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Page 47
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 inco�rdination 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
an�sthesia 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 an�sthesia. 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.
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