I had at one time intended to give, in the first edition of this work, a summary of all my cases, with the results; but what is easy to do in definite maladies like typhoid fever becomes hard in cases such as I here relate. In fevers the statistics are simple,--patients die or get well; but in cases of nervous exhaustion, so called, it is impossible to state accurately the number of partial recoveries, or, at least, to define usefully the degrees of gain. For these reasons I have not attempted to furnish full statistics of the large number of cases I have treated.

In the debate before the British Medical a.s.sociation the question of the permanence of cures by this method was the subject of discussion. I have lately been at some pains to learn the fate of many of my earlier cases, and can say with certainty that every case then treated was selected because all else had failed, and that I find relapses into the state they were in when brought to me to have been very uncommon. A vast proportion have remained in useful health, and a small number have lost a part of their gains. I now make it a rule to keep up some relation with patients after discharge, by occasional visits or by letter, and believe that in this way many small troubles are hindered from becoming large enough to cause relapses.

I said in my first edition that I did not doubt that the statements I made would give rise in some minds to that distrust which the relation of remarkable cures so naturally excites; and this I cannot blame. Every physician can recall in his own practice such cases as I have described, and every medical man of large experience knows that many of these women are to him sources of anxiety or of therapeutic despair so deep that after a time he gets to think of them as destined irredeemably to a life of imperfect health, and finds it hard to believe that any method of treatment can possibly achieve a rescue.

I am fortunate now in having been able to show that in other hands than my own, both here and abroad, this treatment has so thoroughly justified itself as to need no further defence or apology from its author. It has gratified me also to learn that in many instances country physicians, remote from the resources of great cities, have been able to make it available. As I have already said, I am now more fearful that it will be misused, or used where it is not needed, than that it will not be used; and, with this word of caution, I leave it again to the judgment of time and my profession.

CHAPTER X.

THE TREATMENT OF LOCOMOTOR ATAXIA, ATAXIC PARAPLEGIA, SPASTIC PARALYSIS, AND PARALYSIS AGITANS.

In my earliest publication on the treatment of diseases by rest, etc., locomotor ataxia was alluded to as one of the troubles in which remarkable results had been obtained. Rest alone will do much to diminish pain and promote sleep in tabes, rest with ma.s.sage and electricity will do more. It is not necessary to order complete seclusion for such cases, but some special measures will be needed in addition to those already described as of use in various disorders, and these will be discussed in this chapter.

While this is not a treatise on diagnosis, some brief symptom-description is needed to enable one to define clearly the methods of treatment at different stages.

In the middle or late stages there need be little uncertainty in uncomplicated cases; in the earlier periods diagnosis is by no means easy. A history may usually be elicited of important heralding symptoms, such as former or present troubles with the muscles of the eyes, the occurrence of vague but sharp and recurring pains, vertigo, an impairment of balance, unnoticed perhaps, except when walking in the dark or when stooping to wash the face, or especially when going down stairs. Attacks of 'dyspepsia,' as unrecognized visceral crises are often called, should render one suspicious. If, on examination, loss or impairment of knee-jerk be shown, contraction of the pupil with Argyll-Robertson phenomenon and defective station, but little doubt can exist. The discovery by the ophthalmoscope of some degree of beginning optic neuritis would make a.s.surance more sure, and this can often be detected in a very early stage of the disease.

Much controversy has been spent on the question of the share of syphilis in producing tabes, and out of the battle but two facts emerge fairly certain, the one that syphilis often precedes the disease, the other that anti-syphilitic medication is commonly of no service. But syphilis is so frequently antecedent that a history of that infection may make certain the diagnosis when doubt exists. This may be an important point, for some of the cardinal symptoms are occasionally absent; cases are seen with no incoordination, sometimes with the station unaffected, even, though rarely, with the knee-jerk preserved.

The diagnosis established, treatment will somewhat depend upon the stage which the disease has reached.

