WEBVTT 00:00:00.833 --> 00:00:04.799 [HF4088 Multiple sclerosis 1967, Length: 00:26:25, Color, Sound. 00:00:04.800 --> 00:00:07.666 This Beta SP was duplicated from a 16mm answer print by Bono Film & Video, Inc 00:00:07.666 --> 00:00:10.666 for the National Library of Medicine, February, 2010.] 00:00:10.666 --> 00:00:32.399 [Dark, then film leader and countdown] 00:00:32.400 --> 00:00:41.233 [This film has been aquired for distribution by the National Medical Audiovisual Center] 00:00:41.233 --> 00:00:46.533 [Narrator:] The patient with multiple sclerosis staggers down a long road, 00:00:46.533 --> 00:00:50.033 weaving between despair on the one side and hope on the other. 00:00:50.033 --> 00:00:55.599 The doctor who must guide this patient is faced with a disorder in which the diagnosis 00:00:55.600 --> 00:00:58.400 is a gamble of odds and probabilities. 00:00:58.400 --> 00:01:05.300 The etiology is hidden in a jungle of clues and the therapy stirs a broth of heated dispute. 00:01:05.300 --> 00:01:11.633 It is hoped that this film will enable the practitioner and the student to better understand 00:01:11.633 --> 00:01:15.399 this elusive disease. 00:01:15.400 --> 00:01:19.266 [The National Multiple Sclerosis Society presents] 00:01:19.266 --> 00:01:23.399 [Multiple Sclerosis] 00:01:23.400 --> 00:01:27.433 [supervised by The Division of Neurology of The The School of Medicine, 00:01:27.433 --> 00:01:29.733 University of California at Los Angeles] 00:01:29.733 --> 00:01:34.999 [Narrator:] This is a...at 19, she had a two-week episode of burning and hypersensitivity 00:01:35.000 --> 00:01:36.866 of the right arm. 00:01:36.866 --> 00:01:42.899 A second episode occurred nine months later, beginning with sharp pains in the right forehead 00:01:42.900 --> 00:01:49.233 and scalp, then numbness and tingling in the right fingers and toes, ascending in three days 00:01:49.233 --> 00:01:52.466 to include the entire right side below the neck. 00:01:52.466 --> 00:01:57.732 After one month, these symptoms had almost cleared, but she then developed loss of vision 00:01:57.733 --> 00:02:03.733 in the left eye over a three-day period, followed in two weeks by blurring of vision in the right eye 00:02:03.733 --> 00:02:06.799 with pain on movement of the eyes. 00:02:06.800 --> 00:02:13.666 At this time, she also noted a tingling down the back, on bending the head forward. 00:02:13.666 --> 00:02:19.766 On examination at the peak of this attack, she could only count fingers with the left eye, 00:02:19.766 --> 00:02:27.499 and the visual field showed a huge scotoma involving the central region and the area around the blind spot. 00:02:27.500 --> 00:02:34.166 On the right, visual acuity was 20 over 40 and field-testing showed a scotoma involving the area 00:02:34.166 --> 00:02:41.499 around the blind spot and the entire inferior nasal quadrant, but sparing central vision. 00:02:41.500 --> 00:02:43.866 The optic discs appeared normal. 00:02:43.866 --> 00:02:49.899 These findings of optic neuritis gradually disappeared over the next two months. 00:02:49.900 --> 00:02:57.600 In the four years since then, she has remained well, except for one persistent symptom. 00:02:57.600 --> 00:03:02.766 [Patient:] When I bend my neck down, I get an electric shock sensation that extends 00:03:02.766 --> 00:03:06.666 from my neck down my back, through my legs. 00:03:06.666 --> 00:03:14.899 [Narrator:] This electric shock-like sensation on flexion of the neck is called Lhermitte's sign 00:03:14.900 --> 00:03:21.666 and is considered a manifestation of posterior column damage in the cervical spinal cord. 00:03:21.666 --> 00:03:26.966 This is a 43-year-old sales manager for a dairy company. 00:03:26.966 --> 00:03:33.366 At 33, he had an episode of left-sided numbness and weakness, unsteady walk, and double vision, 00:03:33.366 --> 00:03:36.366 with complete recovery in six months. 