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Page 46
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 inco�rdination; 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
inco�rdination 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.
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