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 massage 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 assurance 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 incoördination, 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 incoördination, 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 cystitis, 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 anticipation 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 passed over or glasses 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, sexual 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 sexual power is usually (though not always)
lost early in the disease; and the incoördination lessens his
opportunities of exposure or over-exertion.
During this stage some patients complain most of the numbness,
girdle-sense, and incoördination; 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 incoördination; 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 passive or mild exercise by
having the machine pushed by an attendant. To replace the effects upon
the circulation and bowels of physical activity massage may be used, and
the masseur 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 massage 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 massage. 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 massage as possible lessons in co-ordinate
movements are given, after a week or ten days of massage 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 amusement 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 incoördination; 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
incoördination 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
attitude,--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 substitute 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 incoördination 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 substitution of function, in which other and
associated 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 assail 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
anæsthesia which affects the rectum 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. Cystitis 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 massage 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 anæsthesia. 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
rectum 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-Séquard. 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-Séquard 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 assumed 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' testicles 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 buttocks serve best, or the outer
masses of the pectoral muscles, or the abdominal muscles. If the
administration causes pain (due in part to the large quantity 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 sexual
appetite, 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 masseur 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 cystitis has to be treated and the bladder muscles urged to
activity. Arsenic, 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, æt. 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 sexual 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 massage, 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.
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 glassed by Dr. de Schweinitz. He had gained
some pounds in weight, and walked on straight lines without noticeable
incoördination, 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, æt. forty, single, a large,
strongly-made man, a hard worker, given to excesses in sexual
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 rectum, loss of sexual power, various
anæsthetic 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 massage. Systematic
movements were begun and massage 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 massage and systematic gymnastics. He appears to
report himself once or twice a year. There has been a partial return of
sexual ability.
The next case has points of interest in the later history, but the first
examinations and early treatment may be passed over briefly. X.Y., æt.
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 massage, and a two-months' course of Brown-Séquard fluid
after getting up made a new man of him. Massage and systematic exercise
were kept up together for six months. The massage 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. Mitchell 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 cystitis from retention, violent attacks of rectal
tenesmus, stabbing pains in rectum, perineum, scrotum, and groins, with
almost total anæsthesia of the sacral region, buttocks, scrotum, and
perineum, inability to retain fæces, while passages 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.
Massage 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 rectum, bladder, and buttocks, greatly relieved the
anæsthesia, 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; cystitis. Ordered rest, massage, 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.
Assuming 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 massage: 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-masses 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.
Séguin'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., æt. 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 massage, 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 massage 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
attitude, 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 masseur. 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-masses 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.
INDEX.
Acne, caused by massage, 89.
After-treatment, importance of, 79, 195.
Albuminuria, from exercise, 101.
Alcoholism producing fat, 23.
American race peculiarities, 17, 21, 32.
Anæmia. _Vide_ Cases.
blood-count in, 102.
diagnosis of, 104.
effects of massage in, 101.
fatigue in, 72.
Anæmic obesity, 24, 128.
Asthenia. _Vide_ Cases.
Asthenopia, 67, 145, 149.
Ataxia. _Vide_ Cases.
bathing in, 204, 212.
co-ordinate movements in, 204.
symptoms of, 197.
treatment of, 197.
Bathing, effects of, 67.
in ataxia, 204, 212.
Birth-palsy. _Vide_ Cases.
Bleeding, causing increase of fat, 24.
Blood changes from massage, 99, 101, 185.
Bowditch on weight at different ages, 17, 23.
Bright's disease, a contraindication, 45.
Brown-Séquard's elixir, 212.
Brunton on effects of massage, 101.
Cases:
albuminuria, 183.
amenorrhoea, 149, 193.
anæmia, extreme, 184.
aortic stenosis, 187.
asthenia, 111, 172, 182.
ataxia, 216, 218, 220.
birth-palsy, 226.
chloral habit, 150, 154, 174, 178.
hysteria, 76, 114, 154, 157, 160, 165, 181.
hysteria and neurasthenia, 112.
hystero-epilepsy, 165.
kidney, floating, 191.
morphia habit, 154, 165.
neurasthenia, 144, 171, 174.
neurasthenia and pulmonary disease, 149, 160.
obesity, anæmic, 132, 134.
paralysis, hysterical, 134, 150.
paraplegia, ataxic, 223.
paraplegia, spastic, 228.
tabes. _Vide_ Ataxia.
uterine disease and chloral habit, 150, 154.
Cases, selection of, 33, 60.
Chloral habit. _Vide_ Cases.
treatment of, 137.
Chorea, 33.
Cod-liver oil enema, 140.
Constipation caused by milk diet, 125.
Contraindications to rest, etc., 45.
Corpulence, Harvey on, 129.
Diet-list, 144, 146, 159.
Dietetics, 119, 171.
Drug-habits, treatment of, 137.
