ON THE 
PROGRESSIVE LOCOMOTOR ATAXIA: 
ITS 
HISTORY, SYMPTOMATOLOGY, PATHOLOGY, 
AND TREATMENT. 
BY 
ROBERTS BARTH GLOW, A. M., M. J).. 
Professor of Physics anil Medical Chemistry in the Medical College of Ohio ; Lecturer on Clinical 
Medicine and Physician to St. John’s Hospital ; formerly Assistant Surgeon 
(Captain) U. S. Army, etc. 
CINCINNATI: 
ROBERT CLARKE & CO., 55 WEST FOURTH STREET. 
1866. ON THE 
PROGRESSIVE LOCOMOTOR ATAXIA: 
ITS 
HISTORY, SYMPTOMATOLOGY, PATHOLOGY, 
AND TREATMENT. 
BY 
ROBERTS BARTHOLOW, A. M., M. D., 
Professor of Physics and Medical Chemistry in the Medical College of Ohio; Lecturer on Clinical 
Medicine and Physician to St. John’s Hospital; formerly Assistant Surgeon 
(Captain) U. S. Army, etc. 
CINCINNATI: 
ROBERT CLARKE & CO., 55 WEST FOURTH STREET. 
1866. Neque enim credunt, posse eum scire, quomodo morbos curare con- 
veniat, qui, unde fei sint, ignoret. 
A. Corn. Celsi Medicince Liber I. 
Non minus ccrto etiam a ruinutissimis morb'i circumstantiis indiea- 
tiones curativas possit Mcdieus desumore, quam ab iisdem sumpsit 
diagnostiea. 
Sydenham. Ob. Medicce Prcef. Ed. TerU PREFACE. 
In the preparation of this little essay, I have made liberal use of the 
elaborate work, De L'Ataxie Locomotrice, et en particular de la maladie 
appellee Ataxie Locomotrice Progressive, by Dr. Paul Topinard. The 
sections on the history and symptomatology have been condensed from 
that work chiefly. I have added some historical facts and references; 
and have contrasted the symptomatology of my patient with that de- 
scribed by Dr. Topinard. Whatever aid has been derived from other 
sources is duly acknowledged. 
This essay was written for the Cincinnati Journal of Medicine, and 
appeared in the numbers for April, May, and June. I had the convic- 
tion, in preparing it, that the readers of that periodical would not be 
unthankful for some recent information on a rare form of nervous dis- 
ease, which, as it happened to me, might also happen to them. I do 
not urge the novelty and importance of my labor in justification of its 
republication in this form. It is reprinted now for distribution among 
such of my personal friends and of the professional public as may be 
interested in studies of this character. 
344 Race Street, Cincinnati, 0. 
R. B. PROGRESSIVE LOCOMOTOR ATAXIA: 
ITS 
HISTORY, SYMPTOMATOLOGY, PATHOLOGY 
AND TREATMENT. 
Nomenclature.—The Ataxie Locomotrice Progressive; Duchenne’s 
Disease ; Progressive Spinal Paralysis ; Tabes Dorsalis ; Progressive 
Locomotor Ataxia, etc. 
Stewart Kelch, by occupation a gilder, was admitted to St. John’s 
Hospital, service of Prof. Bartholow, Feb. 10, 1866. 
He gave the following history : 
About the 15th of December last he began to experience some 
troubles of vision; objects were confused and indistinct; soon after he 
had double vision. He noticed that his food had no taste about the 
same time. His hearing and smell were unaffected. In consequence 
of these ocular troubles he consulted a female doctor who had some 
reputation as an oculist, who prescribed an eye-wash and some 
medicine. Finding that no improvement took place he consulted a 
well-known oculist in this city, who, after a prolonged ophthalmoscopic 
examination, directed glasses and gave him some internal remedy. His 
eyesight, soon after this, suddenly improved. 
Whilst he was in attendance upon the female doctor, he began to 
experience numbness and lack of voluntary control in the inferior ex- 
tremities, and the apparent loss of power and the difficulty of locomotion 
were well marked during the period he was under the care of the oculist, 
who, probably, did not recognize the nature of the malady. 
Soon after troubles of the same character appeared in the upper 
extremities. 6 
PROGRESSIVE LOCOMOTOR ATAXIA. 
During the whole period he suffered from nocturnal emissions, saty- 
riasis and at length complete impotence. He had had some troubles in 
micturition and defecation, the desire coming on suddenly and the 
evacuation occurring immediately. 
He had no rheumatic pains. Pricking and tingling in the extremi- 
ties and a dull pain in the loins and limbs, which appeared about the 
time his ocular troubles began, were the only symptoms of this kind. 
Symptoms on admission.—Kelch is 36 years old, 5 ft. 6 in. high, 
light complexion, lymphatic temperament, full face with prominent 
lower jaw ; very protuberant blue eyes. 
He has no troubles of vision at present except some dimness of 
sight; his eyes are more prominent than natural. His face i» express- 
ionless. His taste has returned, but his tongue is protruded to the 
right. Sensibility, both tactile and muscular, diminished in the upper 
extremities, especially the right. Power of co-ordinating movements 
not completely lost, but diminished, in consequence of which his 
attempt to grasp any object is uncertain and vacillating. He can not 
use his knife and fork. He complains especially of a sensation of 
numbness in his hands and forearms, and a sense of pricking. They 
are, .5° F., colder than natural. There is no wasting of the muscles, 
but a contraction of the central tendon of the extensor communis digit- 
orum. His grasp is as strong nearly as in health. 
When requested to stand with his feet together and his eyes closed, 
he can not do so without the support of a chair. He walks as an un- 
practised youth on stilts. When requested to walk across the room, he 
rather runs than walks, and evidently can not control the movements 
of his feet, which are thrown up and down and laterally, in the most 
irregular manner. The chief sensation in his feet is that of numbness. 
Tactile sensibility and myotility are more diminished in lower than 
upper extremities. He perceives the galvanic shock when a strong 
current is passed through his limb, but feebly. The muscular sense is 
almost abolished. In walking, he can scarcely feel the floor, and when 
his eyes are not fixed upon his feet, he can not direct his movements. 
He has been for some weeks entirely impotent. 
His intellect appears to be unimpaired. 
Treatment.—He was put upon the crystallized nitrate of silver, 1-6 
of a grain ter in die. After ten days’ use of this remedy, I gave him 
30 grains of the iodide of potassium daily. His improvement under 
this treatment has been most marked. He is very rapidly regaining 
the power of co-ordination of muscular movements, his cutaneous and 
muscular sensibility are returning ; he walks with considerable vigor PROGRESSIVE LOCOMOTOR ATAXIA. 
7 
and certainty, and tie begins to experience sexual desire with erections. 
