From Big Medical Encyclopedia

MULTIPLE SCLEROSIS (sclerosis disseminata; Greek sklerosis consolidation; synonym: multiple sclerosis, sclerosis multiplex) — the chronic progressing disease which is characterized by the multiple centers of defeat in the central and peripheral nervous system.


Separate a wedge, and morfol, R.'s manifestations by the village were described by Zh. Kryuvelye (1835), Garsvell (R. Garswell, 1838), K. Rokitansky (1856), E. Leyden (1863). As an independent disease of R. of page Zh. Sharko (1868) who in detail described his manifestations and the erased forms is allocated. He considered the most typical for this disease: a mnogoochagovost of defeat, the progressing current with remissions, selective demyelination of nerve fibrils with relative safety of axial cylinders, a triad of symptoms (Sharko's triad): nystagmus, intentsionny trembling and scanning speech.

In the next years a wedge, the picture P.c. it was studied in more detail. G. Oppengeym (1887, 1913) paid attention to disturbance of sensitivity and a peculiar combination of some symptoms at R. of the village of Utkhoff (W. Uhthoff, 1889) noted diagnostic value of eye symptoms. A. Shtryumpell (1896) pointed to lack of belly reflexes. Müller (E. Müller, 1904) gave the detailed description a wedge, pictures P. of page, showed variety and variability of its separate manifestations. Marburg (O. of Marburg, 1906, 1936) allocated five symptoms most characteristic of R. of page, having added primary atrophy of optic nerves, decrease or lack of belly reflexes to Sharko's triad; he paid attention to the acute P.c forms.

The statistics

the Disease is registered in the countries with a frigid climate more often, is much more rare — in tropical countries. Women are ill slightly more often. Most often the disease is observed aged from 20 up to 40 years, however occurs also at children, and also at persons of middle and advanced age.

In the USA, Canada, Australia, countries of Western Europe R.'s frequency of page makes 30 — 80 cases on 100 thousand population. In the countries of Asia, Central America, Africa R.'s incidence of page makes, according to Kurttske (J. Kurtzke, 1977), no more than 5 cases on 100 thousand population.

According to D. A. Markov, A. L. Leonovich, G. I. Mirkina (1976), R. pages makes a considerable part among organic lesions of a nervous system (in the different countries from 4,7 to 10,5%). By data nevrol, clinics, in the USSR in the districts located above the 50th parallel sick R. pages on average make 3,4%, and is lower than this width — 1,2%.

In the Soviet Union R. the page meets in the European part, especially in the republics of the Baltics, in Belarus, in the central regions of RSFSR, in the Western Ukraine more often, in the Urals where on 100 thousand population 25 — 50 cases are celebrated. Less often than R. the page meets in Siberia, napr, in Transbaikalia the intensive indicator of incidence makes 17 on 100 thousand inhabitants. In isolated cases this disease is observed among aboriginals of the republics of Transcaucasia and Central Asia, practically does not occur at Buryats and Yakuts in Siberia.

H. G. Hodos, I. I. Kozhova (1980) pay attention that R. of page tends to extend to those geographical districts where it was not earlier.

An etiology

In R.'s emergence by the village attach significance to a number of exogenous and internal causes. O. A. Hondkarian (1972), B. F. Semenov, V. I. Gavrilov (1976) suggested that among exogenous factors the main place is taken by a virus which concerns to group of slow viruses. Its nature is finally not found out.

Carry a virus of measles, adenoviruses, viruses of a herpes simplex, epidemic parotitis to number of possible activators, etc. Norrbi, Karp, Warner, Mertz (E. Norrby, R. Carp, H. Warner, G. Merz, 1978) specified that the basis for the similar assumption is increase in blood and cerebrospinal liquid of sick R. of page of an antiserum capacity to these viruses, and also allocation of some of these viruses from tissue of a brain of the died patients. The special attention of researchers is drawn by studying possible etiol, roles of a virus of measles at R. with page (and it is possible, and other representatives of the sort Paramixovirus) as the most probable agent promoting developing of a slow infection.

