Lessons in balance and co-ordination were begun in the fourth week of treatment, and supervised carefully for two weeks more. When his station and gait were both improved, he was permitted to walk, always with care not to fatigue himself. At this time, six weeks from commencement of treatment, his eyes were gla.s.sed by Dr. de Schweinitz. He had gained some pounds in weight, and walked on straight lines without noticeable incoordination, but in turning short or walking sharp curves he was still unsteady. He found walking much easier than formerly and was less easily tired. After nine weeks he could stand or walk, even backward, with closed eyes. He was sent home for the summer, with directions to continue his co-ordination movements, to walk very little, and take such exercise as he needed on horseback, riding quietly. He had still some stabbing pains two or three times daily.

He reported in one month, and again in six months, "No improvement in the pains, but I walk well and briskly, can jump on a moving street-car, and have ridden a horse twenty miles in a day without fatigue."

This case was in one way favorable for treatment: the patient, an educated and intelligent man, helped in every way, carrying out minutely all orders, and had the good sense to begin treatment early. But the acuteness and rapidity of onset of the tabetic symptoms were so great that in a little more than two years they had reached a condition which most cases only attain in from five to ten years, and this makes the prognosis somewhat less favorable.

In the instance to be next related there was also antecedent syphilis, and the patient had already been heavily dosed with iodides and repeatedly salivated with mercury. His recovery was and has remained remarkably complete.

H.B., travelling salesman, from New York, aet. forty, single, a large, strongly-made man, a hard worker, given to excesses in s.e.xual indulgence and alcohol for years. Syphilis was contracted fifteen years before the first traceable symptoms of ataxia, which had shown themselves after an attack of grippe, in 1890, in sudden remittent paralysis of the external muscles of the right eye, followed within a few months by gastric crises, general lightning pains appearing a few months later. During the two years succeeding he was drenched with drugs and grew steadily worse. When admitted to the hospital in 1892 he was very ataxic in the legs, suffered greatly from gastric and other pains, difficulties with bladder and r.e.c.t.u.m, loss of s.e.xual power, various anaesthetic areas, could not stand with eyes open unless he had help, total loss of knee-jerk, paralysis of right rectus, indigestion from the irritation of the stomach from medicines as well as from the disease, and, though muscular and over-fat, was flabby and pallid. He had no ataxia or loss of sensibility in the upper half of the body. He was in bed for two weeks, on milk diet, with warm baths and ma.s.sage. Systematic movements were begun and ma.s.sage continued. After the stomach improved he grew better with unusual rapidity. He is now able to work hard again, travels extensively, can walk strongly, but wisely takes his exercise more in the form of ma.s.sage and systematic gymnastics. He appears to report himself once or twice a year. There has been a partial return of s.e.xual ability.

The next case has points of interest in the later history, but the first examinations and early treatment may be pa.s.sed over briefly. X.Y., aet.

forty-two, a steady, sober merchant, closely confined by his business, always of excellent habits, with no possible suspicion of syphilis, was seen first in 1894 in a somewhat advanced stage of tabes, but with no optic or gastric disturbances. His station was very bad, but when once erect and started he could walk without a stick. Girdle-pains very marked; bowels very constipated; some trouble in emptying bladder; several points of fixed sharp pain; lightning pain occasional and severe, but not frequent. He was ordered to bed for six weeks.

Galvanism, alternate hot- and cold-water applications to the tender spots, careful ma.s.sage, and a two-months' course of Brown-Sequard fluid after getting up made a new man of him. Ma.s.sage and systematic exercise were kept up together for six months. The ma.s.sage was stopped and the exercises continued, and improvement went on steadily, though the fixed pains kept up in only slightly less severity.

In a year the patient was better in general health, looks, and spirits than he had been for many years before, and remained in good order, except for the daily recurrences of paroxysms of pain of varying but not unbearable severity for two years. He then presumed for a month on his strength, and took much more exercise afoot than was wise, worked late at night over his books, had some additional nervous strain from business worries, and came to Dr. J.K. Mitch.e.l.l in October, 1898, barely able to crawl with two canes, having lost weight, become sleepless, suffered great increase of pain, and grown so ataxic that he could scarcely walk. This change had all occurred in three or four weeks. He became steadily worse for two or three weeks till he could not stand or walk at all, had cyst.i.tis from retention, violent attacks of rectal tenesmus, stabbing pains in r.e.c.t.u.m, perineum, s.c.r.o.t.u.m, and groins, with almost total anaesthesia of the sacral region, b.u.t.tocks, s.c.r.o.t.u.m, and perineum, inability to retain faeces, while pa.s.sages from the bowels took place without his knowledge. He found that an increase in the rectal and abdominal pain followed lying down. He therefore spent day and night sitting up. At the end of three weeks there was total paralysis of the legs, and the outlook seemed most unfavorable.