The iodide of potassium seemed to be indicated by the fact that the 
patient had for ten years followed the profession of a gilder, and had 
during that period of time, absorbed more or less of the mineral mat- 
ter used in the prosecution of his trade. -As M. Melsens has demon- 
strated that this remedy makes soluble combinations with these min- 
eral poisons, thereby facilitating their excretion, it was applicable to 
the treatment of this case on the theory that the alteration in the spinal 
cord might be due to the slow and long continued action of the miner- 
als. Moreover, the iodide of potassium is one of the most reputable 
remedies in this affection.* 
History. The name, ataxie locomotrice 'progressive, was given this 
malady by Duchenne of Boulogne, who described it with more partic- 
ularity than any of his predecessors, but he is not entitled to the merit 
of discovery. It had been recognized in England in 1847, and was 
well described in Germany in 1834, but under other names, as paraplegia 
with disordered co-ordination of movement, tabes dorsalis, gray degen- 
eration of the posterior columns of the spinal cord, progressive spinal 
paralysis, etc. 
The most ancient of these terms, tabes dorsalis, originated with Hip- 
pocrates, who applied it to the accidents produced by the abuses of 
venery. The passage in which the term occurs is found in De Morbis, 
usually ascribed to Hippocrates, but by Hr. Adams, translator of the 
the Sydenham Society edition of the works of Hippocrates, is assigned 
to the Cnidian school: Tabes dorsalis a spinali medulla oritur, maxime 
vero recentes sponsos et libidinosos corripit. 
Sauvages, a long time after, described a group of symptoms, pro- 
duced by the same cause, which closely correspond to the disease now 
known as progressive locomotor ataxia. Lallemand also, under the title 
of the “ dorsal consumption,” described a set of symptoms of the same 
character.f 
The term tabes dorsalis was, by the Germans, changed in its signifi- 
cation, and applied to a disease of the cord characterized by atrophy of 
this organ. The first autopsy, clearly establishing this condition of the 
cord, was made so long ago as 1679. The disease was very clearly 
described in Hufeland’s Practice of Medicine, under the name tabes 
dorsalis, in 1834. Steinthal, in 1844, was equally explicit in his details 
concerning this disease, describing, as had Hufeland, the difficulties of 
* See reports of two cases in the Medical Times and Gazette, treated with this re- 
medy, Jan. 27, 1866, They were only improved, however. 
f Dee per ten seminales involontaires. Paris et Montpelier, 1869-41. 8 
PROGRESSIVE LOCOMOTOR ATAXIA. 
locomotion, tlie loss of power of co-ordinating muscular movements, 
the amaurotic amblyopia, etc. 
Romberg,* in 1851, under the same name of tabes dorsalis, and Wun- 
derlich, the following year, .under the title of progressive spinal paraL 
ysis, particularize with great precision the essential phenomena of this 
disorder. 
The morbid anatomy of progressive locomotor ataxia had been 
studied with the naked eye only, prior to 1857, in which year Ludwig 
Turck published a memoir at Vienna, in which he described the mi- 
croscopic appearances of the degenerated posterior columns of the 
spinal cord. Virchow and Raciborski confirmed these observations, 
which had established that the alteration proper to tabes, consisted in 
an atrophy of the nervous elements with hypertrophy of the interme- 
diate connective tissue. 
Whilst these observations were accumulating in Germany as to the 
nature of tabes dorsalis, attention was being called in England to defects 
of co-ordination, dependent upon an affection of the cord. Todd, es- 
pecially, influenced by the theoretical views which he entertained as to 
the functions of the posterior columns of the spinal cord, and having 
had two cases in which defects in the co-ordination of voluntary move- 
ments existed with integrity of the muscular force, diagnosticated 
during life and confirmed by post mortem observation, a lesion limited 
to the posterior columns. “ Two sorts of paralysis of movement,” 
says Todd, “ are found in the inferior extremities ; one consists in 
feebleness or loss of voluntary movement; the other is distinguished 
by diminution or complete abolition of the power of co-ordination of 
movements.” He says nothing, however, of ocular troubles. 
In 1856 and 1858, Gull published in Guy’s Hospital Reports a long 
series of observations, relative to diseases of the cord. In one case he 
observed trouble in the co-ordination of movements and alterations of 
the posterior columns of the cord. Gull, ignoring the labors of the 
Ger nans in the same field, ant. the investigations of Duchenne not 
having yet seen the light, did not hesitate to ascribe these phenomena 
to chronic myelitis. 
In Trance various observations were made and recorded in the pro- 
ceedings of the anatomical society, and in the immortal work of M, 
Cruveiihier. These observations extend from : 1828, those of M. Hutin; 
1830, those of M. Cruveilliier; 184-5, those of M. Fredault; 1847, those 
of Monod; 1856, those of M. Luys; to 1858, those of M. Laborde. 
* Manual of Nervous Diseases. Syd. Soc. Trans. PROGRESSIVE LOCOMOTOR ATAXIA. 
9 
It is subsequent to these observations that M. Duchenne announced 
in the Archives de Medicine of 1858, the existence of a new disease 
which he proposed to call “ ataxie locomotr ice progressive,” describing it 
in these terms : “ Progressive abolition of co-ordination of movements 
and apparent paralysis, contrasting with integrity of the muscular force.” 
This able observer ignored the ideas of Todd and the labors of Hufe- 
land, Steinthal, Romberg and Ludwig Turck. His merit consists in 
this : that he comprehended the relation of the symptoms, their habit- 
ual succession, and insisted more than Romberg had done, upon the 
ocular troubles. This was certainly the view of the merit of Duchenne 
entertained by Trousseau, when he baptized the new disease by the 
name of its presumed discoverer. 
Symptomatology.—The duration of this malady is from one to 
thirty years; hence, it is useful to make some divisions to facilitate the 
description. We adopt the division of M. Duchenne : “Tiie ataxie 
locomotrice progressive is divisible into three periods : the first charac- 
terized by three symptoms—pains, ocular troubles and anaplirodisia; 
the second, by disorders of muscular sensibility and of the sensibility 
of the inferior extremities; the third, by the extension of the same 
troubles to the superior extremities.” 
Pains.—These are in general the first symptoms to attract the atten- 
tion of the patient. 
In one hundred and four observations made with reference to the 
frequency of the pains and the period of their appearance relative to 
the ataxic symptoms, they were present in forty-four before the locomo- 
tor ataxia; in twenty, after; in eighteen, present, but time not definitely 
fixed ; in twenty-two, absent. 
They were present in the case of Kelch after the locomotor ataxia. 
These pains are observed in all diseases of the cord, but are more 
frequent in progressive locomotor ataxia. 
At their origin, these pains are fugitive and distributed over the sur- 
face of the body or one of its lateral halves, or they are limited to one 
region, to one extremity, especially to the feet. If, after having been 
generally distributed, they disappear in the superior half of the body to 
concentrate in one limb, this part, in which a primitive or secondary 
localization of the pains has taken place, is destined to be the first at- 
tacked by the ataxic disorders. They are sometimes superficial, some- 
times deep-seated, in the muscles or in the neighborhood of the large 
joints. They are encountered in the head, jaws, orbital cavities, exter- 
nal auditory canal, the urethra, the deeper parts of the pelvis. In the 
globe of the eye they give rise to congestive phenomena, identical with 10 
PROGRESSIVE LOCOMOTOR ATAXIA. 
tlio&e that accompany neuralgia of the fifth; injection of the conjunc- 
tiva, lachrymation, heat, dilatation of the pupil. 
