PROGRESSIVE LOCOMOTOR ATAXY. 
No very obvious paralysis of the blad- 
der or lower bowel. 
“ No necessary impairment of sexual 
power. 
“No tingling or kindred phenomena. 
“No marked impairment of muscular nu- 
trition and irritability. 
“ No impairment of the mental faculties. 
“ Occasional injection of the conjunctive, 
with contraction of the pupils.” 
Dr. Radcliffe takes no notice, in this sum- 
mary, of the usual order of precedence in 
the various symptoms. This, as described 
by Duchenne, is shown in the first of the 
following cases. The first period is charac- 
terized by “ paralysis of one or several of 
the motor nerves of the eye, complicated 
with paralysis of the optic nerve, and by 
erratic, boring pains ; the second, by the 
of defects of coordination, and, 
soon after or simultaneously, by muscular 
and cutaneous insensibility, generally in 
the lower limbs, or sometimes in the upper 
limbs; the third, by generalization of the 
disease.” 
Case I.—Mr. came to me last Feb- 
ruary, in accordance with the suggestion 
of Dr. Knight. He said he wished to know 
whether electricity would be of any use in 
restoring his lost power. He seemed to 
have very little faith in any kind of treat- 
ment, and his mental condition was one of 
great despondency. As he expressed him- 
self, he thought he might as well die of this 
disease as of any other, if he was going to 
die at all. 
He is about 59 years of age, has been 
married thirty years and had one child, 
which is dead. His business has been to 
construct and fit the wood-work for machi- 
nery. His father died of paralysis. He 
says he has had rheumatism very severely 
and frequently in every part of his body for 
the last thirty years. He is not aware of 
any cardiac trouble. He has many times 
during the last thirty years strained him- 
self by lifting heavy weights—has at times 
been laid up for several days on that ac- 
count; as he said, has had a “crick” in 
Read before the Boston Society for Medical Observation 
by S. G. Webber, M.D., Boston. 
This disease was knowm formerly as tabes dor- 
salis, and as such is well described by Rom- 
berg ; but the whole of the group of symp- 
toms belonging to it was not fully recog- 
nized until Duchenne (of Boulogne) com- 
municated a memoir on that subject to the 
Society of Medicine of Paris in 1857. This 
memoir is reproduced in all its essential 
particulars in his work “ L’Electrisation 
Since that date, observers in 
other places have continued the investiga- 
tions, and an extensive literature on the 
subject has been created. 
The two cases here related illustrate two 
different forms of the disease ; but in nei- 
ther do all the symptoms occur wjiiqh aro 
metimes met.’ For a luller description 
reference may be made to Trousseau’s Cli- 
nique Medicale de l’H6tel Dieu, t. ii. ; to St. 
George’s Hospital Reports, vol. i.; an arti- 
cle by Dr. J. L. Clarke; or to Reynolds’s 
System of Medicine, vol. ii. Dr. Radcliffe, 
in the last work, sums up the distinctive 
symptoms as follows:— 
“A peculiar gait, arising from want of 
coordinating motor power in the lower ex- 
tremities—a gait precipitate and stagger- 
ing, the legs starting hither and thither in 
a very disorderly manner, and the heels 
coming down with a stamp at each step. 
“No true paralysis in the lower extremi- 
ties or elsewhere. 
“ Characteristic neuralgic pains, erratic, 
paroxysmal, in the feet and legs chiefly— 
pains of a boring, throbbing, shooting cha- 
racter, like those caused by a sharp electric 
shock. 
“ More or less numbness in the feet and 
legs chiefly, in all forms of sensibility, ex- 
cepting that by which differences of tem- 
perature are recognized. • 
“ Frequent impairment of sight or hear- 
ing, one or both. 
_ “ Frequent transitory or permanent stra- 
bismus or ptosis, one or both. 2 
his back by turns for several years. But 
nothing of this kind had occurred for months 
previous to his paralysis. 
For many years he has had attacks of 
numbness in his right thumb, so that he 
could not write, especially in winter. For 
this he had rubbed his thumb with alcohol. 
If the attack was very severe, he might have 
only one dui’ing the winter ; if less severe, 
he might have more. 
