NOTES 
ON 
THE PHYSIOLOGY AND PATHOLOGY 
OF THE 
NERVOUS SYSTEM 
WITH REFERENCE TO 
CLINICAL MEDICINE. 
A—DISSEMINATED SCLEROSIS OF THE BRAIN AND SPINAL CORD 
8.-ANNULAR OR CORTICAL SCLEROSIS OF THE SPINAL CORD. 
■ BY 
MEREDITH QLYMER, M. D. Unit. Penn., 
FELLOW OF THE COLL. PHY3. PHILADELPHIA, ETC., ETC. 
[REPRINTED FROM TEE NEWYORK MEDICAL JOURNAL, MAY, 1870.] 
D. APPLETON & COMPANY, 
NEWYORK: 
90, 92 & 94 GRAND STREET. 
1870. NOTES 
ON 
THE PHYSIOLOGY AND PATHOLOGY 
OF THE 
NERVOUS SYSTEM, 
"WITH REFERENCE TO 
OLINTIOAL MEDIOIAE. 
INTRODUCTION. 
It is proposed in these papers to summarize the recent in- 
vestigations into the physiology and pathology of the nervous 
system which have a bearing on clinical medicine. Quite 
lately much of worth has been done in this direction. New 
and nicer methods of examining the intimate structure of the 
brain and spinal marrow in health and in disease, have unset- 
tled many traditional notions concerning several classical dis- 
orders, and fixed the connection between symptoms and lesions. 
Thanks to the better studies of those who have busied them- 
selves with these subjects, we have now satisfying and trust- 
worthy information, where before confusion and uncertainty, 
or, at best, happy conjecture, ruled. There has been patient 
and productive working; facts have been largely and heed- 
fully gathered, and rightly used ; sagacity has tempered zeal; 
and more concern has been shown about practical results 
than engaging hypotheses. It is not, therefore, claiming too 
much to say that art is a great gainer by these scientific in- 4 
SCLEEOSIS 
quiries. The outcome is a less faulty pathogeny, with a truer 
understanding of many common affections of the nervous 
centres, and surer means of detection and treatment. 
I. 
SCLEROSIS OF THE NERVOUS CENTRES, 
Virchow says, “ Sclerosis (mcXrjpog) signifies thickening 
with condensation.”1 This definition is too limited and 
vague. The term is strictly descriptive, not of induration 
from any cause, hut of changes in the textural condition 
of an organ. It involves both quantity and quality. There 
is overgrowth (proliferation) and transformation of connective 
tissue, with consequent wasting of the proper functional ele- 
ments of the part. The processus is constant wherever it hap- 
pens, and includes both' creation, metamorphosis, and de- 
struction. The undue development of the basis-tissue in the 
liver, kidney, or lung, is always at the cost of the specific 
material of those organs; so sclerosis of the nervous centres 
means not only parasitic exuberance of the connective gangue 
(neuroglia), but proportional compression, deterioration, and 
annihilation of the ganglion-cells and nerve-tubes. There is 
histological substitution. This is its univocal characteristic. 
The perversions of function which we shall study under the 
name of symptoms are all referrible to it. Comprising what 
has hitherto been treated of by writers under the name of 
chronic inflammation of the brain and spinal cord—chronic 
encephalitis and chronic myelitis,—it is only lately that its 
true pathogeny has been intelligently set forth. Morbid con- 
ditions, hitherto confounded but essentially distinct, have been 
differentiated, and the proper signs of each modality estab- 
lished. 
Sclerosis of the nervous centres is met with in four forms : 
A. Disseminated, or Multilocular ; la sclerose en plaques dis- 
seminees; B. Cortical, annular, or peripheral; la sclerose ou 
annulaire, G. Fascicular, a, primitive, d, secondary ;la scle- 
rose rubannee, primitive ou secondaire; JD. Diffuse; la scle- 
rose diffuse. 
1 Cellular Pathology, Chance’s translation. American Reprint, p. 468. OF THE NERVOUS CENTRES. 
5 
A. DISSEMINATED, OR MEL TIL OCULAR, ‘SCLEROSIS OF THE DRAIN 
AND SPINAL CORD. 
Definition.—A disease of the cerebrospinal centres / of 
gradual invasion, beginning with muscular weakness of one 
or both lower limbs, subsequently extending to the xipper, and, 
sooner or later, passing into complete paralysis, which may 
in time affect, in some degree, the muscles of the head, neck, 
face, pharynx, and tongue / no constant derangement of 
cutaneous sensibility / the univocal symptom, tremor in the 
implicated muscles, which happens only when any intentional 
movement is attempted, and ceases in a state of rest; fre- 
quently nystagmus ; attended in the later stages with cramps, 
and permanent rigidity and contraction of the palsied mem- 
bers ’ of probably diathetic origin ; slowly and surely pro- 
gressive in its course, and constantly of fatal termination / 
the anatomical characters being patches or corns of sclerosis, 
irregularly disseminated, in the brain and spinal cord. 
History.—The first mention of a pathological condition of 
the nervous centres which was probably sclerosis, is in a re- 
port of “A Palsy occasioned by a Fall, attended with Un- 
common Symptoms,” by Dr. A. Maty, dated December 29, 
1766, and published in “Medical Observations and Inquir- 
ies ,” vol. iii., 2d edition, London, 1769, p. 257. Count Lordat, 
a French nobleman, had, in the overturning of a carriage, 
his neck sharply twisted. He quickly apparently recovered 
from the effects of the accident, and went through a severe 
military campaign, during which he was constantly exposed 
to damp and wet. Some time after he noticed an impedi- 
ment in his speech; then his left arm grew weak, and the 
corresponding leg; he began to have convulsions all over 
the body, and became paralytic. The account of the 
autopsy was sent to Dr. Maty by the count’s physician in 
France. Fie writes: “We observed no signs of compression 
in the lingual and brachial nerves as high as their exit from 
the basis of the cranium and the vertebrae of the neck ; but 
they appeared to us more compact than they commonly are, 
being nearly tendinous. . . . The central substance of the 
brain appeared much browner than usual. . . .We chiefly 6 
DISSEMINATED SCLEROSIS 
took notice of the medulla oblongata; it was more compact 
. . . the marrow itself had acquired such solidity as to elude 
the pressure of our fingers ; it resisted as a callous body, and 
could not be bruised. This hardness was observed all along 
the vertebrae of the neck, but lessened by degrees, and was 
not near so considerable in the vertebrae of the thorax.” By 
the term vertebrae, the region of the spinal cord is evidently 
meant. 
Dr. Marshall Hall (Diseases and Derangements of the 
Nervous System, 1841) relates the case of a man, aged 
twenty-eight, with tremor of the right arm and leg, who had 
a peculiar rocking motion of the eyes, and a degree of stam- 
mering and defective articulation. This was unquestionably 
an example of Charcot’s disease. 
The earliest description of disseminated cerebro - spinal 
sclerosis is by Cruveilhier, in his Atlas de VAnatomic Patho- 
logique (Paris, 1835-1842). Two cases are given; and their 
clinical history and morbid anatomy, with the accompanying 
plates, leave no doubt of their nature.2 About the same 
time (1838) Carswell gave an accurate representation of it in 
his Illustrations of the Elementary Forms of Disease, under 
the head of “ Atrophy ” (pi. iv., fig. 4). In the descriptive 
note he says : “ Isolated points of the pons varolii, of a yel- 
lowish-brown color, patches of the same kind on the spinal 
chord ; all of them occupying the medullary substance, which 
was very hard, semi-transparent, and atrophied. The atrophy 
was more conspicuous in some points than in others.” In 
1856, Ludwig Tiirck published several cases.3 Rokitansky 
2 Obs. Paraplegic: Degdndration grise de la moelle, du bulbe, de la 
protuberance, des pddoncules cerebelleux, des couches optiques, du corps 
calleux, de la vofite a trois piliers.—Liv. xxxii., pi. ii., fig. 4. 
Obs. Insensibility presque complete des membres inferieurs. Diminu- 
tion de la sensibility des membres superieurs. Diminution notable, mais 
relativement moindre, de la myotility.—Degeneration grise beaucoup plus 
considerable dans les cordons postdrieurs que dans les cordons anterieurs 
de la moelle dpinidre.—Liv. xxxviii., pi. i. and ii. A mixed case, being as- 
sociated with posterior sclerosis, or locomotor ataxy, and to be more par- 
ticularly mentioned hereafter. 
8 Tiirck L. Leber Degeneration einzelner Euckenmarksstrange. Sitz- 
ungsbericht der K. Z. Akad. zu Wien; Matbem. ISTaturw. Classe. 1856. OF THE BEAIH AHD SPHSTAL COED. 
7 
mentions the structural change in his Pathological Anatomy.4 
In 1855, Prerichs (Haser’s Archiy, Bd. x.) published several 
cases and described the lesion. The following year (1856), 
Yalentiner, his assistant, made the first attempt at a systematic 
clinical history of the disorder.5 He reprinted Frerichs’s cases, 
and collected a number of others (15), which he supposed to be 
of the same kind. But, according to Dr, Charcot, he did not 
group them with any exactness, and, under the same title, de- 
scribed conditions quite dissimilar. Hasse, in Yirchow’s 
Jlandbuch, and Eiemeyer in LehrbucJi der Special. Patholog. 
und' TTierap., have followed Yalentiner’s mixed description. 
Jaccoud says that Demme published a case of sclerosis of the 
antero-lateral columns, with microscopical examination, in 
1859, but where he does not state, and I have been unable to 
find it. Prof. Oppolzer, in 1861,6 published a case of paraly- 
sis agitans, with induration of the pons, medulla oblongata, 
and of the lateral columns, particularly in the lumbar region. 
In Leyden’s well-known contribution on gray degeneration of 
the cord (1863), the case numbered XXXI. is one of diffuse 
sclerosis.7 Frommann reproduced this case in his work on the 
normal and pathological anatomy of the spinal cord, and de- 
tails with great minuteness the histology of the lesion.8 Pind- 
fleisch, too, has described its histology with exactness,9 and 
In previous papers (1851, 1853, and 1855), be had described secondary 
sclerotic degenerations of the cord. In this he treats of primary sclerosis 
of the lateral and antero-lateral columns, and gives three cases, with 
microscopic examinations. 
4 Rokitansky, 0. Lebrbnch der Pathol. Anat., Zweiter Band, p. 488, 
1856. Ueber Bindcgewebs-Wucherung im Hervensystems, Wien, 1857. 
6 Yalentiner. Ueber die Sclerose des Gehirns and Riickenmarks. 
Deutsche Klinik, Bd. xiv., 1856. 
6 Oppolzer. Wiener medicin. Wochenschi’ift, 36, 38, 1861. Oanstatt’s 
Jahrb., hi., 78, 1861. Trousseau’s Clinical Medicine, Bazire’s translation, 
vol. i., 446. 
7 Die graue Degeneration der hinteren R tlckenm arksstran go, Berlin, 
1863. Also Yirchow’s Arcliiv, xxix., 202, 1864. 
8 Frommann. Dntersucbnngen liber die normale n. patbolog. Anatomic 
des Ruckenmarks, 2 Theil. 77, pi. i., Jena, 1867. 
9 Rindfleisch. Histolog. Detail zu der grauen Degeneration von Him u. 
Rtickenmarks. Yirchow’s Arclhy., Bd. xxvi., 1863. 8 
DISSEMINATED SCLEROSIS 
Zenker published (1865) a very carefidly-drawn-up case.10 A 
case of Skoda (1862) should have been also mentioned.11 L. 
Leo’s valuable cases were published in 1868.12 
In France, Drs. Charcot and Yulpian had studied its ana- 
tomical characters between 1863 and 1865. On the 26th -Jan- 
uary, 1865, Charcot read a paper before the Societe Medicale 
des Ilopitaux de Paris, on “ Sclerosis of the Lateral Columns 
of the Spinal Cord, in an Hysterical Woman, whose four 
limbs had, during life, been permanently contracted.” It ap- 
peared in the Gazette Hebdomadaire, February 17,1865. The 
first complete and accurate description of the disease, clini- 
cally and anatomically, was, however, by Dr. Yulpian, in 
1866.13 Three cases were given, one of his own, and two 
of Dr. Charcot’s. Dr. C. Bouchard utilized Charcot’s and 
Yulpian’s cases, which he had seen at La Salpetriere, and 
made a communication on the subject to the Medical Con- 
gress at its meeting at Lyons, 1867. In 1866, Dr. Jaccoud 
gave a clinical lecture at the Hopital de la Charite on a 
a case which he styled diffuse sclerosis, and which has been 
since published.14 In 1868, Dr. Ordenstein’s thesis appeared, 
in which Charcot’s views were represented, and the differen- 
tial diagnosis between paralysis agitans and disseminated scle- 
rosis was for the first time15 set forth. In the spring and sum- 
mer of 1868, Dr. Charcot largely and minutely discussed the 
subject in his Clinical Lectures at La Salpetriere. These were 
subsequently published.16 A case was communicated to the 
Societe de Biologie, in January, 1869, by Joffroy, The case 
10 Zenker, Ein Beitrag zur Sclerose des Barns u. Rilckenmarks, Zeit- 
schr. f. rat. Medizin. Bd. xxiv. 
11 Skoda, Wien. Med. Halle, hi., 13, 1862. Schmidt’s Jahrbucheck, 
No. 119, p, 294. Syd. Soc. Year Book, 1863, 100. 
12 Leo. L. Deuts.. Archiv. f. Klin. Med.. 1868. 151. 
13Yulpian. Note sur la Scl&rose en plaques de la moelle 6pini£re. 
Union Mbdicale, 1866. 
14Jaccoud. Le§ons de Clinique Medicale, 2d ed., Paris, 1869. In Les 
ParapKgies et I’Ataxie da Mouvement (p, 245), 1864, he had already alluded 
to the subject. See also Traitd de Pathologic Interne, t. i., 821, Paris, 
1869, by the same author. 
15 Ordenstein. Sur la Paralysie agitante et la sclerose en plaques gen- 
6ralisees. Paris, 1867. 
16 Gazette des Hopitaux, 1868. OF THE NERVOUS CENTRES. 
9 
of Dr. Pennock, by Drs. Morris and Weir Mitcliell, appeared 
in tbe American Journal of the Medical Sciences, July, 1868. 
