170 In healthy persons the extent of the knee-jerk is increased by the spinal ascending galvanic current, and possibly this observation may lead to the establishment of a rational basis for its use in cases where the reflex is abolished or diminished.
Peripheral Treatment.—A number of therapeutical applications are made to the periphery where the symptoms of the sclerotic process are localized. The rationale of such applications is based on the assumption that peripheral conditions are capable of modifying the nutrition and functions of the cord. This is proven not alone by a host of observations made on the normal cord, but is also disastrously illustrated in the part played by surface chilling in the etiology of many acute and chronic diseases of the cord. Notwithstanding this latter, a large and influential body of German neurologists recommend cold baths and cold spinal douches in these affections. I have seen such excellent results from the use of warm baths that I am compelled to plead, in defence of my ignorance of the effect of cold ones, that I have never dared to use them. In numerous cases the beneficial effect of a warm bath is almost instantaneous. Warmth in any shape, whether atmospheric or in the shape of baths, is usually agreeable to patients suffering from the various forms of sclerosis. Cold, on the other hand, is disagreeable, aggravates the symptoms, and in many cases at least hastens the progress of the disease. A winter spent in the latitude of New York or Boston means so much ground lost by the patient, and a sojourn during the colder months in Southern California, New Mexico, Florida, or the West Indies enables the patient to avoid this loss. As regards the choice of climate and baths for sclerotic patients, I should be inclined to roughly formulate the indications as being identical with those of chronic rheumatism. The reaction against the use of warm baths in Germany, where they once were popular,171 is due to the employment of too high temperatures. Hot baths, in the strict sense of the term, including the various forms of vapor-bath, act badly. They increase instead of calming the irritative symptoms, as moderately warm baths do, and they entail too sudden a change in the bodily state. That, for the present, it is advisable not to adopt unreservedly either the extreme plan once in vogue or the equally extreme one which constitutes the reaction against it, is shown by the observations of Richter of Dalldorf, who records some discouraging results obtained by the use of cold baths in cases of tabes dorsalis. It is but necessary to refer to the fact that the lancinating pains of the latter disease, the rigidity of diffuse myelitis, and the spasms of lateral sclerosis are usually most severe in cold weather, and that the diseases mentioned appear to be rare in warm countries, to show the need of caution in using a therapeutical measure so similar in its action, even if it be but momentary and followed by a reaction, to those which provoke or aggravate the original disease. Eulenburg has seen five recoveries in tabes, and under such different plans of treatment that the latter is not credited by him with the good result. Three were treated with warm baths, one with cold baths, and one with nitrate of silver. It is seen here that the warm baths were used with good results more frequently than the cold.
171 The mud-baths of Cudowa in Gallicia had a very high reputation.
One of the most singular delusions of modern therapeusis—nerve-stretching—has, following the prediction made by several on both sides of the Atlantic, become obsolete. Introduced by Langenbuch, a surgeon, and attacking the disease at the sciatic nerve—a point where, as well-versed students knew, it was not located—the operation was looked upon with distrust from the beginning. The enthusiasm with which it was taken up by surgeons and by the interested portion of the laity—ever hopeful as tabic patients are of new drugs and methods of treatment—has led to a large number of trials, now numbering several hundred, and from which the useful lesson can be gathered that the good ripens slowly. Nerve-stretching in an organic disease of the spinal cord may take its place among the needless vivisections; it has not influenced the progress of a single case in any essential feature. On the contrary, it has more than once been directly responsible for acute myelitis, spinal hemorrhage,172 and pyæmia. In a number of cases reported by Langenbuch,173 Benedict, Erlenmeyer, Schweminger, Debove, and W. J. Morton, the ataxia of the patient has been reported as relieved; in one case, exhibited by the latter operator before the American Neurological Association, this appeared quite evident, but not because the disease proper had been influenced, but for the same reason that prevents the development of marked ataxia in combined sclerosis. Just as the lateral-column lesion inhibits the ataxia which is due to the posterior-column lesion, so the motor paresis produced by stretching the sciatic nerves neutralizes the manifest features of the ataxic gait. As soon as the paresis is recovered from, the ataxia returns in its original form, unless, happily, one of the common spontaneous changes for the better occur. As a therapeutic procedure nerve-stretching is to-day properly limited to affections of the peripheral nerves.
172 Zacher, Archiv für Psychiatrie, xv. p. 430.
173 Westphal showed after the autopsy of Langenbuch's first successful case that there had been no spinal lesion whatever.
One of the most useful peripheral remedies in the sclerotic processes is the faradic wire brush. It is both an anodyne and remedial for anæsthesia. A number of the tabic patients to whom I referred as not having deteriorated within long periods are provided with a portable faradic battery, and apply the brush to the spots affected by terebrating pains the moment these commence, obtaining instantaneous relief. As has been shown by Rumpf,174 the cutaneous space-sense becomes more delicate in healthy and improved in tabic patients under its continued use. And while the inco-ordination of tabes is in part independent of the disturbance of cutaneous sensibility, yet if the latter can be refined the ataxic disturbance may be mitigated—a result occasionally obtained through the methodical use of the wire brush.
174 Report of a discussion, Neurologisches Centralblatt, 1885, p. 526.
It is frequently found that sufferers from tabes dorsalis and other forms of sclerosis accompanied by ataxia walk much better in their stocking feet and in slippers than they do in the conventional street shoe or boot. The reason for this is obvious. The patient's gait is impaired by the disease, and, whether the ataxia be a pure co-ordinatory trouble or no, subjective uncertainty regarding contact with the ground which is experienced by most ataxic patients is an aggravating factor. Our modern foot-clothing, with its inflexible soles and raised heels, handicaps the patient as it were, depriving him of the use of what little tactile sensibility may be left him.175 The use of low-heeled shoes with thin and flexible soles is therefore advantageous.
175 The question whether tabes dorsalis is a disease of civilization has not been raised in any treatise I am acquainted with. Myelitis, both acute and chronic, occurs, however, rarely in the lower animals, as do also central dilatation of the cord and congenital defects of the latter. Posterior sclerosis I can find no record of in veterinary pathology. The influence of the repression of normal aids to locomotion by the foot-gear of civilized life as a possible predisposing factor in the etiology of ataxic troubles is a legitimate subject of inquiry. The lateness of the infant of civilized parents in acquiring the art of skilled locomotion may be in part, as philosophers claim, a penalty of exuberant development of the higher and inhibitive centres. But what part has the artificial obliteration of solar sensibility and pedal flexibility played in this inherited feature? What is its influence in establishing a pathological vulnerability?