Three or four years ago, his eyes were 
affected, on which account he consulted 
Dr. Williams, who told him he had amauro- 
sis. The right eye was the worst, and was 
almost blind. The affection of the eyes 
came on rather suddenly. Subsequently, 
the amaurosis improved. He acknowledges 
no trouble in the head and no vertigo. 
About one year ago last January, he no- 
ticed, while at work, that he had suddenly 
lost power over the left leg. He could not, 
while sitting on his stool, extend his leg. 
He did not fall down when he tried to walk, 
but could draw his leg after him. If he 
stumbled, however, he could not recover 
his balance. At the same time with the 
motor paralysis, there was a slight loss of 
sensation in the same leg. He seems sub- 
sequently to have regained considerable 
control over the muscles of his leg, or else 
the paralysis was not so complete as he 
stated, since, when 1 saw him, not 
very marked. 
For several months there was a slow ad- 
vance in the paralytic symptoms. The pa- 
ralysis extended to his right leg, and that 
became worse than the left. It gradually 
extended up the right side to the right arm 
and then to the left arm. 
Last December, he had paralysis of mo- 
tion and somewhat of sensation in the right 
side of his face, and ptosis of the right 
eyelid. This did not last long. He wet 
his face in the morning in cold water, and 
used friction with a coarse salted towel; 
to this he ascribes the impi'ovement which 
took place in his facial paralysis. 
He thinks that since December he has 
been losing ground slowly, and that the dis- 
ease has been gradually advancing. 
Now, he has some difficulty in seeing, 
especially with his right eye, which reacts 
rather sluggishly under the influence of 
light. He has no abnormal sensations, as 
of itching, tingling, formication, &c. He 
has a sensation as of a cord bound round 
about the middle of the left arm. This 
sensation exists nowhere else. He com- 
plains of a sensation of cold nearly all the 
time, especially in the feet, up to the mid- 
dle of the leg, and to a less degree in the 
body, but most marked in the left great toe 
and along the inside of the foot to the heel, 
and here it is accompanied with numbness. 
It exists to a less degree in corresponding 
parts of the right foot. The numbness also 
extends partly up the leg. 
He balances tolerably well, and with his 
eyes shut can walk, though with a very 
unsteady gait. He can stand with his feet 
together and eyes shut, but sways back- 
wards and forwards more than is natural 
in health. He thinks he has most difficulty 
in moving his legs in the morning, after 
lying a-bed all night. 
When walking, he feels as though he 
must go fast, so as not to fall forwards, so 
that his feet may keep up with his head. 
Sensation is not very good in the back of 
his head, and he is very sleepy. He feels 
best when lying down. 
His appetite is poor; he is constipated, 
but is not troubled with flatus. 
The examination ceased here, owing to 
the lateness of the hour, and I told him I 
would call the next day at his house for the 
purpose of examining the condition of the 
various sensations. The next day, excuse 
was made that his wife was sick, and I 
have not heard from him since. 
Case II.—0. McG., a laborer, I saw at 
the City Hospital, in the service of Dr. 
Dial . wi » has kindly permitted me to 
mal jf the case tu further illustra 
the subject. The hospital record states 
that he was a hard drinker till eight years 
ago, and since that time has indulged im- 
moderately in whiskey, but has always 
been well and strong till last May. About 
one month before that time he was knocked 
down by a horse, which trod upon his right 
side. He is not aware of any injury to his 
head or back, though after the accident he 
had much pain in his side on breathing. 
About May 1st, he first experienced a 
cold sensation in the left foot, as of a wet 
stocking drawn over it. In a month, the 
right foot was affected in a similar way. 
The sensation gradually extended, and in 
three months had reached the knees, when 
he was obliged to give up work. 
He had no headache nor any trouble with 
his head for three months after the trouble 
in the lower extremities commenced. He 
then had sharp, darting pains in teeth, face 
and head, and since that time has felt light- 
headed. 
At present, the sensation of coldness has 
invaded the whole of the lower extremities 
and the body below a line passing through 
the lower ribs. There is also marked im- 
pairment of sensibility, which is worst at 3 
extremities more frequently and more se- 
verely than elsewhere. It would also be 
very unusual that one should have rheuma- 
tism repeatedly, and the pains be so 
severe that their recollection was disagree- 
able, and yet be aware of no cardiac com- 
plication. I ought to say, however, that I 
did not make any examination, intending 
to do so while he was in bed next day. The 
disease is sometimes of very long duration ; 
thus Mr. Carre refers to cases which had 
lasted 20, 21, 24 and even 28 years. 