Ma.s.sage was begun again, strychnia and salol were administered, and a short course of full doses of the testicular fluid was given. A rapidly interrupted faradic current, with an uncovered electrode, to the neighborhood of the r.e.c.t.u.m, bladder, and b.u.t.tocks, greatly relieved the anaesthesia, upon which galvanism had no effect; and, in brief, from a state which looked almost as if the last paralytic stage of tabes had suddenly come upon him, he recovered in two months, and is now (July, 1899) better than he was a year ago, before the relapse, and will probably remain so, as he has had his warning.

Without multiplying case histories, it may be said that ataxic paraplegia (a combination of lateral and posterior sclerosis) may be treated in much the same manner. In this disease there is usually much less pain than in ataxia, but greater weakness, and late in its course some rigidity in the extensor groups of the legs; the knee-jerk is preserved or exaggerated. The disease is a rare one. But two recent distinct cases are in my list, and one of these, the one here reported, seems rather more like an ataxia with some anomalous symptoms. The second one had the symptom, uncommon in this malady, of very frequent and excessively severe stabbing pains, and though his co-ordination grew somewhat better, he improved very little in any other way, which, as his trouble was of fourteen years standing, was not astonishing.

The other patient, seen in 1897, was a rancher from New Mexico, thirty-three years old, who had led an active, hard-working, much-exposed life, but had been perfectly well until 1891, when he was said to have had an attack of spinal meningitis, from which he recovered very slowly. Four years later he noticed numbness of feet and weakness of legs, great enough to make it hard for him to get a leg over his horse. Some pains were felt in the limbs, and a constriction about the chest and abdomen, which had steadily increased in severity. Sharp attacks left distinct bruise-marks at the seat of pain each time. Could not empty bladder. Gait feeble, spastic, and paralytic, could not mount steps at all or stand without aid, sway very great. Knee-jerks and muscle-jerks increased, especially on left; ankle-clonus; very slight loss of touch-acuity in lower half of body. Eyes: muscles and eye-grounds negative; pupils equal and active. Bladder could not be emptied; cyst.i.tis. Ordered rest, ma.s.sage, electricity, and full doses of iodide in skimmed milk. In this way he was able to take without distress or indigestion amounts as large as four hundred and forty grains a day.

When education in balance, etc., was begun he could not walk without aid, or more than a few steps in any way. In three months from the time he went to bed he walked out-of-doors alone with no stick, and in five months went back to work. The bladder did not improve much until after regular washing out and intravesical galvanism were used, with full doses of strychnia. He was soon able to empty the organ twice a day, and since leaving the hospital writes that it gives him very little annoyance, though as a measure of precaution he uses a catheter once daily. His pains have entirely disappeared, and he is daily on horseback for many hours.

In spastic paralysis, whether in the slowly-developing forms in which it is seen in adults, due sometimes to multiple sclerosis, sometimes to brain tumor, sometimes following upon a transverse myelitis, or in the central paraplegia or diplegia of "birth-palsies," some very fortunate results have followed the careful application of the principles of treatment already described. Absolute confinement to bed is seldom required or in adults desirable, though exercise should be carefully limited to an amount which can be taken without fatigue, and some hours'

rest lying down is usually advantageous.

a.s.suming that the necessary treatment for the disease originating the paralysis is to be carried on in the ordinary way, I will only describe the special forms and methods of exercise I have found serviceable.

Whatever the cause, this will be much the same, though in birth-palsies the teaching may have to include groups of muscles and instruction in the co-ordination of actions which are not affected in adult subjects.

First, as to ma.s.sage: the operator must direct his efforts primarily to the relaxation of the tense muscles, secondarily to the strengthening of the opponent groups, this last being of special importance where actual contraction has taken place. He should make frequent attempts by stretching the rigid groups to overcome the spasm, which in large muscle-ma.s.ses may be done by grasping with both hands, taking care not to pinch, and pulling the hands apart in the line of the muscle's long axis, thus stretching the muscles. Pressure will sometimes accomplish the same end, and it will be found in certain cases that by kneading _during action_,--that is, while the patient endeavors to produce voluntary contraction,--the result will be better. Except in the most spastic states, a certain degree of relaxation is possible by effort, though not without practice, and this has to be constantly inculcated and encouraged. After a period varying in length according to the case, lessons in co-ordinating movements are begun. It is best for the patient's encouragement to start with the least affected muscles, so that, seeing the good results, he may be stimulated to persistent effort. The lessons differ only in detail from those given in the list under tabes. Improvement is slower than in ataxia.