It is tbe only contribution of this country. It does not appear 
that the diagnosis was made during life. In 1869, Drs. Bourne- 
yille and Guerard published their essay, “De la Sclerose en 
Plaques Disseminees; ” and subsequently Dr. Bourneville his 
“ Nouvelle Etude sur quelques Points de la Sclerose en 
Plaques Disseminees.” They are a reproduction of Charcot’s 
Clinical Lectures, with a collection of all the known cases of 
the affection. In the last volume of the Memoirs of the 
Biological Society of Paris, Dr. Liouville has two interesting 
cases, and Dr. Magnan one, in which there was papillary atro- 
phy of both eyes.17 
To Dr. Charcot, therefore, unquestionably belongs the 
credit of distinguishing this affection from other paralytic dis- 
orders, and notably from paralysis agitans, of recognizing its 
pathological individuality, and tracing its clinical history. 
He has done for it what Chomel and Louis did for typhoid 
fever when they established it as a distinct species of contin- 
ued fever, characterized by a definite group of symptoms. 
There has always been much confusion in the clinical history of the 
disorders of the nervous system in which tremor is a chief symptom ; and 
the result has been to confound diseases pathogenetically distinct. A 
proper comparative study of the different forms of tremor, and an ac- 
curate investigation of the quality of the symptom have been only recently 
made. There are two morbid groups in which tremor is a prominent symp- 
tom, and in each its character is proper and distinct. In the one it is a 
constant symptom, or, if temporarily suspended, it is only during sleep; 
in the other it never happens except as accompanying a voluntary move- 
ment ; it is always absent -when the limb or body is at rest. Galen seems 
to have noted the two kinds, and to have made a distinction between 
rpdfiog (tremor) and ttalpbg (tremor coactus). Van Swieten speaks of 
tremor coactus, always present except during sleep, and tremor debilitate, 
which accompanies intentional movements. (Comment. Aph., 625.) Dr. 
Gubler recognized also the two varieties of trembling, but made no at- 
tempt at any clinical or pathological interpretation (Archives Gen. de Med., 
5e s., t. xv., p. 702, 1860). 
17 Liouville. Deux cas de sclerose en ilots multiples et diss6min6s du 
cerveau et de la raoelle epiuiere. Comptes rendus des seances et Me- 
moires de la Soci6t6 de Biologic, t. xx., 1869. 
Magnan. Note sur une observation de sclerose en plaques ebrebro-spi- 
nale avec atrophie papillaire des deux yeux. 1. c. Archives de Phys. Nor, 
et Path. 2'^me annee (1869) p. 765. 10 
DISSEMINATED SCLEROSIS 
All the English authors confound this disorder with paralysis agitans. 
Parkinson, whose description of shaking palsy has been closely followed, 
unquestionably did. He was aware of Maty’s case, refers to it, and ex- 
presses the opinion that the probable morbid condition in paralysis agitans 
may prove to be induration of the upper part of the medulla spinalis, 
oblongata, and pons, due, as he supposes, to simple inflammation, or rheu- 
matic, or scrofulous affection of the nervous substance or membranes. 
Dr. TV. R. Saunders (Reynolds’s “ System of Medicine,” vol. ii.), in an ex- 
cellent article on paralysis agitans, confuses it with diffuse cerebro-spinal 
sclerosis; though aware of the sclerotic lesion of the cord, he is greatly at 
fault Avhen he attempts to connect it with its proper clinical history. For 
example, he says: “In more inveterate, especially senile cases, paralysis 
agitans appears to depend on a discoverable lesion, namely, an atrophic 
condition of the spinal cord,” etc. (p. 199). Again : “This atrophy would 
explain the chief features of the disease. . . , the occurrence in old age, 
. . . under conditions of premature senility ” (p. 199). Previously (p. 186) 
he writes: “Lastly, the term paralysis agitans, or shaking palsy, has been 
applied to cases of ordinary motor paralysis (hemi- and paraplegia) com- 
plicated with tremors—a complication not uncommon in diseases of the 
brain, and in certain cases of chronic myelitis, and of locomotor ataxia. . . . 
Parkinson’s malady is idiopathic paralysis agitans, in which the tremors 
are the chief and earliest symptom, and the paralysis entirely subordinate 
and peculiar, true hemi- or paraplegia being rare complications; while, in 
the cerebral and spinal affections just referred to, the loss of motion or sen- 
sation is the main feature of the disease, and the tremors and spasmodic 
agitations are only concomitants (i. e., the paralysis agitans is symptomatic). 
Hence the latter kind of cases should be styled, not paralysis agitans, but 
hemi- or paraplegia, or spinal or cerebral disease complicated with paralysis 
agitans ; i. e., with spasmodic tremors. This description, which is essen- 
tial for the accurate definition of Parkinson’s disease, has often been over- 
looked, and requires, therefore, to be specially insisted on.” Really, 
though imperfectly, describing diffuse sclerosis of the nervous centres, at 
p. 193, he says: “ Occurring in middle life (twenty-five to fifty), however 
formidable in appearance, it is susceptible of amelioration, and sometimes 
of cure.” There is other evidence in the article to show how unsatisfac- 
tory the writer’s notions are respecting the disease we are about to de- 
scribe. 
The latest British authority, Dr. Handfield Jones (Studies on Func- 
tional Nervous Disorders, 2d edition, London, 1870), treating of paralysis 
agitans, remarks: “It appears to me a question whether two distinct affec- 
tions are not often comprehended under this name ” (p. 383). But, from 
what immediately follows, it is clear that he had not disseminated cerebro- 
spinal sclerosis in mind, as one of the two indiscriminated affections. He 
goes on to say: “For, on the one hand, it appears pretty certain that there 
is one form which is met with in old persons, is quite incurable, and is asso- OF THE NEEYOUS CENTRES. 
11 
dated with, if not dependent on, organic wasting changes in the nervous 
centres; while another form occurs in younger persons, is more curable, 
and is therefore presumably not dependent on organic change.” 
Clinical History.—Although the anatomical characters of 
this affection are constant, and always of the same histological 
constitution, their territorial distribution may vary. This 
capriciousness of site consequently qualities the symptoms, and 
it is necessary to admit several forms of the disorder, each 
to a certain extent represented by proper functional disturb- 
ances ; these are determined by the exclusive, or predominant, 
occupation by the lesion of one or more districts of the cere- 
bro-spinal system. 
Disseminated sclerosis of the nervous centres may be de- 
scribed, therefore, under three divisions, according to situa- 
tion : a, cerebral form; b, spinal form; c, cerebro-spinal form. 
a. Cerebral Form.—It is doubtful if this form ever hap- 
pens strictly alone. The only recorded observation is that by 
Yalentiner and Frerichs, and here the spinal cord was not 
examined after death with proper care. 
Case.—A youth, nineteen years of age, was suddenly 
seized, without apparent cause, with unilateral (left) motor 
and sensory paralysis, which soon extended to the other side. 
There was general muscular unsteadiness, and voluntary move- 
ments brought on excessive tremor in the extremities, which 
after a while was induced by any attempt at speaking or by moral 
emotion. The gait was oscillating, and the patient obliged 
to use crutches. At first, some mental excitement was noticed, 
but there soon succeeded spells of melancholy. There were 
eccentric neuralgia and twitchings in the affected muscles, 
and subsequently attacks of vertigo, with pain in the occipital 
region. Two years after the outset, paralysis of the limbs was 
almost complete, though still most marked on the left side; 
the tremor had increased and was nearly constant; speech 
unintelligible; urination and defecation irregular; nystagmus; 
and gradual weakening of the intellect. A few days before 
death, which occurred about this time, tremor ceased. Patches 12 
DISSEMINATED SCLEROSIS 
of sclerosis were found in the pons varolii, olivary bodies, and 
at the base of the brain. 
ib. Spinal Form.—The invasion is usually very gradual, 
the first symptoms being tingling and numbness in one 
or both legs, or soles of the feet, which are soon followed 
by weakness in the limbs; this last may, however, be an 
initial symptom. The paresis grows worse by degrees, and 
if it has been limited to one extremity, as is often the case, 
will, after a while, involve the other, and extend to the upper 
extremities. The gait, which from the outset may have been 
more or less unsteady, is now staggering like that of a drunken 
man. All muscular acts are uncertain, and rhythmical spasms 
accompany any voluntary movement of the affected muscles. 
Cutaneous sensibility, in respect to touch, pain, and tempera- 
ture, is unaffected, the cases in which, at this time, any modi- 
fication has been noticed, being exceptional. The general 
health is good. As the disease advances, paralysis, more or 
less complete, succeeds the paresis; all the symptoms just de- 
scribed worsen, and new ones appear. They are: 1. Tonic 
muscular spasms, occurring spontaneously, or after artificial 
excitation. Although generally happening at a late period, 
they have been met with during the early stages, particularly 
in those cases in which paraplegia has set in soon. These 
cramps are mostly limited to the lower extremities, rarely 
affecting the upper, and, when they do, only in a slight de- 
gree. One or both lower limbs may become suddenly rigid, 
and any attempt to move them in certain directions is found 
to be difficult or impossible. After some time this rigidity 
passes off, and the affected member may be moved at the will 
of the operator. 2. Permanent contractions, which follow 
strictly in their development the course of the palsy, 
striking first the legs, then the arms, and occasionally the 
muscles of the trunk. The position of the lower ex- 
tremities is, for a while, that of fixed extension, while the fin- 
gers are bent inwards. Finally, motility, which has been pro- 
gressively growing weaker, is totally abolished; all power of 
voluntary motion in both the upper and lower extremities is 
lost, and the unfortunate patient is condemned to keep his OF THE NERVOUS CENTRES. 
13 
bed. The legs are forcibly flexed on tbe tbiglis, tbe thighs 
on the pelvis, and the heels are drawn closely np towards the 
buttocks. It is almost impossible to straighten the limbs, 
an effort to do so causing great pain. Sensibility is still often 
intact. In some patients, reflex movements may be provoked 
by pinching the skin, or tickling the soles of the feet, while in 
others these excitations are without result. Finally, the gen- 
eral health fails; nutrition becomes defective, and there is 
rapid emaciation ; sloughs form on the sacrum, and death hap- 
pens from exhaustion, or some intercurrent acute disease. 
There are several varieties of this form of spinal sclerosis, 
as one or other column of the cord is chiefly or exclusively 
affected; or more than one column may be implicated, and in 
such cases the symptoms will be of a mixed character, as when 
the lesion involves the posterior and anterior, or antero-lateral, 
columns at the same time. In such cases the phenomena proper 
to locomotor-ataxy will be associated with those of the spinal 
form of disseminated sclerosis. (See Cases in Appendix.) 
g. Cerebrospinal Form.—The accession may be insidious, 
as in the preceding form, or abrupt. Simultaneously with, or 
foregoing, or following, the motorial troubles, there are ocular 
or cerebral disorders, as constant vertigo, pain in the head, 
difficult articulation, weakness of sight, or diplopy; these 
may be only transitory. In some instances there have been 
occasional attacks of cerebral congestion, without loss of con- 
sciousness, but attended by temporary hemiplegia (Charcot, L. 
Leo). Sooner or later tremor affects the extremities and eye- 
ball (nystagmus). The paralytic symptoms follow very much 
the same course as in the spinal form, attended with rigidity 
and permanent contraction. These latter have appeared as 
early as two years after invasion, but most generally not 
sooner than five or six years, so that if the patient should die 
from an acute disease before that time they may be altogether 
wanting. The spasmodic jerkings of the paralyzed muscles, 
spontaneous or induced, are nearly always limited to the in- 
ferior extremities. The ocular troubles get worse, and the 
ophthalmoscope shows flight dilatation of the retinal 
veins, and sometimes atrophy of the papilla. Articulation is 14 
DISSEMINATED SCLEROSIS 
more difficult and fragmentary; the words are as it were 
scanned, each syllable being distinctly and slowly pro- 
nounced, owing to muscular weakness hindering the move- 
ments necessary to proper utterance, and not to any cerebral 
defect. The several forms of cutaneous sensibility in many 
cases are undisturbed, or nearly so. The expression of 
the face is natural. The mental faculties may be for some 
time perfect, but after a while memory is impaired, the tem- 
per becomes irritable or melancholic, and intelligence grows 
feebler by degrees, until it is quite lost. The general func- 
tions are yet good, though there may be constipation and fre- 
quent micturition. The progressive loss of motility renders 
the patient perfectly helpless ; the muscles of the mouth and 
pharynx are paralyzed, and mastication and the deglutition 
of solids, and even of liquids, difficult or impossible; the saliva 
accumulates in the mouth, or dribbles out of the corners of the 
lips, after ineffectual attempts at swallowing it. Sloughs form 
on the parts of the body exposed to pressure. Bapid de- 
terioration of the system causes death from exhaustion ; or an 
attack of caseous pneumonia, bronchitis, erysipelas, dysentery, 
or acute phthisis, or apoplexy, proves quickly fatal. 
Consideration of the Special Symptoms.—lnvasion.—ln a few 
cases, as has been stated, the onset is without warning or ap- 
parent cause, the patient becoming suddenly paraplegic—in 
one instance with lessened sensibility. Or the attack may be- 
gin with an apoplectic seizure with or without loss of conscious- 
ness, and followed by temporary hemiplegia, and tits of ver- 
tigo. But in a large majority the approach is insidious, and 
before any weakness in the lower extremities is complained of, 
there is tingling in the legs and soles of the feet, with occa- 
sional numbness and coldness, and a sense of fatigue after 
slight exertion. Some stiffness and awkwardness in the move- 
ments may be noticed; and in a few instances, probably where 
the posterior columns of the cord were affected from the out- 
set, there have been darting pain-spells. 
Motility.—The paresis may be regularly progressive from 
the outset, or it may abate from time to time. After a while 
the gait becomes uncertain; the patient stumbles on level OF THE NERVOUS CENTRES. 
15 
ground, or on meeting with the slightest obstacle; he gets 
weary quickly, and is obliged to use a cane, or some support. 
The loss of voluntary power in the muscles rapidly increases, 
and the limbs are useless. The paralysis follows invariably 
the course of the paresis; and frequently in this order ; first, 
the left leg, then the right, the left upper extremity, next the 
right; afterward the muscles of the face, neck, and trunk. 
Tremor.—This is the univocal pathognomonic symptom, 
to which all others are secondary, and by which the diagnosis 
is made. It gives the disease its special physiognomy, like the 
peculiar gait of locomotor ataxy. The period of its appear- 
ance is variable, and often difficult to fix. In one case it was 
evident three months after the onset; in one, eight months; 
in one, fifteen months ; and in others it was not noticed until 
several years after the paraplegia had set in. It never occurs 
except on some voluntary muscular effort, or, as happens in 
the later stages, when excited by mental emotion, as the 
sight of a stranger, or the examination of the physician. At 
first it is slight; and, if the patient keeps his bed, may be 
overlooked, for it is always absent when the muscles are at 
rest. Under these circumstances it must be sought for; the 
patient should be made to execute certain movements, as car- 
rying his hand to his head, or a vessel to the mouth. In the 
erect position a series of oscillations takes place, the equilib- 
rium being maintained with difficulty, and the body swaying 
towards all sides. If walking is possible, titubation or stagger- 
ing, as in the gait of a drunken man, is well marked, and 
there is a constant tendency to fall over, or sometimes back 
ward. Like the paralysis, tremor extends upward, and after 
the arms and hands, the head, eyes, and tongue, may be affected. 