Epidemiol. the researches conducted in the different countries showed that features of the environment also exert impact on developing of a disease. Zones with high and low risk of a disease of R. of page are revealed. Studying of migratory processes showed that the persons who moved from a zone of high risk to a zone of low risk to 15-year age are ill R. page considerably less than it takes place on their Rhodinum. On the contrary, the persons migrating aged are more senior than 15 years, keep the same opportunity to ache with R. page, as well as in the area of their previous accommodation. Among other exogenous factors exerting possible impact on R.'s emergence by the village, some researchers point to insufficient contents in food unsaturated fat to - t that, in particular, is confirmed by low level linoleic to - you in blood serum of patients. The internal causes important in emergence P, page are especially intensively studied in immunogenetic aspect.

The pathogeny

the Pathogeny is difficult p is insufficiently studied. In R.'s development by page many factors, especially metabolic matter that is established at biochemical and gistokhy. researches. Kazner, Barnard, Mac-Gregor, Borshell, Davison (M. of Cuzner, R. Barnard, V. of MacGregor, N. Borshell, A. Davison, 1976) found selective loss of the main protein of a myelin in the centers of demyelination in connection with its splitting by proteolytic enzymes. These enzymes are revealed in cerebrospinal liquid of patients, and their level is increased in areas of active demyelination and not changed in intact white matter. At R. of page the proteinaceous composition of cerebrospinal liquid often changes. Increase in the content of gamma-globulins in it (at 85% of patients) is noted though contents them in blood can remain normal. Quite often correlation between increase in content of gamma-globulins in cerebrospinal liquid and characteristic of R. of page paralytic reaction of Lange takes place (see. Cerebrospinal liquid ).

A certain place in R.'s pathogeny of page is taken by a delay of age involution of a thymus (see), its frequent hyperplasia at sick R. page. By data I. N. Dyakonova (1975), morfol, changes of a thymus at R. the page (a hyperplasia, existence of lymphoid follicles and plasmocytes) are close to changes at collagenoses that confirms R.'s belonging of page to autoimmune diseases.

By means of a computer tomography it is established that at R. the page breaks function of a blood-brain barrier: in an acute stage of a disease around patol, the center there is a zone of hypostasis which gradually disappears in process of improvement of a condition of the patient, especially against the background of treatment by corticosteroids.

An immunopathology

During the studying of an immunopathology of R. of page consider four groups of the factors having important theoretical and practical value:

1. The experimental allergic encephalomyelitis representing immunol. the disease, is characterized by symptomatology very similar to symptomatology at R. page. By data the Grater (J. L. Turk, 1978), focuses of demyelination at these diseases have a similar perivenous arrangement and the same perivascular infiltration by mononuclear cells.

2. Detection in sick R.' blood of page of the raised credits of autoantibodies and antibodies against some viruses, in particular measles. 3. Shifts in indicators of cellular immunity — decrease in quantity or activity of T-suppressors, oppression of products of mediators of cellular immunity and interferon. 4. These R. V. Petrova (1976), Sveygorda (A. Svejgaard, 1980) that the frequency of emergence of R. of page correlates with a frequency of some genes of the main complex of histocompatability which controls the majority immunol. reactions (see. Immunity transplant , histocompatibility antigens).

According to Madden (D. Madden, 1980) and other researchers, 4,1 times more often R. of page the people possessing DR2 antigen get sick (or DW2). In the region of HLA-D the immune response genes controlling height and efficiency immunol are localized. reactions in relation to specific antigens. Therefore if the organism to which the virus got bears a gene of a low contestability in relation to its antigens, he is not able to develop an effective immune response. The virus in small amounts can persistirovat in an organism for years and cause hron, defeat of this or that fabric, to cells a cut it has at least a nek-ry tropnost.