00:03:36.366 --> 00:03:43.799 At 36, he developed slurred speech, difficulty focusing his eyes, clumsiness of the left arm and leg, 00:03:43.800 --> 00:03:49.433 hypersensitivity of the right side of the body, and Lhermitte's sign. 00:03:49.433 --> 00:03:53.833 He improved after one month but was left with permanent residual. 00:03:53.833 --> 00:03:58.266 This stayed the same for the next four years, then slowly worsened. 00:03:58.266 --> 00:04:01.799 Ten years after onset, he demonstrates the following: 00:04:01.800 --> 00:04:06.466 His eye movements are impaired in all directions of gaze. 00:04:06.466 --> 00:04:10.266 When he looks to the sides, the in-turning eye is paralyzed. 00:04:10.266 --> 00:04:13.299 The out-turning eye shows horizontal nystagmus. 00:04:13.300 --> 00:04:19.666 There is weakness of upward gaze, left more than right, and vertical nystagmus 00:04:19.666 --> 00:04:21.399 on upward and downward gaze. 00:04:21.400 --> 00:04:28.833 This disconjugate gaze difficulty is called internuclear ophthalmoplegia. 00:04:28.833 --> 00:04:35.266 It represents damage to the median longitudinal fasciculus, a tract that runs through 00:04:35.266 --> 00:04:39.066 the dorsal portion of the brain stem on each side of the midline. 00:04:39.066 --> 00:04:44.366 Bilateral internuclear ophthalmoplegia is considered by many authorities 00:04:44.366 --> 00:04:48.499 to be pathognomonic of multiple sclerosis. 00:04:48.500 --> 00:04:55.300 His speech shows dysarthria characterized by jerky rhythm and slurring. 00:04:55.300 --> 00:05:03.600 [Patient 2:] On July 24th, 1858, after consulting friends about the proposal, Abraham Lincoln, 00:05:03.600 --> 00:05:12.466 the Republican candidate for senator, challenged his Democratic opponent, the incumbent, 00:05:12.466 --> 00:05:23.032 Stephen A. Douglas, to divide time and address the same audience during the present canva... 00:05:23.033 --> 00:05:27.433 [Narrator:] Testing of his hands shows good coordination on the right. 00:05:27.433 --> 00:05:33.033 But on the left, there is a tremor of the outstretched hand accentuated 00:05:33.033 --> 00:05:34.933 by performing any accuracy test. 00:05:34.933 --> 00:05:40.133 There is also inability to perform rapid alternating movements with this hand. 00:05:40.133 --> 00:05:46.933 These signs represent the ataxia of cerebellar disease. 00:05:46.933 --> 00:05:57.299 Testing of his legs reveals the weakness on the left. 00:05:57.300 --> 00:06:08.500 [The doctor examines the way each leg reacts to stretches.] 00:06:08.500 --> 00:06:14.066 There is ankle clonus on the left. 00:06:14.066 --> 00:06:19.366 There are bilateral upgoing toes on plantar stimulation. 00:06:19.366 --> 00:06:25.166 These signs are indicative of damage to the pyramidal tract somewhere between 00:06:25.166 --> 00:06:31.966 the cerebral cortex and the lumbar cord. 00:06:31.966 --> 00:06:35.599 This is a 23-year-old insurance company clerk. 00:06:35.600 --> 00:06:39.200 Beginning at age 18, she has had one episode each year. 00:06:39.200 --> 00:06:44.133 The first attack consisted of buzzing and decreased hearing in the left ear, double vision, 00:06:44.133 --> 00:06:48.366 and impaired balance, with complete recovery in six weeks. 00:06:48.366 --> 00:06:54.799 The second attack included left-sided tinnitus and hearing loss, staggering walk, double vision, 00:06:54.800 --> 00:07:00.466 slurred speech, tingling in the right hand, and numbness in both legs below the knees. 00:07:00.466 --> 00:07:05.532 After six months, these symptoms improved, but she was left with permanent nystagmus 00:07:05.533 --> 00:07:08.499 and ataxia. 00:07:08.500 --> 00:07:14.100 Her third attack began with pain and foggy vision in the right eye, reaching a peak in one month, 00:07:14.100 --> 00:07:21.166 at which time the visual acuity was 20 over 30, and the visual fields showed a scotoma adjacent 00:07:21.166 --> 00:07:22.632 to the macular region. 00:07:22.633 --> 00:07:28.299 This paracentral scotoma of optic neuritis remitted in another month. 