An attempt to drink will set the head shaking, or even raising 
it from the pillow. The oscillatory movements of the eyeball 
(nystagmus) are often so great as to hinder ophthalmoscopic ex- 
ploration. They usually occur only on using the eye, and try- 
ing to fix an object. The nystagmus is nearly always binocu- 
lar, only one case being reported where it was monocular. 
When the tongue is protruded it is found to be tremulous; 
words are uttered in a peculiar manner, the difficulty of articu- 
lation increases, and, finally, speech is unintelligible. 16 
DISSEMINATED SCLEROSIS 
The kind or type of the tremor, is a series of rhythmical 
twitchings (secousses) or short spasms, which at first are mod- 
erate, and do not prevent the usual movements of the affected 
limb, but modify their mechanism. In raising a glass of water 
to the lips, the gesture is not continuous and harmonious, but 
broken, jerking, and ill-regulated; the control of the will over 
the muscular effort is manifestly weakened; and the hand is 
carried in various directions before the act is accomplished; 
or, from the violence of the jactitations, it may become im- 
possible. The tremors of the limbs are usually in the direction 
of flexion and extension, sometimes of ab- and adduction, and 
occasionally in that of rotation. The head nods, rolls, or 
partially rotates; and the motions of the jaw are lateral. 
Towards the end, when the limbs are permanently con- 
tracted, and consequently immovable, the tremors cease in 
them, but may continue in the head, neck, and trunk. 
Sensibility.—Sensibility to touch, pain, tickling, and tem- 
perature, may be not at all or but little deranged. Partial 
hypersesthesia was noticed in a few instances. In two cases there 
was muscular anaesthesia, the notion of position of the limbs be- 
ing lost, but cutaneous sensibility was natural (L. Leo). One 
patient had analgesia (Charcot); and in another con tactile dis- 
crimination was lessened or wanting in certain areas of the 
skin (Liouville). A superficial burning heat in the lower ex- 
tremities was constantly felt by one individual; and Dr. Pen- 
nock had the sensation of a narrow band around one of his 
legs. 
Of the special senses, vision is the one most commonly af- 
fected. The sight is frequently weak from the outset; pho- 
topsia has occurred with amblyopia. Once it is stated that 
the sense of smell was lost, and at the autopsy patches of scle- 
rosis were found in the olfactory nerves. 
Contractions.—These never occur before the paralysis is fully 
established, usually after several years, and hence belong to a 
late period of the disease. They too follow the line of attack 
of the palsy; beginning in the lower extremities, they are at 
first partial and intermittent, but finally become generalized 
and permanent, often extending to the muscles of the jaws and 
trunk, in which case the patient lies a helpless, inert mass, OF THE NERVOUS CENTRES. 
17 
drawn up in a heap. The direct relation between symptom and 
lesion has several times been demonstrated. In one case of con- 
traction of the left arm, examination of the cord after death 
showed that the two anterior columns, and the left lateral col- 
umn, at the level of the middle of the cervical enlargement, had 
undergone sclerotic transformation (Charcot). In another, 
where there had been rigidity of the right upper extremity 
with slight flexion of the forearm and permanent extension of 
the extremities, a band of sclerosis on the right antero-lateral 
column extended from just below the olivary body to the up- 
per part of the cervical enlargement. 
Cramps.—These occur in paroxysms, lasting from a few 
minutes to several days. A limb may of a sudden become 
thoroughly rigid, and resist all efforts to move it. One in- 
stance is mentioned where the lower extremities were seized 
when in a state of adduction. They are often very painful, and 
when over leave a sense of fatigue in the limb. 
Muscular spasm-spells—the spinal epilepsy of Brown-Se- 
quard—are almost limited to the lower extremities. The limbs 
are jerked about as by rapid electric shocks. When their de- 
gree is less, the spasms are like the muscular startings from 
strychnine. If they happen before motility is completely 
abolished, they may alternate with the cramps. 
Patho-Anatomy.—The morbid appearances of the spinal cord 
will be first described. The membranes are usually healthy, 
although sometimes there are a few brown dr amber-yellow 
stains on the pia mater immediately over the affected seg- 
ments of the cord; the stellate cells in these spots are filled 
with pigment matter.18 Often, through the pia mater, grayish 
patches may be distinguished here and there on the surface of 
the cord. On stripping off the membranes, which is easily 
done, these are found to have irregularly oval but, well-de- 
18 In one of Vulpian’s cases (No. 2) there were several librold patches 
adherent to either layer of the arachnoid. There was hyperaemia of the pia 
mater of the inferior segment of the cord in another (No. 3), with some 
cartilaginous patches on the visceral layer of the arachnoid. When me- 
ningitis is found after death, it is almost always recent, about the cauda 
equina, and ascending, and secondary, being caused by the sloughs on the 
sacrum. 18 
DISSEMINATED SCLEROSIS 
fined outlines, of an ashen or ground-glass color, and to he dis- 
tributed over several columns of the same side, or confined, or 
nearly so, to symmetrical columns. They frequently intersect 
the fissures and lines of emergence of the nerves. Their di- 
mensions are variable, generally from three to four centime- 
tres long, by two or three broad; they may be mere grains or 
linear streaks. They are firmer to the touch than the sur- 
rounding tissue, and somewhat depressed and shrunken, though 
in a few instances they were slightly prominent (Cruveilhier, 
Charcot), probably indicating an early stage of development, 
for they were turgescent and less dense. By exposure to the 
air the patches acquire a rosy or salmon tint.19 On slicing 
them, they prove to be conical masses, more or less deeply em- 
bedded, or rather wedged, into the white substance. They 
shade off imperceptibly into the healthy tissue, there being no 
precise delimitation. (Fig. 1.) Most commonly discrete, they 
are sometimes confluent, and Cruveilhier has represented this 
arrangement very accurately in one of his plates. 
Fig. 1. 
Transverse sections of the cord. I), Anterior fissure. A, Above cervical enlargement. 
B, B', In the middle portion of cord. C, Three centimetres above terminal end of cord. 
—Chaboot. 
In the medulla oblongata the patches are met with sep- 
arately or conjointly on the olivary and restiform bodies, and 
the pyramids, but most often on the olivary bodies. The 
pons varolii is the frequent seat of sclerosis, especially its infe- 
rior surface, where it appears as gray patches, with a wavy 
contour, disposed transversely across the median line, and 
may extend to the cerebral peduncles in one direction, and the 
19 If portions of the cord are placed in a solution of chromic acid, the 
diseased tissue becomes at first yellow, then white and opaque, contrast- 
ing strikingly with the greenish-gray tint of the healthy substance; or, as 
suggested by Bouchard, a camel’s-hair pencil, moistened with an ammo- 
niacal solution of carmine, may be passed several times over the surface, 
which is then exposed to a stream of water. The carmine will have 
stained only the altered tissue. OE THE NERVOUS CENTRES. 
19 
medulla oblongata in the other. In one case, the aqueduct of 
Sylvius was surrounded by a large patch, with processes on 
the pons, and towards the fourth ventricle. (Fig. 2.) 
Fis. 2. 
Section of the pons yarolii. A, A, A, A, Patches of sclerosis on cut' surface of upper por- 
tion.—Charcot. 
The cortex of the cerebellum is scarcely ever affected, the 
patches of sclerosis, when present in the organ, being in the 
white substance, or in the corpus dentatum. 
Rare in the convolutions, the patches are, sometimes,.found 
where the gray and white substances join, but are more com- 
mon on the walls of the lateral ventricles, and may extend to 
the intraventricular nuclei of the corpora striata. When ex- 
isting in the centrum ovale, corpus callosum, and septum lu- 
cidum, they are yery apparent, and are generalized. They 
have occurred in the optic thalami. 
Though as a rule the cerebral nerves escape, in one of Cru- 
veilhier’s cases, the hypoglossal, glosso-pharyngeal, and pneu- 
mogastric were implicated; in two cases reported by Drs. 
Yulpian and Liouville, the optic and olfactory nerves had 
patches visible to the naked eye; and in one of Dr., Orden- 
stein’s observations the hyperglossal and left motor oculi ex- 
ternus were distinctly sclerosed. In their configuration they 
resembled the patches in the pons and medulla oblongata, and 
in nowise could be confounded with the tissue-changes of 
these nerves noticed in locomotor ataxy. 
With one exception, the spinal nerves have been free from 
sclerosis, the nerve-roots often issuing perfectly sound from 
the midst of a patch. At a meeting of the Societe de 20 
DISSEMINATED SCLEROSIS 
Biologic, July 30, 1869, Dr. Liouville stated that lie had seen 
one case where the spinal nerves had sclerotic patches 
(Memoires, etc. 1. c.) 
Histological Alterations and Microscopical Appearances in Dif- 
ferent Stages.—In studying in detail the essential anatomical 
characters of this lesion, it is necessary to understand the 
modifications the histological elements undergo in the succes- 
sive phases of the morbid processus. The minute anatomy of 
the nervous system has been accurately studied but quite re- 
cently, and though there are yet many points under discussion, 
certain fundamental facts have been generally accepted; these 
should be borne in mind to intelligently appreciate the exact 
nature of the tissue-changes in disease. The proper element- 
ary structure of the nervous centres, consisting of the nerve- 
fibres or tubes, and ganglion-cells or corpuscles, lies embedded 
in, or, more correctly, is bound together by, a kind of con- 
nective tissue, which Kolliker called reticulum, and Virchow 
neuroglia. It is this connective framework, or gangue, which 
is specially interested in the lesion under consideration.20 
If a thin section of the cord, hardened in a solution of 
chromic acid, and colored by carmine, and afterwards made 
transparent, be examined with a low power, the white mat- 
ter seems at first to be entirely composed of small, regularly- 
rounded bodies, or disks, placed side by side, and of about the 
same diameter; these are the cut-nerve tubes; the small red 
points, looking like minute globules, in the midst of these 
shining translucent disks, are the colored axis-cylinders. A 
closer examination shows that these disks are not contiguous, 
but are really separated by an apparently homogeneous sub- 
stance, not so deeply tinted as the axis-cylinders, and which 
seems to fill up, like a cement, the interspaces between the 
nerve-tubes. This is the neuroglia or reticulum. In the gray 
substance this interstitial matter is still more abundant than 
20 The connective tissue of the cord was first investigated by Keuffel 
(Reil’s Archiv, x., 1811). Cruveilhier, in the article Apoplesie, Diction- 
naire de MMecine et de Chirurgie Pratiques, ed. 1820, writes: “ The ex- 
tremely delicate serous cellular tissue which unites and separates the cere- 
bral fibres, and which forms an excessively fine web ” OF THE NERVOUS CENTRES. 
21 
in the white; certain portions are wholly formed by it, as the 
periphery of the centrum ovale, and the central thread of the 
ependyma (Yirchow). It is in excess, too, in the gelatinous 
substance around the expanded extremity of the posterior cor- 
nua of the cord, and in the posterior commissure, which, when 
treated with a solution of carmine, shows a nearly uniform 
reddish hue, while the anterior commissure, from the number 
of nerve-tubes which cross it transversely, is less perfectly 
stained. The meshes of the neuroglia are liner in the gray 
substance than in the white, and its texture appears more cel- 
lular or spongy. This connective framework in both sub- 
stances gives support to the ramifying blood-vessels. The 
zone of this tissue around the peripheral portions of the 
nervous centres, described by Bidder and Frommann, is called 
the cortical layer of the reticulum; it sends processes towards 
the central parts of the cord, which form triangular compart- 
ments or trabecula), their bases being on the circumference, 
and apices in the gray matter. These processes divide and sub- 
divide, forming a reticulated arrangement, whose interspaces 
vary in size; in the largest of these, eight or ten nerve-tubes 
may be lodged, while the smaller ones may contain only a 
single tube. 
What is the histological constitution of the neuroglia? 
This is an open question, and micrographers are still dis- 
puting about its intimate nature. On one point they are, 
however, pretty generally agreed, namely, that it is not ordi- 
nary connective tissue.21 The opinion most largely held (From- 
21 The anatomical fact of the reticulum or neuroglia, is disputed by sev- 
eral histologists, especially by Robin and Henle. The former asserts that 
it has no natural existence, hut is a product of art. He holds that in a 
fresh state, before the cord has been subjected to the action of reagents, 
the spaces between the nerve-tuhes are not filled by a reticulated connec- 
tive tissue, hut by a grayish, soft, amorphous, and finely granular matter, 
in the midst of which the myelocytes (the nuclei of the neuroglia of Yir- 
chow) are suspended. Alcohol and certain acids, especially chromic, 
cause this matter to become hard without shrinking, and it is to this 
property that the reticulated arrangement is due.* The answer to this 
is: while it is admitted that in the fresh cord amorphous matter in very 
* Programme du Cours d’Histologie, 1870. Dictionnaire Encyclo- 
pSdique des Sciences Medicales, 2me serie, t. i. DISSEMINATED SCLEROSIS 
maim, Max Scliultze, Kolliker), and wliicli Dr. Charcot’s per- 
sonal observations tend to confirm, is, that it is constituted as the 
stroma of the lymphatic glands, after the type of the simple reti- 
culated connective tissue of Kolliker. If, according to those 
authorities, thin sections of the cord, prepared in chromic acid, 
and colored with carmine, are examined under the microscope, 
the following conditions are noticed: 1. In the white sub- 
stance, at those points of the reticulum where several tra- 
beculae meet, enlargements or knots are seen, in whose centre 
are nuclei, with a well-defined contour, deeply colored, and 
which are the myelocites of Eobin, and the nuclei of the neu- 
roglia of Yirchow.22 In transverse sections, the trabecular 
structure, with its homogeneous, brilliant, fibroid-looking 
walls, constantly anastomosing, seems to form interspaces con- 
small quantity is interposed between the nerve-elements, and that in this 
state the reticulum is less clearly made out than in sections which have 
been hardened in chromic acid, it is not less true that in fresh pieces of the 
cord the white substance, placed in iodized serum, and dilacerated under 
the microscope, show unquestionably on their edges the presence of con- 
nective tissue (Kolliker, Froramann, M. Schultze) ; and that this tissue is 
more susceptible of demonstration in certain morbid conditions, in which 
the healthy structure becomes exaggerated, without undergoing complete 
transformation (Yirchow). This is particularly the case in simple sclerosis, 
when the alteration has not gone beyond the first stage of its evolution; 
the effect of these reagents is limited to rendering more distinct the 
reticulated structure of the connective framework of the spinal cord.f 
Henle and Meckel have recently attempted to show, by observations 
which are entitled to consideration, that the chemical reactions of the 
neuroglia are directly the opposite of those of connective tissue. (JJeber 
die sogenannte Bindessubstanz der Gentralorgane des Nervensystems, Henle 
and Pfeufer’s Zeitsohrift. Bd. xxxiv., 1869). Of course, the patho- 
genetic processus of sclerosis of the nervous centres is differently inter- 
preted according to the histological theory held: one set regarding it as 
an exaggerated development of preformed tissue—a simple hyperplasia, 
as sclerosis of the lung, liver, spleen, etc.; and the other, as a lesion sui 
generis, consisting of the heterologous, or abnormal formation, of an 
element or tissue, differing from the physiological type of the organ; in 
fact, a Jieterotopical neoplasm. 