These pains are resolvable into two classes: the one, dull and nearly 
continuous, exceptional; the other, short and sharp, habitual. 
The first have been compared to the sensation produced by the con- 
striction of a limb by a cuirass. 
The second, are sharp pains in the extremities shooting toward the 
trunk; more rarely, they are likened to flashes of fire, puncture of an 
awl, strokes of a hammer, or vibrations flowing along in the direction 
of the muscles, or more commonly, as a tic tac in some point like that 
of a watch. 
Their fundamental character is their mobility and intermittence. 
They may appear and disappear many times a day, and the attacks vary 
in duration from some hours to seven days or more. It is exceptional 
for them to increase at night. Sometimes the pains are so horrible as 
to justify the expression of Remak : tabes dolorosa. 
Their analogy with certain rheuipatismal pains is remarkable. They 
are influenced by all those atmospheric causes which exasperate rheu- 
matic pains. Hence it is that winter is a bad season for the ataxic. 
Functional troubles of the cranial nerves.—These functional derange- 
ments of the cranial nerves were well marked in our case. He had am- 
blyopia, diplopia, protrusion of the eye, paralysis of taste, etc. The 
comparative frequency of these functional troubles of the cranial 
nerves—optic, motor oculi, hypoglossal, auditory, facial, glosso-pha- 
ryngeal, etc., without regard to period is as follows : present in ninety- 
seven cases ; absent in twenty-eight. 
The cranial nerves are divisible into two or three orders: the first 
preside over movement; the other over special sensibility, but some of 
their filaments have general sensibility. What is the nature of the .dis- 
order proper to each ? 
It is evident that the alterations of the optic, auditory, lingual, trige- 
minal (sensitive part), produce but two orders of phenomena: hyper- 
esthesia (the neuralgic or rheumatic pains already alluded to) ; special 
anesthesia (amblyopia, paralysis of taste). 
In regard to the motor oculi, facial, inferior maxillary, hypoglossal, 
that portion of the pharyngeal plexus which presides over the muscu- 
lar sensibility of the vail of the palate, and of the pharynx, and the 
recurrents, their functions will be exalted, or abolished, or perverted; 
the muscles to which they are distributed will be .either paralyzed or 
ataxic. PROGRESSIVE LOCOMOTOR ATAXIA. 
11 
The phenomena proper to the motor oculi are constantly paralysis* 
except two cases in which Friedreich saw double bilateral nystagmus* 
and one in which M. Beau speaks of defects in the co-ordination of the 
movements of the eyes. 
Facial hemiplegia, when there exists greater or less irregularity in 
the two sides of the face, has been noticed. 
Embarrassment of speech and pronunciation has been observed in 
sixty-seven cases. 
The time when these functional troubles of the cranial nerves appear 
Varies. The ocular troubles in more than half of the cases appear in 
the first period, a little after the pains and sometimes in their absence ; 
the feebleness of vision and the embarrassment of speech appertain to 
the second period; and the dysphagia and the paralysis of the vail of 
the palate to a still more advanced period. The most ephemeral and 
intermittent of the ocular troubles are the diplopia and strabismus. 
The temporary character and spontaneous disappearance of these acci- 
dents give rise to a therapeutic illusion. Thus, the subject is surprised 
by them in good health; the pains which precede or accompany them 
are referred to rheumatism; the connection between the two is not un- 
derstood. He goes to an oculist who diagnoses congestion of the papilla 
Or paralysis of the third pair, orders an unguent and collyria, electrizes 
the orbital cavities, and as if by enchantment the malady disappears. 
These examples are very common. It is the history of our own case. 
Did the oculist effect a cure? The symptoms would have disappeared 
as well with cold water. 
The disorders pertaining to the orbital cavities are paralysis of motor 
oculi, producing ptosis, external strabismus, diplopia, and dilatation of 
the pupil; paralysis of the motor externus, producing internal stabis- 
mus and diplopia; paralysis of the patheticus, producing also diplopia 
and strabismus and other vague symptoms. Finally, kopiopia, ambly- 
opia, and amaurosis occur. The diplopia is generally attributed to 
defect in the convergence of the two visual axes upon the object 
examined. 
The condition of the retina, according to the ophthalmoscopic ex- 
aminations, consists in congestion or atrophy, more or less advanced, 
of the optic papilla. This is confirmed by some post-mortem observa- 
tions; in others, however, no alteration is found after death. The 
absence of lesions, remarked by various authors, in the cranial nerves 
affected with functional troubles, is in conformity with the temporary 
character of the different symptoms. It is this fugitiveness which 12 
PROGRESSIVE LOCOMOTOR ATAXIA. 
enables the distinction to be made between them and similar maladies 
arising from other causes. 
Troubles in the genital organs.—In respect to importance, the disorders 
of the genital organs take place after the pains and ocular derange- 
ments. In Germany especially, where the ancient views on the subject 
of tabes dorsalis are not yet forgotten, a particular interest attaches to 
these symptoms. That venereal excesses are causative can hardly be 
admitted. As it is difficult to question females, all our observations 
are silent with regard to them. Moreover, nocturnal pollutions may 
occur without constituting a morbid state. Finally, the subjects who 
are attacked by this malady have generally attained the age of from 
thirty-five to forty years, the period of natural decline in the sexual 
desire. 
Four symptoms present themselves: spermatorrhoea, anaphrodisial 
and impotence. The first occurs among the earliest symptoms of the 
first period. In the case of Kelch, spermatorrhoea had existed for six 
months prior to the occurrence of the ocular troubles. He admitted to 
venereal excesses. The nocturnal pollutions, accompanied at first by 
erection and pleasurable sensations, finally became passive. After the 
spermatorrhoea, or sometimes preceding it, there is a progressive dimi- 
nution of the venereal desires, difficulty in satisfying them, and at 
length complete impotence. 
Vesical disorders are observed in some cases. The trouble con- 
sists in slow emission of the urine, incompleteness in emptying the 
bladder, and inability to determine when the emission of urine has ter- 
minated. Incontinence has been observed, but retention rarely. 
Among the disorders of micturition is found anaesthesia of the vesi- 
cal and urethral mucous membrane, in consequence of which the indi- 
vidual is unconscious of the emission of urine. The dysuria, as the 
ocular paralysis, is temporary and intermittent. 
Rectal troubles are rare. Constipation is habitual. When the mat- 
ters are liquid they escape before the patient has time to reach the 
closet. Incontinence does not occur until about the commencement of 
the second period. 
These vesical and rectal troubles occurred in our patient Kelch. PROGRESSIVE LOCOMOTOR ATAXIA. 