In the 2d volume of Reynolds’s System 
of Medicine, Dr. C. B. Radcliffe does not 
recognize the fact that the upper extremi- 
ties may be involved. Yet in the first case 
there was partial loss of sensation in the 
right thumb, occurring before the loss of 
motion in the lower limbs. Many other 
cases are on record, one by Duchenne, in 
which the abnormal condition was perceiv- 
ed in the upper extremity. Also, at post 
mortems, changes have been recognized in 
the cervical region of the cord. In a post 
mortem by Dr. J. L. Clarke, recorded in the 
Lancet, June 10, 1865, the change was 
noticed as high as the second cervical 
nerve. 
The change usually found after death, as 
described by various observers, is degene- 
ration of the posterior columns of the spi- 
nal cord., chiefly in the lumbar region, occa- 
sionally extending as high as the cervical, 
rarely confined to the latter region. This 
degeneration may extend to the neighbor- 
ing posterior cornua and gray matter ; it 
may even involve the posterior roots. This 
last is not a constant lesion, but is usually 
found where there is loss of sensation. 
“ The degeneration is essentially charac« 
terized by gradual and progressive atrophy 
of the nervous elements, and by a gradual 
and progressive development of the con- 
nective tissue which separates them.”— 
Carre, p. 189. 
Similar changes have been found in the 
optic nerves, and also other cranial nerves 
when these have been affected, but more 
especially the motor nerves of the eyes. 
Various influences have been assigned as 
the cause of this disease. Comparatively 
a large number of patients have suffered 
either from strains of the back or fatigue, 
or have been exposed to wet and cold dur- 
ing a long period of time. In both the 
cases herewith reported, there is a history 
of injury ; in the first case often repeated 
straining, and the first pains appeared at 
about the same period as the first strain, or 
thirty years ago. In the second case, there 
is a history of an injury to the side, and 
the feet and decreases upwards. Reflex 
action is very much diminished or lost in 
the feet. Sensation and motion of the up- 
per extremities seem to be impaired. Eye- 
sight but little affected ; he sometimes sees 
specks floating before his eyes. April 1st, 
the day of entrance into the hospital, in the 
afternoon, he complained of a cloudiness of 
vision for the first time. Pupils act natu- 
rally. Taste and smell unimpaired. 
He is obliged to micturate quite frequent- 
ly,, and sometimes when he feels the desire 
to do so, he has a passage of urine unwit- 
tingly. He never passes urine while 
asleep. 
His gait, when walking, is peculiaidy 
characteristic of this affection ; much more 
so than in the previous case. When at- 
tempting to walk, even if supported on 
each side, his legs are moved about in a 
very disorderly manner, sometimes side- 
ways, sometimes forwards and backwards, 
sometimes crossing each other, and the heel 
comes down with emphasis upon the floor. 
If his eyes are shut, he cannot stand when 
the feet are brought together. 
He became dissatisfied and homesick, 
and left the hospital in two days. 
Only occasionally, as at the commence- 
ment of the attack in the first case, is there 
real paralysis of motion; the patient is 
unable to walk, and is perhaps confined to 
the bed, but can movo bis linibs with power, 
though in a disorderly manner and perhaps 
by jerks, not being able to check them at 
just the point desired. 
The affection with which locomotor ataxy 
is most likely to be confounded is disease 
of the cerebellum, especially one of slow 
growth, as a tumor. But in an affection of 
the cerebellum there is found vertigo, some- 
times vomiting, headache, or perhaps throb- 
bing sensations in the head. The defect 
in motion is also different. The gait is un- 
steady rather from lack of power over the 
muscles, or on account of the vertigo, than 
from defect of coordinating power. The 
vision may be affected in both diseases. 
The second case is one of the more erra- 
tic cases, commencing with the second pe- 
riod, the symptoms of the first period ap- 
pearing only intercurrently. 