22 Yirchow, E. Die krankhaffcen Gesckwiilste, t. ii,, p. 127; 1864-’65. 
tlTayem. Differentes Formes cle I’Encdphalite, 1868. Hayem and 
Magnan. Journal de la Physiologic, No. 1, 1869. 
Deiter. Untersuchungen fiber Gehirn uud Kiickenmarks, p. ii., Braun- 
sweig, 1865. OF THE NERVOUS CENTRES. 
23 
taining the nerve-tubes; while in longitudinal sections they 
appear to subdivide and ramify indefinitely, producing the 
finest meshes, which are interposed between the nerve-tubes. 
The interspaces between the sheaths and the tubules are filled 
by a small quantity of finely-granular amorphous matter. 
We will now briefly examine the histological changes 
which are met with in those portions of the spinal cord af- 
fected with disseminated sclerosis. 
According to Frommann, who had an opportunity to ob- 
serve the tissue-changes at an early stage of the morbid pro- 
cessus, and liindfleisch, the walls of the arterioles and capilla- 
ries are thickened by a proliferation of small, rounded cells; 
the cells of the neuroglia are increased in size, and their pro- 
cesses dilated; the nuclei are large and surrounded by a layer 
of protoplasm, while their number is increased, one cell con- 
taining from two to ten nuclei, either in one mass, or each 
with its own membrane, in which case each of these nuclei ap- 
pears as a cell detached from the envelope and contents of the 
primitive connective corpuscle. In consequence of the progress 
of the nuclear multiplication, nuclei form in the processes of the 
connective corpuscles, and these processes grow larger as their 
anastomoses become more apparent. A little later the anas- 
tomotic net-work of the connective processes is filled with 
nuclei, and it is by the abnormal accumulation of these ele- 
ments that the sites of the original cells are discerned. 
The sum of these changes may be shortly stated; as an 
overgrowth of connective nuclei and cells, and the subsequent 
development of fibrillary elements of great tenuity, which may 
be seen on the cut surfaces, and behave like elastic tissue. 
These elements originate probably in the amorphous funda- 
mental matter of the neuroglia. According to Rindfleiseh, 
the morbid tissue is moistened by a viscous, intercellular 
liquid, slightly coagulable in water, and containing the nuclei 
and small uninuclear cells; by pressure, this liquid is forced 
out on the surface of a recent section, giving rise to the epen- 
dymoid formation of Kokitansky. 
In consequence of the modifications of the reticulum, the 
nerve-elements are compressed and atrophied ; the tubes lose 24 
DISSEMINATED SCLEROSIS 
their myelin, which undergoes granular disintegration; the 
axis-cylinders become paler and very translucent, with, fre- 
quently, a longitudinal striation, or have a finely-graimlar as- 
pect, which From maim regards as the beginning of the mo- 
lecular destruction. Around the atrophied nerve-tubes a large 
number of globules are seen, formed by a coagulated fatty 
matter. In proportion as the atrophy of the nerve-elements 
advances, the fibrillary tissue is developed, and gradually 
assumes the characters of genuine connective tissue. Re- 
gressive transformations now take place, fatty granulations 
are deposited in the interstices of the tubes, and amyloid 
corpuscles are produced at the expense of the small uninu- 
clear cells of the intercellular viscous liquid. The absorption 
of this liquid, favored by the contraction of the connective 
elements, marks the last stage of the processus. The diseased 
tissue, deprived of its juice, is composed solely of connective 
fibres immediately contiguous, whose unequal shrinkage gives 
rise to partial distortions. Finally the whole mass becomes of 
a grayish fawn-color, often closely resembling the tint of 
ground glass. 
Charcot has described these histological changes in the several stages 
of the processus more fully. On placing under the microscope a prop- 
erly-prepared thin transverse section of the diseased cord, several concen- 
tric zones are recognized; these correspond to the different phases of the 
lesion, a. In the peripheral zone, the trabecula) of the reticulum are 
thickened; the nuclei of the enlargements of the reticulum are swollen; the 
nerve-tubes are atrophied at the expense of the medullary sheath, the 
axis-cylinder being whole, b. In the second, or transitory zone, the size 
of the nerve-tubes is still less—indeed, in many the myelin has disap- 
peared, the axis-cylinder only remaining, which may he hypertrophied. 
The trabeculm are more transparent, their contour less definite, and at 
certain points they are replaced by bundles oflong, delicate fibrilla), analo- 
gous to those which are characteristic of common connective tissue. These 
are developed at the expense of the meshes which contain the nerve-tubes, 
and the consequence is that the reticulated aspect of the healthy neuroglia 
has a tendency to disappear, c. In the central zone, that is, in the midst 
of the sclerosed patch, all traces of fibroid reticulum have gone; there are 
neither cells nor trabecula); bundles of fibrils fill the alveolar interspaces, 
from which the myelin has entirely disappeared; the axis-cylinders are 
atrophied to such a degree that it is hard to distinguish them from the 
newly-formed fibrils. The persistence of these cylinders in the midst of OF THE NERVOUS CENTRES. 
25 
the tissue which has undergone fibroid substitution, is, Dr. Charcot thinks, 
peculiar to disseminated sclerosis. 
The characters of the fibrillary tissue are particularly well exhibited in 
longitudinal sections. It is seen to be composed of parallel fasciculi, formed 
of delicate, opaque, smooth fibrils, rarely subdividing and anastomosing, 
but frequently interlacing, after the manner of felting, and which are col- 
ored by carmine. These characters enable us to distinguish it from the axis- 
cylinders, which are usually larger, transparent, and do not ramify. (Fig. 3.) 
Fig. 3. 
Recent preparation from centre of a patch of sclerosis of the cord, colored hy carmine and 
dilacerated. In the centre a capillary vessel with numerous nuclei. On either side 
axis-cylinders, some large, others quite small, deprived of their myelin. The capillary 
and the axis-cylinders, strongly colored hy carmine. The latter are perfectly smooth, 
and have no ramifications. Between the axis-cylinders, delicate fibrils of recent forma- 
tion are seen; on the right nearly parallel to each other, while in the centre and on 
the left, they form a sort of net-work, resulting from their interlacement, or anastomo- 
sis. They may he distinguished from the axis-cylinders by their diameter, which is 
much less, by their numerous ramifications, and by not being colored by carmine. 
Scattered nuclei are also visible; several are in connection with the fibrils, and others 
are of irregular form, from the action of the ammoniacal solution of carmine.—Chaecot. 
They may be distinguished, also, from the fibres of the reticulum by these 
being thicker, shorter, and always having branchlike processes. Finally, 
they differ from the elastic fibres by their swelling up from the action of acetic 
acid, and forming a transparent hyaline mass, which is not the case with the 
elastic fibres. In the midst of this fibrillary tissue there is always a con- 
siderable number of corpora amylacea. 
The vessels which traverse the patches of sclerosis, undergo alteration. 
In the peripheral zone, the walls of these vessels are thickened, and contain 26 
DISSEMINATED SCLEEOSIS 
more nuclei than in the normal state; nearer the centre the nuclei are 
more numerous, and the lymphatic sheath is replaced by several layers of 
fibrils like those developed in the thickness of the reticulum. Owing to 
the concentric hypertrophy of their walls, the calibre of the blood-vessels 
is lessened. 
There are certain changes which can be best or only studied in the re- 
cent state. In the centre of the sclerosed mass, globules or granules of a 
fatty kind are nearly constantly met with. These elements have two 
chief aspects: in the one the masses have sinuous, dark outlines, with, like 
the myelin, a double contour; the other are true fatty granulations, some- 
times isolated, at others agglomerated, so as to form granular bodies. (Fig. 4.) 
Fig. 4. 
Patch of sclerosis from cord in a recent state, a. Lymphatic sheath of a vessel distended 
hy large fatty globules, b. Vessel cut across ; the lymphatic sheath is separated from 
the tunica adventitia by an empty space, the fatty globules which distended the sheath 
having disappeared, c. c. Little collections of fatty globules scattered over the prepa- 
ration.—Chaecot. 
These drops of myelin and fat granules may infiltrate through the meshes 
of the reticulum, and spread themselves abroad; they never occupy the 
centre of the patch, for there the fibrillary metamorphosis and the de- 
structive process as regards the nerve-tubes are ended; but they are seen 
about its periphery at those points where the medullary sheath has almost 
disappeared, hy the compression first of the trabeculae, and afterwards of 
the fibrillary fasciculi, which gradually invade and occupy the alveola?. 
The nerve-tube is finally represented by the axis-cylinder alone. The OF THE NERVOUS CENTRES. 
27 
accumulation of the medullary or fatty globules and the destruction of the 
medullary sheath are contemporaneous, and when the one is accomplished 
the other ceases to occur. We may then infer that the medullary and 
fatty corpuscles are detritus resulting from the disintegration of the nerve- 
tubes. Dr. Charcot believes that the absence of these fatty granules in the 
centre of the patches is due to their absorption, and this view seems sus- 
tained by the fact that within the lymphatic sheaths of the arterioles those 
fat-corpuscles are sometimes so abundant as to notably increase their vol- 
ume, and are visible by the naked eye in the form of white lines on the 
gray ground of the patch. The changes in the vessels before described are 
not a primitive lesion, or an essential part of the degenerative processus, 
but simply a consecutive fatty infiltration of the lymphatic sheaths. 
These morbid changes are also met with in the gray matter; the gan- 
glion-cells, however, are not the seat of the nuclear proliferation observed 
in the connective cells, but undergo a peculiar alteration known by the 
name of yellow degeneration, from its ochrey tint: they can no longer be 
colored by carmine, as in the healthy state; and finally, all the constitu- 
ents of the cell become atrophied. 
The consecutive phases of the morbid processus may he 
summarized as consisting: 1. Of the initial fundamental fact 
—-proliferation of the nuclei, with concomitant hyperplasia 
of the reticulated fibres of the neuroglia / and, 2. Of the 
secondary, consecutive atrophic degeneration of the proper 
nerve-elements. 
Differential Diagnosis.—This affection has sufficient individ- 
uality to secure, in most instances at least, its ready recogni- 
tion, notwithstanding resemblances between its several forms 
and other diseases of the nervous system. The disorder with 
which it has been heretofore invariably confounded is, as has 
been stated, paralysis agitans, or shaking palsy. Besides a 
pathogenetic distinction founded upon the sure basis of mor- 
bid anatomy, there are differences of clinical history which 
should forbid confusion or mistake. Paralysis agitans is 
chiefly met with in persons of declining years (Trousseau). 
Sauvages says, “ While chorea, or scelotyrbe sancti viti attacks 
the young, ballismus, or scelotyrbe festinans, attacks those of 
advanced life; ” and Saunders observes, “ Age is of primary 
importance, both in causing the affection and aggravating it.” 
Disseminated sclerosis of the cerebro-spinal centres is a disease of 
adult life. There is some parallelism in the invasive stage 
ot the two disorders, the approach of both being often so 28 
DISSEMINATED SCLEROSIS 
imperceptible that it is difficult for the patient to fix the 
exact period of commencement. In both there are crawl- 
ing sensations and numbness, and sense of diminution of mus- 
cular power; but in the neurosis these are almost constantly 
felt in tbe arms, while in the organic disease they are almost as 
constantly experienced in the legs. In paralysis agitans, a ten- 
dency to trembling is an initial symptom, and precedent to the 
paresis; in sclerosis, on the contrary, tremor invariably follows 
paralysis, limb by limb. The muscular weakness of paralysis 
•agitans begins in one arm, or both, and then extends to the 
lower extremities', and when it does pass into true paralysis, 
which is very rare, it is in the final stage; in diffuse cerebro- 
spinal sclerosis, one or both lower limbs are first attacked with 
paresis, and, sooner or later, become completely deprived of all 
motor power, rendering the patient perfectly paraplegic and 
unable to walk. Hence the gait in the two diseases is emi- 
nently diacritic. A patient with shaking palsy in its devel- 
oped stage, after the customary balancings and oscillations of 
the body, starts with the head and trunk bent forward, on the 
toes or forepart of the feet, with short, quick steps, and, to 
maintain the centre of gravity, thus displaced, goes trotting 
and hopping along, at almost running speed, with one or 
both arms and wrists semiflexed and closely pressed to the 
sides; he seems, as Trousseau observes, to be running after 
himself. This festinating, procursive gait is pathognomonic. 
Nothing of the kind is seen in cerebro-spinal sclerosis ; the 
gait is that of paraplegia, according with the degree of 
palsy, and will be presently more fully described. Tremor 
is a prominent and common symptom of the two affections, 
and from this has arisen much of the confusion which led 
writers so persistingly to associate pathological species ge- 
netically distinct; for when this sign is analyzed and com- 
paratively studied in the two disorders, great differences, not 
only of development but of degree, become evident. One of 
the earliest phenomena of shaking palsy, in disseminated sclero- 
sis it is invariably consecutive to the motorial troubles. In 
the former disorder, trembling is incessant, and is but little 
modified whether the patient be at rest or in motion, 
and in the developed stage is scarcely interrupted by OF THE HEEYOUS CEHTEES. 
29 
sleep; while in the latter, it is never spontaneous, hut is 
always provoked by, or follows upon, any muscular move- 
ment ; and though it may be started by emotion, it will be 
found, on observation, that this deviation from the rule is 
only apparent, for some change of position of a limb, or of the 
head or trunk, is always involved. Nystagmus, so constantly 
present in sclerosis, is never met with in paralysis agitans. 
The peculiar slow, scanning articulation of a sclerotic is very 
different from the embarrassed, indistinct utterance noticed in 
paralysis agitans. The intellect in paralysis agitans is gen- 
erally unaffected until near the close, while in diffuse cerebro- 
spinal sclerosis it is mostly weakened from an early period. 