Hron, defeat by a virus of nervous or related cells can lead to emission in blood of their autoantigens with development of autoimmunization (see the Immunopathology). It is confirmed by existence at sick R. of page of autoantibodies against the main protein of a myelin. Development of autoimmune process especially is probable that the number and activity of T-suppressors which during remission are in limits of norm decrease in the period of an exacerbation of a disease. A.S. Pavlyuk et al. (1978) revealed total absence of a suppressor lymphocyte activity of blood at sick R. of page in the period of an aggravation. It is known that T-suppressors provide normal impossibility of development of autoimmune reactions.

In blood and cerebrospinal liquid the ratio of T - and V-lymphocytes changes: the number of the first decreases, and the number of the second remains without change. In some cases, especially at the long course of a disease, quantitative indices of T - and V-lymphocytes of blood can be normal, however their functional activity (reaction to mitogens) is broken, and extent of its disturbance is directly proportional to duration of a disease.

It is possible that autoantibodies against a myelin have no patol, values, and only demonstrate to its defeat that immunol. reactions are implemented between viral antigens and antibodies against them not in nervous cells, and in the fabrics which are closely connected with tissue of a brain. Apparently, these reactions cause the inflammatory and destructive processes leading to destruction of myelin covers.

The most widespread hypothesis explaining a pathogeny of a disease is the assumption stated by R. V. Petrov (1975) that R. is connected by page with existence of such alleles of immune response genes which determine inefficiency of an immune response to this or that virus which is assumed etiol by a factor. In this regard one patients with the causal agent can have one virus, at others — another. The permanent persistirovaniye of a virus capable to strike nervous or is close with it the connected fabric, leads to release of autoantigens or to permanent stimulation of an immune response proteins, kompleksirovanny with a viral antigen. Ia-or SD antigens of the main complex of histocompatability can be such complexes. It is proved that viral antigens stimulate immunity only after a kompleksirovaniye with antigens of the main complex of histocompatability. Sensibilized lymphocytes, antibodies or autoantibodies, connecting to causal antigen, cause the inflammatory and destructive changes leading to demyelination.

The pathological anatomy

the Pathoanatomical picture P. of page is characterized by existence of multiple focal damages of various departments of c. N of page which cornerstone processes of demyelination (damage and destruction of a myelin) in combination with death of oligodendroglyocites are at long safety of the axial cylinder of nerve fibril. The combination of demyelination to reactive changes of other glial elements — proliferation of fibrous astrocytes and microglias leads to formation of peculiar centers which call plaques of multiple sclerosis. In lethal cases later it is long the proceeding disease such plaques come to light in a head and spinal cord. Along with it secondary changes in other bodies and systems are found: general exhaustion, atrophy of muscles of extremities and trunk, hron, cystitis and pyelonephritis, pneumonia, decubituses, dystrophic changes of a myocardium and liver. With the smaller duration of process, especially in acute cases of R. of page, structural changes come to light only in c. N of page.

Signs of an atrophy of a brain are most expressed in the basis a pitch about a liyev of the bridge and in the field of a konveksitalny surface of big hemispheres as expansion of furrows of various areas. They are quite often combined with the moderate internal hydrocephaly (see) which is expressed in preferential increase in cavities side and the fourth ventricles of a brain. In a spinal cord on cross sections the degrowth of white matter (side, front and back cords) comes to light. Often sharp thinning of optic nerves takes place. On cuts of an unstable brain plaques — the centers oval, roundish clearly are visible, is more rare than irregular shape, gray, white-yellow pink color of a pla with unsharply or with accurately expressed contours. The sizes them, as a rule, do not exceed 2,5 cm, seldom reach 4 — 5 cm in the diameter. Quantity of plaques and their localization in c. N of page are variable though it is tended to the bigger frequency of defeat and the expressed prevalence of process in white matter. In a brain of a plaque are located chaotically, most often near side ventricles in frontal and parietal lobes, is more rare on border with bark or directly in it. In a brain trunk the tendency to localization of plaques in white matter and near the fourth ventricle is also clear. In a spinal cord at early stages of development of a disease the centers of demyelination and the created plaques are visible well, but in process of progressing patol, process the centers of demyelination lose the clearness of an outline, they merge with sites of a secondary (vallerovsky) degeneration of conduction paths (see Valera regeneration), edges quite often extends on all length of a spinal cord. Plaques can be found also in roots craniocereberal (cranial, T.) and spinal nerves.

