"Such were the salient features of this case; and I can assure you that I was as much impressed by the happy results of the treatment as were a host of anxious and doubting friends.

"Very faithfully yours, "WM. GOODELL."

* * * * *

Miss C., an interesting woman, aet. 26, at the age of 20 passed through a grave trial in the shape of nursing her mother through a typhoid fever. Soon after, a series of calamities deprived her of fortune, and she became, for support, a clerk, and did for two years eight hours' work daily. Under these successive strains her naturally sturdy health gave way. First came pain in the back, then growing paleness, loss of flesh, and unending sense of tire. Her work, which was a necessity, was of course kept up, steadily at first, but was soon interfered with by increase of the menstrual flow, with unusual pain and persistent ovarian tenderness. Very soon she began to drop her work for a day at a time. Then came an increasing asthenopia, with evening headaches, until her temper changed and became capricious and irritable. When I saw her, she had been forced to abandon all labor, and had been treated by an accomplished gynaecologist, and was said to be cured of a prolapsus uteri and of extensive ulceration, despite which relief she gained nothing in vigor and endurance and got back neither color nor flesh.

She went to bed December 10, and rose for the first time February 4, having gained twenty-nine pounds. She went to bed pale, and got up actually ruddy. In a month she returned to her work again, and has remained ever since in health which enables her, as she writes me, "to enjoy work, and to do with myself what I like."

Miss L., aet. 26, came to me with the following history. At the age of 20 she had a fall, and began in a week or two to have an irritable spine. Then, after a few months, a physician advised rest, to which she took only too kindly, and in a year from the time of her accident she was rarely out of bed. Surrounded by highly sympathetic relatives, to whom chronic illness was somewhat novel, she speedily developed, with their tender aid, hyperaesthetic states of the eye and ear, so that her nurses crept about in a darkened room, the piano was silenced, and the children kept quiet. By slow degrees a whole household passed under the selfish despotism of an hysterical girl. Intense constipation, anorexia, and alternate states of dysuria, anuria, and polyuria followed, and before long her sister began to fail in health, owing to the incessant exactions to which she too willingly yielded. This alarmed a brother, who insisted upon a change of treatment, and after some months she was brought on a couch to this city.

At the time I first saw her, she took thirty grains of chloral every night and three hypodermic injections of one-half grain of morphia daily. As to food, she took next to none, and I could only guess her weight at about ninety pounds. She was in height five feet two and a half inches, and very sallow, with pale lips, and the large, indented tongue of anaemia. I made the most careful search for signs of organic mischief, and, finding none, I began my treatment as usual with milk, and added massage and electricity without waiting. Her digestion seemed so good that I gave lactate of iron in twenty-grain doses from the third day, and also the aloes pill thrice a day. It is perhaps needless to state that I isolated her with a nurse she had never seen before, and that for seven weeks she saw no one else save myself and the attendants. The full schedule of diet was reached at the end of a fortnight, but the chloral and morphia were given up at the second day. She slept well the fourth night, and, save that she had twice a slight return of polyuria, went on without a single drawback. In two months she was afoot and weighed one hundred and twenty-one pounds. Her change in tint, flesh, and expression was so remarkable that the process of repair might well have been called a renewal of life.

She went home changed no less morally than physically, and resumed her place in the family circle and in social life, a healthy and well-cured woman.

I might multiply these histories almost endlessly. In some cases I have cured without fattening; in others, though rarely, the mental habits formed through years of illness have been too deeply ingrained for change, and I have seen the patient get up fat and well only to relapse on some slight occasion.

The intense persistency with which some women study and dwell upon their symptoms is often the great difficulty. Even a slight physical annoyance becomes for one of these unhappily-constituted natures a grave and almost ineradicable trouble, owing to the habit of self-study.

Miss P., aet. 29, weight one hundred and eleven pounds, height five feet four inches, dark-skinned, sallow, and covered with the acne of bromidism, had had one attack which was considered to have been epileptic, and which was probably hysterical, but on this matter she dwelt with incessant terror, which was fostered by the tender care of a near relative, who left her neither by night nor by day. Vague neuralgic aches in the limbs, with constant weariness, asthenopia, anaemia, loss of appetite, and loss of flesh, followed. Then came spinal pain and irregular menstruation, a long course of local cauterizations of the womb, spinal braces, and endless tonics and narcotics.

I broke up the association which had nearly been fatal to both women, and, confidently promising a cure, carried out my treatment in full In three months she went home well and happy, greatly improved in looks, her skin clear, her functions regular, and weighing one hundred and thirty-six pounds.

It is vain to repeat the relation of such cases, and impossible to put on paper the means for deciding—what is so large a part of success in treatment—the moral methods of obtaining confidence and insuring a childlike acquiescence in every needed measure.