In the pre-ataxic stage, where slight unsteadiness, often not troublesome except in the dark or with closed eyes, sharp stabbing pains here and there, numbness of the feet, girdle-sense in the region of chest, waist, or belly, some recurrent difficulty in emptying the bladder, a fugitive partial palsy of the external muscles of the eye, are the chief or, perhaps, the only complaints, it would not be justifiable to put the patient to bed at complete rest. This early stage calls for a different plan of treatment, to be presently described.

In the middle or more distinctly ataxic period long rest in bed should be prescribed, and will be gratefully accepted by a patient whose sufferings from incoordination, pains, and numbness of the extremities are often so great as to incapacitate him.

The bladder muscles share in the ataxia, and the consequent retention of urine frequently causes cyst.i.tis, and may endanger life by the involvement of the kidneys.

The bowels cannot be emptied or are moved without the patient's knowledge, and these annoyances combine with the pain and nervous apprehension to drive the victim into a melancholic or neurasthenic state. He suffers, too, from want of occupation, from the absence of exercise, from the antic.i.p.ation of worse changes in the near future, and usually by the time he reaches the specialist has been more or less poisoned with iodide of potash and mercury, and perhaps with morphia.

In the third, the paralytic stage, which seldom comes on until the symptoms have lasted for years, there is gradual loss of power and ataxia, increasing until he is totally unable to walk. If a patient is not seen until this condition of things has been reached, but little can be hoped from any treatment, though in a few cases energetic measures may bring about a marked improvement, which is rarely lasting.

A combination of tabes with lateral sclerosis, or with general paralysis of the insane, is sometimes seen, but needs no special consideration.

The first or pre-ataxic stage is, to the great detriment of patients, too seldom recognized. The pains are called rheumatic, the eye symptoms are lightly pa.s.sed over or gla.s.ses are ordered, the difficulty of micturition is treated by drugs, and the slightly impaired balance unnoticed or unconsidered.

When such a patient comes into our hands the history, and especially the history of predisposing causes, needs the most careful examination. It is well established that syphilis is a common precedent of ataxia, occurring in at least two-thirds of the cases; it is even more firmly settled that iodide and mercury in large doses do no good in advanced ataxia. I say in advanced ataxia, because a few cases are seen in which the syphilis has been of recent occurrence, or where the spinal symptoms are of decidedly acute character, and in these anti-syphilitic medication is needed and useful; but such cases should be described as acute or subacute spinal syphilis, not as ataxia. When nerve degeneration has once begun, iodide will do little good and mercury may do positive harm, if used in large doses. The other common predisposing causes, exposure to cold, over-exertion, s.e.xual excess, need concern us only as they suggest warnings to be given, especially when the patient is improving. Until he does improve not much need be said about them; he cannot indulge in venery, as s.e.xual power is usually (though not always) lost early in the disease; and the incoordination lessens his opportunities of exposure or over-exertion.

During this stage some patients complain most of the numbness, girdle-sense, and incoordination; others of the stabbing pains or the bladder weakness. The general treatment must be much the same, however, in all, with special attention besides to the special needs of each individual.

Fatigue makes all the symptoms worse, increases pain, and impairs still more the muscular incoordination; it is, therefore, of the first importance in every instance to forbid all over-exertion. Walking, more than any other form of exercise, hurts these cases. The patient should not walk beyond his absolute necessities. To get the needed fresh air, let him, according to his situation in life, drive out or use the street-cars. In some cases the use of a tricycle on a level floor or on good roads is not so harmful as walking, for obvious reasons; this tricycle exercise may at first be made a pa.s.sive or mild exercise by having the machine pushed by an attendant. To replace the effects upon the circulation and bowels of physical activity ma.s.sage may be used, and the ma.s.seur must have directions as to gentle handling of the tender places at first. These are usually in fixed positions, and can be avoided or only lightly touched. The shooting pains may be lessened by deep, slow ma.s.sage in the tracks of the nerves affected. If, as generally happens, there are also regions of defective sensation, these should receive after the general manipulation active, rapid circular friction, and, perhaps, experimentally, open-hand slapping. As constipation is one of the troublesome features, the abdomen should have particular attention, and an unusual amount of time be given to manipulations of the colon, as described in the chapter on ma.s.sage. A full hour's rest in bed, preferably in a darkened room, must follow the rubbing.

