Chapter 10. Treatment Of Locomotor Ataxia, Ataxic Paraplegia, Spastic Paralysis, And Paralysis Agitans

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_ 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 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 incooerdination, 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 incooerdination, 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 incooerdination lessens his opportunities of exposure or over-exertion.

During this stage some patients complain most of the numbness, girdle-sense, and incooerdination; 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 incooerdination; 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 incooerdination; 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 incooerdination 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 incooerdination 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 anaesthesia which affects the rectum and its vicinity.

[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.]

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 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 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 deg. 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 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, 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 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 incooerdination, 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 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 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 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., 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 massage, and a two-months' course of Brown-Sequard 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 anaesthesia of the sacral region, buttocks, scrotum, and perineum, inability to retain faeces, 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 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; 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.

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 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.

[THE END]
S. Weir Mitchell's essays: Fat and Blood: Treatment of Certain Forms of Neurasthenia and Hysteria

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