Eccles on massage, 101.
Electricity, 108.
Beard on, 115.
causing insomnia, 118.
during menstruation, 90.
in ataxia, 211.
in constipation, 109.
mode of using, 108, 116.
rise of temperature from, 110, 116.
when needed, 118.
Face, massage of, 105.
Fat in alcoholism, 23.
in its relation to health, 16.
increased by bleeding, 24.
milk-diet in, 128.
mode of accumulation of, 27.
reduction of, 128.
varieties of, 25.
Food, amount of, 146, 159.
in obesity, 130.
Goitre, exophthalmic, 46.
Gymnastics, Swedish, 92.
Harvey on corpulence, 129.
Head, massage of, 105.
Headache from massage, 100.
massage for, 105.
Heart-disease, treatment of, 45.
Hysteria. _Vide_ Cases.
Introduction, 9.
Iodide in ataxia, 201.
Iron, use of, 142.
Jackson on rest, 58.
Karell on milk-treatment, 120, 128.
Keen on albuminuria, 101.
Kidney, floating. _Vide_ Cases.
belt for, 190.
treatment of, 48, 66, 189.
Letheby on fattening stock, 26.
Malt extract, 138.
Japanese extract of, 141.
Marshall on urinary changes, 127.
Massage, 80.
abdominal, 86.
amount of, 92.
blood-changes from, 101.
causing acne, 89.
causing headache, 100.
chilliness from, 91.
during convalesence, 34.
during menstruation, 90.
Eccles on, 101.
effect on temperature, 93.
effects of general, 98, 101.
frequency of use, 90.
in anæmia, 101.
in heart-disease, 46.
in spastic paralysis, 225.
Lauder-Brunton on, 101.
lubricant undesirable in, 89.
of face, 105.
of head, 105.
order of application, 82, 91.
sexual excitement from, 91.
why useful, 98.
Melancholia, treatment of, 46.
Menstruation, effects of rest on, 149, 193.
electricity during, 90.
massage during, 90.
Milk, in alcoholism, 137.
in chloral habit, 137.
pasteurized, 121.
peptonized, 122.
quantity to be used, 123.
sterilization of, 121.
Milk diet, 119.
constipation caused by, 125.
disappearance of uric acid during use of, 126.
effects of, on urinary pigments, 126.
general effects of, 124.
in obesity, 128.
in obesity with anæmia, 128.
Karell on, 120, 128.
precautions in using, 123.
sleepiness from, 125.
stools during use of, 125.
urinary changes from, 126.
Morphia habit, treated by rest, etc., 137, 154, 165.
Movements, co-ordinate, in ataxia, 204.
in paralysis agitans, 231.
in paraplegia, 223.
in spastic paralysis, 226.
Swedish, 92.
Neurasthenia. _Vide_ Cases.
Nurse, choice of, 53.
Obesity, milk diet in, 128.
with anæmia, 128.
with anæmia. _Vide_ Cases.
Ovarian disorders treated by rest, etc., 47.
Paralysis agitans, 231.
Paraplegia, ataxic, 223.
spastic, 228.
Partial rest, 63.
schedule for, 64.
Peculiarities of American race, 17, 21, 32.
Phthisis, gain of weight in, 35.
Pollock on, 35.
Playfair on nerve-prostration, 12, 150.
Quetelet on gain of weight at different ages, 17.
Rest, 57.
definition of, 62.
effects of, on menstruation, 149, 193.
in ataxia, 203, 210, 230.
in neuralgia, 58.
in spinal disease, 58, 197, 230.
Jackson on, 58.
length of, 66, 68.
mental, 71.
mode of terminating, 63, 78.
moral uses of, 69.
partial, 62.
reasons for, 61, 70, 182.
Schedule for partial rest, 64.
Seclusion, 50.
Selection of cases, 33, 60.
Soup, raw, mode of making, 139.
Spine, irritable, 163, 178.
Syphilis preceding tabes, 198, 201.
Tabes. _Vide_ Ataxia.
Temperature after electric treatment, 110, 116.
after massage, 93.
Treatment, season for, 53.
selection of cases for, 33.
Urinary pigments, changes in, during milk diet, 126.
Weight at different ages, Bowditch on, 17, 23.
gain or loss of, 14.
loss of, relation to an anæmia, 15.
Quetelet on, 17.
THE END.
FOOTNOTES:
[Footnote 1: The Systematic Treatment of Nerve Prostration and Hysteria.
London, 1883.]
[Footnote 2: The Pennsylvania Orthopædic Hospital and Infirmary for
Diseases of the Nervous System.]
[Footnote 3: Sur l'Homme, p. 47, et seq.]
[Footnote 4: Growth of Children, p. 31.]
