a s positive. Cerebrospinal fluid (CSF) analysis revealed no cells, a protein o f 0-24 g/ l (normal < 0 45), a n d a non-reactive VDRL. Thoracic a nd lumbosacral spine myelography, CT, and M RI were normal. Sural, median, an d ulnar sensory a n d peroneal a n d poste- rior tibial motor nerve conduction studies were normal. Actual values (amplitude, distal latency, conduction velocity, respectively; normal values i n parentheses) were: sural 15 p V (.6), 3 - 4 ms (<4 2) ; median sensory 4 5 p V (.22), 2 5 m s (<3-4), 6 2 m / s (.53); ulnar sensory 3 0 p V (.10), 2 - 5 m s ( < 3 2 ); peroneal motor 5 mV (.2), 4 5 m s (<6-1), 5 1 m / s (.41); a n posterior tibial 4mV (.3), 3 9 m s (<62), 4 7 m/ s (.41). F-response latencies were normal: peroneal 4 5 6 m s ( < 5 6 ) a n d posterior tibial 47-6 m s ( < 58), but posterior tibial nerve H-reflexes were absent. Median nerve somatosensory evoked potentials (SEPs) were normal, ye t posterior tibial nerve SEPs demonstrated posterior dysfunction (fig). EMG w a s unremarkable except f o r minimal spontaneous activity i n both medial gas- trocnemius muscles. Needle examination of lumbosacral paraspinal muscles was normal. T h e patient's pupillary, neurological, urological, ortho- paedic, a n d serological manifestations confirmed th e diag- nosis o f tabes dorsalis. he denied previous syphilis injection, b u t subsequent questioning o f relatives uncovered a previously-undisclosed history o f syphilis i n both maternal grandparents a n d h er mother, i n t h e latter case during the patient's childbirth. Because o f th e uncertainty o f previous treatment, t h e patient received a full course o f intravenous a n d intramuscular penicillin. 1097
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8/3/2019 Tabes Dorsalis-electrodiagnostic Features
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J o u r n a lo f N e u r o l o g y .N e u r o s u r g e r Y,t U lP s Y c h i a t r i y1 9 8 8 ; 5 1 : 1 0 9 7 - 1 0 9 9
S h o r tr e p o r t
Ta b e sd o r s a l i s :e l e c t r o d i a g n o s t i cf e a t u r e sPETER D DONOFRIO, FRANCIS 0 WALKER
F r o mt h eD e p a r t m e n to f N e u r o l o g y ,Wake F o r e s t U n i v e r s i t y ,BowmanG r a yS c h o o lo fM e d i c i n e ,W i n s t o nS a l e m ,N o r t hC a r o l i n a ,USA
S U MM A RYE l e c t r o d i a g n o s t i cd a t a h a v en o t b e e n p r e v i o u s l yr e p o r t e d i n t a b e sd o r s a l i s .A p a t i e n tw i t h t a b e sd o r s a l i si s d e s c r i b e dw h o s en e r v ec o n d u c t i o ns t u d i e sa n dm e d i a nn e r v es o m a t o s e n s o r ye v o k e dr e s p o n s e s( S E P s )w e r en o r m a l .H - r e f l e x e sw e r ea b s e n t .S E P so f t h et i b i a ln e r v e s u g g e s t e dp o s t e r i o rc o l u m nd y s f u n c t i o n .T h e s ee l e c t r o d i a g n o s t i cf i n d i n g sc o r r e l a t ep r e c i s e l yw i t h t h e knownp a t h o l o g yo f t a b e sd o r s a l i s .
A l t h o u g ht a b e sd o r s a l i si s t h em o s t common n e u -r o l o g i c a le x p r e s s i o no f t e r t i a r ys y p h i l i s , 'n o r e p o r t se x i s to f i t sc l i n i c a le l e c t r o p h y s i o l o g y .S i n c et h es y m p -t o m sa n ds i g n so f t a b e sd o r s a l i sm i m i ct h o s eo f s e v e r ep e r i p h e r a ln e u r o p a t h yo r my e l o p a t h y ,p a t i e n t sw i t ht a b e sd o r s a l i smay b e r e f e r r e df o re l e c t r o d i a g n 6 s i s .We d e s c r i b et h ee l e c t r o d i a g n o s t i c f i n d i n g si n t h i s d i s -o r d e r .