Another class of cases will, however, bear some further illustration. We meet with women who are healthy in mind, but who have some chronic pain or some definite malady which does not get well, either because the usual tonics fail, or because their occupations in life keep them always in a state of exhaustion. If by rest we slow the machinery, and by massage and electricity deprive rest of its evils, we can often obtain cures which are to be had in no other way. This is true of many uterine and of some other disorders.

Miss B., aet. 37, height five feet five inches, weight one hundred and fifteen pounds, a schoolteacher, without any notable organic disease, had a severe fall, owing to an accident while driving. A slight swelling in the hurt lumbar region was followed by pain, which became intense when she walked any distance. Loss of color, flesh, and appetite ensued, and, after much treatment, she consulted me. I could find nothing beyond soreness on deep pressure, and she was anything but hysterical or emotional.

Two months' rest with the usual treatment brought her weight up to one hundred and thirty-eight pounds, and she has been able ever since to do her usual work, and to walk when and where and as far as she wished.

Several years ago I treated with some reluctance a lady who had extensive bronchitis and a slight albuminuria. This woman was a mere skeleton, with every function out of order. I undertook her case with the utmost distrust, but I had the pleasure to find her fattening and reddening like others. Her cough left her, the albumen disappeared, and she became well enough to walk and drive; when a sudden congestion of the kidneys destroyed her in forty-eight hours.

The following case of extreme anaemia, with striking resemblance to the pernicious type in some of its features, is especially interesting for the ease and rapidity of improvement under rest and massage without electricity or excessive amounts of food.

Mrs. T., aet. 40, the mother of several children, had been unwell for years, and almost totally incapacitated for exertion for two years before admission, in January, 1894. She complained of extreme feebleness, distaste for and inability to digest food, a great and constant difficulty in swallowing, shortness of breath, dropsy of the ankles if she walked or stood, hemorrhoids from which some bleeding often occurred, extreme constipation, constant chilliness, and frequent violent headaches. Her appearance was that of a person with pernicious anaemia, a very yellow muddy skin, dry and harsh to the touch, and the hands and feet cold, almost to the point of pain.

On examination the spleen was decidedly large; the lower border of the stomach reached to the level of the umbilicus. Two cardiac murmurs were present, the one a sharp and well-defined mitral regurgitant sound, confirmed by the dyspnoea and dropsy as organic, the other a loud musical murmur of haemic origin. The trouble in deglutition proved to be due to an oesophageal narrowing. The blood examination bore out the suggestion of probable pernicious anaemia, the red cells being only 1,500,000, haemoglobin 18 per cent.: the microscope showed microcytes, megaloblasts, nucleated red cells, and a large increase in white corpuscles. In order to study the effect of massage alone upon the blood no other treatment was used, though of course the patient was kept at "absolute rest." No drugs were given, electricity was not used, and extra food was omitted, as the irritability of the oesophagus made her unwilling to attempt the exertion and annoyance of frequent feeding. The general chilliness was at once helped by massage, and in a few days only felt in the small hours of the night, and the patient gained weight from the first. After one week of treatment a blood count was made: red cells were 3,800,000, more than double the former figure; haemoglobin, 35 per cent., almost double its original value. On the same day, one hour after the completion of an hour's massage, the corpuscular count had attained 5,400,000, the haemoglobin remaining 35 per cent.

At the end of two weeks the haemic murmur had faded into a faint soft bruit, though the mitral murmur was unchanged, the skin had improved in color, the aches and weariness were gone, and the blood count had reached nearly five million cells, with 50 per cent. of haemoglobin. The extraordinary results of the blood examination were confirmed by observations made by Professor Frederick P. Henry, Dr. Judson Daland, and Dr. J.K. Mitchell, who all practically agreed. Professor Henry made several studies and stained a number of slides, verifying in his report the statements of the presence of megaloblasts and nucleated red cells made above.

Owing to the necessity for an operation on the hemorrhoids, which caused loss of blood, the patient was somewhat retarded in her progress to recovery, but by the tenth week was so far better that the blood showed no microscopic abnormalities, the count was full normal, and the haemoglobin over 70 per cent. Her color and strength were good, the heart was perfectly strong, the anaemic murmur was gone, and the oesophagus was so much less irritable that it was possible to begin dilatation of the stricture.

I have heard within a year that though occasionally annoyed by this last trouble if she becomes much fatigued, she has remained in other ways well.

Mrs. G., the daughter of nervous parents, was always a nervous, over-sensitive, serious child, worked hard at Vassar, broke down, recovered, returned to college, was attacked with measles, which proved severe, and by the time she graduated had been made by her own tendencies and the anxious attention of her family into a devoted member of the class which I may permit myself to describe as health-maniacs.