The characteristic deformities, described first by Parkinson, 
and recently by Charcot,83 which occur in shaking palsy, can- 
not be confounded with the permanent contractions of late 
muscular rigidity, so constant in the terminal period of diffuse 
sclerosis. 
There are some symptoms in common between the ordi- 
nary forms of multilocular sclerosis of the anterior, or antero- 
lateral, columns of the cord and locomotor ataxy (posterior 
sclerosis) in the forming stages of the two disorders. In both 
there are often tinglings, and occasional numbness, and ready 
fatigue after slight muscular exertion. In locomotor ataxy 
these are, however, very often accompanied by ocular troubles, 
as weakness of sight, defective accommodation, strabismus, 
ptosis, or double vision. In the spinal form of disseminated 
sclerosis these are wanting, and when they happen in the 
cerebral, or cerebro-spinal form, they are always persistent, 
while in locomotor ataxy they are generally temporary. The 
terrible boring, gnawing, or lancinating, pains of the ataxic, so 
frequently preceding marked motorial troubles, are rare in 
disseminated sclerosis. The course and physiognomy of the 
two diseases in their developed state, when one does not com- 
23 In the hand, the contortion is very characteristic. At first, the pha- 
langes are partly flexed on the metacarpal bones, and drawn toward the 
thumb, as if the patient were holding a pen, or about taking a pinch of 
snuff. After a while this condition is aggravated, the first phalanges of the 
fingers are closely and tightly bent, while the second are in a state of per- 
manent hyperextension; on the first and the third in a slight degree, of 
flexion on the second (Ordenstein). 30 
DISSEMINATED SCLEKOSTS 
plicate tlie other, are too distinct to allow of any confusion. The 
characteristic hitchy, catching-up gait of the ataxic, resulting 
from impaired muscular adjustment, has nothing in common 
with the paraplegic shuffling of Charcot’s disease. Even in the 
paretic stage of multilocular sclerosis, the gait is distinctive; 
the lifted leg is brought forward, not in a direct antero-posterior 
plane, as in the physiological act of walking, but the foot de- 
scribes an arc of a circle, and from within outward, at first; 
and then, having reached the extreme point of the curve, it is 
thrown inward, coming to the ground with a flap, the sole 
striking at all points at the same time. With this excentric 
curvilinear projection of the foot, there is a cadenced oscilla- 
tion, an exaggerated alternate semi-rotation of both halves of 
the pelvis (Jaccoud). Early paresis passing, certainly, and 
more or less speedily, into paralysis, characterizes multilocular 
sclerosis; while paraplegia is always a very late phenomenon 
in ataxy, and in nowise a necessary one, so long as the tissue- 
changes are limited to their own district. When the posterior 
columns of the cord are invaded by the sclerotic patches, al- 
ready existing in the anterior, or antero-lateral, then the signs 
of the two affections will coexist, but the phenomena proper 
to each can generally be separated by careful examination. 
Course and Duration.—The course of this affection is pro- 
gressively invasive, whether it begins in the lower or upper 
extremities, or in the head. Muscular enfeeblement slowly but 
certainly increases, until all the voluntary muscles are more or 
less disabled. Tremor, at the outset slight, partial, and occa- 
sional, comes to be violent, spreads over the whole body, and 
is started on the least voluntary movement, or by any emotion. 
Convulsive agitations of the extremities, spells of rigidity, and 
permanent contraction of the muscles succeed; nutrition trou- 
bles set in, and prepare the way for some acute intercurrent 
disease which is commonly fatal. But there are a few excep- 
tional instances in which the advance was not continuous. In 
one, there were repeated pauses and recommencements before 
the disease became regularly progressive (Yulpian). Leo re- 
ports a case in which the palsy, at first uni- and then bilateral, 
disappeared for a while altogether. One patient improved so OF THE NERVOUS CENTRES. 
31 
much under the use of strychnine, that he could stand 
without support, which he had not been able to do for some 
time; and this continued for two months (Zenker). Another 
recovered of the paraplegia, and rectal and vesical paralysis, 
and during six months could walk alone, when the symptoms 
started afresh (Bourneville). Dr. Charcot relates the case of a 
woman, who for two years was obliged to remain almost com- 
pletely motionless, the limbs being permanently contracted, 
with scarcely a few short intervals of relief; at the end of that 
time she became able to walk about and attend to her household 
duties; when, after a fit of convulsive hysteria, all her limbs 
and the muscles of the trunk became rigid, and remained per- 
sistently so to her death, nine years later {Gas. HehdomFeb- 
ruary, 1865). In two cases there was decided amendment on 
the appearance of the catamenia, and which ceased on their 
stoppage. Another remarkable case of repeated pauses, improve- 
ment, and aggravation, is reported by Yulpian. During an 
attack of small-pox, both paraplegia and contraction ceased 
in the eruptive stage, and after convalescence all signs of the 
disorder had vanished. This lasted for three years, when, 
after a fright, which suppressed the menstrual flow, slight 
paresis was felt; this passed off, however, on the reestablish- 
ment of the catamenia. Three years subsequently this patient 
had an attack of jaundice; the motor troubles recommenced, 
and, after some fluctuations, pursued a regularly onward 
course. 
The average duration may be stated at from eight to ten 
years. In seventeen fatal cases, it lasted for two years in 2, 
five to ten years in 9, thirteen years in 2, seventeen years in 1, 
twenty years in 1, and twenty-four years in 1. The age of 
death in these cases was: from twenty-five to thirty, 2; from 
thirty to thirty-five, 5 ; from thirty to forty, 4 ; from forty-one 
to forty-five, 2; from forty-six to fifty, 2; from fifty-one to 
fifty-five, 1. 
Causes and Pathogeny.—lt is essentially a disease of adult 
life. In the eighteen cases collected by Bourneville, fourteen 
were between twenty-six and thirty-six years of age; and of 
these, fifteen were females ; but it must be borne in mind that, 32 
DISSEMINATED SCLEEOSIS 
of the physicians who have busied themselves with the study of 
this affection, nearly all were attached to institutions special 
to women, the Salpetriere, for example. In thirteen cases in 
which the occupations were known, there were : 1 physician, 1 
theological student, 1 male teacher, 1 female teacher, 1 pianist, 
3 seamstresses, 3 domestic servants, 1 truck gardener (female), 
1 flower-woman. Several would seem to have suffered from 
previous nervous disorders, as hysteria, hemicrania, etc. Ex- 
cess in alcoholic drinks is mentioned in one case. A fall im- 
mediately preceded the onset in another (Yulpian). In three 
instances it appeared during pregnancy. Once it was de- 
veloped after violent fatigue. Exposure to damp cold may 
probably be named as one of the few known causes; it is par- 
ticularly mentioned by Parkinson as giving rise to paralysis 
agitans. There is no evidence to show the influence of hered- 
ity ; the father of one patient is reported as having had tremor 
of the head at fifty. 
It must be allowed that the pathogeny of this affection, as 
well as that of other kindred diseases of the great nervous 
centres, is obscure and unsettled. May we not possibly find 
a truer interpretation of their nature by admitting their con- 
nection with and dependence on some latent but distinct con- 
dition of the constitution of the body, which favors the devel- 
opment of this peculiar form of morbid action ? That they 
are simply varieties of chronic inflammation of the brain and 
spinal cord cannot well be admitted. They are more than 
this. The common assigned causes seem insufficient for their 
genesis without some impalpable preexisting tendency. May 
they not be like Bright’s and Addison’s diseases, local expres- 
sions of a general state, in which a specific diathesis enters as 
an essential factor ? When sclerosis of the posterior columns 
of the cord (locomotor ataxy) comes to be treated of, this theory 
of the pathogenesis of the class of disorders under considera- 
tion will be more amply examined, and the evidence in its 
favor more largely set forth. Should this view gain favor at 
any time, its practical application is clear, and it will necessa- 
rily be followed by an entire change in the therapeutics of 
these disorders. OF THE NERVOUS CENTRES. 
Prognosis.—No instance of recovery has been reported. In 
the actual state of our knowledge, it may be said to be incu- 
rable, and progressively fatal. 
Treatment.—Electricity, blisters, counter-irritants, ergot, ar- 
senic, and belladonna, have all been used, without good effect. 
Chloride of gold and phosphate of zinc aggravated the symp- 
toms (Charcot, Yulpian). Strychnine temporarily modified 
the tremors in five cases. Nitrate of silver appears to have 
done the same, but it does harm if there is muscular contrac- 
tion, or clonic spasms. One case is reported as improved by 
tonics and sulphur-baths. Dr. Pennock was, benefited by hy- 
drotherapy; The constant galvanic current should in all in- 
stances be fairly tried. If the writer’s suggestion as to the 
diathetic character of this and similar disorders should prove 
correct, it may be possible, at least in the early stage, to arrest 
the progress of this affection, by a method of treatment 
founded on this theory. This practical point will be more 
particularly discussed and applied in a subsequent article. 
APPENDIX. 
Case I.—Spinal Form. (Reported by J. C. Moeeis, M. 1). 
Microscopical Examination by S. Wiee Mitchell, M. D. 
Transactions of tbe College of Physicians of Philadelphia, 
1868.) 
Dr. Caspar W. Pennock, of Philadelphia, of large frame and muscular 
development, began, in the winter,of 1842-43, when about forty years of 
age, to feel numbness and a sense of heaviness in his left leg. The sensa-. 
tion was that of a tight band around the leg, three or four inches in width 
He had been laboriously occupied during the summer with professional 
duties, which severely taxed both his mental and physical powers. Dur- 
ing six years, in spite of counter-irritation to the spine, galvanism, and 
hydrotherapy, (which latter seemed to have some temporary effect), the 
symptoms increased, extending to the whole limb, and then appeared in 
the right lower extremity; and in 1849 he had become gradually para- 
plegic. In 1853 he was attacked with apparently phlegmasia dolens in the 
lower limbs. It ran its course in three weeks, leaving him ever after- 
ward unable to walk, and he was entirely confined to the sitting or 
horizontal position. In time the paralysis reached the upper extremities, 
beginning in the left arm, and then spreading to the right, and becoming DISSEMINATED SCLEROSIS 
so great as to prevent him during the last ten years of his life from feeding 
himself. Sensibility of the paralyzed limbs was somewhat lessened, hut 
never entirely lost. Five years before death there was temporary paralysis 
of the bladder. His intellect was uninterruptedly clear and bright to the 
latest period of life, and he took a deep interest in every thing. Death 
from acute intercurrent disease in 1867, twenty-four years after invasion. 
Course of disorder regularly progressive. There was total loss of volun- 
tary motor power below the neck. Reflex action intact. 
Autopsy.—The cerebrum, cerebellum, and pons were without notable 
change. At the upper part of the posterior face of the medulla oblongata, 
in the mouth of the fourth ventricle, lying between the restiform bodies 
and posterior pyramids, there was a small, irregularly-rounded concretion, 
of two lines in diameter. 
The cervical and dorsal regions of the spinal cord presented in the fresh 
state, to the naked eye, a series of gray translucent spots, of irregular form, 
and sometimes almost transparent. They were all a little sunken below the 
level of the surface of the cord. 
The microscopic examination of these spots, which lay chiefly in the 
white substance, showed—l. Total absence of nerve-tubes and nerve-cells; 
2. Finely-granular matter, molecules, and small globules of fat in great 
quantity; 3. No granulation-corpuscles; 4. Numerous fibres. The vessels 
of the cord were everywhere altered by fatty deposits, which were particu- 
larly conspicuous in the neighborhood of the spots. No vessel was detected 
in the altered tissue. Excepting in a small spot which invaded the right pos- 
terior horn of gray matter at the level of the first cervical nerve, and a like 
spot on the left side in the same situation, the change respected the posterior 
horns and columns of the cord. The lateral columns were extensively af- 
fected, the spots, as a rule, lying between the anterior nerve-roots, and the 
central line of the lateral columns, involving, therefore, most largely, the 
parts nearest the anterior nerve-roots (see Figs. 6 and 7). In three places 
the changes passed across the anterior columns. From the seventh dorsal 
to the eighth dorsal nerve, a large spot extended across both the anterior 
columns; its depth and form are seen in Fig. 5. About the level of the 
Fig. 5. 
tenth dorsal, and at the second lumbar nerves, two spots 
were found crossing on to the right and left anterior 
columns respectively, but not involving the whole width 
of either. Below these points no spots were found in 
any part of the cord. The most extensive lesions were 
in the lateral columns of the cervical cord. Their sur- 
face extent is shown in Figs. 6 and 7. Their depth and 
the parts affected in the interior of the cord are seen in Figs. 8, 9, 10, 
11 and 12. 
In the dorsal region the spots were abundant, but less numerous than 
above, about half as many for equal areas of tissue. In many portions 
both of the cervical and dorsal regions, the changes involved the point ot OE THE HEEVOTJS CEHTEES. 
35 
entry of the anterior nerve-roots and the gray matter of the anterior horns 
{see Figs. 10, 11, and 12). The central canal was distinct throughout its 
course. 
Fig. 6. 
Fig. 7. 
Right and left lateral surface view of the lesions of the cervical cord. 
Fig.'S. 
Fig. 9. 
Fig. 10. 
Fig. 11. 
Fig. 12. 
7th. 
Bth. 
Cross-sections of cervical cord, showing lesions at the level of the nerve-roots, indi" 
cated by the numbers. 36 
DISSEMINATED SCLEOSIS 
Case ll.—Spinal Form. No sclerotic patches risible to the 
naked eye on the examination of the cord. The microscope 
shows the characteristic lesion.—(Charcot; reported by 
Bourneville.) 
0. 0., female, aged forty-one, seamstress, widow. Intellect very feeble, 
and memory almost gone; not able to give any history of her case. En- 
tered hospital February 18,1868. Face pale, pupils natural; vision a little 
weakened; speech embarrassed, and accompanied with tremor of the lips; 
stiffness of muscles of the neck; hands cold and purple. In a state of 
repose, nothing abnormal in upper extremities. Eigidity of the shoulder 
and elbow-joints. Holding her snuff-bos in the left hand when she at- 
tempts to open it with the right, it is at once affected with tremor. 
When she attempts to carry a glass of water to her mouth, holding the 
vessel in the right hand, she always fails after repeated efforts. Muscular 
power diminished in the right upper limb; sensibility to pinching and 
pricking appears natural. The thighs arc flexed on the pelvis at a right 
angle; the legs on the thighs; the lower extremities regarded as a whole 
are in adduction, and that to such a degree that the knees can be separated 
from each other but very slightly, without causing great pain. It is pos- 
sible to extend the legs somewhat without causing pain to the patient. 