00:07:28.300 --> 00:07:35.766 A right oculomotor nerve palsy lasting five weeks constituted the fourth attack. 00:07:35.766 --> 00:07:41.499 She is now in her fifth attack with symptoms of vertigo, slurred speech, double vision, 00:07:41.500 --> 00:07:46.033 staggering gait, and numbness in the right hand. 00:07:46.033 --> 00:07:51.533 Examination of eye movements reveals coarse horizontal nystagmus on lateral gaze, 00:07:51.533 --> 00:07:54.099 vertical nystagmus on gaze up and down. 00:07:54.100 --> 00:07:57.100 A rhythmic head tremor may also be seen. 00:07:57.100 --> 00:08:02.366 This represents damage to vestibular pathways. 00:08:02.366 --> 00:08:07.566 When she holds out the left hand, there is a flapping tremor at the wrist, 00:08:07.566 --> 00:08:10.232 intensified by performance of the finger-to-nose test. 00:08:10.233 --> 00:08:13.666 This is independent of whether the eyes are open or closed. 00:08:13.666 --> 00:08:19.266 It represents the intention tremor of cerebellar disease. 00:08:19.266 --> 00:08:25.466 The right hand exhibits searching movements of the fingers when the eyes are closed, 00:08:25.466 --> 00:08:31.366 and hesitancy on the finger-to-nose test, which is not present when the eyes are open, 00:08:31.366 --> 00:08:37.766 indicating position sense loss due to posterior column damage in the spinal cord. 00:08:37.766 --> 00:08:44.932 Her gait is weaving and lurching because of ataxia in the legs. 00:08:44.933 --> 00:08:52.299 She has bilateral ankle clonus. 00:08:52.300 --> 00:09:03.900 And Babinski signs as a result of pyramidal tract damage. 00:09:03.900 --> 00:09:10.800 This is a 41-year-old housewife and mother whose first symptoms occurred at age 30, 00:09:10.800 --> 00:09:13.800 when she developed weakness of the left leg. 00:09:13.800 --> 00:09:17.633 At 33, she had nystagmus and an ataxic gait. 00:09:17.633 --> 00:09:22.366 Since 35, both legs have become progressively weaker and stiffer. 00:09:22.366 --> 00:09:24.132 There have been no remissions. 00:09:24.133 --> 00:09:27.099 After 11 years, she shows the following. 00:09:27.100 --> 00:09:33.400 Testing of eye movements demonstrates bilateral internuclear ophthalmoplegia, 00:09:33.400 --> 00:09:43.400 with weakness of the adducting eye and jerking of the abducting eye on gaze to each side. 00:09:43.400 --> 00:09:56.600 There is a mild intention tremor of both hands, representing damage to the cerebellar system. 00:09:56.600 --> 00:10:08.200 Babinski signs are present bilaterally. 00:10:08.200 --> 00:10:33.900 Both legs show spasticity and weakness, the left more than the right. 00:10:33.900 --> 00:10:38.833 The patellar reflexes are hyperactive bilaterally. 00:10:38.833 --> 00:10:46.233 This spastic paraparesis with hyperactive and pathological reflexes denotes pyramidal tract 00:10:46.233 --> 00:10:49.299 damage in the spinal cord. 00:10:49.300 --> 00:10:55.100 This is a 41-year-old schoolteacher whose symptoms began at age 31 when he developed 00:10:55.100 --> 00:11:01.066 difficulty focusing his eyes with apparent movement of objects upon which he would fix. 00:11:01.066 --> 00:11:03.466 This represented nystagmus. 00:11:03.466 --> 00:11:06.799 It occurred intermittently for one year, then disappeared. 00:11:06.800 --> 00:11:11.700 At 33, he noted intermittent balance difficulty and weakness of the legs. 00:11:11.700 --> 00:11:15.100 At 34, incoordination of the hands and feet. 00:11:15.100 --> 00:11:20.133 At 36, his left leg and arm became weak and have remained so ever since. 00:11:20.133 --> 00:11:22.899 After ten years, he shows the following. 00:11:22.900 --> 00:11:28.200 There is mild ataxia of all four limbs on coordination testing. 00:11:28.200 --> 00:11:30.766 This is more prominent on the left. 00:11:30.766 --> 00:11:37.066 A slight head tremor occurs intermittently with effort. 00:11:37.066 --> 00:12:07.232 [The doctor watches the way the patient's wrists and ankles tremble as he attempts to stretch.] 00:12:07.233 --> 00:12:12.233 Spasticity in the left arm and leg is demonstrated when he walks. 