Health-foods, health-corsets, health-boots, the deeply serious consideration of how to eat, on which side to sleep, profound examination of whether mutton or lamb were the more digestible flesh,—these were her occupations,—and two or three years before her panic about her health had been made worse by the discovery of an aortic stenosis, of which an over-frank doctor had thought it best to inform her. When I saw her she had been three years married, was childless, and, between the real cardiac disease and her own anxieties about it, had driven herself into a state of great physical debility and a mental condition approaching delusional insanity.

A too restricted diet, lacking both in variety and appetizingness, had had its usual result of upsetting digestion and destroying desire for food. Even with the small amounts which she ate she considered it necessary to chew so carefully and to feed herself so slowly that from one hour to an hour and a half was used for each meal. The heart, under-nourished, beat feebly, there was constant slight albuminuria with evidences of congested kidneys, and she could only rest in a semi-erect position.

The heart condition, with its renal results, proved the most rebellious part of the trouble. A firm and intelligent nurse soon overcame the difficulties and delays about food, and my final refusal to discuss them disposed for the time of some of the fanciful theories about digestion and so on. Her meals were ordered in every detail, and she was told that they were prescribed and to be taken like medicine, and, fed by the nurse, she began to take more nourishment. Massage relieved some of the labor of the heart, and gradually the semi-erect posture was exchanged inch by inch for a semi-recumbent one. Not to prolong the relation of details, it was found needful to keep this lady in bed for five months before the heart seemed to recover sufficiently to allow her to get up. Even then, although improved in color, flesh, and blood condition, she had to attain an erect station almost as slowly as she had had to reach recumbency. Slow, active Swedish movements, to which gentle resistance movements were very gradually added, helped the heart. Her cure was completed by five or six months' camp-life in the woods, and she is now the mother of a healthy child and herself perfectly well, the valvular disease only to be detected by the most careful examination, and never, even during pregnancy and parturition, causing any annoyance.

The surgeons, who once thought a floating kidney could be permanently fixed in its place by stitching, have now concluded that this is very doubtful, and the treatment of this displacement is never very satisfactory by any method. Still, some success has followed long rest in the supine position, which encourages the kidney to return to its normal place, until careful full feeding has renewed or increased the fatty cushions which hold it up. It is best during the first weeks of treatment not to allow the patient to sit or stand, or if she should be unable to avoid the occasional need for these positions, an abdominal binder must be applied by the nurse and drawn tightly before she moves. The masseuse is directed to avoid any movements which might further displace the organ, and may cautiously push it upward and hold it there with one hand while with the other the manipulation of the abdomen is performed. However long it may require, the patient should not get up until examinations, supine, lateral, prone, and erect, combine to assure us that the kidney is replaced. Repeated investigation of this point will be required,—for the kidney will sometimes be in place for a little while and next day or even a few hours later have slipped down again. Before any exertion is permitted, even ordinary walking, an accurate close-fitting abdominal belt with a kidney-pad should be applied. Those kept in stock are seldom properly adjusted, and usually have the pad in the wrong place. If rightly made, they can be worn with comfort and tight enough to be useful. If not rightly made, they are useless instruments of torture.

Mrs. Y., aet. fifty-six, was sent to Dr. J.K. Mitchell by Professor Osler for treatment. She had all the usual intestinal derangements and discomforts attendant upon a floating kidney: constipation alternated with diarrhoea, or rather with a sort of intestinal incontinence; vague pains in the back, flanks, and stomach were frequent; attacks of acute pain began in the right hypogastrium and ran down to the symphysis or into the groin; she had constant flatulence, weight, and oppression after food; was pale, flabby, and emaciated, but had no emotional or nervous symptoms except an annoying amount of insomnia. The lower border of the stomach was fully two inches below the navel in the middle-line, even when only a glass of water had been taken. It was a little lower after a small meal. The colon was distended and very variable in position, probably changing its relations with the landmarks as it happened to be more or less filled with food or gases. The abdominal walls were flabby, relaxed, and pendulous, and the whole surface tender. The patient gave a history of sudden loss of flesh with almost no reason some three years before, and increasing indigestion in all forms ever since. The tenderness made careful abdominal study difficult, but lessened enough after a few days in bed to permit the perception of a displacement of the right kidney, whose lower edge could be felt on a level with the umbilicus and two inches to the right of it. No change of position would bring it any lower. Examined with the patient prone, two-thirds of the kidney could be outlined, extremely tender, and causing nausea and sinking if pressed upon.