C a s ep r e s e n t a t i o n
A 5 4 y e a ro l dwoman w a s r e f e r r e df o rp o o r b a l a n c e ,l e gw e a k n e s sa n d p a i n ,r e c u r r e n tl e f tk n e ee f f u s i o n s ,a n d a p r e -v i o u sh i s t o r yo f " p o l i o " .S h e d e v e l o p e dw e a k n e s so f b o t hl e g sa t a g e 7 y e a r s ,d i a g n o s e da s " p o l i o " .S e v e r a ly e a r sl a t e r ,s h eb e g a nt o e x p e r i e n c ed i m i n i s h e dl o w e re x t r e m i t ys e n s a -t i o na n d g a i td e t e r i o r a t i o n .S e v e r a ly e a r sa f t e ro n s e to f t h ed i s e a s e ,b l a d d e rd i s t e n s i o n
a n d o v e r f l o wi n c o n t i n e n c ef u r t h e rc o m p l i c a t e dh e r i l l n e s s .A d d i t i o n a ld i s a b i l i t i e si n c l u d e dl o w e r e x t r e m i t yl i g h t n i n gp a i n s ,r e c u r r e n t k n e e e f f u s i o n s ,a n d c h r o n i ct o e i n f e c t i o n sn e c e s s i t a t i n ga m p u t a t i o n .
E x a m i n a t i o nr e v e a l e da n e n l a r g e dl e f tk n e e ,p e sc a v u sa n dh a m m e rt o ed e f o r m i t i e s ,a n dam p u t a t i o no f b o t hs m a l lt o e s .P u p i l sw e r e l a r g ea n d u n r e a c t i v et o l i g h ta n d a c commo-
d a t i o n .D i l u t ep i l o c a r p i n ed i d n o t c o n s t r i c tt h e m .R e f l e x e sw e r e n o r m a li n u p p e r e x t r e m i t i e sa n d a b s e n t i n t h el e g s .L i g h tt o u c h , p i n p r i c k ,a n d c o l ds e n s a t i o nw e r em a r k e d l yr e d u c e di n t h el e g sf r o m 5 cm a b o v e t h ep a t e l l ad i s t a l l y .V i b r a t i o ns e n s a t i o nw a sa b s e n td i s t a l t ot h ep e l v i s .P r o p r i o -c e p t i o nw a sa b s e n ta t t h eg r e a tt o e a n da n k l e ,a n dm a r k e d l y
A d d r e s sf o rr e p r i n tr e q u e s t s :P e t e rD D o n o f r i o ,M D . ,D e p a r t m e n to fN e u r o l o g y ,Bowman G r a y S c h o o lo f Me d i c i n e ,3 0 0 S . H a w t h o r n eR o a d ,Wi n s t o n - S a l e m ,NC 2 7 1 0 3 ,USA.
R e c e i v e d5 J a n u a r y1 9 8 8a n d i n r e v i s e df o r m 1 1M a r c h1 9 8 8 .A c c e p t e d1 5M a r c h1 9 8 8
r e d u c e da t t h ek n e e .C o o r d i n a t i o nw a ss e v e r e l yi m p a i r e di nh e rl e g s .H e r g a i tw a s w i d e- ba se da n d u n s t e a d y ;s h ew a su n a b l et o t a n d e mw a l k .R o m b e r gm a n o e u v r ed e m o n s t r a t e dp r o f o u n di n s t a b i l i t y .