00:12:12.233 --> 00:12:20.233 The left arm does not swing, and the left leg is used stiffly. 00:12:20.233 --> 00:12:30.266 [The patient walks around to demostrate the difference in the way each leg works.] 00:12:30.266 --> 00:12:50.266 The reflexes are hyperactive everywhere. 00:12:50.266 --> 00:12:59.499 [The patient's reflexes are tested in various parts of his body.] 00:12:59.500 --> 00:13:08.266 Hoffmann signs are present bilaterally. 00:13:08.266 --> 00:13:12.099 There are bilateral Babinski signs. 00:13:12.100 --> 00:13:18.600 This patient's findings indicate damage to the pyramidal tract and the cerebellar system 00:13:18.600 --> 00:13:23.166 bilaterally, most likely in the brain stem. 00:13:23.166 --> 00:13:28.266 Multiple sclerosis can be diagnosed with certainty only at autopsy 00:13:28.266 --> 00:13:33.799 when a picture of patchy demyelination in the central nervous system is seen. 00:13:33.800 --> 00:13:40.700 The glial scars or plaques may be seen and felt on the surface of the brain or spinal cord, 00:13:40.700 --> 00:13:44.400 as grayish-brown, firm, translucent spots. 00:13:44.400 --> 00:13:51.800 All of these pictures are from one patient, a 24-year-old lady with a four-year history 00:13:51.800 --> 00:13:53.666 of multiple sclerosis. 00:13:53.666 --> 00:14:00.766 Here on the pons is a large, brown, sclerotic plaque with two smaller lesions above it. 00:14:00.766 --> 00:14:08.299 These lesions represent a late stage in the pathological process, the demyelinated patch 00:14:08.300 --> 00:14:15.266 having been filled in by a scar of glial cell overgrowth. 00:14:15.266 --> 00:14:21.732 When cut sections of brain or cord are viewed, foci of demyelination appear as brown patches 00:14:21.733 --> 00:14:24.333 in the white matter. 00:14:24.333 --> 00:14:30.599 Cerebral foci have a predilection for the white matter immediately adjacent to the ventricles, 00:14:30.600 --> 00:14:34.633 especially posterior and inferior horns, 00:14:34.633 --> 00:14:39.966 and the white matter about the cortical and basal nuclear gray matter. 00:14:39.966 --> 00:14:45.399 The lesions in the cerebral hemisphere vary in size from that of a pinhead 00:14:45.400 --> 00:14:48.333 to several centimeters in diameter. 00:14:48.333 --> 00:14:54.999 Similarly, numerous areas of discoloration are found in the brain stem and cerebellum. 00:14:55.000 --> 00:14:59.366 Early in the plaque formation, there is perivascular inflammation. 00:14:59.366 --> 00:15:03.499 Then tissue is destroyed, myelin preponderantly. 00:15:03.500 --> 00:15:10.500 Myelin sheaths fragment into globules, fat is liberated, and macrophages ingest the fat. 00:15:10.500 --> 00:15:19.933 As the lesion ages, glial cells proliferate and produce fibrils, which give the older lesions 00:15:19.933 --> 00:15:25.866 their sclerotic appearance and make them visible to the naked eye. 00:15:25.866 --> 00:15:31.299 Here on a freshly cut section of the spinal cord, only a faint area of discoloration is seen 00:15:31.300 --> 00:15:34.933 in the posterior columns. 00:15:34.933 --> 00:15:41.299 When stained for myelin, the lesions appear as pale foci within the darkly staining white matter. 00:15:41.300 --> 00:15:45.266 Many more plaques are now apparent. 00:15:45.266 --> 00:15:49.132 The lesions are often far in excess of what one would've expected 00:15:49.133 --> 00:15:53.699 from the patient's symptoms and signs during life. 00:15:53.700 --> 00:15:58.966 Thus, many plaques may be clinically silent, such as this demyelinated patch 00:15:58.966 --> 00:16:01.366 in the optic radiation of the cerebrum. 00:16:01.366 --> 00:16:07.666 In fact, there is evidence that a patient may go through life with pathological demyelination 00:16:07.666 --> 00:16:12.732 and yet have no clinical manifestations of multiple sclerosis. 00:16:12.733 --> 00:16:18.399 [Louis J. Rosner:] The only relatively consistent laboratory abnormalities in multiple sclerosis 00:16:18.400 --> 00:16:22.033 are spinal fluid changes. 