The chief trouble in treatment proved to be the irritability of the intestines, which was brought on in most unexpected fashion by foods of the simplest kind. For some time it was so persistent that the suspicion of intestinal tuberculosis was entertained; but it finally disappeared, and after that the case progressed more favorably and she was out of bed with a tight belt and kidney-pad in a little more than twelve weeks. The kidney was then, and has remained since, in its normal position. The patient gained twelve pounds in weight, and should have gained more, but she found the hot weather during the latter weeks of her treatment very trying. The intestinal indigestion was only partially relieved, but the gastric symptoms, the general pains, and weakness all disappeared, and with precaution she will continue to improve. It is best to advise the constant use of the belt in such a case. In a patient who has made a large gain in flesh, as this one did not, and who has been found after some months to maintain the increased weight, the belt might gradually and experimentally be left off; but repeated examinations should be made for a year or two to be sure that no displacement results.

I could relate cases of gain in flesh without manifest relief. As I have said, these are rare; but it is less uncommon to see great relief without improvement in weight at all, or until the patient is up and afoot for some weeks; and I could also state several cases in which a repetition of the treatment won a final and complete success after the first effort at cure had failed or but partially succeeded; and of this, I believe, Professor Goodell has seen several examples.

I have mentioned more than once the singular return of menstruation under this treatment, and as examples I add a brief list of some notable instances.

Mrs. N., aet. 29, no menstruation for five years; return of menstruation at thirtieth day of treatment; continued regularly ever since during three years.

Mrs. C., aet. 42, eight years without menstruation; return at fourteenth day of treatment; now regular during five months.

Miss C., aet. 22, no menstruation for eight months; return at close of sixtieth day of treatment; regular now for four months.

Miss A., aet. 26, irregular; missing for two or three months, and then menstruating irregularly for two or three months. No flow for two months. Menstruated at nineteenth day of treatment, and regular during thirteen months ever since.

I had at one time intended to give, in the first edition of this work, a summary of all my cases, with the results; but what is easy to do in definite maladies like typhoid fever becomes hard in cases such as I here relate. In fevers the statistics are simple,—patients die or get well; but in cases of nervous exhaustion, so called, it is impossible to state accurately the number of partial recoveries, or, at least, to define usefully the degrees of gain. For these reasons I have not attempted to furnish full statistics of the large number of cases I have treated.

In the debate before the British Medical Association the question of the permanence of cures by this method was the subject of discussion. I have lately been at some pains to learn the fate of many of my earlier cases, and can say with certainty that every case then treated was selected because all else had failed, and that I find relapses into the state they were in when brought to me to have been very uncommon. A vast proportion have remained in useful health, and a small number have lost a part of their gains. I now make it a rule to keep up some relation with patients after discharge, by occasional visits or by letter, and believe that in this way many small troubles are hindered from becoming large enough to cause relapses.

I said in my first edition that I did not doubt that the statements I made would give rise in some minds to that distrust which the relation of remarkable cures so naturally excites; and this I cannot blame. Every physician can recall in his own practice such cases as I have described, and every medical man of large experience knows that many of these women are to him sources of anxiety or of therapeutic despair so deep that after a time he gets to think of them as destined irredeemably to a life of imperfect health, and finds it hard to believe that any method of treatment can possibly achieve a rescue.

I am fortunate now in having been able to show that in other hands than my own, both here and abroad, this treatment has so thoroughly justified itself as to need no further defence or apology from its author. It has gratified me also to learn that in many instances country physicians, remote from the resources of great cities, have been able to make it available. As I have already said, I am now more fearful that it will be misused, or used where it is not needed, than that it will not be used; and, with this word of caution, I leave it again to the judgment of time and my profession.



CHAPTER X.

THE TREATMENT OF LOCOMOTOR ATAXIA, ATAXIC PARAPLEGIA, SPASTIC PARALYSIS, AND PARALYSIS AGITANS.

In my earliest publication on the treatment of diseases by rest, etc., locomotor ataxia was alluded to as one of the troubles in which remarkable results had been obtained. Rest alone will do much to diminish pain and promote sleep in tabes, rest with massage and electricity will do more. It is not necessary to order complete seclusion for such cases, but some special measures will be needed in addition to those already described as of use in various disorders, and these will be discussed in this chapter.

While this is not a treatise on diagnosis, some brief symptom-description is needed to enable one to define clearly the methods of treatment at different stages.

In the middle or late stages there need be little uncertainty in uncomplicated cases; in the earlier periods diagnosis is by no means easy. A history may usually be elicited of important heralding symptoms, such as former or present troubles with the muscles of the eyes, the occurrence of vague but sharp and recurring pains, vertigo, an impairment of balance, unnoticed perhaps, except when walking in the dark or when stooping to wash the face, or especially when going down stairs. Attacks of 'dyspepsia,' as unrecognized visceral crises are often called, should render one suspicious. If, on examination, loss or impairment of knee-jerk be shown, contraction of the pupil with Argyll-Robertson phenomenon and defective station, but little doubt can exist. The discovery by the ophthalmoscope of some degree of beginning optic neuritis would make assurance more sure, and this can often be detected in a very early stage of the disease.