A schedule for the day on about the lines of the "partial rest"

schedule, as described on a previous page, should be followed. A prolonged warm bath, with cool sponging after, if the latter be well borne, is useful in lessening pains and nervous irritability,--and this may begin the day or be used at any convenient hour.

At an hour as far from the ma.s.sage as possible lessons in co-ordinate movements are given, after a week or ten days of ma.s.sage has prepared the muscles, and baths and a quiet life have steadied the nerves. For many years past, certainly fifteen or sixteen, the students and physicians who have followed my service at the Infirmary for Nervous Diseases have seen this systematic training given, and no doubt they received with some amus.e.m.e.nt the excitement about it as a new method of treatment when it was proclaimed in Europe two or three years ago.

The indication for this teaching appeared too obvious to publish or talk much about. The patient has incoordination; one, therefore, does one's best to teach him to co-ordinate his movements by small beginnings and by small increases.

The lessons may be given by the physician at first and be executed under his eye. After a few days any tolerably intelligent patient should be able to carry them out alone, but still each new movement should be personally inspected to make sure that it is done correctly.

In patients in the first stage of ataxia the most striking result of incoordination is the impairment of station. We therefore begin with balancing lessons. The patient is directed to stand at "Attention," head up and chest out, not looking at his feet, as the ataxic always wishes to do. At first this is enough to require; it will not do to be too particular about how his feet are placed, so long as he does not straddle. He can repeat this effort for himself a dozen times a day, for a minute or two each time. Next we try the same position with a little more care about getting the feet pretty near together and parallel, or with the toes turned out only a very little. In another couple of days a little more severity may be exercised about maintaining the correct att.i.tude,--heels touching, hands hanging down, and eyes looking straight forward,--and until he is able to do this _easily_ it is best to ask nothing more. Then he is requested to stand on one foot, being permitted just to touch a chair-back or the attendant's hand to give confidence.

This is practised until he can keep his erect station for a few seconds without difficulty. This point of improvement may be reached in three days or a week or may take a fortnight. Women, as I have before observed, although rarely in America the victims of tabes, when they do have it have far less disturbance of balance than men, and this is to be attributed to their life-long habit of walking without seeing their feet. I have found in the few cases of ataxia in women that I have seen that they benefited much more quickly by these balance instructions than did men, though their other symptoms were in no way different.

Continuing every day the practice of all the previous lessons, movements are rapidly added as soon as station is better. A brief list of them follows. When the exercises grow so numerous as to take overmuch time, the simpler early ones may be omitted.

When the learner is able to stand on one foot, let him slowly raise the other and put it on a marked spot on the edge of a chair. This, like all the other exercises, must be practised with both feet.

Stand erect without bending forward and put one foot straight back as far as possible.

Do the same sideways.

Stand and bend body slowly forward, backward, and sideways, with a moment's rest after each motion.

Having reached this point, I usually order the patient to practise all these with closed eyes. When he can do this, he begins to take one or two steps with shut eyes, first forward, then sideways, then backward.

If he falter or move without freedom, he is kept at this until he does it confidently. Then exercises in following patterns traced on the floor are begun. In hospitals, or where bare floors are to be found, the patterns may be drawn with chalk. In carpeted rooms, which by the way are less suited for the work than plain boards or parquet floors, a piece of half-inch wide white tape may be laid in the required pattern, first in a straight line, later, as proficiency is gained, in curved, figure-of-eight, or angular patterns. The patient must be made to walk _on_ the line, putting one foot directly in front of the other, with the heel of the forward foot touching the toe of the one behind.

Walking over obstacles is tried next. Wooden blocks measuring about six by twelve inches and two inches thick are stood on edge at intervals of eighteen inches and the patient walks over them, thus training several groups of muscles; the blocks are at first set in straight lines, then in curving patterns. An ordinary octavo book makes a good subst.i.tute for a block.