If, after extending the right leg as much as possible, it is raised from the 
bed, the foot begins to tremble; and, if at this time the sole of the foot is 
tickled, there is produced a sudden spasm in the whole limb, as from an 
electric shock. The different kinds of sensibility natural in both lower 
limbs. Although from the mental state of the patient the commemoratives 
were wanting, the diagnosis, made with some reserve, was spinal dissemi- 
nated sclerosis, based on her condition when admitted into the hospital; 
the paraplegia and permanent contraction of the lower extremities, the 
tremor on voluntary movements, the spinal epilepsy, etc. The absence of 
trembling of the head and of nystagmus seemed to show that the brain 
was not implicated. 
Autopsy,—Ho patches of sclerosis were visible in any part of the cord; 
but on microscopic examination of sections of different portions of the cord, 
the existence of sclerosis was made certain by the histological changes 
present. There was considerable connective-tissue proliferation, in cer- 
tain districts, with fibroid substitution, but the nerve-tubes were yet gen- 
erally intact. “Are we,” asks the importer, Hr. Bourneville, “from this 
case to conclude, by those lesions not being appreciable to the naked eye, 
that there maybe several varieties of sclerotic patches ? or that the change 
was yet in its earliest period ? ” This latter hypothesis seems, from the 
histological appearances, to be the correct one. Besides, the same thing 
has been already seen in sclerosis of the posterior cords (locomotor ataxy), 
as in the instances reported by Dr. Gull, of London, and Drs. Charcot and 
Bouchard, in which no tissue alteration apparently existed, and the micro- 
scope revealed the characteristic changes. OF THE NERVOUS CENTRES. 
37 
Case 111.—Cerebro-Sjpinol Form.—(Charcot; reported by 
Boukneyille.) 
H. 8., female, aged forty-one, admitted January 6, 1868. Health deli- 
cate in youth; after fourteen, when menstruation began, good. Married at 
twenty-three; has had three children. At the age of twenty-eight, during 
second pregnancy, had a fall. When about thirty, after a long walk, first felt 
weakness in the legs; this gradually increased, so that in two years she 
could not walk without aid ; at this time there was incontinence of urine 
and faeces. Under a tonic treatment and sulphur-baths, the paralysis of 
the sphincters disappeared, and her lower limbs became so much stronger 
that she could walk without support, but could be easily thrown down. 
This improvement lasted for six months, when the paraplegia returned and 
regularly progressed. The lower limbs felt weighted and stiff. During 
her third pregnancy walking became impossible; she had to be lifted in and 
out of bed. About nine years after onset she began to have a sensation of 
fatigue in both upper extremities, and in the same degree. The rigidity of 
the lower limbs increased. Her condition on January 7,1868, day after her 
admission to hospital: General health and nutrition good; constipation; 
menstruation unaffected. Rigidity of lower extremities, which are in a 
state of adduction; rigidity most marked on left side; motility completely 
abolished; sensibility to pricking, pinching, tickling, and cold and heat, 
natural; the latter, perhaps, slightly increased ; no pains in limbs, no for- 
mication or numbness, but a constant feeling of fatigue and heaviness; 
no palsy of sphincters. Severe pain, almost continuous, but with exacer- 
bations, in the lower lumbar spine and sacrum; small bed-sore over 
sacrum. 
Both upper extremities are weak, the left more than the right. When 
quite still, no tremor noticeable; but so soon as she attempts to carry any 
thing to the mouth, there is trembling of the left side, and the head is at the 
same time agitated. 
There had been for some time, .exactly how long the patient was unable 
to say, weakness of sight, greater in the left than the right eye, with oc- 
casional diplopy; no periorbitar pains ; no ocular delusions. 
January 17.—Pains around the base of the chest, hindering respiration, 
and more marked on the right side. Shooting-pain spells, during which 
there is slight congestion of the face ; the neuralgic points are; 1. To the 
right of fifth dorsal vertebra; 2. Below the right breast; 3. Slight hyper- 
oesthesia at epigastrium. 
January 81.—Redness in the metacarpo-phalangeal and finger-joints, 
with pain, increased on motion. Sacral sore larger. Rigidity of lower 
limbs, as well as tendency to adduction, lessened. Severe pain at times in 
instep, compared to the part being squeezed in a vice. 
February s.—The lower extremities, which on the day previous were 
without any rigidity, are drawn up, and to effect extension requires much 
effort, particularly on the left side, and they become immediately again 38 
DISSEMINATED SCLEROSIS 
semi-flexed. On pinching the skin of the thighs and legs, and tickling the 
soles of the feet, the legs become rigid and bent on the thighs, especially 
the left, and reflex movements are exerted, which throw the limb upwards. 
Application of cold produces the same phenomena, but to a less degree. 
The greater the degree of flexion, the less the tendency to adduction. 
When the sole of the foot is tickled for some time, tetany is induced in the 
limb, which lasts for some time after the excitation has ceased. Occa- 
sional subsultus in the lower limbs. After a while, the rigidity and con- 
traction pass off, and the position of the limbs becomes natural. A con- 
strictive pain around the hips, from the sacrum to the pubis, complained 
of. 
In the upper extremities a feeling of uneasiness is experienced from 
time to time, when the hands cannot be used, and there is tremor on volun- 
tary movement. About this time, ascending spinal meningitis from the 
sacral slough set in. On February 16th, the pulse-rate was 100 to 120; 
respiration, 36 to 40; body heat, 39°5 0. to 40°1 O. February 20th.—In- 
voluntary stools; lower extremities flaccid and handling, and kneading 
them, even, do not cause contraction ; tactile sensibility natural; tempera- 
ture of lower extremities less than of upper ; pupils normal; sight a little 
dim. 
On the 4th of March pneumonia set in, with diarrhoea and disturbed di- 
gestion. Up to this time no headache had been felt, but now, when the 
head is moved, there is a deep-seated sensation in the upper part of the 
occipital region as if a blow had been received there, and this lasts for an 
hour at the time. Memory good ; no disturbance of ideation; no feeling of 
heaviness, or of increase or diminution in the size of the head; no stiffness 
of the neck. 
March 23.—Oontactile and thermic sensibility perfect and without re- 
tardation in the lower limbs, which are relaxed; a little stiffness in the 
knees; some tendency to adduction ; no voluntary movements, even of the 
toes; reflex movements exaggerated ; on tickling the sole of the foot, the 
leg becomes flexed on the thigh, and the thigh on the pelvis; and if the ex- 
citation is continued for any time, a series of convulsive movements is pro- 
voked in the limb, which continues bent. During the night involuntary 
muscular startings in the lower extremities, in the direction of flexion, are 
frequent. 
There are spells of increased weakness of the arms; the trembling of 
head worsens; new sloughs form; the lumbar pains are more intense; 
evacuations involuntary; diarrhoea; dilatation of the pupils, the right more 
than left; objects placed at the right of the eye appear double with both 
eyes, but are correctly seen by the single eye. The lung-trouble becomes 
developed, and the patient dies April 6, 1868, 
Autopsy.—Patches of sclerosis in the cerebral hemispheres and pons 
varolii. In the spinal cord they are scattered throughout the whole 
length, and in every part except the posterior columns. OF THE NEEYOIJS CENTRES. • 
39 
The association of fasciculated sclerosis of the posterior 
columns of the cord with disseminated sclerosis of the ante- 
rior and antero-lateral columns, is shown in the two following 
cases, reported by Friedreich in his paper on “ Atrophic De- 
generation of the Posterior Columns of the Spinal Cord” (lo- 
comotor ataxy), published in Yirchow’s Arcbiv. fur Pathol. 
Anat. n. Physiol,, u. fur Klin. Medicin., 1863, pp. 119-133. 
Case IY.—(Fkiedkeich.) 
J. S., female: first felt weariness, then weakness of right leg at sixteen 
years of age; and at the same time severe shooting, intermittent pains in 
the lower extremities. "When about twenty, she noticed increasing weak- 
ness of the right arm, and soon after of the left, while the paralysis of the 
inferior extremities grew worse. Nine or ten years later, severe pains were 
felt in the ends of the fingers, hut more in the right than the left hand ; 
about this time there were convulsive startings in the muscles of the leg, 
particularly while in bed, which would cause involuntary flexion of the legs 
on the thighs, and the thighs on the pelvis. Eleven years afterwards the 
head became tremulous as soon as it was raised from the pillow, and there 
was bilateral nystagmus, when any object was steadily looked at. Speech 
was embarrassed to a degree to be almost unintelligible (set. 21); no head- 
ache, but vertigo; spasmodic contractions of lower limbs; ataxia. Death 
from typhoid fever, fifteen years after onset. Sensibility and vision had 
remained intact. At the autopsy, sclerosis of all the columns of the cord 
was found. 
Case Y.—(Feiedeeich.) 
N. S., female: was seized with feebleness and lancinating pains in both 
lower extremities at the age of seventeen. Towards twenty the paraplegia 
increased, and a sense of heaviness in both arms was felt, but no pain. 
At twenty-six, speech became affected, and there was stuttering. The 
pain-spells in the lower limbs recurred from time to time, until her en- 
trance into the hospital, when she was twenty-eight years of age. During 
the two previous years there had been occasional spasms of the peroneal 
muscles, and within a year severe frontal neuralgia, lasting sometimes for 
a whole day. On the day she came to the hospital, her speech was almost 
unintelligible; voluntary motion of arms difficult and uncertain, so that 
she could not button her clothes, or thread a needle, or squeeze an object 
only after many attempts; there was small control over the muscles of 
the arms; she could neither stand nor sit; electro-sensibility and contrac- 
tility natural; in the lower extremities, strong currents, which induced 
violent contractions, caused less pain than in the upper; cutaneous sensi- 
bility, tested by sesthesiometer, everywhere good. Special senses natural; 
slight nystagmus; no paralysis of the muscles of the face; right cyphosis DISSEMINATED SCLEROSIS 
and scoliosis of dorsal spine. Death from typhoid fever a few months 
after admission. Examination of the spinal cord showed extensive scle- 
rosis of the posterior columns, and the posterior nerve-roots were atrophied. 
In a segment of the cord adjacent to the lumbar enlargement, although 
the naked eye could detect no lesion of the lateral columns, the micro- 
scope showed connective proliferation analogous to that in the posterior 
column ; there was fibrillary tissue, with some atrophy .and decided vari- 
cosity of the nerve-tubes. In the pia mater of the cervical region and 
upper part of the medulla oblongata, there was intense yellowish-brown 
pigmentation, though no alteration of the posterior columns could be 
made out at these levels. [lt does not appear that those portions were ex- 
amined microscopically; had they been, the essential tissue-changes would, 
most likely, have been seen.] On exposing the fourth ventricle the epen- 
dyma of the inferior half of the rhomboid fossa, near the cord, was found 
to be much thickened and hard [a patch of sclerosis probably ?], while the 
upper part was normal. 
Case Yl.—Cerebro-Spinal Form, with Atrophy of Optic 
Fisks of both Retinue.—(Magnan. Memoires de la Societe 
de Biologie, Paris, 1869.) 
M. S., female, aged thirty-four; admitted July 6, 1869. At thirteen 
years of age (1848), had an attack of typhoid fever, which lasted six weeks. 
During convalescence the sight began to grow dim, and she soon became 
totally blind. The general health was good, and her intellect unimpaired, 
until the beginning of 186T, when trembling of the hands and arms was no- 
ticed whenever any movement requiring nicety or precision was at- 
tempted. The tremor gradually grew worse, and extended to the lower 
extremities. During the eight months previous to above date, walking was 
very difficult, she was confined to her chair or bed, and was unable to 
feed herself. Sensory troubles now appeared, pain-spells occurring in dif- 
ferent parts of the body, particularly on the right side. While the patient 
remains sitting, and is perfectly quiet, there is nothing peculiar in her ap- 
pearance ; but, the moment she is spoken to, and she turns to answer, on 
moving her head, it is seized with an irregular, interrupted tremor ; there is 
nystagmus; and the muscles of the trunk are agitated, as if by a series of 
shocks; the arras and hands too are tremulous, to a degree to prevent a 
glass of water being carried to the lips without spilling the contents. When 
standing, or on attempting to walk, the legs begin to tremble, and then 
sudden, irregular, spasmodic contractions of the muscles occur, which are 
quickly propagated to the muscles of the trunk, setting the whole body 
convulsively shaking. Speech is drawling, hesitating, and slightly thick. 
Darting pains and cramps are felt in the legs, sometimes in the arras, par- 
ticularly of the right side; and the pains extend to the back. In the right 
cheek there is severe pain in the course of the branches of the facial nerve, 
and especially in the direction of the inferior dental and frontal branches. OP THE NEEVOUS CEHTEES. 
41 
At times a disagreeable sensation of burning is felt in the cheek and legs, 
with tinglings along the spine. On several occasions there has been a feel- 
ing of heat in the belly, and, within a few days of date, a tympanitis was 
developed, which seems to be passing otf. 
The intellect is weakened, but there is no special delusion. Sight is 
entirely lost. Ophthalmoscopic examination shows: in the right eye, optic 
disk oval, and of a pearl-white tint, with the vessels very small; in the left, 
optic disk white, contour well defined, and both arteries and veins of less 
than natural size. 
Eemaeks.—The point of special interest in this case, re- 
ported by Dr. Magnan, is the probable occurrence of sclerosis 
of the optic nerves many years previously to the development 
of disseminated cerebro-spinal sclerosis, which was the diagno- 
sis. There is likely tissue-change in the facial nerve. When, 
Dr. Magnan remarks, similar facts are more numerous, and 
we have had larger opportunities of studying simultaneous al- 
terations in both the peripheral and central districts on the 
one hand, and, on the other, extensions of the morbid processus 
from the centres, primarily affected, to the periphery, we shall 
be better able to understand the intimate relations between 
these several localizations. 
The following is an abstract of Oppolzer’s case, already 
referred to (page 5). Anatomically it is an example of mul- 
tilocular sclerosis, while clinically it differs from all the other 
collected cases by the persistence of the trembling when the 
patient was at rest. 
Case YII.—Spinal Form.—(Oppolzee. Canstatt’s Jahres- 
bericht, 1861, vol. iii., p. 78, from Spital-Zeit.) 
Male, aged seventy-two, of diminutive stature, admitted to the clinic 
June 20, 1860, with violent trembling, which hindered him from using his 
hands. He never suffered from any serious illness until 1848 (aged sixty), 
when, during the bombardment of Vienna, he had a severe fright. He was 
carried to his home; and had scarcely recovered from the attack, when, a 
bomb bursting near the house, brought on another. A few hours after- 
ward, on trying to take food, he found himself unable to use his hands, 
for, on attempting it, they began at once to tremble violently. After a 
while his lower limbs commenced to tremble, but less violently, and #e 
could still walk. In spite of treatment, the disorder grew worse. The 
trembling persisted even when he was at rest, and involved other muscles. 