13 
Duchenne's Second Period.—The boundary between the first and 
second period is not so clearly marked as the arbitrary division of Du- 
chenne would indicate. It is by very gradual and sometimes almost 
imperceptible steps that the patient passes from one to the other, al- 
though but a few months may be occupied in the transition. It is by 
accident, in the street, at night or morning, that the patient perceives 
suddenly a numbness in the bottom of his feet, heaviness and feebleness 
in the inferior members, or some difficulty in walking. Our patient, 
Kelch, described these very characteristically. On rising in the morn- 
ing, he first began to perceive that his feet were “ asleep,” that it was 
necessary to stamp them upon the floor for sometime before he was able 
to walk with any degree of certainty. This symptom was at first only 
experienced in the morning, but it gradually increased so as to be felt 
at all times. He attributed the uncertainty of his steps entirely to the 
sensation of numbness* 
The progress of the malady is not always gradual; sometimes the 
symptoms occur suddenly and by leaps, as it were. When the symp- 
toms of the first period have not appeared, or should they be incom- 
plete, the beginning of the second period may be still either insidious 
or well-marked. Numbness, ataxia, anaesthesia, dysuria, and the same 
ocular phenomena may appear at the same time or at short intervals. 
Numbness.—The ataxic allude under this name, to an internal sensa- 
tion of heaviness, seated in a part or whole of a member, as if it were 
asleep. The numbness is a phenomenon, connected with the general 
sensibility, but distinct from the sense of touch, of heat, of pain, and 
from the muscular sensibility. It is a perversion of the functions of the 
sensitive nerves, as is the pains or the tingling. Some patients employ 
the words numbness and tingling as convertible terms. Kelch, so em- 
ploys them in describing his sensations. The tingling, however, be 
refers to his forearms and hands, especially the right, more than to the 
inferior extremities. It corresponds to the distribution of certain fila- 
ments of the radial nerves and is accompanied by uncertainty of touch 
and inability to use his hands properly. As remarked in the history of 
his case, he had been unable for sometime to use his knife and fork. 
This sensation, however, did not extend to the trunk as it often does. 
Cutaneous Anaesthesia.—Anaesthesia is one of the habitual symptoms 
of the progressive locomotor ataxia. In 109 observations, this symp- 
tom, complete or incomplete, was present in 76 cases, very lightly in 15, 
and not at all in 18 cases. It was very manifest in our patient, Kelch. 
A diminution, perversion, or exaltation of sensibility is found in this 
malady in the skin and in the mucous surface accessible to our investi- 
gation ; but we have here in view the cutaneous anaesthesia, chiefly. PROGRESSIVE LOCOMOTOR ATAXIA. 
14 
M. Beau recognizes two modes of sensibility in the integument—one 
special, or sensorial, as the sense of touch; the other general, as the 
sense of pain. M. Landry distinguishes a third, the sensibility to 
temperature, 
When the anaesthesia is complete there is no difficulty; but if one or 
two of the three kinds of sensibility, only, is involved and that lightlyy 
it is important to apply the best and most delicate tests. An examina- 
tion of the ataxic to be complete should be extended to the four mem- 
bers, to the trunk and face, and to many points in the various regions,, 
which habitually, are very unequally and differently affected. The 
prick of a sharp pin, pinching with the nails and with an artery forceps,- 
plucking the hairs, tickling, the successive application of one or more 
fingers, of cold or hot bodies, the electric shock, may all be applied to- 
determine the extent of the anaesthesia. When it is difficult to deter- 
mine the modification of sensibility, comparison should be made between 
two symmetrical points, as the plantar surface of the feet, the inner faces 
of the thighs, the forearms, etc. Incomplete anaesthesia, as the numb- 
ness, advances step by step, from the plantar surface of the foot toward- 
the pelvis and trunk. Its intensity is stronger in- the part primitively 
affected, and its superior limit is not well defined. For example, the 
plantar surface of the foot, is without sensibility to touch, to pain or to- 
tickling, the calf of the leg is somewhat more sensitive, the thigh is slow 
in transmission of the impression only, and the belly is normal. In the 
superior extremities the anaesthesia is experienced in the fingers, espe- 
cially the ring and little fingers, diffuses itself over the rest of the hand 
and forearm, rarely passing above the elbow; but it reappears in the 
neck, in the inferior half of the face, and extends to the tongue, to the 
internal face of the jaws and to the vail of the palate. In our patient 
Kelch, this partial anaesthesia was confined to the hands and forearms— 
the ring and little fingers being more affected than the rest of these 
parts. The two halves of the body are not necessarily symmetrically 
affected. Thus one arm, one side of the face, of the tongue, is affected,, 
while the other side may not be. 
The sensibility to pain is diminished or abolished in places, in 
regions or in the whole extent of a member. The part affected may be 
pricked and the blood drawn without evidence of pain, but it is indis- 
pensable that the point of the instrument be exceedingly fine, for an 
ordinary pin will arouse the sense of touch. Pinching with the nails,, 
which is easily graduated, has not this inconvenience. The sense of 
touch is habitually altered. The patient is deceived as to the real cause 
of an impression and as to the point at which it is made. He does not dis- 15 
PROGRESSIVE LOCOMOTOR ATAXIA. 
tinguish the touch of one or more fingers, from that of some other 
object. He confounds a small roll of paper with a pencil. The con- 
sequences of tactile anaesthesia may be, thus, attributed to ataxia. 
Trousseau and Duchenne have observed that the thermoscopic sensi- 
bility continues in the ataxic. It was hence supposed that this consti- 
tuted a means of differential diagnosis between progressive locomotor 
ataxia and other affections of the cord, but subsequent investigations 
have shown that this view is erroneous; the thermoscopic sensibility may 
exist in various diseases of the cord. 
Muscular Anaesthesia.—The sentiment of muscular activity, the mus- 
cular sense, the muscular conscience, are synonymous terms, clearly 
separable, however, from the muscular sensibility. 
Several methods may be adopted to ascertain the state of the muscular 
sensibility. The electrical method is mathematically accurate. It is 
applied as follows : the skin having been dried with some absorbent 
powder to neutralize the superficial effects of the electricity, a current 
of variable intensity is passed through a muscle in the direction of its 
length. In the physiological state this current determines a contraction, 
but in addition thereto, a dull sensation if it is feeble, and a pain if it 
is strong. This sensation—as was the case in our patient Keleh—what- 
ever may be the intensity of the current, is in the ataxic, either very feeble 
or null. We thus measure the electro-muscular sensibility as it is 
called. The second method is more easy of execution. This consists 
in ascertaining the degree of sensation produced by pinching with the 
pulps of the fingers a sufficient quantity of the skin; afterward of a por- 
tion of healthy muscle, the sterno-mastoid, or biceps for example. This 
pressure graduated at will, may be made to produce acute pain. The 
suspected muscles are afterward explored in the same fashion. It is 
rare that the responses of the patient, how little intelligent soever he 
may be, leave any room for doubt. The third method is more especi- 
ally to determine the state of the muscular sense. It is based upon 
this : In the physiological state, without having recourse to our sense 
of vision, we are concious of the direction which the will imposes upon 
our members, and of the precise point at which a movement is arrested. 
The use of the eyes is necessary to the ataxic, to conduct his movements 
It is also useful to ascertain the degree in which the patient possesses 
the faculty of appreciating the weight of bodies, or the knowledge of 
the amount of muscular force necessary to raise a given weight. With 
this view different weights are placed in his hands, and his appreciation 
of them noted. 