Microscopic changes reflect stages of development patol, process. Conditionally allocate the following stages of formation of a plaque. Initial changes arise in the first days of a disease and death of oligodendroglyocites and initial signs of proliferation of astrocytes consist in insignificant structural damages of a myelin (uneven coloring, swelling and vacuolation). In 3 — 4 weeks there occurs the progressing disintegration of myelin covers, proliferation of astrocytes and a microglia accrues, there are macrophages (see) containing the remains of a myelin and sudanophil substance. At this stage of development of demyelination and reactive changes of a glia with the expressed fibrillogenesis axial cylinders are kept, in them the raised argentofilnost is only sometimes noted. Existence of not changed axons and neurons within a zone of the expressed demyelination with massive accumulation of macrophages is the main sign distinguishing the forming plaque from the fresh center of a necrosis of other etiology. In several weeks the typical plaque microscopically comes to light — the site of tissue of brain is not painted on a myelin, and by means of special methods of coloring in this zone hypertrophied fibrous astrocytes, microgliocytes, axial cylinders come to light; oligodendroglyocites disappear. In peripheral departments of a plaque quite often around small veins there are infiltrates consisting of lymphoid elements and single plasmocytes (see). In several months in the plaque having structure of the center of a fibrillar gliosis macrophages with lipids which in a small amount can be found around veins in tissue of a brain, boundary to a plaque, do not come to light. This fact demonstrates a certain progressing of process. The so-called old plaque without signs of activity consists of axial cylinders, neurons (if it is localized in gray matter), vessels and dense network of glial fibers. At it is long the current disease in the axial cylinder there are signs of destruction, and then the typical vallerovsky degeneration, edges sometimes reaches considerable degree, striking conduction paths on different sites of a brain, and also a corpus collosum.

Gistokhim. the researches conducted by Zaytelberger (F. Seitelberger, 1965), Ibrahim, Adams (M. of Z. Ibrahim, Page W. Adams, 1977), demonstrate some disturbances of enzymatic activity in oligodendroglyocites at the earliest stages of a disease: the amount of oxidizing enzymes increases and activity of ATP increases. At a submicroscopy in early terms reveal signs of destruction of a myelin: disturbance of frequency of lipoprotein complexes of myelin covers with the advent of cracks in them of 4 — 5 nanometers and vacuoles; disintegration in oligodendroglyocites of a cytoplasmic reticulum (see. An endoplasmic reticulum) and rough changes in cristas of mitochondrions (see); emergence in astrocytes of fine fibrous structures which are located among not changed organellas of a cell. There are single researches in which intranuclear virus-like particles in oligodendroglyocites are described, however their relation to viruses is not established.

The clinical picture

the Clinical picture at R. page differs in extreme polymorphism. The beginning of a disease equally often happens poly-and monosimptomny. In most cases the disease begins with motive disturbances, hl. obr. from weakness in legs. Quite often it is characterized by paresthesias in the beginning (see). Sometimes R. begins page with unsteadiness of gait and is followed by dizziness, vomiting, a nystagmus (see). In some cases the disease is shown by defeat of cranial nerves, and the optic nerve especially often suffers — are noted retrobulbar neuritis (see. Optic nerve) and scotomas (see); more rare — the taking-away nerve, is even more rare — oculomotor that is shown by a diplopia (see). At the beginning of a disease defeat of a facial nerve is possible (see). Bulbar frustration are noted seldom. Sometimes at the beginning of a disease there can already be dysfunctions of pelvic bodies. Idiosyncrasy of early stages P. of page — gradualness of emergence of separate symptoms of a disease.

