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.