It is certainly a long duration for the dis- 
ease to have dated back thirty years, yet 
that is the date at which the rheumatic 
pains were first felt, and according to his 
description they seemed to resemble the 
tearing and boring pains of locomotor ataxy 
more than those of rheumatism. Though 
not stated in the notes, I believe he com- 
plained of the pains having been in his lower 4 
consequent difficulty of breathing, about a 
month before the peculiar coldness of the 
feet was noticed. 
Duchenne states briefly—“Some pa- 
tients accuse sudden or too prolonged cool- 
ing, suppression of transpiration ; thus, for 
example, there is a sportsman who often 
has remained a long time with the feet and 
legs in the water. Once, the phenomena 
of this disease have shown themselves after 
a too prolonged sitz bath. Trousseau men- 
tions hereditary taint, also, as a predispos- 
ing cause. This may appear in the first 
case, where it is stated that the father died 
of paralysis. 
Out of 132 cases referred to by Carre, 
some of which, however, were not of this 
disease, 66 have no cause assigned, and no 
antecedents are given. In 17 there was a 
previous history of syphilis, in 8 of rheu- 
matism, 6 had been exposed to unusual and 
frequent fatigue, 23 had been subjected to 
cold and dampness in various ways—either 
dwelling in damp houses, sleeping in the 
open air on damp ground, working in damp 
places, or were subject to sudden cooling 
while perspiring freely, and immediately 
after felt the first signs of the disease. In 
9, there had been emotional excitement or 
long-continued anxiety. In 5, disease of 
the nervous system had existed among the 
ancestors. In 5, abuse of wine or venereal 
excess had been noted. 
Topinard, who has collected a very large 
number of cases, says that among predis- 
posing causes, “ there are few so efficacious, 
when united together, as disappointment, 
emotion, and bad hygiene.” He also looks 
upon rheumatism as playing a certain rdle 
in this relation. With regard to dampness, 
he says :—“ But the most common cause is 
dampness and sudden cooling, since 16 
times it is indicated as determining and 15 
times as predisposing, that is to say 31 
times in all.” He concludes the chapter 
on Etiology: — “Progressive locomotor 
ataxy is a disease peculiar to adult age ; 
more frequent in males, in those who are 
addicted to excesses of all kinds, who are 
exposed to dampness and to great fatigue. 
Among temperaments, the nervous alone is 
certainly disposed to a particular form of 
the disease. Among diatheses, the rheu- 
matic is the only one whose influence is in- 
contestable.” In some cases, he thinks it 
seems to be hereditary. 
Eisenmann recognizes essentially the 
same causes, only concussion of the spinal 
cord through falls and strains he considers 
as perhaps causing rather a local disease, 
and not properly locomotor ataxy. 
The despondency in the first case, and 
the similar feeling of homesickness in the 
second, are phenomena worthy of notice. 
If the disease is considered a derange- 
ment of the vaso-motor system, much that 
is otherwise anomalous ceases to be so. 
Many of the earlier symptoms are explain- 
ed by the existence of congestion of the 
nerve centres. In the first case, there was 
a sudden loss of power over the left leg. 
Previous to that, amaurosis had occurred. 
Both these symptoms had diminished very 
much in intensity. The numbness of the 
right thumb had occurred and disappeared 
again and again. Later, there was paraly- 
sis of the right side of the face, which had 
nearly or quite disappeared when I saw the 
patient. In other cases, certain symptoms 
are found occurring and then disappearing, 
as strabismus in M. Duchenne’s case No. 
122 ; also incontinence of urine. Occa- 
sionally the amaurosis, which occurs early 
in the disease, so far disappears that the 
patient does not think to speak of it with- 
out being questioned. Congestion may 
well be supposed to be the cause of such 
temporary symptoms. 
Another proof of the truth of this theory 
is given by M. Trousseau, in the congested 
state of the conjunctiva and contraction of 
the pupil which he observed in many - 
Hcntp.; bn* :' ■ conf r'ri >n disappeared . I 
the pupih diUted-v.-Heis here was an e - 
cess of severe pain. M Duchcnnt* and 
Radclifte have observed the same. 
The means used to dissipate the numb- 
ness of the thumb and the paralysis of the 
face might well act by causing reflex chan- 
ges in the vessels of the cord :—stimula- 
ting friction to the parts affected and cold 
water to the face. 