Locomotor Ataxia.—The locomotor ataxia is described in general 16 
PROGRESSIVE LOCOMOTOR ATAXIA. 
terms by Topinard, as a disorder of the function which presides over 
progression, equilibration, and other voluntary muscular acts, not caused 
by paralysis, muscular atrophy, deformity of the skeleton, etc., and 
different from paralysis agitans, chorea, or general or partial convulsions 
tonic or clonic. 
The phenomena of the locomotor ataxia are to be studied as they 
manifest themselves in the inferior extremities, in the superior extremi- 
ties, in the face, etc. Those partaining to the inferior extremities are 
most interesting and important. In our patient Kelch, as indeed in the 
greatest number of cases, the uncertainty of locomotion was most mani- 
fest in the morning in dressing. Sometimes it is felt in the street, 
more often in the evening and in darkness. They experience pain in 
mounting the stairs, or in stepping up on to the pavement. They con- 
tinue to attend to business, but find they grow more readily fatigued 
than was their wont. A strong emotion, a slippery pavement, or the 
exertion to avoid an approaching carriage causes them to trip and fall 
unless there be some ready support at hand. Already they appreciate 
the utility of vision, and say that the disorders of locomotion are ex- 
aggerated because their attention is withdrawn from their own move- 
ments. To give them assurance in walking, they must have the idea 
that some one is near to succor them. The fears which they display, 
come of the experience which they have acquired of the instability of 
their movements and insufficiency of their support, and do not prove 
pusillanimity. Some authors have imagined that the defects of control 
of the voluntary movements are only experienced by the patient in the 
erect position ; but they are also observed when he is in the recumbent 
position. When the patient gets under the bed clothes he extends him- 
self by a quick and rough movement. If he be desired to execute a 
given movement, the muscles become rigid, the foot is extended upon 
the leg, the leg upon the thigh, and the limb, all of one piece, launches 
out at a single bound, or by irregular jerks, in the desired direction. 
The motions of the pelvic-femoral muscles, are most visibly ataxic. In- 
telligent patients explain the rigid extension which they instinctively 
give to the foot and leg in executing a given movement, by saying that 
their muscles are more rebellious to the will in intermediate attitudes. 
When the patient is required to assume the erect posture, and place 
his feet together, he is seen to oscillate from side to side, betrays a cer- 
tain anxiety, stretches out his arms like a ballancer, in spite of himself, 
and finally falls. 
In walking the ataxia assumes considerable proportions, in many 
cases ; in others, however, it is almost inappreciable. To facilitate the 17 
PROGRESSIVE LOCOMOTOR ATAXIA. 
description, we distinguish arbitrarily, in respect to intensity, three 
degrees of ataxia. 
In the first degree the patient raises his feet roughly, one after the 
other; they describe the arc of a circle with the convexity turned out, 
without dragging upon the floor; the toes elevate themselves a little in 
advancing, and the heels turn in toward each other, striking the ground 
with force. He walks without decision, and can not place his feet where 
he desires. 
In the second degree, the walking has been compared to that of a 
man inebriated, or to that of a landsman on a sailing packet, or to that 
of a rope dancer. An examination of the muscles discloses the fact 
that the flexors and extensors are hard and stiff. The triceps forms a 
considerable protuberance, which gives to the limb a special and forced 
configuration. The walk is carried on by the aid of the pelvic-femoral 
muscles. The feet are raised quickly, are jerked forward, the toes being 
elevated. 
In the third degree of ataxia the patient is unable to step without 
holding on to a chair, to the bed post, or without being supported by 
two attendants. The sole of his foot seems in perpetual search of a 
point of support which continually escapes. Sometimes one of the feet 
turns into such a position that its outer side rests on the ground, and 
its dorsum appears in advance; or one leg, describing a great circle, 
becomes locked behind the external malleolus of the opposite limb. 
It is difficult to describe the precautions and the stratagems which 
are used by those patients who have retained the use of their arms, in 
getting out of bed on to a chair and in pushing up to the stove. Their 
attention is applied to avoid the most feeble voluntary movements, they 
dare not abandon their caution for an instant, knowing that the first 
effort of muscular contraction will be the signal of an agitation which 
all their efforts can not repress. 
In the superior extremities the ataxic disorders are less characteristic, 
and, also, less frequent. In Kelch they were marked and came on early. 
In 118 cases collected by Topinard, the ataxic disorders extended to the 
upper extremities in 46 cases, and in one only, were limited exclusively 
to these members. There are some differences, also, in the phenomena 
observed, due to certain differences in the physiological properties of 
the lumbar and cervical enlargements of the cord. 
To discover the troubles of co-ordination of the superior extremities, 
many methods are employed. They were disclosed in Kelch by an ina- 
bility to use his knife and fork. The patient may be desired to make 
the sign of the cross, to carry his index finger to the extremity of his 18 
PROGRESSIVE LOCOMOTOR ATAXIA. 
nose, to pick up some small object, etc. His movements may be ex- 
amined when lie eats, dresses, sticks a pin, ties a cravat, etc. These 
ataxic disorders appear in the upper extremity usually after they attack 
the lower; sometimes in the two extremities simultaneously. The first 
indication of them is seen in the awkwardness of the patient in perform- 
ing the various acts above mentioned. lie does not touch directly with 
the index finger, the point of his face which is designated to him. In 
all those acts in which the sense of touch is employed, and in picking- 
up small objects, the ataxia becomes plainly visible. 
In the third period, all of the symptoms of progressive locomotor 
ataxia have become general; the signs of the first and second period 
are united, much more intense and occupy a more extended surface. 
The movements are frightfully irregular and disordered in the erect 
position; prehension is impossible; cutaneous anaesthesia extends to 
impressions of heat and cold ; the muscular anaesthesia is absolute ; the 
muscular sense is abolished; there is incontinence of urine and fames, 
and lastly, a true paralysis supervenes. 
State of the Muscular force.—The ataxies are in general vigorous sub- 
jects, well nourished, whose muscles are hard and prominent, and limbs 
are voluminous. A small number, on the contrary, are irritable charac- 
ters, hypochondriacs and feeble. 
Before using the dynamometer to ascertain the state of the muscular 
force, the physician must study the constitution, temperament, idiosyn- 
crasies of the subject, the lowering of his vital forces by mental depres- 
sion, insomnia, bad hygiene, by the sojourn in hospital, etc. A simpler 
method than the use of the dynamometer, is that employed by Topinard, 
as also by Duchenne. For the muscles of the arm, shoulder, thigh, leg 
or foot, they should be placed in the attitude to insure their maximum 
contraction, and the patient should be directed to maintain, with all his 
force, this position; the degree of force necessary to overcome this re- 
sistance, will be a measure of the muscular force. It is sometimes 
necessary in the same subject to compare sound with affected muscles, or 
one side of the body with the other. 
The fundamental condition of the ataxic paraplegia of Todd, and the 
progressive ataxia of Duchenne is the integrity of the muscular force. 