Further at most of patients the course of a disease has remittiruyushchy character and only in 15% of cases — steadily progressing. At a remittiruyushchy current allocate the period of emergence of new symptoms (ekzatserbation) and the period of their regress (remission). Both after an ekzatserbation, and after remission the period of a stationary state of various duration can be observed.

In the developed R.'s stage of page in a wedge, a picture symptoms of defeat of pyramidal, cerebellar and sensitive ways, separate cranial nerves and dysfunction of pelvic bodies most often come to light. Idiosyncrasy of R. of page — instability of separate symptoms which can be noted only within several days and even hours. Paresis and lacks of coordination of movements take the leading place among displays of a disease. Paresis is more expressed in proximal departments of extremities. The lower spastic paraparesis is especially often observed, is more rare — tetraparesis (see. Paralyses , paresis). In hands the muscle tone is more often reduced. Increase in tendon jerks (see) and periosteal reflexes (see), especially standing is in most cases noted. But also decrease, and in rare instances and lack of these reflexes due to defeat of reflex arcs or heavy cerebellar disturbances is possible.

One of characteristic symptoms of R. of page is absence or decrease in superficial belly reflexes, often asymmetric. Decrease and loss a cremaster reflex is less often possible.

At sick R.' most villages are caused patol, Babinski's reflexes and Rossolimo. Reflexes are not rare hand patol (see Reflexes pathological). The clonus (see) stop is often observed, is more rare — patellas, and sometimes — protective reflexes (see). Reflexes of oral automatism come to light approximately in 30% of observations. Atrophies of muscles are seldom noted. At some patients violent laughter and crying are observed.

Typical signs of R. of page — intentsionny trembling (see) and koordinatorny frustration: Romberg's symptom (see. Romberg symptom ), an ataxy (see) in hands and legs, adiadokhokinez, an ataxic gate (see), change of handwriting.

At certain patients generalized convulsive epileptic seizures are noted (see Epilepsy). Carry an epileptiform neuralgia to rare manifestations of R. of page (see), paroxysmal attacks of a dysarthtia (see) and an ataxy, tonic paroxysms (see).

Choreic hyperkinesias are sometimes observed (see). Also the hyperkinesias caused by defeat gear krasnoyadernykh ways, which are characterized by a large and wide tremor and sharply amplifying at purposive movement are noted.

At many patients disturbances of sensitivity (see) as subjective (paresthesias and pains various, localizations), and objective, prevailing in legs are observed (disturbance of hl. obr. vibration and joint myesthesia). Superficial sensitivity changes less often, generally on radikulonevritichesky type.

A peculiar reaction of patients to influence of heat is sometimes noted. So, in some cases during reception of a hot bathtub and even hot food the aggravation of symptoms of patients is observed: paresis goes deep, sight worsens, more expressed there are koordinatorny disturbances.

Disorders of function of pelvic bodies are shown in the form of imperative desires or delays of an urination, locks. Sexual weakness and disturbance of a menstrual cycle is noted. In single observations there are decubituses (see).

At many patients at the long course of a disease mental disturbances and changes of century of N of take place of different degree of manifestation. Emotional lability, euphoria, the noncritical relation to the state are most often observed. Less often heavy mental disorders are defined.

Depending on preferential localization patol, process allocate cerebral, spinal and cerebrospinal a wedge, forms of a disease though a number of scientists considers that they on - to a being are stages of development of R. of page. The cerebral form P. of page is characterized by generally oculomotor, visual, cerebellar and trunk disturbances, epileptic seizures, mental disorders are less often noted motive pathology in the form of a hemiparesis and subcrustal frustration. At a spinal form the lower spastic paraparesis with dysfunction of pelvic bodies is more often observed, disorders of sensitivity standing are less often noted. The cerebrospinal form is characterized by the expressed symptoms of damage of both a head, and spinal cord.