00:16:22.033 --> 00:16:24.766 The spinal fluid may be entirely normal. 00:16:24.766 --> 00:16:30.199 This occurred in 40 percent of patients in the UCLA Multiple Sclerosis Clinic. 00:16:30.200 --> 00:16:38.766 An elevated gamma globulin content, over 13 percent of the total protein, was found in 58 percent. 00:16:38.766 --> 00:16:44.766 The colloidal gold curve was abnormal, the numbers adding up to ten or more in 36 percent. 00:16:44.766 --> 00:16:49.366 This test is an indirect measure of relative gamma globulin elevation. 00:16:49.366 --> 00:16:56.332 There was an elevated protein in 35 percent, an increased white cell count in 20 percent. 00:16:56.333 --> 00:17:03.499 With no pathognomonic laboratory test by which to confirm the diagnosis, the doctor must rely 00:17:03.500 --> 00:17:08.600 on his evaluation of the history and the physical examination. 00:17:08.600 --> 00:17:13.700 The clinical criteria for the diagnosis of multiple sclerosis are two. 00:17:13.700 --> 00:17:16.800 Number one, episodic course. 00:17:16.800 --> 00:17:24.666 Number two, multiple symptoms and signs pointing to optic nerve, brain stem, or spinal cord. 00:17:24.666 --> 00:17:31.899 Optic nerve manifestations are: decreased visual acuity, central scotoma, 00:17:31.900 --> 00:17:36.166 or paracentral, cecocentral, or peripheral on visual field examination 00:17:36.166 --> 00:17:39.899 and optic atrophy on ophthalmoscopic examination. 00:17:39.900 --> 00:17:45.900 Brain stem manifestations include nystagmus, the disconjugate gaze difficulty known as 00:17:45.900 --> 00:17:51.966 internuclear ophthalmoplegia, trigeminal neuralgia, facial sensory deficit, facial weakness, 00:17:51.966 --> 00:18:00.566 vertigo, dysarthria, dysphagia, emotional lability, and ataxia of the head, trunk, or limbs. 00:18:00.566 --> 00:18:07.299 Spinal cord manifestations consist of the electric sensations on flexing the neck 00:18:07.300 --> 00:18:14.233 known as Lhermitte's sign, tight band feelings around the trunk called girdle sensations, 00:18:14.233 --> 00:18:20.966 superficial or proprioceptor sensory deficit, spastic weakness with hyperactive and pathological reflexes, 00:18:20.966 --> 00:18:25.166 and neurogenic bladder disorder. 00:18:25.166 --> 00:18:32.132 Variations in the course and in the signs define four varieties of multiple sclerosis, 00:18:32.133 --> 00:18:34.899 the incidence of which is as follows. 00:18:34.900 --> 00:18:41.900 Number one, episodic disseminated, the classical type, 78 percent. 00:18:41.900 --> 00:18:46.233 Number two, progressive disseminated, 15 percent. 00:18:46.233 --> 00:18:50.299 Number three, episodic non-disseminated, five percent. 00:18:50.300 --> 00:18:54.866 Number four, progressive non-disseminated, two percent. 00:18:54.866 --> 00:18:59.432 Returning to our five patients, it will be seen that the first three represent 00:18:59.433 --> 00:19:02.433 the classical type of multiple sclerosis. 00:19:02.433 --> 00:19:09.033 The other two, atypical types. 00:19:09.033 --> 00:19:15.466 The college student in the first year of her illness had intermittent sensory symptoms 00:19:15.466 --> 00:19:17.132 with no objective signs. 00:19:17.133 --> 00:19:20.199 She was considered neurotic at that time. 00:19:20.200 --> 00:19:26.700 Many patients in the early stages of multiple sclerosis are given the diagnosis of psychoneurosis. 00:19:26.700 --> 00:19:28.900 The differential can be a difficult one. 00:19:28.900 --> 00:19:34.100 It is recommended that multiple sclerosis be diagnosed only if there are 00:19:34.100 --> 00:19:37.633 documented, objective abnormalities on examination. 00:19:37.633 --> 00:19:43.533 When this young lady developed the scotomas of optic neuritis and the Lhermitte's sign 00:19:43.533 --> 00:19:49.533 of spinal cord involvement, there was objective evidence of neurological disease 00:19:49.533 --> 00:19:51.466 and definite evidence of dissemination. 