Ro u t i ne b l o o da n d u r i n es t u d i e sw e r e n o rm a l . S e r u mf o l a t el e v e lw a s n o rm a la sw a sS c h i l l i n g ' sT e s t ,P a r t 1 .S e r u mVDRL w a sn o n - r e a c t i v e(VDRL w a sr e a c t i v ei n a p r e v i o u sh o s p i t a l i s a t i o n ) .S e r u m m i c r o h a e m a g g l u t i n a t i o n -T r e p o n e m ap a l l i d u m(MHA-TP) w a sp o s i t i v e .C e r e b r o s p i n a lf l u i d( C S F )a n a l y s i sr e v e a l e dn o c e l l s ,a p r o t e i no f 0 - 2 4g / l( n o r m a l<0 4 5 ) ,a n d a n o n - r e a c t i v eVDRL. T h o r a c i ca n d
l u m b o s a c r a ls p i n em y e l o g r a p h y ,C T , a n dMRI w e r en o r m a l .S u r a l ,m e d i a n ,a n du l n a rs e n s o r ya n dp e r o n e a la n d p o s t e -r i o rt i b i a lm o t o r n e r v e c o n d u c t i o ns t u d i e sw e r e n o r ma l .A c t u a l v a l u e s( a m p l i t u d e ,d i s t a l l a t e n c y ,c o n d u c t i o nv e l o c i t y ,r e s p e c t i v e l y ;n o r m a lv a l u e si n p a r e n t h e s e s )w e r e :s u r a l 1 5pV ( . 6 ) ,3 - 4ms (<4 2 ) ;m e d i a ns e n s o r y4 5 pV( . 2 2 ) ,2 5 ms ( < 3 - 4 ) ,6 2 m/ s ( . 5 3 ) ;u l n a rs e n s o r y3 0 pV( . 1 0 ) ,2 - 5ms ( < 3 2 ) ;p e r o n e a lmo t o r 5 mV ( . 2 ) ,4 5 ms( < 6 - 1 ) ,5 1m / s ( . 4 1 ) ;a n dp o s t e r i o rt i b i a l4mV ( . 3 ) ,39 ms( < 6 2 ) , 4 7 m / s ( . 4 1 ) .F - r e s p o n s el a t e n c i e sw e r e n o r ma l :p e r o n e a l4 5 6 ms ( < 5 6 )a n d p o s t e r i o rt i b i a l4 7 - 6ms ( < 5 8 ) ,b u tp o s t e r i o rt i b i a ln e r v eH - r e f l e x e sw e r ea b s e n t .M e d i a nn e r v e s o m a t o s e n s o r ye v o k e dp o t e n t i a l s( S E P s )
w e r en o rm a l ,y e tp o s t e r i o rt i b i a ln e r v e S E P sd e m o n s t r a t e dp o s t e r i o rc o l u m nd y s f u n c t i o n( f i g ) .EMG w a su n r e m a r k a b l ee x c e p tf o rm i n i m a ls p o n t a n e o u sa c t i v i t yi nb o t hme d i a lg a s -t r o c n e m i u sm u s c l e s .N e e d l ee x a m i n a t i o no f l umb os a c r a lp a r a s p i n a lmu s c l e sw a sn o rm a l .T h e p a t i e n t ' sp u p i l l a r y ,n e u r o l o g i c a l , u r o l og i c a l ,o r t h o -
p a e d i c ,a n d s e r o l o g i c a lm a n i f e s t a t i o n sc o n f i r m e dt h ed i a g -n o s i so f t a b e sd o r s a l i s .S h ed e n i e dp r e v i o u ss y p h i l i si n j e c t i o n ,b u t s u b s e q u e n tq u e s t i o n i n go f r e l a t i v e su n c o v e r e d ap r e v i o u s l y - u n d i s c l o s e dh i s t o r yo f s y p h i l i si n b o t h m a t e r n a lg r a n d p a r e n t sa n d h e r m o t h e r ,i n t h el a t t e rc a s e d u r i n g t h ep a t i e n t ' sc h i l d b i r t h .B e c a u s eo f t h eu n c e r t a i n t yo f p r e v i o u st r e a t m e n t ,t h ep a t i e n tr e c e i v e da f u l lc o u r s e o f i n t r a v e n o u sa n d i n t r a m u s c u l a rp e n i c i l l i n .
