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.