Much controversy has been spent on the question of the share of syphilis in producing tabes, and out of the battle but two facts emerge fairly certain, the one that syphilis often precedes the disease, the other that anti-syphilitic medication is commonly of no service. But syphilis is so frequently antecedent that a history of that infection may make certain the diagnosis when doubt exists. This may be an important point, for some of the cardinal symptoms are occasionally absent; cases are seen with no incooerdination, sometimes with the station unaffected, even, though rarely, with the knee-jerk preserved.

The diagnosis established, treatment will somewhat depend upon the stage which the disease has reached.

In the pre-ataxic stage, where slight unsteadiness, often not troublesome except in the dark or with closed eyes, sharp stabbing pains here and there, numbness of the feet, girdle-sense in the region of chest, waist, or belly, some recurrent difficulty in emptying the bladder, a fugitive partial palsy of the external muscles of the eye, are the chief or, perhaps, the only complaints, it would not be justifiable to put the patient to bed at complete rest. This early stage calls for a different plan of treatment, to be presently described.

In the middle or more distinctly ataxic period long rest in bed should be prescribed, and will be gratefully accepted by a patient whose sufferings from incooerdination, pains, and numbness of the extremities are often so great as to incapacitate him.

The bladder muscles share in the ataxia, and the consequent retention of urine frequently causes cystitis, and may endanger life by the involvement of the kidneys.

The bowels cannot be emptied or are moved without the patient's knowledge, and these annoyances combine with the pain and nervous apprehension to drive the victim into a melancholic or neurasthenic state. He suffers, too, from want of occupation, from the absence of exercise, from the anticipation of worse changes in the near future, and usually by the time he reaches the specialist has been more or less poisoned with iodide of potash and mercury, and perhaps with morphia.

In the third, the paralytic stage, which seldom comes on until the symptoms have lasted for years, there is gradual loss of power and ataxia, increasing until he is totally unable to walk. If a patient is not seen until this condition of things has been reached, but little can be hoped from any treatment, though in a few cases energetic measures may bring about a marked improvement, which is rarely lasting.

A combination of tabes with lateral sclerosis, or with general paralysis of the insane, is sometimes seen, but needs no special consideration.

The first or pre-ataxic stage is, to the great detriment of patients, too seldom recognized. The pains are called rheumatic, the eye symptoms are lightly passed over or glasses are ordered, the difficulty of micturition is treated by drugs, and the slightly impaired balance unnoticed or unconsidered.

When such a patient comes into our hands the history, and especially the history of predisposing causes, needs the most careful examination. It is well established that syphilis is a common precedent of ataxia, occurring in at least two-thirds of the cases; it is even more firmly settled that iodide and mercury in large doses do no good in advanced ataxia. I say in advanced ataxia, because a few cases are seen in which the syphilis has been of recent occurrence, or where the spinal symptoms are of decidedly acute character, and in these anti-syphilitic medication is needed and useful; but such cases should be described as acute or subacute spinal syphilis, not as ataxia. When nerve degeneration has once begun, iodide will do little good and mercury may do positive harm, if used in large doses. The other common predisposing causes, exposure to cold, over-exertion, sexual excess, need concern us only as they suggest warnings to be given, especially when the patient is improving. Until he does improve not much need be said about them; he cannot indulge in venery, as sexual power is usually (though not always) lost early in the disease; and the incooerdination lessens his opportunities of exposure or over-exertion.

During this stage some patients complain most of the numbness, girdle-sense, and incooerdination; others of the stabbing pains or the bladder weakness. The general treatment must be much the same, however, in all, with special attention besides to the special needs of each individual.

Fatigue makes all the symptoms worse, increases pain, and impairs still more the muscular incooerdination; it is, therefore, of the first importance in every instance to forbid all over-exertion. Walking, more than any other form of exercise, hurts these cases. The patient should not walk beyond his absolute necessities. To get the needed fresh air, let him, according to his situation in life, drive out or use the street-cars. In some cases the use of a tricycle on a level floor or on good roads is not so harmful as walking, for obvious reasons; this tricycle exercise may at first be made a passive or mild exercise by having the machine pushed by an attendant. To replace the effects upon the circulation and bowels of physical activity massage may be used, and the masseur must have directions as to gentle handling of the tender places at first. These are usually in fixed positions, and can be avoided or only lightly touched. The shooting pains may be lessened by deep, slow massage in the tracks of the nerves affected. If, as generally happens, there are also regions of defective sensation, these should receive after the general manipulation active, rapid circular friction, and, perhaps, experimentally, open-hand slapping. As constipation is one of the troublesome features, the abdomen should have particular attention, and an unusual amount of time be given to manipulations of the colon, as described in the chapter on massage. A full hour's rest in bed, preferably in a darkened room, must follow the rubbing.

