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.