Another fact directly bearing upon this 
point may be found in Trousseau’s Clinique, 
in an account by Luys of the microscopic 
appearances. “ In following into the grey 
substance of the fourth ventricle the inves- 
tigation upon the trunk of the external mo- 
tor nerve of the eye, up to its point of real 
origin, a series of large vascular trunks 
were seen in the tract of the primitive 
fibres of this nerve, which they probably 
must have compressed in a notable degree.” 
The coldness complained of by both these 
patients is a proof of vaso-motor distur- 
bance. That this coldness is not merely a 
subjective sensation there is nothing record- 
ed in recent writers to show ; but Hasse 
states that there is a reduction of l°-2° R. 
in the part. 
One case, at least, is on record where the 
patient, dying of some acute disease, little or nothing has been found to account for 
the ataxic symptoms. 
I quote from Topinard the appearance 
found after death. The patient had had 
symptoms of locomotor ataxy since thirteen 
years, and for six months had been unsteady 
in his gait. Cutaneous sensibility was al- 
tered. He died during an attack of variola, 
in the last part of which he had true mus- 
cular paralysis. “ At the autopsy, abso- 
lutely nothing was found to the naked eye 
in the encephalon, cerebellum, the roots or 
columns of the spinal cord. The whole 
cord was very much injected ; the optic 
nerves were grey, semi-transparent, softened 
between the papillae and the corpora geni- 
culata exclusive. One of the common mo- 
tor nerves was flattened, diminished in vol- 
ume, but was not grey. The microscopic 
examination found the posteriorcolumns and 
roots healthy, and the usual alteration of 
the optic nerves. Having myself compared 
a transverse section of the lumbar enlarge- 
ment of this patient with a similar section 
from the ataxic patient of whom we had made 
the autopsy fifteen days before in the ser- 
vice of M. Trousseau, I have been able to 
testify to that integrity. However, in more 
closely examining it, it has seemed to me 
that the posterior border of the grey com- 
missure, in place of being suddenly arrest- 
ed, was diffuse and insensibly confounded 
with Listr ceiitie of the posterior column, 
as if the iatter commenced to be altered in 
their depth.” 
Several cases are recorded in which the 
symptoms of locomotor ataxy occurred, but 
which recovered entirely. It can scarcely 
be supposed that in such the nerve fibres 
had been completely disorganized. 
The causes above referred to are calcu- 
lated to produce derangement in the circu- 
lation. The effect of damp cold in derang- 
ing the circulation is well known, and the 
vaso-motor nerves are peculiarly suscepti- 
ble to influences of an emotional nature 
From these facts in regard to some of the 
fugitive symptoms of the disease, from the 
case in which such accurate observers as 
MM. Gubler, Luys and Duchenne found 
nothing but congestion of the posterior 
cords, from the fact that patients have en- 
tirely recovered after the second stage of 
the disease has made great progress, and 
from the nature of the causes which act to 
produce it, I am inclined to look upon it as 
an affection primarily of the vaso-motor 
nerves, producing congestion, which being 
only moderate in degree and being long 
continued causes proliferation of connective 
tissue, and, as it were, strangles the nerve 
fibres, causing their absorption. 
The question arises, what is the cause of 
this congestion, of this vaso-motor distur- 
bance ? The sympathetic is looked upon 
as the regulator of the bloodvessels, and 
disturbance of its function or lesion of its 
structure interferes materially with the dis- 
tribution of the blood. M. Duchenne is in- 
clined to refer the changes of the cord to 
changes in that nerve. In an article in the 
Gazette Hebdomadaire, Feb. 19 and March 
4,1864, he advocates this view. He founds 
his belief principally on the vascular phe- 
nomena connected with the eye, which has 
been already referred to, and on the symp- 
toms connected especially with the bowels, 
bladder and other viscera. He thinks that 
if the ganglia connected with the lower 
part of the cord were examined, changes 
might be found to throw light upon the 
sclerosis of the cord. 
One case is recorded by Donnezan in the 
Gazette Hebdomadaire, May 6, 1864, in 
which, though the autopsy was not com- 
plete, a partial answer is given on this 
point. M. M was attacked with the 
pains of this disease in 1858, and in 1860 
was unable to walk without support. Ob- 
stinate constipation caused a distressing 
sensation of a girdle around the body. 