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 incooerdination; 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 incooerdination 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.

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 incooerdination 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 anaesthesia 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 anaesthesia. 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 deg. 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.

For several years past in all patients with the general lowering of nervous force and vitality so common in this disease I have habitually used the testicular elixir of Brown-Sequard. The ridiculous length to which organic therapeutics have been carried, the extravagant advertising claims, and an absurd expectation of impossible results have combined to make the profession shy of those organic preparations which have not very good evidence in their favor, and for some time I shared in this prejudice against the Brown-Sequard fluid. A talk with that most distinguished physician and an examination of some of his cases led me to a trial for myself, and I am at present very well convinced that, whether a physiologic basis can reasonably be assumed or not, we have in the fluid a tonic remedy of great power. While I have used it with good effect in other conditions, it is in ataxia that I have found it of most value.

The glycerin extract is freshly prepared from bulls' testicles in exact accordance with the directions of the discoverer. It is used hypodermatically every other day, beginning with a diluted ten-minim dose and increasing by two or three drops up to about forty minims. The effect is at its height twelve to twenty-four hours after the administration in most patients, hence the reason for using it only once in two days. The skin is prepared, the needles and syringe disinfected, and the tiny puncture sealed afterwards with as minute care as would be given to a surgical operation. By these precautions the danger of abscess, always considerable if hypodermics are carelessly given, is minimized. As the dose is large, a site must be selected for the injection where the tissue is loose, otherwise the pain will interfere with the desired frequency of use. The buttocks serve best, or the outer masses of the pectoral muscles, or the abdominal muscles. If the administration causes pain (due in part to the large quantity used and in part to the local effect of glycerin), a fraction of a grain of cocaine may be added to the solution when measured out for use.

It may at once be said, emphatically, that in some cases remarkable results have followed the use of this material, while in others no good has been done; but the same may be said of most plans of treatment in this disorder. As to possible danger from it, no harm has been done to any patient known to me, except that abcesses have occurred sometimes, though very rarely, for in many hundreds of injections it has been my good fortune to see abscesses form only three or four times, two of these instances, by curious ill luck, being in physicians. Patients describe a stimulating effect not unlike that of strong coffee, following a few hours after use and lasting for a day. The sexual appetite, if present, is increased; if absent, it is often renewed, sometimes in elderly men to an inconvenient extent. In one tabetic subject who had lost desire and ability for more than three years both returned in sufficient force to allow him to beget a child. This patient, like most of the others, was ignorant of what drug was being used and of what effects might be expected, so suggestion played no part. Apart from this special effect, the solution acts only as a highly stimulating tonic.

The full dose of forty minims or thereabouts is maintained for a fortnight or less, and then gradually diminished in the same way that it was increased. Sometimes, when the effect has been good, a second "course" may be given after two or three weeks' interval.

During the treatment by hypodermic the masseur should be told to avoid rubbing where the injections have been given. A few trials with the fluid internally have produced so little result of any kind that I am inclined to think the gastric juices must alter it so as to lessen or wholly destroy its power.

As to other drugs, experience has not given me much confidence in any of those usually recommended. Strychnia, belladonna, and those antiseptic drugs which are eliminated chiefly by the kidneys are of use when cystitis has to be treated and the bladder muscles urged to activity. Arsenic, the chloride of gold and sodium, and chloride of aluminium are suggested by various authorities, but they have not been of any value in my hands. In hopeless cases, where all treatment fails, as will sometimes happen, or in patients in whom the paralytic stage is already far advanced, if other measures are unsuccessful, morphia is left as a forlorn hope, which will at least relieve their pains.

An outline report of several cases of different types and degrees is appended:

M.P. of North Carolina, aet. thirty-seven, general health excellent until syphilis in 1894, was admitted to the Infirmary in 1898. He had had for two years recurrent attacks of paralysis of the external rectus muscle of the right eye, slight gastric crises, and stabbing pains in the legs; station very poor, but strength unimpaired, and he was able to walk after being a few minutes on his feet; when first rising he was very unsteady. Knee-jerk lost, no reinforcement. No sexual power. Some difficulty in emptying the bladder. Examination showed slight atrophy of both optic nerves, Argyll-Robertson pupil, and myosis. He was ordered two weeks' rest in bed, with massage, cool sponging daily, and galvanization of the areas of neuralgia. After two weeks he was allowed to get up gradually, to occupy himself as he pleased, but not to walk. 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 glassed by Dr. de Schweinitz. He had gained some pounds in weight, and walked on straight lines without noticeable incooerdination, 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 sexual 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 rectum, loss of sexual 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 massage. Systematic movements were begun and massage 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 massage and systematic gymnastics. He appears to report himself once or twice a year. There has been a partial return of sexual ability.

