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Page 50
Without multiplying case histories, it may be said that ataxic
paraplegia (a combination of lateral and posterior sclerosis) may be
treated in much the same manner. In this disease there is usually much
less pain than in ataxia, but greater weakness, and late in its course
some rigidity in the extensor groups of the legs; the knee-jerk is
preserved or exaggerated. The disease is a rare one. But two recent
distinct cases are in my list, and one of these, the one here reported,
seems rather more like an ataxia with some anomalous symptoms. The
second one had the symptom, uncommon in this malady, of very frequent
and excessively severe stabbing pains, and though his co-ordination grew
somewhat better, he improved very little in any other way, which, as his
trouble was of fourteen years standing, was not astonishing.
The other patient, seen in 1897, was a rancher from New Mexico,
thirty-three years old, who had led an active, hard-working,
much-exposed life, but had been perfectly well until 1891, when he was
said to have had an attack of spinal meningitis, from which he recovered
very slowly. Four years later he noticed numbness of feet and weakness
of legs, great enough to make it hard for him to get a leg over his
horse. Some pains were felt in the limbs, and a constriction about the
chest and abdomen, which had steadily increased in severity. Sharp
attacks left distinct bruise-marks at the seat of pain each time. Could
not empty bladder. Gait feeble, spastic, and paralytic, could not mount
steps at all or stand without aid, sway very great. Knee-jerks and
muscle-jerks increased, especially on left; ankle-clonus; very slight
loss of touch-acuity in lower half of body. Eyes: muscles and
eye-grounds negative; pupils equal and active. Bladder could not be
emptied; cystitis. Ordered rest, massage, electricity, and full doses of
iodide in skimmed milk. In this way he was able to take without distress
or indigestion amounts as large as four hundred and forty grains a day.
When education in balance, etc., was begun he could not walk without
aid, or more than a few steps in any way. In three months from the time
he went to bed he walked out-of-doors alone with no stick, and in five
months went back to work. The bladder did not improve much until after
regular washing out and intravesical galvanism were used, with full
doses of strychnia. He was soon able to empty the organ twice a day, and
since leaving the hospital writes that it gives him very little
annoyance, though as a measure of precaution he uses a catheter once
daily. His pains have entirely disappeared, and he is daily on horseback
for many hours.
In spastic paralysis, whether in the slowly-developing forms in which it
is seen in adults, due sometimes to multiple sclerosis, sometimes to
brain tumor, sometimes following upon a transverse myelitis, or in the
central paraplegia or diplegia of "birth-palsies," some very fortunate
results have followed the careful application of the principles of
treatment already described. Absolute confinement to bed is seldom
required or in adults desirable, though exercise should be carefully
limited to an amount which can be taken without fatigue, and some hours'
rest lying down is usually advantageous.
Assuming that the necessary treatment for the disease originating the
paralysis is to be carried on in the ordinary way, I will only describe
the special forms and methods of exercise I have found serviceable.
Whatever the cause, this will be much the same, though in birth-palsies
the teaching may have to include groups of muscles and instruction in
the co-ordination of actions which are not affected in adult subjects.
First, as to massage: the operator must direct his efforts primarily to
the relaxation of the tense muscles, secondarily to the strengthening of
the opponent groups, this last being of special importance where actual
contraction has taken place. He should make frequent attempts by
stretching the rigid groups to overcome the spasm, which in large
muscle-masses may be done by grasping with both hands, taking care not
to pinch, and pulling the hands apart in the line of the muscle's long
axis, thus stretching the muscles. Pressure will sometimes accomplish
the same end, and it will be found in certain cases that by kneading
_during action_,--that is, while the patient endeavors to produce
voluntary contraction,--the result will be better. Except in the most
spastic states, a certain degree of relaxation is possible by effort,
though not without practice, and this has to be constantly inculcated
and encouraged. After a period varying in length according to the case,
lessons in co-ordinating movements are begun. It is best for the
patient's encouragement to start with the least affected muscles, so
that, seeing the good results, he may be stimulated to persistent
effort. The lessons differ only in detail from those given in the list
under tabes. Improvement is slower than in ataxia.
In birth-palsy cases not much can be accomplished in the way of
education, beyond the attempt by such means as ordinary gymnastics and
lessons in drill and walking offer, until the child shall have reached
an age when he is able to comprehend what is being attempted. For the
imbecile, idiotic, or backward a training-school is the proper place,
where mental and bodily functions may both receive attention and where
constant intelligent supervision is available.
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