This proposition of Duchenne, is a little too absolute. Ordinarily the 
ataxia exists with persistence of a sufficient degree of muscular force to 
preclude the idea of paralysis; but, also, in a great number of cases 
there is a progressive feebleness, more apparent in the regions where 
the evidence of the other affections is most prominent, due to the influ- 
ence of the cord upon nutrition and to an alteration of the motor parts PROGRESSIVE LOCOMOTOR ATAXIA. 
19 
of this organ. Finally incomplete, and sometimes, complete paralysis 
is a remote termination of the malady. The anatomy and physiological 
pathology of this disease agree perfectly with this view. Considered 
with reference to the periods, it is certain that integrity of the muscular 
force is a character more constant in the second, although its diminution 
is an indication of aggravation of the lesion in the cord. 
Course and Duration.—The course of the malady has been suf- 
ficiently indicated in the preceding pages. The duration of the first period 
only, can be approximatively fixed. We have before remarked that it 
oscillates between some months and twenty years; it averages from four to 
five years. From the origin of the disease, indicated with more or less 
clearness by the pains, the ocular troubles and the ataxia, to the second 
period—in 4 cases the duration is spoken of as months; in 6 cases as 
one year ; in 27, as from two to three years ; in 47, as from four to seven 
years; in 17, as from eight to fourteen years; in 18, as from fifteen to 
thirty years. The average is seven years. We have seen that in our 
patient Kelch, the duration of the first period, was somewhat less than 
one year—taking as the point of departure from the state of health, the 
sudden occurrence of spermatorrhoea. If, however, we assume that the 
ocular troubles were the first symptoms in his case, six months will in- 
clude the whole course of the malady, so far as it had developed itself. 
There can he no question that the sexual disorder was the first symptom. 
It will be perceived that the phenomena observed in his upper extremi- 
ties, were those of the first period, and not of the second. We have 
consequently no means of determining the duration of the first period 
if its evolution had not been interfered with it. As Topinard’s statis- 
tics show, somewhat more than four per cent, had a duration less than 
one year. 
Complications.—These are divisible into two classes: those pertaining 
to the cerebro-spinal axis; those of other parts of the body. Among 
the first are spinal meningitis, congestion and softening of the cord and 
of the brain, general paralysis, and progressive muscular atrophy. 
Cephalalgia, dizziness and intellectual disorders which sometimes ac- 
company the ocular derangements, must be viewed as complications.. 
Some patients complain of loss of memory, and forgetfulness of certain 
words, certain events, etc. Others present various hallucinations. 
Mania or dementia, is found at an advanced period—the termination of 
the second or in the third period. 
The complications of the second class are either acute or chronic. Of 
the acute affections, cystitis, enteritis and erysipelas are the most fre- 
quent. Cystitis usually results from the prolonged retention of the 20 
PROGRESSIVE LOCOMOTOR ATAXIA. 
urine—the bladder expelling it but in part. The symptoms first ob- 
served, are those of sub-acute, afterward of chronic cystitis. The in- 
flammation extends along the ureter to the kidneys, and finally gives 
rise to urinous fever and putrid infection. The occurrence of enteritis, 
Topinard is disposed to ascribe to the prolonged use of the nitrate of 
silver, the remedy so much vaunted by Wunderlich in the treatment of 
the progressive locomotor ataxia. Of the chronic affections, phthisis 
pulmonalis is most common. In 44 deaths, 13 were attributed to this 
cause. 
common form presents two distinct periods—the first 
and the second—or begins by locomotor ataxia, and has f<?r characteristic 
the appearance, sooner or later, of functional disorders of the cranial 
nerves, of which the ocular troubles are the most important. In the 
paraplegic form, the affection is limited to the inferior members. To 
distinguish this from an ordinary myelitis, it is necessary to pay great 
attention to the progress of the case, to the physiognomy of the symp- 
toms and to the characters of the ataxia. 
In the cerebral form, cerebral phenomena are added to the symptoms 
of the common form, indicating morbid alterations in the brain corres- 
ponding to those affecting the cord and the periphery of the cranial 
nerves. Cephalalgia, changes of humor, loss of memory and delirium 
are the cerebral derangements characteristic of this form. 
Our author strongly objects to the so-called acute form of this disease 
in which the total duration of it is limited to some months. The age 
of the subject (referring to one of these cases reported by M. Bourguig- 
non), the rapid succession of the accidents, the total duration of four 
months and a half, the prompt and radical cure, are all in contradiction 
with the mass of our observations. He therefore rejects this form, but 
it seems to us, on insufficient grounds. 
Pathological ANATOMY.“~The alterations characteristic of this 
disease have been carefully studied both by the naked eye and by the 
microscope. In the work of Topinard* very full and exact descrip- 
tion of the morbid appearances is given. Trousseauf quotes with 
approbation from the essay of Dr. Axenfeld, Des lesions atrophiques de 
la moelle epiniere. Having had no opportunity of studying these 
lesions for ourself, we propose nothing more than to condense from 
these authorities an account of the pathological anatomy sufficient to 
* Op. Cit., p. 310 to 387 inclusive. 
f Clinique Medicate de L'Hotel-Dieu de Paris. Tome deuxieme, p. 534 el seq. Paris, 
1865. PROGRESSIVE LOCOMOTOR ATAXIA. 
21 
give some completeness to this essay, without running into prolixity of 
detail. 
As a general rule the spinal meninges are free from disease; in a 
single case only in forty autopsies, according to Topinard, were they 
considerably affected. There is sometimes increased vascularity of the 
meninges, especially in the vicinage of the posterior columns. 
The characteristic alterations are found in the posterior columns and 
in the posterior roots of the spinal nerves. These alterations consist in 
changes of form, volume, consistence, and color. The change in form 
and volume is due to atrophy of the columns affecting their antero- 
posterior diameter. There is usually a diminution of consistence, but 
in a few instances induration has been observed. The change in color 
is, according to Topinard, constant and almost pathognomonic. The 
columns become semi-transparent, of a gray color, variegated here and 
there of an amber yellow, which may become rose, according to the 
quantity of blood, and contrast strongly with the normal whiteness of 
the adjacent parts. The alterations in the posterior roots proceed cor- 
respondingly with the changes in the posterior columns. In Topi- 
nard’s forty autopsies these roots were altered more or less in all but 
four cases. It is exceptional for this degeneration to invade the antero- 
lateral columns; it is ordinarily limited to the posterior columns. 
There are no constant and characteristic alterations of cerebrum and 
cerebellum. The cranial nerves, whose functional derangement is a 
prominent feature in the symptomatology of this disease, are found to 
be more or less affected. In twelve cases carefully observed, two only, 
according to Topinard, presented no evidences of disease. The optic is 
probably more constantly affected than any other cranial nerve. The 
changes observed in it consist of an increase in vascularity, diminution 
in size and firmness, softening and atrophy, gray degeneration, and 
semi-transparency. Sometimes the atrophy is so considerable, that 
the nerve becomes transformed into a fibrous cord. 