[Footnote 5: See a valuable paper by Dr. Gerhard, Am. Jour. Med. Sci.,
1876. Also Lectures on Diseases of the Nervous System, especially in
Women. S. Weir Mitchell. Phila., 1881, p. 127. See also the papers by
Dr. Morris J. Lewis on the seasonal relations of chorea, analyzing seven
hundred and seventeen cases of chorea as to the months of onset (Trans.
Assoc. Amer. Phys., 1892), and Osler On Chorea (1894).]
[Footnote 6: Statistics (Anthropological) Surgeon-General's
Bureau--1875.]
[Footnote 7: This excess of corpulence in the English is attained
chiefly after forty, as I have said. The average American is taller than
the average Englishman, and is fully as well built in proportion to his
height, as Gould has shown. The child of either sex in New England is
both taller and heavier than the English child of corresponding class
and age, as Dr. H.I. Bowditch has lately made clear; while the English
of the manufacturing and agricultural classes are miserably inferior to
the members of a similar class in America.]
[Footnote 8: Zeitschrift für Biol., 1872. Phila. Med. Times, vol. iii.,
page 115.]
[Footnote 9: Letheby on Food, pp. 39, 40, 41.]
[Footnote 10: Am. Jour. Med. Sci.; Proc. Phil. Coll. of Phys., 1883;
Phil. Med. News, April, 1883.]
[Footnote 11: Chorea. See Lancet, Aug. 1882.]
[Footnote 12: "Nurse and Patient." S. Weir Mitchell. Lippincott's
Magazine, Dec. 1872.]
[Footnote 13: See Philip Karell's remarks on the use of treatment by
milk in cardiac hypertrophy. Edin. Med. Jour., Aug. 1866.]
[Footnote 14: Trans. Obst. Soc. of London, vol. xxxiii.]
[Footnote 15: Séguin Lecture, _op. cit._]
[Footnote 16: "Pinch" is used to avoid the use of a technical term, but
should be understood to mean the grasping and squeezing of a part with
the whole hand, using the palmar portion of the fingers to press the
grasped mass against the "heel" of the hand. Fuller technical details of
the massage process and consideration of its effects will be found in
the excellent "Handbook" of Kleen, in the works of Dr. Douglas Graham,
Dr. A. Symon Eccles, and in an article in Professor Clifford Albutt's
"System of Medicine" (1896), by Dr. John K. Mitchell.]
[Footnote 17: Dr. Symon Eccles in "The Practice of Massage" recommends
this order.]
[Footnote 18: Some care is needed not to overwork patients. For details
I must refer to manuals of Swedish Gymnastics.]
[Footnote 19: See also page 91.]
[Footnote 20: A number of observations in late years have been made upon
the effect of massage upon elimination. Among the articles to which the
practitioner desiring further to study this subject may be referred
are,--
_Edin. Clin. and Path. Jour_., Aug., 1884.
_Jour, of Physiol._, vol. xxii., p. 68.
_Centralbl. f. Inner. Med._, 1894, No. 40, p. 944.
_Munch. Med. Woch._, April 11 and April 18, 1899 (Influence of bodily
exercise upon temperature in health and disease).
Numerous articles by Mosso, Arbelous, W. Bain, Lauder-Brunton, Lepicque
and Marette, and Maggiora.]
[Footnote 21: American Journal of the Medical Sciences, May, 1894.]
[Footnote 22: Numerous examinations made since have quite uniformly
agreed with the former remarkably constant results.]
[Footnote 23: J.K. Mitchell, _loc. cit._]
[Footnote 24: Most induction batteries are without any arrangement for
making infrequent breaks in the current.]
[Footnote 25: In the extreme constipation of certain hysterical women,
good may be done by placing one conductor in the rectum and moving the
other over the abdomen so as to cause full movement of the muscles. This
means must at first be employed cautiously, and the amount of
electricity carefully increased. It is doubtful if any movement of the
intestinal muscle-fibres is thus caused, but that it is a useful method
of stimulation in obstinate cases may be taken as proved.]
[Footnote 26: Harvey on Corpulence.]
[Footnote 27: The management of the morphia or chloral habit becomes
much more easy under a milk diet, massage, and absolute rest, and I can
with confidence commend their use in these difficult cases. Massage in
the morning is liked, and general surface-rubbing without
muscle-kneading at night very often proves remarkably soothing, while
the rest in bed cuts off many opportunities to indulge in the temptation
to secure the desired drugs.]
[Footnote 28: I have found that this may be usefully replaced by one of
the numerous peptonized foods described in the pamphlets issued by the
manufacturers of the peptonizing powders. The ready-made peptonized
preparations vary very much, like some of the beef extracts, but a trial
will discover which of them is best fitted for an individual case.]
[Footnote 29: Nerve Prostration and Hysteria.]
[Footnote 30: It is worth mentioning that where ataxic patients have to
use canes, a crutch-cane with a base some six or eight inches long and
well shod with roughened rubber is far more useful and safer than the
ordinary stick.]