The next case has points of interest in the later history, but the first examinations and early treatment may be passed 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 massage, and a two-months' course of Brown-Sequard fluid after getting up made a new man of him. Massage and systematic exercise were kept up together for six months. The massage 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. Mitchell 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 cystitis from retention, violent attacks of rectal tenesmus, stabbing pains in rectum, perineum, scrotum, and groins, with almost total anaesthesia of the sacral region, buttocks, scrotum, and perineum, inability to retain faeces, while passages 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.

Massage 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 rectum, bladder, and buttocks, 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 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.

Many children the subjects of cerebral diplegia are credited with less intelligence than they really possess, partly because they are necessarily backward, and partly because of their difficulty in expressing themselves, the speech-muscles sharing in the disease. These muscles need to be carefully educated, and this might almost be made the subject of a treatise by itself. Each case will require study as to the special difficulties in the way of speech. Some experience most trouble with the vowel sounds, more find the consonants the worst obstacles. Patient practice in forming the sounds soon produce some results; the pupil must be taught, like the deaf mute, to watch and imitate the movements of the lips and tongue.

Seguin's books and the numerous special works should be consulted by the physician or parent desiring to pursue these methods to their fullest development.

When once the control of muscular movement begins to improve, more elaborate exercises may be set. In speech, if the patients be intelligent, they will sometimes be amused and profitably trained at the same time by the effort to learn and repeat long words or nonsensical combinations of difficult sounds, like the "Peter Piper" nursery rhymes.

B.M., aet. fourteen, an intelligent lad, of Jewish parentage, suffered a forceps-injury at birth, and had convulsive seizures later. He began to make futile attempts at walking when five or six years of age, when the spastic rigidity was first noticed. His speech was better at this time than later, and a sort of relapse seemed to be precipitated by a fall in which he struck his head when seven years of age. His mother, finding it almost impossible to teach him to walk, devoted herself faithfully to improving his mind, so that at fourteen years of age he read well and enjoyed books, and was mentally clear, observant, and docile. His speech was almost incomprehensible,—stuttering, thick, and nasal. He stood, swaying in every direction, though not apt to fall, with bent knees, rounded shoulders, every muscle in the extremities rigid, the mouth half-open, the head projected forward, and, upon attempting to move, the toes turned in, the legs almost twined around one another, and, unless supported, he would stumble and twist about, scarcely able to get forward at all. With a guiding hand he did a little better. His first lessons were in "setting-up drill," while the feeble, disused muscles were strengthened by massage, which served at the same time to help his very irritable and imperfect digestive apparatus, so that it was soon possible to give him a greater variety and more nourishing kinds of food than he had before been able to take. He was kept in bed up to three o'clock in the afternoon, the morning hours occupied with massage and a half-hour's lesson in erect standing, with slow trunk movements afterwards. An hour after dinner he was dressed and taken for two hours in a carriage or street-car. He did his reading and some study on his return, and had another half-hour's drill, superintended by his mother. In two or three weeks some improvement began to be observable in his attitude, and a great change in his color and general expression, but it was three months before it was thought wise to attempt education in small co-ordinate movements. At about the same time speech-drill was commenced.

In all these lessons the greatest care was taken that adequate rest should intervene between each series of efforts, and it was always found that fatigue distinctly impaired his co-ordination, as did emotion or indigestion. When his speech grew clearer he was set tasks of learning many-syllabled words and also began to practise drawing patterns. Every new lesson was first given under medical supervision and then continued by his mother or by the masseur. To shorten the history it will suffice to say that in six months he was able to go to school, where with certain allowances made for his thick speech by a kindly master he did well, and returned to his home in the South able to walk without attracting attention, to speak comprehensibly, to write a good letter, and with every prospect fair for a still greater improvement, which I learn he has since made.

The important things to be recognized in the treatment of these cases are, first, that rest in proper proportion allows of the patients doing an amount of exertion which, ungoverned, or performed in wrong ways would harm them; secondly, that full feeding is of value, because these disorders are mostly of the character of degenerations and involve failure of nutrition in various directions; and, lastly, that the exactness of routine is of the highest moral and mental as well as physical importance.