1 0 9 7
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l may b e a s y m p t o m a t i ca n d may n o t ma n i f e s ts i g n snn e r v e c o m m o n l ya s s o c i a t e dw i t h c o n g e n i t a ls y p h i l i s .E v e n
t h o u g hm o s tf e a t u r e so f t a b e sd o r s a l i sd o n o t d e v e l o pu n t i l1 0 - 2 5y e a r sa f t e rp r i m a r yi n f e c t i o n ,t h i sl a t e n c ymay b e a s s h o r ta s 5y e a r si nc h i l d r e n . 3S e r o l o g i c a lf i n d i n g sa r e v a r i a b l ei n t a b e sd o r s a l i s
d e p e n d i n go n t h ec l i n i c a la c t i v i t ya n d d u r a t i o no f t h ed i s e a s e . 'S i n c eMHA-TP d e t e c t sa n t i b o d i e ss p e c i f i cf o rT r e p o n e m ap a l l i d u m ,r e a c t i v i t yp e r s i s t sr e g a r d l e s so f d i s e a s ed u r a t i o n ,s e v e r i t y ,o r p r e v i o u st r e a t m e n t .
5 1 2 C o n v e r s e l y ,VDRL i s n o n - r e a c t i v ei n 2 5 t o 57% o fp a t i e n t sw i t h l a t es y p h i l i s .' 4 - 6 CSF a n a l y s i smay b es i m i l a r l yi n s e n s i t i v ei n t a b e sd o r s a l i s .A n o n r e a c t i v eVDRL a n da c e l l u l a rc o u n ti sn o t u n u s u a lp a r t i c u l a r l y
2 - u V i n " b u r n t o u t c a s e s " . 1I n Me r r i t t ' s s e r i e so f 1 0 0+ p a t i e n t sw i t h t a b e sd o r s a l i s ,CSF s e r o l o g ywas n o n -
- I - - r r e a c t i v ei n 2 8 p a t i e n t sa n d a n o r m a lWBC c o u n twa s4 0 5 0 o b s e r v e di n 5 3p a t i e n t s . 3
I n a d d i t i o nt o t h ec l a s s i cs y m p t o ma n d s i g nt r i a d s ,o u r p a t i e n td i s p l a y e do t h e r f e a t u r e so f t a b e sd o r s a l i s .
l T h e s e i n c l u d e ds e v e r en o c i c e p t i o nl o s si n t h e l e g si e r v e r e s u l t i n gi np a i n l e s st r a u m a ,r e c u r r e n tt o ei n f e c t i o n s ,
a n d a m p u t a t i o no f s e v e r a lt o e s .R e c u r r e n tl e f tk n e ee f f u s i o n sp r o b a b l yr e p r e s e n t e da n e a r l yC h a r c o tj o i n t ,a l t h o u g hr a d i o g r a p h sd i dn o t c o n f i r m d e s t r u c t i v ec h a n g e s .D i s t a lw e a k n e s sa n d a t r o p h ymay b e l a t em a n i f e s t a t i o n so f t a b e sd o r s a l i s ,a t t r i b u t e dt o e x t e n -s i o no f t h es y p h i l i t i cp r o c e s st o a n t e r i o rh o r nc e l l so rm o t o rr o o t s . 3C l i n i c a le l e c t r o p h y s i o l o g yh a s n o t b e e np r e v i o u s l y
r e p o r t e di n t a b e sd o r s a l i s .D y c kr e c o r d e dn o r m a la m p l i t u d ea n d c o n d u c t i o nv e l o c i t i e so f A a l p h a ,A
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2uV I e m e r g e sf r o mt h ee l e c t r o d i a g n o s t i cr e s u l t si nt h i sc a s e- i - - - - - " .. a n d t h ek n o w np a t h o l o g yo f t a b e sd o r s a l i s .A b n o r -4 0 5 0 ma l i t y i n t a b e sd o r s a l i si s c o n c e n t r a t e di n t h ed o r s a l