The description of the microscopic appearances by Dr. Axenfeld, 
quoted by Trousseau, is the most succinct, consistent with clearness, that 
has fallen under our observation. According to this author, the white 
substance of the posterior columns becomes gray or yellowish, and the 
nerve tubes, pale and shrunken, are sometimes reduced to the mere en- 
velop containing granular contents. But few of them preserve the 
cylinder axis. An increase of the conjunctive hyaline substance in 
which the nerve tubes are implanted, gives to the nerve substance a 
fibrillar appearance; and there may be found here, in greater or less 
abundance, amyloid corpuscles, recognizable by their reaction with the 22 
PROGRESSIVE LOCOMOTOR ATAXIA. 
tincture of iodine. In the posterior cornua of the gray substance 
there occur the same alterations, but to a less marked extent. The 
changes in the posterior roots do not differ from those of the corres- 
ponding column. The vessels also are seen to he considerably enlarged, 
their coats thickened and incrusted with fat granules. “ To sum up,” 
says Axenfeld, “all of these alterations clearly consist in an atrophy of 
the nervous elements.” 
Topinard (p. 335) also, after a very elaborate discussion of the micro- 
scopic appearances, sums up his conclusions in a few words : “The mi- 
croscopic examinations have shown the essential lesion in the different 
parts of the nervous system to consist of a gray, semi-transparent, or as 
it is styled by Cruveilhier and Virchow, a gelatiniform degeneration 
with a progressive atrophy of the nervous elements, hypergenesis of the 
conjunctive substance, amyloid bodies, and molecular granules.” 
Are the above described alterations constant to all stages of this dis- 
ease? Is the progressive locomotor ataxia, in any part of its course, a 
functional disorder? At what period do these lesions of the posterior 
columns and roots manifest themselves? These are questions of pecu- 
liar interest. It has been said that the case of Kelch was not one of 
progressive locomotor ataxia, because the symptoms were evolved in so 
short a period of time, and were so much mitigated by treatment. For- 
tunately, the data exist for a solution of two of the problems proposed 
for our consideration. Let us take the testimony of Trousseau upon 
the first two questions. This ablest of modern physicians, in his lec- 
ture on this subject (vol. ii, p. 545-6), places this disease among the 
neuroses. He bases this opinion upon clinical observation, upon the 
nature of the symptoms which characterize the nervous troubles, upon 
the apyretic march of the symptoms, and upon the mode of evolution, 
the variety, and especially the mobility of the symptoms. “When,” 
says Trousseau, “I assert that the malady is not subordinate to the ex- 
istence of material lesions, I refer only to those lesions appreciable by 
our means of investigation.” He quotes in support of this opinion the 
remarkable case observed by M. Gubler, in which, although the patient 
had been long afflicted with progressive locomotor ataxia, after death 
by variola, there was found absolutely nothing in the encephalon, in the 
medulla oblongata, and in the posterior columns and roots of the spinal 
cord. “The cord was, it is true, generally injected, but this may be 
explained by the paralysis supervening in the course of the variola.” 
The optic nerves had undergone gelatiniform degeneration, and the 
rnotores oculorum were flattened, diminished in volume, but were not 
gyay. In every other part of the nervous system the characteristic PROGRESSIVE LOCOMOTOR ATAXIA. 
23 
alterations were entirely wanting. Topinard, who gives the same case 
(p. 353), concludes that the preceding observation (case of M. Gfubler) 
tends to demonstrate, 1. That the symptom ataxia is not the imme- 
diate effect of the gray degeneration of the posterior columns ; 2. That 
it may exist six months before the degeneration of the posterior columns 
manifests itself, that is to say, without anatomical alteration appreciable 
by our present means of investigation ; 3. That in the evolution, not 
only of the degeneration, but of the disease considered in its totality, 
the visible alteration of the optic nerves is anterior to that of the cord. 
To obviate the difficulty in accounting for the phenomena observed in 
Gfubler’s case not dependent upon anatomical lesions, M. Topinard in- 
vents the words dynamical alteration (alteration dynamique), which, we 
may be permitted to observe, express no understood pathological law 
or doctrine. 
A variety of clinical facts support the conclusions of morbid anato- 
my. A certain number of cases of progressive locomotor ataxia, treated 
early, are either cured, arrested, or decidedly ameliorated. We have 
already alluded to the case of M. Bourguignon (Topinard, p. 298), in 
which there occurred complete recovery, the case having progressed 
through its several stages in a period of six months. Topinard also 
gives a case (p. 305) admitted to the Hotel-Dieu in the service of Pro- 
fessor Trousseau, in which very decided amelioration took place after 
one year and nine months of treatment. Dr. Radcliffe, physician to 
Westminster Hospital, in a recent lecture* on progressive locomotor 
ataxia, speaks of “two cases which justify a much more hopeful 
opinion” than is usually prognosticated. D. Meryonj' gives a case for 
which he advised the twentieth of a grain of strychnia to be taken 
night and morning, and the employment of very weak cutaneous fara- 
disation, in which, after five months’ perseverance, “there is decided 
improvement.” Further, the great apostle of this disease, Duchenne, 
■affirms that he has cured by faradisation cases in his first stage. We 
may safely add to this array of testimony our own observation. What 
is the present state (May 1) of our patient, Kelch ? The amelioration 
in all of his symptoms, described in the first part of this paper, con- 
tinues, but he has not entirely recovered. A certain degree of ataxia 
remains, and is especially manifest when he rises from his chair and at- 
tempts to walk, or when he turns without using his eyes to direct his 
* London Lancet, January, 1866. 
f Practical and Pathological Researches on the various forms of Paralysis. Lon- 
don, 1864, _ 24 
PROGRESSIVE LOCOMOTOR ATAXIA. 
feet. Thus far we can only affirm, with regard to his case, that it is one 
of “decided improvement.” 
A careful study of the clinical facts and post mortem observations 
authorize the conclusion that in the beginning the progressive locomo- 
tor ataxia is a functional disorder, and that a certain number of cases, 
if not curable, are capable of very great improvement. The boundary 
between functional disorder and organic change is unfortunately not at 
all clearly marked in our clinical observations, and not well defined 
even by our present means of investigations in morbid anatomy. When 
does the degeneration commence in the posterior columns? The symp- 
toms do not enable us to decide this question. Topinard, as we have 
seen, asserts that the ataxia may exist six months before any but a “dy- 
namic alteration” occurs. The division of Duchenne into the three 
periods based upon the symptomatology is, therefore, an arbitrary ar- 
rangement. 
Division into Periods based upon the Patholgical Condi- 
tions.—In this view, the first period is one of functional trouble 
merely: the second period one of organic change. The first period is 
characterized by the mobility and intermittence of all the symptoms, 
their spontaneous disappearance, or the decided amelioration of them 
by treatment \ the second by the persistence and progressive increase 
in the gravity of all the symptoms, especially the amaurosis and the 
difficulty in the co-ordination of voluntary movements. All of the 
phenomena in our patient, Kelch, would, therefore, be referred to the 
First Period, except the ataxia, which, persisting, probably inaugu- 
rates the Second Period. 