If the trunk muscles are affected by the ataxia, further exercises are ordered for them, bending and twisting movements, picking up objects from the floor, etc. For the hands and arms, which, except in those very rare cases where the ataxia first shows itself in the upper extremities, seldom exhibit much incoordination in the primary and middle stages, the movements are the picking up of a series of different-shaped small articles, arranging objects like dominoes, marbles, or the kindergarten sticks in patterns, bringing the fingers of the two hands one after another together, or touching a finger to the ear or the nose, at first with open and then with shut eyes.

With these methods, needing not more than twenty minutes three times a day, the ataxic symptoms sometimes rapidly diminish. In certain cases no other improvement will be observed, showing that what has taken place is of course not an alteration of the diseased nerve-tissues for the better, as no treatment can restore sclerotic spinal tissue to a normal state, but is merely a subst.i.tution of function, in which other and a.s.sociated nerve-tracts have replaced in control the ones affected.

As to the pains and bowel and bladder disturbances, their handling will be discussed in considering the treatment of the next or middle stage of tabes. In this period the ataxic symptoms are most prominent; the gait has become so unsteady that the patient needs canes to walk at all and must constantly watch his feet. He walks a little better when well under way, but at starting or when standing still he sways and totters. The girdle-sense is severe and constant, various pains a.s.sail the body and limbs; the numbness of the feet, often described as a feeling "like walking with a pillow under the foot," still further incommodes his walking.[30] The bladder control may be so enfeebled as to require daily catheterization, and the bowels move only with enemas or purgatives, and often without the patient's knowledge, owing to the anaesthesia which affects the r.e.c.t.u.m and its vicinity.

One of the first things to attend to when patients are in this stage is the bladder, as the retention is the only condition likely to produce serious disorder. Cyst.i.tis is or may be present, and with the retention is a constant threat to the kidneys. Catheterization and washing out with an antiseptic must be regularly practised while treatment is used to improve the condition.

For these patients rest in bed is a prime necessity in order to remove all excuse for exertion. The method of application of ma.s.sage has already been suggested. Care must be taken that the patient eats well and of the best food. Except for occasional gastric or intestinal crises of pain, sometimes with vomiting, sometimes with diarrhoea, the digestive functions are usually well performed, unless the stomach has been greatly upset by over-use of iodide. The most liberal feeding consistent with good digestion is indicated, for it must be remembered that we are dealing with a disease in which degenerative changes play an important part. The usefulness of electricity in ataxia has been denied by some authors, while others praise it indiscriminately. Perhaps a reason for this difference of opinion may be found in its different effects upon individual patients; but I see few in whom I do not find electricity in one or another form helpful. For pains I order the galvanic current through the affected nerves as strong as the man is able to bear. If after a few days of this the pains are unchanged, a rapidly interrupted faradic current is tried, and failing to do good with this, I use light cauterization or a series of small blisters to the spine at the point of exit of the painful nerves. Galvanization of the bladder with an intravesical electrode is sometimes of service to strengthen its capacity for contraction. Faradism is applied in the form just described, using a wire brush as an electrode to the areas of numbness and anaesthesia. Lately I have found that this current in a strength which would be very painful to the normal skin will in some instances relieve the feeling of pressure and dull discomfort about the r.e.c.t.u.m and perineum, and it has been successful when galvanism did no good. In patients within reach of a static machine, this form may be used for the numbness if the others do not help it.

For the attacks of pain, if general, a prolonged hot bath lasting from ten to twelve minutes, at a temperature of 100 F. or even more, should be first tried; if this fail, antipyrin, phenacetin, acetanilid, or cannabis indica may be used, or, as a last resort, morphia. For the local pains hot water is also useful, and in the intervals I order applications of hot water to the tender points, as hot as can be borne, alternating with ice-water, each rapidly applied three or four times. In severe attacks, and with all due caution to avoid habituation, cocaine injections may be given. In cases with high arterial tension the daily administration of nitroglycerin in full doses will not only lower the tension but decrease the pains in force and frequency.