r o o t s ,d o r s a lf u n i c u l i ,a n d p o s t e r i o rc o l u m n so f t h ef i n e d l u m b o s a c r a la n d l o w e rt h o r a c i cs p i n a lc o r d . 38 U s u -E r b d sp o i n t a l l ys p a r e d a r et h e a n t e r i o rh o r n c e l l sa n d v e n t r a ln u l a t i o n . r o o t s . 8T h ed o r s a lr o o t g a n g l i aa re r a r e l ya f f e c t e dt oe r e s p o n s e s a s i g n i f i c a n td e g r e ea n d i n d i v i d u a lg a n g l i o nc e l l sd or t h es c a l p . n o t s h o wf e a t u r e so f d e g e n e r a t i o n . 91 oS t e r ni d e n t i f i e d
i n f l a mm a t i o ni nt h e d o r s a lr o o t g a n g l i af r o mo n l yo n e
o f n i n ep a t i e n t sw i t h t a b e sd o r s a l i s . 9N o r m a ls e n s o r yc o n d u c t i o ns t u d i e sv e r i f yi n t e g r i t yf s y m p t o m s o f t h es en s o r y n e r v esa n dd o r s a lr o o t g a n g l i a .A b s e n tl e r r i t t ,t h a t H - r e f l e x e sc a n b e a t t r i b u t e dt o a t r o p h y o ft h ed o r s a li d d y s u r i a )r o o t si n t h es a c r a l a r e a ,p r e v e n t i n ge n t r y o f t h es e n -p p r i o c e p t i v es o r ya r co f t h eH - r e f l e x .A b s e n tc o r t i c a lS E P s o nt i b i a li y s i o l o g i c a ln e r v es t i m u l a t i o na r ee x p l a i n e db y p o s t e r i o rc o l u m nv i o u sp o l i o d e g e n e r a t i o n .N o r m a lm e d i a nn e r v e S E P sc o n f i r me d s y p h i l i si n t e g r i t yo f t h es e n s o r yp a t h w a yi n t h ec e r v i c a la r e amptoms o f t h r o u g ht h ed o r s a lc o l u m n st o t h e s o m a t o s e n s o r y- t e da tb i r t h c o r t e x .M o t o rc o n d u c t i o ns t u d i e sa r en o r m a ls i n c e
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m y e l i t i s ,we h y p o t h e s i s et h a ts h e a c q u i rc o n g e n i t a l l ya n d e x p e r i e n c e dh e r f i r s ts y it e r t i a r yd i s e a s ea t a ge 7 yea r s . I n f a n t si n f e c
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Ta h e sd o r s a l i s :e l e c t r o d i a g n o s t i cf l a t u r e s
m o t o r f i b r e sa r e r a r e l ya f f e c t e di n t a b e sd o r s a l i s .F i b r i l l a t i o np o t e n t i a l si n t h eg a s t r o c n e m i u smu s c l e sc o u l d b e e x p l a i n e db y s u p e r i m p o s e dS , r a d i -c u l o p a t h i e s ,b u t a b s e n c eo f S 1 r o o ta b n o r m a l i t yi np r o x i m a la n d p a r a s p i n a lmu s c l e sa r g u e sa g a i n s tt h i se x p l a n a t i o n .A m o r ep l a u s i b l ei n t e r p r e t a t i o nw o u l d
b e p a r t i a la n t e r i o rh o r n c e l li n v o l v e m e n tk n o w nt oo c c u ri n s o m ec a s e so f t a b e sd o r s a l i s . 3P u p i l l a r ya b n o r m a l i t i e se x c l u d e d ,t a b e sd o r s a l i s
m im i c sp e r i p h e r a ln e u r o p a t h y ,s p i n a lc o r d d i s e a s e ,a n d l u m b o - s a c r a lp o l y r a d i c u l o p a t h y .Ta b e sd o r s a l i ss h o u l db e c o n s i d e r e di n a n y p a t i e n tm a n i f e s t i n gt h ee l e c t r o d i a g n o s t i ct r i a do f n o r m a ln e r v ec o n d u c t i o ns t u d i e s ,a b s e n tH - r e f l e x e s ,a n d i m p a i r e dp o s t e r i o rc o l u m nc o n d u c t i o n .