Differential Diagnosis.—There can be little difficulty in the di- 
agnosis of a pronounced case of progressive locomotor ataxia. During 
Duchenne’s first period—the stage of functional disorder—it is not al- 
ways possible to interpret the pains, the ocular troubles, and the ana- 
phrodisia correctly. It is very important to recognize early the import 
of these symptoms, which may be done by attention to the order iu 
which they occur, to their temporary character, and to their unaccount- 
able disappearance. As the disease progresses the difficulties in diag- 
nosis diminish. The particular maladies with which it is most liable 
to be confounded are myelitis, softening of the brain, and general 
paralysis. The pains, the muscular anaesthesia, the persistence of the' 
thermoscopic sensibility, the urinary and genital troubles, the ataxia, 
and the persistence of the muscular force, clearly distinguish this' 
disease from those above mentioned, in which these symptoms are- 
wanting. Some excellent observations on the differential diagnosis PROGRESSIVE locomotor ataxia. 
25 
have been made by Althaus, Hugblings Jackson, Radcliffe, and 
others in the London Lancet during the past year. All of these 
observers allude especially to the ataxia and to the persistence of the 
muscular force as diagnostic. 
(p. 371), after a careful analysis of one hun- 
dred and nineteen cases, sums up his conclusions as to the causes of this 
disease in the following terms: “The progressive locomotor ataxia is a 
disease of mature age, more frequent in the male sex, in those who are 
addicted to excesses of all kinds, and who are exposed to humidity and 
to great fatigue. Among the temperaments, the nervous is the only one 
which certainly disposes to a particular form of the malady. Among 
the diatheses, the rheumatismal is the only one the influence of which is 
incontestible.” Trousseau (vol. ii, p. 514) ascribes considerable im- 
portance to hereditary tendency. It will be found in many cases, he 
says, that the direct or collateral ancestors have been affected with 
other forms of nervous diseases. 
The relation of sexual excesses to the production of this disease is 
an interesting question. We have already presented the opinions of 
Topinard on this point. The views of many of the German pathologists 
of the causes producing tabes dorsalis have descended from Hippocra- 
tes. “Tabes dorsalis,” says Hippocrates,* “arises from the medulla 
spinalis, and happens chiefly to those who are libidinous or lately mar- 
ried,” etc. Celsusf alludes to similar effects caused by nimia profusio 
seminis. Yan SwietenJ repeats the observations of Hippocrates. Lal- 
lemand,§ in his description of the “dorsal consumption,” speaks of 
troubles of vision, amblyopia, diplopia, anaesthesia, and difficulties of 
locomotion, etc., resulting from spermatorrhoea. “It is impossible, 
says Dr. Meryon (op. cit., p. 197), “to ignore the resemblance between 
this disease and that which is known as tabes dorsalis. Roth may be 
occasioned by onanism or by excessive veneryj both give evidence to 
the existence of irritation in the spinal cord, in both enuresis and sper- 
matorrhoea frequently occur,” etc. This view of the influence of sex- 
ual disorder can hardly be admitted. The venereal excesses and the 
spermatorrhoea must be regarded as symptoms, chiefly, of the mischief 
in progress in the spinal cord. Trousseau (loc. cit.) gives some striking 
facts in proof of this; cases in which the singular faculty existed of 
* De Morbis, lib. ii, cap. 19. I have already remarked that Dr. Adams assigns 
this work to the Cnidian school, 
f De Medicina, lib. iv, p. 187. Edit, Ed, Milligan. Edinburgh, 1831. 
Commentaries, vol. v. p. 85. 
$ Dictionnaire de Medecine, Art. Spermatorrhee, par M. Raige-Delorme. 26 
PROGRESSIVE LOCOMOTOR ATAXIA* 
being able to repeat the sexual act frequently in a short space of time) 
“a deviation from the physiological state.” One of these patients ad- 
mitted to having intercourse six or seven times in twenty-four hours> 
The first symptom in our patient, Kelch, was a remarkable increase in 
the activity of his sexual desires) this, however, was quickly followed by 
profuse spermatorrhoea. 
Was there any thing in the occupation or external conditions of our 
patient, Kelch, to account for the production of his symptoms? In his 
business, as a gilder, gold foil is the substance chiefly employed, and a 
small quantity of white lead in the preparation of the frames. The 
symptoms have been ascribed, by some persons unacquainted with the 
essential phenomena of the progressive locomotor ataxia, to lead poison- 
ing. We might adduce, in answer to this doubt, two cases quoted by 
Topinard, in the first of which (ob. xxxiii) the symptoms were clearly 
those of lead poisoning (intoxication saturnine), but in the second, a 
painter (ob. cxcviii), all of the phenomena were those of the progres* 
sive locomotor ataxia. Kelch had never suffered from colic, paralysis, 
nor did he present any of the evidences of mineral poisoning, except 
the symptoms of the disease under which he labored, which may or 
may not be attributed to his occupation ; most probably not. There is 
no evidence of hereditary tehdency in his case. 
Treatment.—The treatment of the progressive locomotor ataxia is 
a most unsatisfactory subject. The term progressive is unfortunately 
too often most fitting) for no matter what therapeutical expedients we 
may adopt, the disease continues on its course. Much depends, how- 
ever, as we have already seen, upon the period of the disease in which 
we find our patient. The very unfavorable prognosis ordinarily ex- 
pressed, heretofore, must now be somewhat modified. The cases which 
we have adduced show that appropriate treatment may accomplish 
much, if employed during the stage of functional derangement. 
JDuchenne relies upon the iodide of potassium and faradisation. We 
have quoted two cases from the Medical Times and Gazette, in which 
the use of the iodide was followed by improvement. Dr. Huglilings 
Jackson says that this drug was of considerable benefit in one case un- 
der his charge, and without service in others. Our own case is a strik- 
ing example of its value. 
The nitrate of silver, proposed by Wunderlich, has been much em-- 
ployed with apparent advantage in some cases, but in many more it has 
failed utterly. The propriety of prolonged administration of this 
remedy is very questionable; at most the benefit is very doubtful, and 27 
PROGRESSIVE LOCOMOTOR ATAXIA. 
its ill results are certain. Topinard attributes to this remedy the 
ritis which has been observed in some cases. 
Ergot and belladonna in combination proved very successful in the 
hands of Dr. Charles Taylor. Trousseau thinks favorably of the latter, 
Arsenic, oil of turpentine, and strychnia have also been used without 
any very decisive results. 
The favorite remedies with the Drench are sulphur baths, douches, 
and electricity faradisation chiefly. 
An improved hygiene is very important. The subjects of this mal- 
ady are principally those who have been exposed, by reason of poverty 
and unhealthy occupations, to the common causes of disease. A more 
abundant diet, a purer atmosphere, warmer clothing, and cleanliness 
have in many instances apparently arrested the progress of the disease. 
These hygienic means should not be neglected in any case. Without 
their aid remedial agents will probably prove useless. Certainly the 
facts which we have presented in the course of this paper give us en- 
couragement to persevere in the treatment, for, if not curable, we have 
every reason to hope for an arrest of the morbid action, an improve- 
ment in the symptoms, or a decided amelioration in all of the attendant 
phenomena,