At preferential localization patol, process in a brain such forms of a disease as visual — decrease in visual acuity, scotoma, disturbance of color sensation are possible; hyperkinetic — the krupnorazmashisty hyperkinesia amplifying at purposive movements; cortical — epileptic seizures, disturbance of a praksis (see), afazichesky character the speech; cerebellar — a hypomyotonia, an ataxy; trunk — a nystagmus, dizziness, defeat of cranial nerves; trunk and cerebellar — symptoms of the combined damage of a cerebellum and a brain trunk. At preferential spinal localization patol, process allocate a lumbosacral form, at a cut note an atrophic lower paraparesis, disorders of function of pelvic bodies, the pseudo-tabic form which is characterized by hl. obr. disturbance of proprioceptive sensitivity in legs, is more rare in hands, and a sensitive ataxy (see); allocate also a symptom complex of defeat of a brain cone with loss of sensitivity in a crotch and an incontience of urine, Broun-Sekar's syndrome (see Broun-Sekar a syndrome).

The page, most typical for R., is the remittiruyushchy current. The periods of a stationary state after remission can be different duration: from several months to several years and even decades. Expressiveness of symptoms of a disease at the same time can decrease considerably, they can even disappear completely. The first remission more often happens longer, than the subsequent. The nature of remissions is finally not found out. Some researchers connect regress of symptoms with remyelination.

Less often at R. the page observes the progressing current, a cut is characterized by steady increase of signs of defeat of a nervous system.

In an initial stage of R. of page at young age the remittiruyushchy nature of disease prevails, at more advanced age the progressing nature of a disease is more often noted.

Some researchers allocate high-quality and malignant options of a current of R. of page. Refer observations with long-term remissions and almost full regress to high-quality type of a course of a disease nevrol, symptoms. Cases, in a wedge to which picture the generalized tremor caused by defeat gear krasnoyadernykh ways prevails carry to the malignant option of a current of R. of page leading to a bystry invalidism of patients.

Among R.'s complications of page are most often observed pneumonia (see), cystitis. (see), pyelonephritis (see).

The diagnosis

the Diagnosis is made on the basis of signs of multifocal defeat of a nervous system, preferential white matter of a head and spinal cord, fading in of various symptoms of a disease, instability separate of them, the remittiruyushchy course of a disease and these laboratory researches.

Laboratory diagnostic methods Rubles of page divide into two groups: 1) methods of identification of the subclinical centers of demyelination, 2) the methods allowing to judge activity patol, process.

The first group of methods is developed rather fully, includes researches of visual and somatosensory evoked potentials (see the Potentials caused) for the purpose of identification of the centers of the current demyelination or the created plaques at sick R. of page in the absence of accurate a wedge, signs of defeat of a nervous system. Carry to them also researches of a blink reflex in response to electric irritation of a supraorbital nerve (see the Blinking) that allows to reveal the subclinical centers of demyelination in a brain trunk; studying of an elektrospinogramma in the course of registration of potentials in cervical department of a spinal cord in response to electric irritation of a median nerve that gives the chance to objektivizirovat damage of a spinal cord; the computer tomography (see the Tomography computer), with the help a cut is revealed by the centers of demyelination in a brain at a subclinical stage patol, process.

The second group of methods is developed to a lesser extent and therefore has in diagnosis of P.c. relative value. Quite often at R. of page colloid reaction of Lange has paralytic character.

Increase in a caption of clumsy antibodies in blood and cerebrospinal liquid is characteristic, in a cut also the hypergammaglobulinemia, at the same time at most of patients is observed (to 90%) define oligoklonalny immunoglobulins.

Differential diagnosis carry out with rheumatism (see), syphilis (see), a toxoplasmosis (see), a brucellosis (see) and other diseases at which signs of involvement in patol, process of a nervous system are, as a rule, combined with symptoms of defeat of other bodies and systems.

At differential diagnosis with degenerative diseases of a nervous system — family spastic paralysis (see the Paraplegia), hepatocerebral dystrophy (see), a family ataxy of Fridreykh, a hereditary cerebellar ataxy of Pierre Mari (see the Ataxy), etc. — in addition to the careful analysis a wedge, manifestations, the family anamnesis and features of a course of these diseases consider. Unlike R. of page progressing only throughout a certain time term, after to-rogo patol is characteristic of them, honor process or it is completely stabilized.