00:19:51.466 --> 00:19:56.432 The spinal fluid was normal, except for an elevated gamma globulin of 20 percent. 00:19:56.433 --> 00:20:00.266 Then the diagnosis of multiple sclerosis could be made. 00:20:00.266 --> 00:20:08.032 The excellent remission further confirmed this impression. 00:20:08.033 --> 00:20:13.166 The sales manager began with an attack suggesting both brain stem 00:20:13.166 --> 00:20:15.666 and spinal cord pathology. 00:20:15.666 --> 00:20:20.366 With complete remission of these symptoms, multiple sclerosis was suspected, 00:20:20.366 --> 00:20:25.432 but other remitting conditions occurring at the cervicomedullary junction region 00:20:25.433 --> 00:20:27.066 were still possible. 00:20:27.066 --> 00:20:32.732 After a two-year interval, he developed the disconjugate gaze difficulty of brain stem disease 00:20:32.733 --> 00:20:36.399 and the spinal cord sign of Lhermitte. 00:20:36.400 --> 00:20:42.066 Now, the diagnosis of multiple sclerosis was definite on the basis of episodic course 00:20:42.066 --> 00:20:44.932 and disseminated signs. 00:20:44.933 --> 00:20:53.333 A normal spinal fluid reinforced this conclusion. 00:20:53.333 --> 00:20:59.433 The pretty young clerk had only brain stem manifestations with her first attack. 00:20:59.433 --> 00:21:04.833 Multiple sclerosis could not be diagnosed at that time, as several other diseases 00:21:04.833 --> 00:21:07.466 can give a similar picture with remission. 00:21:07.466 --> 00:21:11.166 For example, cholesteatoma in the posterior fossa. 00:21:11.166 --> 00:21:16.499 In the second attack, there were sensory symptoms suggestive of spinal cord involvement 00:21:16.500 --> 00:21:19.900 in addition to the previous brain stem signs. 00:21:19.900 --> 00:21:24.400 There was still the possibility of a compressive lesion at the foramen magnum. 00:21:24.400 --> 00:21:29.000 Only with her third attack, when signs of optic neuritis occurred, 00:21:29.000 --> 00:21:31.833 was dissemination unequivocal. 00:21:31.833 --> 00:21:42.233 The diagnosis could not be made with assurance then, until this, the third year of her illness. 00:21:42.233 --> 00:21:47.233 The housewife has had a progressive, non-remitting course. 00:21:47.233 --> 00:21:52.933 This occurs in ten to 40 percent of MS patients in different large series. 00:21:52.933 --> 00:21:59.199 It is more common with an older age of onset and with a spinal cord type of onset. 00:21:59.200 --> 00:22:05.300 With time, it became apparent that this lady had damage in both the brain stem and spinal cord, 00:22:05.300 --> 00:22:12.466 as evidenced by the nystagmus and ataxia on the one hand and the spastic paraparesis on the other. 00:22:12.466 --> 00:22:18.066 The further development of bilateral internuclear ophthalmoplegia confirms the diagnosis 00:22:18.066 --> 00:22:25.432 of multiple sclerosis. 00:22:25.433 --> 00:22:29.966 The schoolteacher initially had only nystagmus, which remitted. 00:22:29.966 --> 00:22:34.399 After a one-year interval, intermittent ataxia appeared. 00:22:34.400 --> 00:22:41.200 Subsequently, the ataxia became constant, and he developed a spastic left hemiparesis 00:22:41.200 --> 00:22:45.433 with bilateral hyperreflexia and pathological reflexes. 00:22:45.433 --> 00:22:49.133 All signs could be localized to the brain stem. 00:22:49.133 --> 00:22:53.633 The early remissions suggested multiple sclerosis, but the absence of 00:22:53.633 --> 00:22:59.299 signs of dissemination necessitated the performance of many special tests. 00:22:59.300 --> 00:23:04.133 The entirely normal spinal fluid was further evidence of multiple sclerosis. 00:23:04.133 --> 00:23:12.066 However, in this type of case, the doctor should be especially cautious in his diagnosis. 00:23:12.066 --> 00:23:15.032 After the diagnosis, then what? 00:23:15.033 --> 00:23:21.666 Although multiple sclerosis has been known for almost 100 years, its etiology and its treatment 00:23:21.666 --> 00:23:24.032 are still unsettled. 00:23:24.033 --> 00:23:28.733 One important clue is the epidemiology of the disease. 