Paralysis (paraplegia?) came on. After a few years he was unable to 
stand erect, and as soon as he made the attempt, there was an irresistible DISSEMINATED SCLEROSIS 
tendency to fall forward, so that, to avoid toppling over, he was obliged to 
lay hold of any near object, or to walk hurriedly. His intellectual facul- 
ties and his senses had slowly hut progressively diminished. Tea, coffee, 
and spirituous drinks, increased the trembling. The agitation of the lower 
limbs was more marked in the evening, and when the patient had walked 
during the day. Six months previously to admission, the sphincters be- 
came paralyzed. Five weeks before, after a severe attack of vertigo, he 
dropped down suddenly, and was unable to rise, but did not lose con- 
sciousness, Since that time emaciation had rapidly increased ; the patient 
can stand and walk for a very short time only, and with very great effort. 
Condition on Admission.—Great emaciation; earthy tint of skin, which 
is covered with numerous epithelial scales; perspiratory secretion in- 
creased on face, hut seems lessened in other regions ; temperature of skin 
lower than natural. Muscles of face, tongue, neck, and upper limbs are 
affected with violent trembling, which never ceases during the waking 
state, and is completely suspended only during profound sleep. The lower 
limbs shake periodically only, and when there is a general exacerbation of 
all the symptoms. The muscles, which are the seat of the trembling, are 
rigid at the same time, especially the muscles of the neck and shoulders. 
Pupils dilate and contract naturally. Mouth incompletely closed, and 
saliva dribbles out of both corners over chin. Articulation embarrassed. 
Sensibility everywhere normal; muscles contract, though somewhat feebly, 
by galvanic excitation. Slight dulness over apex of right lung, with 
diminution of respiratory murmur. Frequent vertigo; occasional cepha- 
lalgia ; stools natural; urine alkaline, and contains some pus. Questions 
answered slowly, but pretty clearly. Physiognomy expressive of indiffer- 
ence and apathy. 
June 22d to 24th; severe diarrhoea, and involuntary stools, which 
yielded to opiate injections. 
June 25th; hut little sleep last night, and delirium; about 10 A. m. had 
an epileptiform seizure, during which the head was drawn to the right, 
right eye turned outward and upward, and the left downward and inward. 
Eyelids and tongue at the same time continually oscillating; while the 
muscles of the face were rigid. Upper and lower extremities flaccid, offer- 
ing hut little resistance when moved. Complete loss of consciousness, 
pulse and respiration weak and irregular; duration of fit, eight minutes. 
Between Ist and 7th of July, fresh seizures, after which the trembling 
ceased for half an hour, and then recurred with increased severity. Gen- 
eral sensibility diminished from day to day; and the face had a besotted 
look, like that of typhoid fever. Abdomen swollen, stools involuntary; 
the patient lay in a sort of sleep, and it was impossible to fix his attention, 
answering in monosyllables the questions put to him. Strength failed 
rapidly, pneumonia set in, and death July 11th. 
Autopsy.—Tubercular cavities at apex of right lung, and granular 
hepatization of lower lobe. In tbe substance of the right optic thalamus, 
apoplectic cyst of the size of a small bean, the walls of which contained OF THE NERVOUS CENTRES. 
43 
pigment. The pons varolii and the medulla oblongata manifestly indurated. 
The spinal cord was firm, and the lateral columns, principally in the lum- 
bar region, presented opague gray striae. On a microscopical examination, 
there was found, in the substance of the pons varolii and of the medulla 
oblongata, an abnormal production of connective tissue. The opaque 
striaa in the lateral columns of the cord were due to the presence of con- 
nective tissue in process of development. 
In the subjoined tables, sixteen cases of disseminated scle- 
rosis are analyzed with reference to age, sex, anatomical char- 
acters, disorders of motility, sensibility, special senses, intellect, 
and the cause of death. They have been carefully selected 
from the whole number of cases with autopsy now on record, 
and may be considered as fair types of the several varieties of 
this lesion of the brain and spinal cord. Case YII. has points 
of special interest, and the diagnosis offered some difficulties. 
The paroxysmal lightning-pains in the lower limbs, the tight 
band around the waist, slight weakness of sight, impossibility 
of walking with the eyes shut, and the cutaneous anaesthesia, 
all pointed to locomotor ataxy. On the other hand, the sight- 
troubles were developed at a late stage, and were insignificant; 
muscular weakness in the lower limbs was an early, indeed 
the first symptom ; and, although the patient could not walk in 
the dark or with his eyes closed, still the peculiar, wild thrust- 
ing out of the limbs so constant and proper to locomotor ataxy 
was wanting. There were, moreover, tremor, rigidity, and con- 
vulsive movements of the lower extremities, all of which are 
exceptional in the latter disorder. Finally, the notion of posi- 
tion was retained, and this very rarely happens in the advanced 
stages of locomotor ataxy. At the autopsy various sections of 
the spinal cord showed patches of sclerosis, irregularly scat- 
tered over all the columns, particularly in the cervical region, 
but it was on the posterior columns that they were found of 
greatest extent, thus accounting for some of the embarrassing 
symptoms, the lancinating pains, etc. 44 
DISSEMINATED SCLEEOSSIS OF 
CASES. 
AGE. 
SEX. 
LESIONS. 
DISORDERS OF 
REMARKS. 
MOTILITY. 
SENSIBILITY. 
sp’l senses. 
INTELLECT. 
I. CruveilMer. 
Atlas d’Ana- 
tomie Patho- 
logique, Liv. 
xxii., PI. II., 
Fig. 4, p. 22. 
37 
Female. 
Indurated spots on the an- 
terior pyramids, right oli- 
vary Body, and corpora 
restiformia. The roots of 
the hypoglossal, glosso- 
pharyngeal, and pneumo- 
gastric nerves, gray. 
Patches of induration on 
anterior face of cord, on 
the pons, inferior surface 
of cerebral peduncles, 
corpus callosum, and for- 
nix. 
At set. 31, weakness felt in 
left leg; three months after, 
in right. Later, superior 
extremities affected; they 
are feeble and tremulous, 
but are still capable of use 
in taking food. Finally, 
total loss of motion of all 
the limbs. Articulation 
embarrassed : deglutition 
difficult. When spoken to, 
the muscles of the limbs 
and trunk are the seat 
of involuntary movements, 
which cause the whole body 
to tremble. 
Natural. 
Sight feeble. 
Perfect. 
Lungs tubercu- 
lous. Lobu- 
lar pneumonia. 
Bronchitis. — 
Death from 
pulmonary dis- 
ease. 
II. CruveilMer. 
Atlas d’Ana- 
tomic Patho- 
logique, Liv. 
xxxviii., PI. 
v.,Fig. land 
1', pp. 1 and 
2. 
38 
Female. 
Gray degeneration of the 
cord in the form of 
patches, more or less 
large, and in much greater 
number on the posterior 
than anterior columns of 
the cord. No alteration 
of the nerve-roots. Simi- 
lar patches on several 
points of the pons varolii. 
All have a certain depth. 
Eighteen months previously, 
tinglings were felt in the 
soles of the feet and in the 
leg, and, almost concur- 
rently, weakness in the 
lower limbs. Soon after, 
the arms began to tremble. 
Fifteen months subse- 
quently, the patient dragged 
her legs, particularly the 
left; both constantly gave 
way under her. She can- 
not walk without assist- 
ance. The left leg more 
feeble than the right. 
Little or no 
sen sation 
i n lower 
limbs; sen- 
s i b i 1 ity 
very much 
1 e s s e ned 
in the up- 
per. The 
inferior 
e x t r e mi- 
ties have 
at no time 
been af- 
fectedwith 
cramps or 
convulsive 
move- 
ments. 
Death from pleu- 
risy. 
Analysis of Sixteen Cases of Disseminated Sclerosis. THE HEEYOUS CENTEES. 
45 
III. Friedreich. 
21 
Ma\e. 
Patches of sclerosis on the 
Unsteadiness of movements; 
0 c c a s ional 
— 
At the be- 
Death from pa- 
Eeported by 
mamillary tubercles, the 
staggering gait; violent 
trembling, happening when 
attacks of 
ginning, 
ralysis of the 
Yalentiner. 
cerebral peduncles, pons 
vertigo; 
m e n t al 
pneumogas- 
varolii, corpora olivaria, 
the patient is spoken to, 
pains in 
e x c i te- 
trie. 
Deutsche 
in the substance of the 
and which affects the move- 
the head, 
ment; 
Klinik, No. 
cerebral peduncles, and 
the medulla oblongata. 
ments of the hands; similar 
particular- 
toward 
14, 1856, 
tremor of the head; later, 
ly in the 
the end, 
nystagmus. 
occipital 
a kind ol 
region. — 
stupor. 
Sometimes 
shoot ing 
pains in 
the legs. 
IV. Friedreich. 
20 
Female. 
Patches of sclerosis on the 
Onset at ffit. 17, after sudden 
S e n s i bility 
— 
At the 
Death from 
Eeported by 
surface and in the interior 
chill. Weakness of right 
of limbs 
same 
sloughs over 
Yalentiner. 
of the pons varolii. In- 
leg, afterward of left. Trem- 
bling of the hands when 
slightly 
time, 
sacrum. 
duration of the cerebral 
d i minish- 
with dif- 
Deutsche 
substance which sur- 
they are used, afterward 
ed. 
ficult ar- 
Klinik, 1856, 
rounds the lateral ven- 
participation of the muscles 
t i c u 1 a- 
No. 14. 
tricles. Patches of scle- 
rosis on the cord. 
of the eye and tongue. 
Speech - trouble. Toward 
the end total paralysis of the 
lower limbs. 
t i o n, a 
not able 
diminu - 
tion o f 
i n t e Hi- 
V. Zenker. 
SO 
Female. 
Induration of ependyma of 
At set. 26, weakness and trcm- 
Violent car- 
Slight dimi- 
gence. 
Death from 
Z e i t s ehrift 
both lateral ventricles. 
bling of lower limbs; later, 
d i a 1 g i o 
nution of 
sloughs. 
Sclerosis of the cornus 
of the hands and head. The 
spells at 
sight from 
fiirrat. Med. 
ammoni, corpora striata, 
unsteadiness of gait pre- 
the onset 
the outset. 
Bd. xxiv., 
fornix, peduncles of the 
vented any employment, al- 
though she could still use 
the hands. At set. 80, tre- 
mor, not apparent when the 
patient was quiet, nor dur- 
and during 
lift. 2 and 8. 
pineal gland, corpus cal- 
losum, taenia semicireu- 
laris, pons varolii, cere- 
bral and cerebellar pe- 
the course 
of the dis- 
ease. Cu- 
taneous 
duncles, and upper part 
of the spinal cord. 
xng sleep, seized the limb 
s ensibility 
when any movement was 
ab o lished 
attempted; on this, the up- 
per and lower extremities, 
and the head, began to 
tremble; in the erect posi- 
tion the whole body began 
to shake. At the terminal 
period, complete paraplegia. 
Embarrassment in move- 
ments of tongue. 
toward the 
termin- 
al stage. 
Muscular 
sense less- 
ened from 
the begin- 
ning. 46 
DISSEMINATED SCLEROSIS OF 
CASES. 
AGE. 
SEX. 
LESIONS. 
DISORDERS OF 
REMARKS. 
MOTILITY. 
SENSIBILITY. 
sp’l senses. 
INTELLECT. 
YI. Yulpian. 
Union Medi- 
cale, June 7, 
1866. 
51 
Female. 
Patches of grayish color, 
variable size, distinct, sit- 
uated in one district on 
the right lateral columns 
of the cord, in others, on 
the left lateral columns; 
and, at certain points, on 
the anterior columns, and 
at others, on the posterior 
columns. Same coloring 
on the, medulla oblongata, 
■where it extends to the 
lateral portions and pos- 
terior surface, and reaches 
as far as the floor of the 
fourth ventricle. The 
lower half of the left oli- 
vary body has the same 
hue. The size of the 
cord is evidently dimin- 
ished, and in those points 
where the gray tint is 
most extendedj there is, 
at the same time, well- 
marked antero-posterior 
flattening. 
At set. 24, the left foot was 
suddenly twisted, and be- 
gan to drag immediately 
afterward. Three years 
later, after a fail, the right 
leg becomes weak, then the 
right arm, and, finally, ten 
years later, the left arm. 
Twenty years after onset 
(1865) the condition of the 
patient was: permanent 
contraction of all the limbs; 
spells of spasmodic rigidity 
coming on very frequently 
in the muscles of the trunk 
and limbs; when one of 
the feet is flexed, and kept 
in that position, there is 
immediately severe trem- 
bling, which is very diffi- 
cult to stop, and impossible 
at times when the right 
foot is the subject of ex- 
periment. 
Slight hyper- 
iesthesia. 
Death from bron- 
chitis. 
YU. Charcot. 
48 
Female. 
Patches of sclerosis in the 
walls of the lateral ven- 
tricles, in the substance 
of the corpora striata, on 
the surface, and in the 
substance of the pons, and 
in the posterior and lat- 
At ast. 36, diminished power 
in the lower limbs, which 
become easily tired; at 
set. 42, walking impossible 
without assistance. Later, 
rigidity of the inferior ex- 
tremities, and, at times, 
Two years 
before on- 
set, dart- 
ing pains 
in the 
limbs dur- 
i n g the 
Sight weak. 
Good. 
Death from 
sloughs. 
Analysis of Sixteen Cases of Disseminated Sclerosis. THE NEEYOUB CENTRES. 
eral columns of the cord, 
particularly in the cer- 
vical region. A centre 
of softening, about the 
size of a walnut, corre- 
sponding to the posterior 
convolution of right pari- 
etal lobe. 
convulsive tremors in them. 
Three weeks before death, 
apoplectiform attacks; the 
legs became rather flaccid— 
could not be raised beyond 
the bed. Four days later, 
second attack of left facial 
hemiplegia, followed by pa- 
ralysis of the left arm. 
night,once 
or twice a 
month; la- 
ter, waist- 
p a i ns. 
General 
sensibility 
somewhat 
lessened. 
Loss of no- 
tion of po- 
sition of 
limbs. 
Headache, 
lasting two 
or three 
days each 
month. 
VIII. Yulpian. 
53 
Female. 
Eeddish-gray spots on the 
pons varolii, olivary 
bodies, particularly the 
left 5 on the corpora py- 
ramidalia, especially the 
right; in the white sub- 
stance of the centrum 
ovale. Patches scattered 
on the different columns 
of the cord to within two 
and a half centimetres 
of its termination, where 
the cord was entirely 
sound. 