For several years past in all patients with the general lowering of nervous force and vitality so common in this disease I have habitually used the testicular elixir of Brown-Sequard. The ridiculous length to which organic therapeutics have been carried, the extravagant advertising claims, and an absurd expectation of impossible results have combined to make the profession shy of those organic preparations which have not very good evidence in their favor, and for some time I shared in this prejudice against the Brown-Sequard fluid. A talk with that most distinguished physician and an examination of some of his cases led me to a trial for myself, and I am at present very well convinced that, whether a physiologic basis can reasonably be a.s.sumed or not, we have in the fluid a tonic remedy of great power. While I have used it with good effect in other conditions, it is in ataxia that I have found it of most value.

The glycerin extract is freshly prepared from bulls' t.e.s.t.i.c.l.es in exact accordance with the directions of the discoverer. It is used hypodermatically every other day, beginning with a diluted ten-minim dose and increasing by two or three drops up to about forty minims. The effect is at its height twelve to twenty-four hours after the administration in most patients, hence the reason for using it only once in two days. The skin is prepared, the needles and syringe disinfected, and the tiny puncture sealed afterwards with as minute care as would be given to a surgical operation. By these precautions the danger of abscess, always considerable if hypodermics are carelessly given, is minimized. As the dose is large, a site must be selected for the injection where the tissue is loose, otherwise the pain will interfere with the desired frequency of use. The b.u.t.tocks serve best, or the outer ma.s.ses of the pectoral muscles, or the abdominal muscles. If the administration causes pain (due in part to the large quant.i.ty used and in part to the local effect of glycerin), a fraction of a grain of cocaine may be added to the solution when measured out for use.

It may at once be said, emphatically, that in some cases remarkable results have followed the use of this material, while in others no good has been done; but the same may be said of most plans of treatment in this disorder. As to possible danger from it, no harm has been done to any patient known to me, except that abcesses have occurred sometimes, though very rarely, for in many hundreds of injections it has been my good fortune to see abscesses form only three or four times, two of these instances, by curious ill luck, being in physicians. Patients describe a stimulating effect not unlike that of strong coffee, following a few hours after use and lasting for a day. The s.e.xual appet.i.te, if present, is increased; if absent, it is often renewed, sometimes in elderly men to an inconvenient extent. In one tabetic subject who had lost desire and ability for more than three years both returned in sufficient force to allow him to beget a child. This patient, like most of the others, was ignorant of what drug was being used and of what effects might be expected, so suggestion played no part. Apart from this special effect, the solution acts only as a highly stimulating tonic.

The full dose of forty minims or thereabouts is maintained for a fortnight or less, and then gradually diminished in the same way that it was increased. Sometimes, when the effect has been good, a second "course" may be given after two or three weeks' interval.

During the treatment by hypodermic the ma.s.seur should be told to avoid rubbing where the injections have been given. A few trials with the fluid internally have produced so little result of any kind that I am inclined to think the gastric juices must alter it so as to lessen or wholly destroy its power.

As to other drugs, experience has not given me much confidence in any of those usually recommended. Strychnia, belladonna, and those antiseptic drugs which are eliminated chiefly by the kidneys are of use when cyst.i.tis has to be treated and the bladder muscles urged to activity. a.r.s.enic, the chloride of gold and sodium, and chloride of aluminium are suggested by various authorities, but they have not been of any value in my hands. In hopeless cases, where all treatment fails, as will sometimes happen, or in patients in whom the paralytic stage is already far advanced, if other measures are unsuccessful, morphia is left as a forlorn hope, which will at least relieve their pains.

An outline report of several cases of different types and degrees is appended:

M.P. of North Carolina, aet. thirty-seven, general health excellent until syphilis in 1894, was admitted to the Infirmary in 1898. He had had for two years recurrent attacks of paralysis of the external rectus muscle of the right eye, slight gastric crises, and stabbing pains in the legs; station very poor, but strength unimpaired, and he was able to walk after being a few minutes on his feet; when first rising he was very unsteady. Knee-jerk lost, no reinforcement. No s.e.xual power. Some difficulty in emptying the bladder. Examination showed slight atrophy of both optic nerves, Argyll-Robertson pupil, and myosis. He was ordered two weeks' rest in bed, with ma.s.sage, cool sponging daily, and galvanization of the areas of neuralgia. After two weeks he was allowed to get up gradually, to occupy himself as he pleased, but not to walk.