00:23:28.733 --> 00:23:33.099 The geographical distribution is that of a low prevalence in tropical zones 00:23:33.100 --> 00:23:38.033 and a high prevalence in temperate and northern zones where studies have been made. 00:23:38.033 --> 00:23:44.333 Certain factors commonly found to precipitate exacerbations of the disease include 00:23:44.333 --> 00:23:48.666 physical exhaustion, infection, surgical procedures, and emotional crises. 00:23:48.666 --> 00:23:55.432 This patient's most recent exacerbation was in association with an emotional crisis. 00:23:55.433 --> 00:23:59.899 When an attack occurs, bed rest at the beginning may decrease the duration 00:23:59.900 --> 00:24:01.633 and the severity of the relapse. 00:24:01.633 --> 00:24:06.966 Symptomatic treatment includes the use of anti-vertigo drugs, muscle relaxants, 00:24:06.966 --> 00:24:09.699 antispasmodics for the bladder, and physical therapy. 00:24:09.700 --> 00:24:14.833 Most important of all is the psychological support that the doctor can render the patient 00:24:14.833 --> 00:24:18.699 by giving him attention, encouragement, and hope. 00:24:18.700 --> 00:24:24.166 Specific treatment for multiple sclerosis must await the discovery of the cause. 00:24:24.166 --> 00:24:27.632 Many theories have been proposed, but none has been proved. 00:24:27.633 --> 00:24:33.699 Research programs are now studying the problems of precipitants in the exacerbations of MS: 00:24:33.700 --> 00:24:39.733 geographical factors in its incidence, the nature and function of myelin, the significance of 00:24:39.733 --> 00:24:45.899 anti-myelin antibodies, and the experimental demyelinating disease of animals. 00:24:45.900 --> 00:24:51.566 The solution to multiple sclerosis will open the door to an understanding 00:24:51.566 --> 00:24:55.732 of many other neurological problems. 00:24:55.733 --> 00:25:01.633 Speaking for the National Multiple Sclerosis Society is Dr. Augustus S. Rose, 00:25:01.633 --> 00:25:07.799 Professor of Neurology at the University of California, Los Angeles. 00:25:07.800 --> 00:25:11.933 [Dr. Augustus S. Rose:] It is generally believed that patients derive encouragement and hope 00:25:11.933 --> 00:25:16.266 through the effort and programs of the National Multiple Sclerosis Society. 00:25:16.266 --> 00:25:22.299 Not many years ago, there was comparatively little scientific and public interest in the problem 00:25:22.300 --> 00:25:25.100 of multiple sclerosis. 00:25:25.100 --> 00:25:32.800 Today, it is recognized as the leading neurological disorder of our time and a major health problem. 00:25:32.800 --> 00:25:38.600 A large and diversified research program is being conducted in many laboratories throughout 00:25:38.600 --> 00:25:42.066 the world and with promising results. 00:25:42.066 --> 00:25:46.799 Through research and research fellowship training grants, the National Multiple Sclerosis Society 00:25:46.800 --> 00:25:53.300 supports fundamental, applied, and clinical studies considered to have relationship 00:25:53.300 --> 00:25:57.333 to the problem of multiple sclerosis and demyelination. 00:25:57.333 --> 00:26:04.766 Positions and research persons at a postdoctoral level interested in these programs 00:26:04.766 --> 00:26:10.132 should communicate with the medical and research director of the National Multiple Sclerosis Society 00:26:10.133 --> 00:26:14.566 in New York City. 00:26:14.566 --> 00:26:17.566 [written and narrated by Louis J. Rosnerm M.D., assistant Professor of Neurology, U.C.L.A. 00:26:17.566 --> 00:26:23.732 in association with Augustus S. Rose, M.D., Professor of Neurology, U.C.L.A.] 00:26:23.733 --> 00:26:28.133 [Produced and donated to The Multiple Sclerosis Society by] 00:26:28.133 --> 00:26:32.466 [Rex Fleming Productions Santa Barbara, Calif.] 00:26:32.466 --> 00:26:34.132 [presented by the] 00:26:34.133 --> 00:26:41.933 [National Multiple Sclerosis Society 257 Park Avenue South New York, N.Y. 10010]