Towards the last, he lost all motor power, 
and died in 1864. At the autopsy, the pos- 
terior columns in the cervical region were 
found somewhat affected ; the dorsal and 
lumbar regions were extensively changed. 
Only the upper cervical sympathetic gang- 
lion could be obtained for examination, 
owing to the opposition of friends. It was 
found to be harder, more resisting, and of 
a more yellowish white than in health. 
The cells did not differ from those of a 
healthy ganglion. The communicating 
branch, however, had become tendinous; 
the proper nervous tissue had disappeared. 
Friedreich, on the other hand, gives a 
very detailed account of an autopsy, and 
states that the sympathetic was normal.— 
Virchow's Archives, vol. xxvi. 
In an examination made by Luys, and 
quoted by Trousseau, the ganglia on the 
posterior roots in the lumbar region were 
all increased in size, and unusually red and 
vascular. Their enveloping membrane was 
considerably thickened. On section, the 
capillaries were found dilated. The gang- 
lionic corpuscles (cells) were covered with 
brown pigment-granules, and some were 
torn and shrunken ; others were voluminous 
and pale. No part of the sympathetic was 
examined. 
So far as I have been able to learn, this 
is the extent of the investigation in this di- 6 
rection. Much can be said in opposition to 
the theory of the sympathetic origin of the 
disease. Nothing can be settled till a larger 
number of cases have been examined with 
particular reference to this point. 
Treatment.—The benefit to be anticipated 
depends much upon the view taken of the 
pathology. If the disease is, in its earlier 
stages, essentially a vaso-motor disturbance, 
a simple congestion, the expectation of 
benefit would be greater the earlier treat- 
ment was commenced. 
Cases have been recorded where the loss 
of coordinating power was so great that 
the patient could not stand ; yet in three or 
four months restoration was complete. It 
is not necessary, then, to despair of benefit- 
ing a patient, even when he seems to be in 
the advanced stages of the disease. 
Electricity seems to do good occasionally, 
but at best the benefit from it is very un- 
certain. 
The best treatment seems to be, with 
proper diet and hygiene, that proposed by 
Wunderlich—nitrate of silver in quarter- 
grain doses three times a day for four or 
five weeks; after that time it would be 
well to omit the drug for a week or so, to i 
avoid coloring the skin. The same course 
may then be repeated. It may be ! 
necessary to give the nitrate in sm'n r 
doses at first, on account of gastric ir 
tion, and occasionally it must be entfi r j 
omitted. If no benefit follows, the do. 
should be increased. Althaus gives, with 
the nitrate, the hypophosphite of soda, and 
thinks it better than the nitrate alone. 
Many have been relieved by this treat- 
ment. In only a few cases has complete 
cure been obtained. One such is to be found 
recorded in the Gaz. des Hop., Jan. 4, 1863. 
Carre mentions 16 cases where a cure 
was obtained, or the benefit was considera- 
ble. In one of these, the nitrate was ad- 
ministered hypodermically, near the spinal 
column. In 6 cases, the benefit was only 
partial; either a relapse occurred, or after 
a while the drug lost its power, or could 
not be tolerated. In 4 cases, no benefit at 
all was obtained. 
The good effect of the drug is usually 
observed at the end of a week or fortnight. 
The first favorable effect is relief of the 
pain, subsequently return of sensibility, 
and finally return of coordinating power. 
Sometimes sightisrestored. Simultaneous- 
ly the general health is benefited, diges- 
tion is improved and constipation ceases. 
If the congestive theory is correct, bro- 
mide of potassium, belladonna and ergot 
might be of benefit. 
Note.—It will be noticed that I have used 
the term “ congestion ” to express the pri- 
mary morbid condition. It is considered by 
many to be a chronic myelitis. Without 
intending to deny this, I have used “ con- 
gestion to express the view that hyperas;- 
mia of the part was the cause of the subse- 
quent change, and to bring out more clear- 
ly the role p, fed by tin vaso-motor nerves. 
Tne reason ■ poster:o columns are gen 
erally attack; d may that there is a 
greater abundance of vessels and intersti- 
tial tissue naturally in them. See Archives 
de Physiologie Nor male et Pathologique, No. 
2, p. 329.