Part 11 (1/2)
Lessons in balance and co-ordination were begun in the fourth week of treatment, and supervised carefully for two weeks more. When his station and gait were both improved, he was permitted to walk, always with care not to fatigue himself. At this time, six weeks from commencement of treatment, his eyes were gla.s.sed by Dr. de Schweinitz. He had gained some pounds in weight, and walked on straight lines without noticeable incoordination, but in turning short or walking sharp curves he was still unsteady. He found walking much easier than formerly and was less easily tired. After nine weeks he could stand or walk, even backward, with closed eyes. He was sent home for the summer, with directions to continue his co-ordination movements, to walk very little, and take such exercise as he needed on horseback, riding quietly. He had still some stabbing pains two or three times daily.
He reported in one month, and again in six months, ”No improvement in the pains, but I walk well and briskly, can jump on a moving street-car, and have ridden a horse twenty miles in a day without fatigue.”
This case was in one way favorable for treatment: the patient, an educated and intelligent man, helped in every way, carrying out minutely all orders, and had the good sense to begin treatment early. But the acuteness and rapidity of onset of the tabetic symptoms were so great that in a little more than two years they had reached a condition which most cases only attain in from five to ten years, and this makes the prognosis somewhat less favorable.
In the instance to be next related there was also antecedent syphilis, and the patient had already been heavily dosed with iodides and repeatedly salivated with mercury. His recovery was and has remained remarkably complete.
H.B., travelling salesman, from New York, aet. forty, single, a large, strongly-made man, a hard worker, given to excesses in s.e.xual indulgence and alcohol for years. Syphilis was contracted fifteen years before the first traceable symptoms of ataxia, which had shown themselves after an attack of grippe, in 1890, in sudden remittent paralysis of the external muscles of the right eye, followed within a few months by gastric crises, general lightning pains appearing a few months later. During the two years succeeding he was drenched with drugs and grew steadily worse. When admitted to the hospital in 1892 he was very ataxic in the legs, suffered greatly from gastric and other pains, difficulties with bladder and r.e.c.t.u.m, loss of s.e.xual power, various anaesthetic areas, could not stand with eyes open unless he had help, total loss of knee-jerk, paralysis of right rectus, indigestion from the irritation of the stomach from medicines as well as from the disease, and, though muscular and over-fat, was flabby and pallid. He had no ataxia or loss of sensibility in the upper half of the body. He was in bed for two weeks, on milk diet, with warm baths and ma.s.sage. Systematic movements were begun and ma.s.sage continued. After the stomach improved he grew better with unusual rapidity. He is now able to work hard again, travels extensively, can walk strongly, but wisely takes his exercise more in the form of ma.s.sage and systematic gymnastics. He appears to report himself once or twice a year. There has been a partial return of s.e.xual ability.
The next case has points of interest in the later history, but the first examinations and early treatment may be pa.s.sed over briefly. X.Y., aet.
forty-two, a steady, sober merchant, closely confined by his business, always of excellent habits, with no possible suspicion of syphilis, was seen first in 1894 in a somewhat advanced stage of tabes, but with no optic or gastric disturbances. His station was very bad, but when once erect and started he could walk without a stick. Girdle-pains very marked; bowels very constipated; some trouble in emptying bladder; several points of fixed sharp pain; lightning pain occasional and severe, but not frequent. He was ordered to bed for six weeks.
Galvanism, alternate hot- and cold-water applications to the tender spots, careful ma.s.sage, and a two-months' course of Brown-Sequard fluid after getting up made a new man of him. Ma.s.sage and systematic exercise were kept up together for six months. The ma.s.sage was stopped and the exercises continued, and improvement went on steadily, though the fixed pains kept up in only slightly less severity.
In a year the patient was better in general health, looks, and spirits than he had been for many years before, and remained in good order, except for the daily recurrences of paroxysms of pain of varying but not unbearable severity for two years. He then presumed for a month on his strength, and took much more exercise afoot than was wise, worked late at night over his books, had some additional nervous strain from business worries, and came to Dr. J.K. Mitch.e.l.l in October, 1898, barely able to crawl with two canes, having lost weight, become sleepless, suffered great increase of pain, and grown so ataxic that he could scarcely walk. This change had all occurred in three or four weeks. He became steadily worse for two or three weeks till he could not stand or walk at all, had cyst.i.tis from retention, violent attacks of rectal tenesmus, stabbing pains in r.e.c.t.u.m, perineum, s.c.r.o.t.u.m, and groins, with almost total anaesthesia of the sacral region, b.u.t.tocks, s.c.r.o.t.u.m, and perineum, inability to retain faeces, while pa.s.sages from the bowels took place without his knowledge. He found that an increase in the rectal and abdominal pain followed lying down. He therefore spent day and night sitting up. At the end of three weeks there was total paralysis of the legs, and the outlook seemed most unfavorable.
Ma.s.sage was begun again, strychnia and salol were administered, and a short course of full doses of the testicular fluid was given. A rapidly interrupted faradic current, with an uncovered electrode, to the neighborhood of the r.e.c.t.u.m, bladder, and b.u.t.tocks, greatly relieved the anaesthesia, upon which galvanism had no effect; and, in brief, from a state which looked almost as if the last paralytic stage of tabes had suddenly come upon him, he recovered in two months, and is now (July, 1899) better than he was a year ago, before the relapse, and will probably remain so, as he has had his warning.
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 astonis.h.i.+ng.
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; cyst.i.tis. Ordered rest, ma.s.sage, 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 was.h.i.+ng 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.