R e f e r e n c e s
1 S i m o nRD. N e u r o s y p h i l i s .A r c hN e u r o l1 9 8 5 ; 4 2 : 6 0 6 - 1 3 .2 M e r r i t tHH. A Te x t b o o ko fN e u r o l o g y .2 n de d .P h i l a d e l -p h i a ,L e a & F e l s i g e r ,1 9 5 0 : 1 2 9 - 5 3 .3 M e r r i t tHH, Adams RD , S o l o m o nH C . N e u r o s y p h i l i s .
Ne w Yo r k , O x f o r dU n i v e r s i t yP r e s s ,1 9 4 6 .4 H o o s h m a n dH , E s c o b a rMR, K o p fS W .N e u r o s y p h i l i s :
1 0 9 9
a s t u d yo f 2 4 1 p a t i e n t s .JAMA 1 9 7 2 ; 2 1 9 : 7 2 6 - 9 .5 L u g e rA , S c h m i d tB , S p e n d l i n g w i mm e rI , H o r n F .
R e c e n to b s e r v a t i o n so n t h es e r o l o g yo f s y p h i l i s .B r JVe nD i s 1 9 8 0 ; 5 6 : 1 2 - 1 6 .
6 S p a r l i n gP F . D i a g n o s i sa n d t r e a t m e n to f s y p h i l i s .N E n g lJ Me d 1 9 7 1 ; 2 8 4 : 6 4 2 - 5 3 .
7 D y c kP J ,L a m b e r tE H ,N i c h o l sP C . Q u a n t i t a t i v em e a -s u r e m e n to f s e n s a t i o nr e l a t e dt o c o m p o u n da c t i o np o t e n t i a la n d n u m b e ra n d s i z e so f m y e l i n a t e da n du n m y e l i n a t e df i b r e s o f s u r a l n e r v e i n h e a l t h ,F r i e d r e i c h ' sa t a x i a ,h e r e d i t a r ys e n s o r yn e u r o p a t h y ,a n d t a b e sd o r s a l i s .I n : C o b bWA ( e d ) .H a n d b o o ko fE l e c t r o e n c e p h a l o g r a p h ya n dC l i n i c a lN e u r o p h y s i o l o g y .Vo l .9 , S o m a t i cS e n s a t i o n ,Am s t e r d a m ,E l s e v i e rP u b .C o . ,1 9 7 1 : 8 3 - 1 1 7 .
8 G r e e n f i e l dJ G . I n f e c t i o u sd i s e a s e so f t h e c e n t r a ln e r v o u ss y s t e m .I n :B l a c k w o o dW ,McMenemeyWH,M e y e rA , Norman RM, R u s s e l lD S . G r e e n f i e l d ' sN e u r o p a t h o l o g y .2 n d e d , B a l t i m o r e ,Wi l l i a m sa n dWi l k i n sC o , 1 9 6 3 : 1 6 4 - 8 1 .
9 S t e r nRO .A s t u d yo f t h eh i s t o p a t h o l o g yo f t a b e sd o r -s a l i sw i t h s p e c i a lr e f e r e n c et o R i c h t e r ' st h e o r yo f i t sp a t h o g e n e s i s .B r a i n1 9 2 9 ; 5 2 : 2 9 5 - 3 1 6 .
1 0H a s s i nGB .Ta b e sd o r s a l i s ,p a t h o l o g ya n dp a t h o g e n e s i s ,a p r e l i m i n a r yr e p o r t .A r c hN e u r o lP s y c h i a t r Y1 9 2 9 ; 2 1 :3 1 1 - 4 1 .
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