In birth-palsy cases not much can be accomplished in the way of education, beyond the attempt by such means as ordinary gymnastics and lessons in drill and walking offer, until the child shall have reached an age when he is able to comprehend what is being attempted. For the imbecile, idiotic, or backward a training-school is the proper place, where mental and bodily functions may both receive attention and where constant intelligent supervision is available.

Many children the subjects of cerebral diplegia are credited with less intelligence than they really possess, partly because they are necessarily backward, and partly because of their difficulty in expressing themselves, the speech-muscles sharing in the disease. These muscles need to be carefully educated, and this might almost be made the subject of a treatise by itself. Each case will require study as to the special difficulties in the way of speech. Some experience most trouble with the vowel sounds, more find the consonants the worst obstacles.

Patient practice in forming the sounds soon produce some results; the pupil must be taught, like the deaf mute, to watch and imitate the movements of the lips and tongue.

Seguin's books and the numerous special works should be consulted by the physician or parent desiring to pursue these methods to their fullest development.

When once the control of muscular movement begins to improve, more elaborate exercises may be set. In speech, if the patients be intelligent, they will sometimes be amused and profitably trained at the same time by the effort to learn and repeat long words or nonsensical combinations of difficult sounds, like the "Peter Piper" nursery rhymes.

B.M., aet. fourteen, an intelligent lad, of Jewish parentage, suffered a forceps-injury at birth, and had convulsive seizures later. He began to make futile attempts at walking when five or six years of age, when the spastic rigidity was first noticed. His speech was better at this time than later, and a sort of relapse seemed to be precipitated by a fall in which he struck his head when seven years of age. His mother, finding it almost impossible to teach him to walk, devoted herself faithfully to improving his mind, so that at fourteen years of age he read well and enjoyed books, and was mentally clear, observant, and docile. His speech was almost incomprehensible,--stuttering, thick, and nasal. He stood, swaying in every direction, though not apt to fall, with bent knees, rounded shoulders, every muscle in the extremities rigid, the mouth half-open, the head projected forward, and, upon attempting to move, the toes turned in, the legs almost twined around one another, and, unless supported, he would stumble and twist about, scarcely able to get forward at all. With a guiding hand he did a little better. His first lessons were in "setting-up drill," while the feeble, disused muscles were strengthened by ma.s.sage, which served at the same time to help his very irritable and imperfect digestive apparatus, so that it was soon possible to give him a greater variety and more nourishing kinds of food than he had before been able to take. He was kept in bed up to three o'clock in the afternoon, the morning hours occupied with ma.s.sage and a half-hour's lesson in erect standing, with slow trunk movements afterwards. An hour after dinner he was dressed and taken for two hours in a carriage or street-car. He did his reading and some study on his return, and had another half-hour's drill, superintended by his mother.

In two or three weeks some improvement began to be observable in his att.i.tude, and a great change in his color and general expression, but it was three months before it was thought wise to attempt education in small co-ordinate movements. At about the same time speech-drill was commenced.

In all these lessons the greatest care was taken that adequate rest should intervene between each series of efforts, and it was always found that fatigue distinctly impaired his co-ordination, as did emotion or indigestion. When his speech grew clearer he was set tasks of learning many-syllabled words and also began to practise drawing patterns. Every new lesson was first given under medical supervision and then continued by his mother or by the ma.s.seur. To shorten the history it will suffice to say that in six months he was able to go to school, where with certain allowances made for his thick speech by a kindly master he did well, and returned to his home in the South able to walk without attracting attention, to speak comprehensibly, to write a good letter, and with every prospect fair for a still greater improvement, which I learn he has since made.

The important things to be recognized in the treatment of these cases are, first, that rest in proper proportion allows of the patients doing an amount of exertion which, ungoverned, or performed in wrong ways would harm them; secondly, that full feeding is of value, because these disorders are mostly of the character of degenerations and involve failure of nutrition in various directions; and, lastly, that the exactness of routine is of the highest moral and mental as well as physical importance.

Paralysis agitans needs scarcely more than to be mentioned as amenable to the same methods, with small differences in the application of details. Body movements to counteract the tendency to rigidity in the flexor groups of spinal muscles will be especially useful, as the stiffness of these is one of the causes of displacement forward of the centre of gravity, a displacement which results in the festination symptom usually seen in such cases. Prescriptions of special exercises for the muscle-ma.s.ses particularly involved in each instance must be given, remembering that contraction of the affected muscles will to a certain degree overcome their rigidity even at first, and to a still greater extent as the patient reacquires voluntary control.