Carry out also differential diagnosis with tumors of a brain (see) and a spinal cord (see). The diagnosis of a tumor is excluded on the basis of a mnogoochagovost of defeat of c. N of page, lack of accurate disturbances of sensitivity of conduction character, existence of remissions and lack of proteinaceous and cellular dissociation in cerebrospinal liquid.

Tracer techniques of a research are in case of need applied rentgenol, and.


the Main objective of treatment consists in reduction of activity patol, process in the period of an aggravation and in an acute stage of a disease. For this purpose apply in high doses glucocorticoids (Prednisolonum, dexamethasone) and AKTG. Prednisolonum is appointed inside in high or shock doses depending on activity and depth patol, process. Treatment is carried out during 2 — 3 weeks, then the amount of the accepted drug is gradually reduced under control of the general condition of the patient. At the same time appoint anabolic steroids (Nerobolum, retabolil), drugs of potassium and calcium, ascorbic to - that, veroshpiron.

Treatment of AKTG is carried out at the rate of 1000 PIECES on a course. At an exacerbation of a disease during 1 — 2 months can also be applied etimizol which indirectly, through a hypophysis, stimulates development of endogenous corticosteroids.

At steadily progressing R. of page use of corticosteroids is not effective. In these cases use the levamisole (see) which is immunoexcitant.

In all stages of a disease widely use vitamins of group B and biostimulators (extract of an aloe, FIBS, a vitreous). Apply also desensibilizing means, ATP, Trasylolum, Cerebrolysinum.

From symptomatic pharmaceuticals appoint the drugs reducing a muscle tone: Mellictinum, skutamil-S, etc. In certain cases apply to reduction of intensity of a cerebellar ataxy it proper-is lovely. In the presence of hyperkinesias Dinezinum and Norakinum are shown.

In the general complex of treatment use to lay down. gymnastics and massage. The balneoterapiya and mud cure, and also insolations are contraindicated. In initial stages of a disease it can be recommended a dignity. - hens. the treatment of fortifying type which is not connected with jump of usual climatic conditions.

Sick R.' treatment by the village is carried out not only in the period of an exacerbation of a disease, but also during remission. In the latter case it is carried out by 2 times a year (in the spring and in the fall) using vitamins and biostimulators. This treatment with simultaneous use of a complex of actions for the prevention at sick infections, intoxications and overfatigue in a certain measure is prevention of an aggravation of R. of page.

At a hyperkinetic form P. of page, in a wedge, a picture the cut dominates the expressed intentsionny tremor causing disability of patients and inability to self-service, operational treatment is shown; it is carried out with use of a stereotaxic method (see. Stereotaxic neurosurgery).

As stereotaxic destruction of a ventrolateralny kernel of a thalamus or subthalamic area liquidates a tremor at parkinsonism and hyperkinesias at other extrapyramidal defeats, there were bases to assume that similar operation can lead to reduction or disappearance of a tremor at R. page. This assumption came true in practice.

E. I. Kandel, O. A. Hondkarian (1977), etc. showed that after a stereotaxic talamotomiya (see) or subtalamotomiya (see Kampoto a miya) sharply expressed tremor disappears. This effect in most cases remains for many years though the long-term results are less favorable, than the next. Lack of effect or passing complications took place approximately at 8 — 10% of the operated patients. However these operations have palliative character. They are directed to elimination only one, though the leader, a symptom — an intentsionny tremor and do not exert impact on a current of the basic patol, process.

Forecast concerning life at R. of page, as a rule, favorable. At acute bulbar disorders the lethal outcome is possible sometimes. Disability of most of patients comes within the first 3 — 5 years from an onset of the illness though quite often patients can keep working capacity long enough.

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I. A. Zavalishin; E. I. Kandel (neyrokhir.), G. Ya. Levina (stalemate. An.), R. V. Petrov (of).