Invasion at set. 34. After nu- 
merous periods of pauses, 
improvement, and aggrava- 
tion, walking impossible at 
aft. 45. The patient could still 
stand, hut when she did so, 
all the limbs began to trem- 
ble. Severe tremor in the 
feet when they are forcibly 
flexed, or when an attempt 
is made to keep them so. 
Impossible to flex the thigh 
on the pelvis, the leg on the 
thigh, the foot on the leg, 
on part of patient. Al- 
though tickling sole is felt, 
no reflex movement. The 
arms began to grow weak 
at set. 52 ; no other special 
symptom in them. 
Lancinating 
painsinthe 
lower ex- 
tremities, 
especially 
the left; 
sensibility 
normal on 
both sides, 
or perhaps 
slightly 
increased. 
• 
Death from 
sloughs. 48 
DISSEMINATED SCLEROSIS OF 
CASES. 
AGE. 
SEX. 
LESIONS. 
DISORDERS OP 
REMARKS. 
"— 
MOTILITY. 
SENSIBILITY. 
sp’l senses. 
INTELLECT. 
1X. Charcot. 
Reported by 
B ourneville, 
p. 30. 
41 
Female. 
Patches of sclerosis in cor 
pora striata, on external 
wall of right lateral ven- 
tricle, right optic thalami; 
in pons, and nearly whole 
extent of cervical en- 
largement of cord, except 
posterior columns, and 
lateral, anterior, and pos- 
terior columns of dorsal 
region. 
At set. 28, fall during preg- 
nancy ; two years after, 
weakness of legs after long 
walks; two years more, 
could not walk without 
help. Amelioration, lasting 
six njonths. Progress re- 
sumed, and at set. 35 little use 
of lower limbs, which were 
also stiff. At set. 39 both 
upper extremities affected, 
left more than right. An 
attempt to carry any thing 
to mouth caused trembling 
of right side, and slight 
tremor of head. 
Cutaneous 
sensibility 
natural. 
Feeling oi 
heaviness 
in lower 
limbs. 
Darting 
pains 
about fifth 
dorsal ver- 
tebra, be- 
low right 
breast, and 
around 
waist. 
Sight weak, 
particular- 
ly of right 
eye; diplo- 
pia. 
Good. 
Death from 
pneumonia and 
sacral sloughs. 
X. C liar cot. 
Reported by 
I B ourneville, 
i P- 44. 
36 
Female. 
I 
1 
Patches of sclerosis in optic 
thalami, lateral ventricles, 
pons varolii, cerebellum, 
peduncles of cerebellum, 
left olivary body, and 
cord; the nerve-cells of 
anterior cornua are 
shrunken; atrophy and 
sclerosis of optic nerves. 
At set. 30, after sight-troubles 
gait began to be unsteady * 
there was slight hold of 
the ground. Paraplegia 
progressive until total; ri- 
gidity of lower extremities; 
upper extremities become 
weak ; tremor on any vol- 
untary movement. 
A t outset 
p a i ns 
about 
shoulders 
and in tem- 
ples—then 
numbness 
of feet — 
seemed to 
walk on 
down. 
Contactile 
sensibility 
lost about 
insteps 
and lower 
third of 
leg. Anal- 
gesia of 
both lower 
limbs. 
First 
of bar of 
wood in 
eyes; a lit- 
tle while 
after, dim- 
n e s s of 
sight. 
Good. 
Death from 
pneumonia. 
Analysis of Sixteen Cases of Disseminated Sclerosis. THE NERVOUS CENTRES, 
49 
XL J. C. Mor- 
ris and Weir 
Mitchell. 
Transactions 
of the Col- 
lege of Phy- 
sic ia n s of 
Philadel- 
phia, 1868. 
American 
Journal of 
the Medical 
Sciences, 
July, 1868. 
62 
Male. 
Patches of sclerosis on an- 
terior and lateral columns 
of spinal cord. 
At aft. 37, weakness in left 
lower limb, which, in a few 
years, extends to right; 
paraplegia progressive until 
complete; left upper ex-- 
tremity affected, then right. 
Patient condemned to per- 
fect immobility; unable to 
feed himself. 
At outset 
sense of 
weight, 
with 
numbness 
in left leg; 
also sensa- 
tion of a 
bar, an 
inch or so 
wide, 
around left 
leg; then 
in right. 
Sensibility 
in its sev- 
eral forms 
s c a rc e 1 y 
altered. 
Perfect. 
Tubercles in 
lungs and in- 
testines. 
XII. Ludwig 
Leo. 
D eutsche 
Archiv. fur 
Klinik Medi- 
cin, 1868, p. 
151. 
34 
Male. 
Patches of sclerosis on 
walls of lateral ventricles, 
fornix, cerebral pedun- 
cles, ependyma of fourth 
ventricle, and corpus cal- 
losum. Optic nerves 
sclerotic to chiasma; cor- 
pora restiformia; cala- 
mus scriptorius; pons 
varolii. Sclerosis of pos- 
terior, anterior, and later- 
al columns of cord. 
At set. 20, headaches and ver- 
tigo until set. 26, when a 
right hemiplegic attack; 
improvement; progressive 
unilateral paresis; at set. 28, 
gait so unsteady, that he 
cannot walk without aid. 
Another attack, left side ; 
paraplegia progressive • gait 
tottering; when lying down 
can extend and nex, lower 
limbs, but the motions 
brisker than natural; ex- 
aggerated reflex move- 
ments. Upper extremities 
but little affected; tongue 
embarrassed ; series of apo- 
plectic attacks; paralysis 
complete; tremor of hands 
and tongue; muscular con- 
tractions. 
Cutaneous 
sensibility 
in its sev- 
eral forms 
lessened— 
not able to 
localize 
sensations 
felt. Pains 
along 
spine, in 
forehead, 
and in the 
legs, ex- 
tending to 
the toes. 
Diplopia at 
outset; 
myopia. 
Perfect. 
Exhaustion. 50 
DISSEMINATED SCLEEOSIS OF 
CASES. 
AGE. 
SEX. 
LESIONS, 
DISOEDEES OF 
EEMAEKS. 
MOTILITY. 
SENSIBILITY. 
sp’l senses. 
INTELLECT. 
XIII. Charcot; 
Y ulpian, 
Union Medi- 
cate, 1866. 
46 
Female. 
Patches of sclerosis on an- 
terior and antero-lateral 
columns, with lineal 
streaks on posterior col- 
umns in dorsal region. 
At set. 45, weakness of legs ; 
rapid paralysis of all the 
limhs and of the trunk; 
sits up with difficulty, and 
can scarcely support head 
when raised from pillow; 
contraction of lower ex- 
tremities and left arm. 
Urinary and fecal inconti- 
nence. 
Three years 
before mo- 
tor-troub- 
les, dart- 
ing pains 
through 
thighs and 
legs. Sen- 
sibility 
preserved 
m paraly- 
zed limbs. 
Death from ex- 
haustion, four 
years from on- 
set. Probably 
previous syph- 
ilitic troubles. 
XIY. Charcot. 
Y ulpian, 
Union Medi- 
cate, 1866, 
43 
Inmate. 
Patches of sclerosis on pons 
varolii, left anterior cor- 
pus pyramidalis; very 
large patch on right lat- 
eral column of cervical 
region of cord. The 
motor oeuli externus 
nerve altered. 
At rnt. 88, feebleness of lower 
limbs ; a year later, vertigo, 
apoplectic attack, followed 
by right hemiplegia; three 
years after, a second attack, 
followed by contraction of 
flexor muscles of fingers, 
and forearm of right side; 
two years later, a third at- 
tack • right upper extremity 
wholly paralyzed and rigid; 
paraplegia and permanent 
extension of lower ex- 
tremities. 
Long subject 
to 4 flying 
pains and 
facial neu- 
ralgia. Af- 
ter disease 
is estab- 
1 i s h e d, 
pains in 
left ham 
and heel; 
feeling of 
heaviness 
and numb- 
n e s s in 
lower 
limbs. 
Incomplete 
paralysis 
of left mo- 
tor-oculi 
externus 
m uscle, 
with inter- 
nal strabis- 
mus and 
diplopia. 
T owards 
end dart- 
ing pains 
in head. 
Gradual sinking 
after last apo- 
plectic attack, 
December, 
1861 ; death, 
February 7, 
1862, 
Analysis of Sixteen Cases of Disseminated Sclerosis. THE NERVOUS CENTRES. 
51 
XV. Charcot. 
SO 
Female. 
A small patch of sclerosis 
eleven centimetres above 
Unsteadiness of gait, amount- 
ing to titubation; difficulty 
Cutaneous 
sensibility 
Nystagmus, 
in right 
Fair; very 
emotion- 
Tubercles in 
lungs. Death 
0 r denstein, 
p. 78, anc 
B ourneville, 
p. 129. (Case 
reported by 
0 rdenstein 
autopsy by 
Bourne - 
ville.) 
olivary bodies; a larger 
on cervical enlargement; 
two, one on right, other 
on left posterior column; 
in brachial enlargement, 
just outside the origin of 
sensory-nerve roots. A 
large patch surrounding 
aqueduct of Sylvius, with 
processes extending into 
pons; several of consider- 
able size on the walls of 
lateral ventricle, which 
are lost in the substance 
of the hemispheres; in 
cerebellum, a small patch 
on right side, near the 
gray matter of the sur- 
face ; another in pons. 
of speech; tremor on any 
voluntary motion, particu- 
larly in left arm ; cannot 
carry left hand to head or 
mouth directly; tremor oi 
tongue ; muscular force oi 
limbs fair; tendency to fall 
backward in walking ; no 
permanent rigidity; no 
spasmodic muscular con- 
tractions. 
slightly 
increased ; 
darting 
pains in 
head. On- 
set with 
spells of 
vertigo, 
and soon 
after hys- 
t e f i c a 1 
globus in 
throat. 
optic disk, 
b e ginning 
of atrophy; 
in left, 
slight dila- 
tation of 
veins; 
sight a lit- 
tle weak, 
but varia- 
ble. 
al. 
from phthisis. 
XVI. Skoda. 
Eeported by 
Barw inkel. 
'Wien Med. 
Halle, ili., 
13, 1862. 
Schmidt’s 
J ahrhuch, 
ISTo. 119, p. 
294 ; Year- 
Book of New 
S y d e n ham 
Society, 
1863, p. 100. 
34 
Female. 
Walls of ventricles, fornix, 
pons varolii, medulla ob- 
longata, and spinal cord 
remarkably indurated. 
Optic nerves hard and 
flattened. In some 
opaque, reddish spots of 
the brain, the nerve-ele- 
ments are destroyed by 
new connective tissue; 
in the pons and cord 
there was proliferation 
of connective tissue, and 
obliteration of the ves- 
sels.* Fatty degenera- 
tion of muscles. 
At set, 32, feebleness of lower 
extremities, and soon after 
tremor of right hand, and 
then of left—occurring only 
on voluntary movements. 
Both progressive. Speech 
• somewhat indistinct. 
Began with 
vertigo, 
and pains 
in head 
and sa- 
crum. Cu- 
taneous 
sensibility 
s 1 i g h t ly 
lessened. 
Good. 
Good. 
Death from 
small-pox. 
* In this case there would appear to have been not alone disseminated sclerosis, but also diffuse sclerosis.—M. C. 52 
COKTICAL SCLEEOSIS OF THE 
B. CORTICAL SCLEEOSIS OF THE BRAIN AND SPINAL CORD. 
The cortical or annular form of cerebro-spinal sclerosis 
has recently been described by Dr. Yulpian, and an illustra- 
tive case published by him, a brief of which will be sufficient 
to show the symptoms and nature of the morbid process. 
L. B. was admitted into la Salpetriere, November 7,1861, 
with an affection of the spinal cord which began when she was 
fifty-two years of age, by weakness in the lower extremities, 
and was apparently neither preceded nor accompanied by 
lightning-pains nor sight-troubles. This paresis of the lower 
limbs gradually, but very slowly, increased, and fourteen years 
after the onset the patient could only walk with crutches, or 
when helped by some one. Eighteen months later she 
could scarcely maintain the erect position, even when leaning 
on a support. Cutaneous sensibility was, when she was ex- 
amined in 1862 and 1868, very much lessened throughout the 
lower extremities; but, in 1868, on the dorsum of the feet it 
had reappeared, and was nearly natural. 
There were none of the ordinary symptoms of sclerosis of 
the posterior columns; there was but little, if any, ataxy of 
movement; in walking, the left foot was thrown forward in a 
somewhat exaggerated manner, but there was really no true 
motorial incoordination. Lying in bed, she could raise one or 
both legs without any involuntary deviation, and keep them 
in that position without their trembling. The muscular force 
of the lower limbs, tested in the horizontal position, appeared 
good, except perhaps during the last three months.. 
;v lu 1866, for the first time, lancinating pains were felt in the 
lower extremities, accompanied by convulsive jerks; but 
these pains did not seem to have the distinctive lightning (ful- 
gurant) character of locomotor ataxy. Notion of position of 
the limbs was perfectly good, and, except some weakness of 
vision, there were no sight-troubles. 
Toward tlie end of 1867, general tremor of tlie whole body 
was noticed, whenever the patient attempted to stand up, or 
tried to walk. 
The symptoms collectively were still evidently very differ- 
ent from those of posterior sclerosis of the cord, and it was rec- BEAIN Als I) SPINAL COED. 
53 
ognized that the lesion of the cord, whatever it might he, 
must, in some respects at least, be other than that of locomotor 
ataxy. This probability was verified by the antopsy. Instead 
of fascicular sclerosis of the posterior columns, the cortical 
layer of the white substance was found sclerotic throughout 
the periphery and in the whole length of the spinal cord. There 
was also spinal meningitis, particularly well marked on the 
posterior face of the cord, but easily recognizable on the anterior 
and lateral faces. 
135 Lexington Ayextje, 
New York, June, 1870. NOTES 
ON 
THE PHYSIOLOGY AND PATHOLOGY 
OF THE 
NERVOUS SYSTEM 
WITH REFERENCE TO 
CLINICAL MEDICINE 
A—DISSEMINATED SCLEROSIS OF THE BRAIN AND SPINAL CORD 
B-ANNULAR OR CORTICAL SCLEROSIS OF THE SPINAL CORD. 
BY 
MEREDITH CLYMER, M. D. Univ. Penn., 
FELLOW OF THE COLL. PHTS. PHILADELPHIA, BTC., ETC 
[REPRINTED FROM TUE NEWYORK MEDICAL JOURNAL, MAT, 1870.] 
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