Paralysis agitans needs scarcely more than to be mentioned as amenable to the same methods, with small differences in the application of details. Body movements to counteract the tendency to rigidity in the flexor groups of spinal muscles will be especially useful, as the stiffness of these is one of the causes of displacement forward of the centre of gravity, a displacement which results in the festination symptom usually seen in such cases. Prescriptions of special exercises for the muscle-masses particularly involved in each instance must be given, remembering that contraction of the affected muscles will to a certain degree overcome their rigidity even at first, and to a still greater extent as the patient reacquires voluntary control.



INDEX.

Acne, caused by massage, 89.

After-treatment, importance of, 79, 195.

Albuminuria, from exercise, 101.

Alcoholism producing fat, 23.

American race peculiarities, 17, 21, 32.

Anaemia. Vide Cases. blood-count in, 102. diagnosis of, 104. effects of massage in, 101. fatigue in, 72.

Anaemic obesity, 24, 128.

Asthenia. Vide Cases.

Asthenopia, 67, 145, 149.

Ataxia. Vide Cases. bathing in, 204, 212. co-ordinate movements in, 204. symptoms of, 197. treatment of, 197.

Bathing, effects of, 67. in ataxia, 204, 212.

Birth-palsy. Vide Cases.

Bleeding, causing increase of fat, 24.

Blood changes from massage, 99, 101, 185.

Bowditch on weight at different ages, 17, 23.

Bright's disease, a contraindication, 45.

Brown-Sequard's elixir, 212.

Brunton on effects of massage, 101.

Cases: albuminuria, 183. amenorrhoea, 149, 193. anaemia, extreme, 184. aortic stenosis, 187. asthenia, 111, 172, 182. ataxia, 216, 218, 220. birth-palsy, 226. chloral habit, 150, 154, 174, 178. hysteria, 76, 114, 154, 157, 160, 165, 181. hysteria and neurasthenia, 112. hystero-epilepsy, 165. kidney, floating, 191. morphia habit, 154, 165. neurasthenia, 144, 171, 174. neurasthenia and pulmonary disease, 149, 160. obesity, anaemic, 132, 134. paralysis, hysterical, 134, 150. paraplegia, ataxic, 223. paraplegia, spastic, 228. tabes. Vide Ataxia. uterine disease and chloral habit, 150, 154.

Cases, selection of, 33, 60.

Chloral habit. Vide Cases. treatment of, 137.

Chorea, 33.

Cod-liver oil enema, 140.

Constipation caused by milk diet, 125.

Contraindications to rest, etc., 45.

Corpulence, Harvey on, 129.

Diet-list, 144, 146, 159.

Dietetics, 119, 171.

Drug-habits, treatment of, 137.

Eccles on massage, 101.

Electricity, 108. Beard on, 115. causing insomnia, 118. during menstruation, 90. in ataxia, 211. in constipation, 109. mode of using, 108, 116. rise of temperature from, 110, 116. when needed, 118.

Face, massage of, 105.

Fat in alcoholism, 23. in its relation to health, 16. increased by bleeding, 24. milk-diet in, 128. mode of accumulation of, 27. reduction of, 128. varieties of, 25.

Food, amount of, 146, 159. in obesity, 130.

Goitre, exophthalmic, 46.

Gymnastics, Swedish, 92.

Harvey on corpulence, 129.

Head, massage of, 105.

Headache from massage, 100. massage for, 105.

Heart-disease, treatment of, 45.

Hysteria. Vide Cases.

Introduction, 9.

Iodide in ataxia, 201.

Iron, use of, 142.

Jackson on rest, 58.

Karell on milk-treatment, 120, 128.

Keen on albuminuria, 101.

Kidney, floating. Vide Cases. belt for, 190. treatment of, 48, 66, 189.

Letheby on fattening stock, 26.

Malt extract, 138. Japanese extract of, 141.

Marshall on urinary changes, 127.

Massage, 80. abdominal, 86. amount of, 92. blood-changes from, 101. causing acne, 89. causing headache, 100. chilliness from, 91. during convalesence, 34. during menstruation, 90. Eccles on, 101. effect on temperature, 93. effects of general, 98, 101. frequency of use, 90. in anaemia, 101. in heart-disease, 46. in spastic paralysis, 225. Lauder-Brunton on, 101. lubricant undesirable in, 89. of face, 105. of head, 105. order of application, 82, 91. sexual excitement from, 91. why useful, 98.

Melancholia, treatment of, 46.

Menstruation, effects of rest on, 149, 193. electricity during, 90. massage during, 90.

Milk, in alcoholism, 137. in chloral habit, 137. pasteurized, 121. peptonized, 122. quantity to be used, 123. sterilization of, 121.

Milk diet, 119. constipation caused by, 125. disappearance of uric acid during use of, 126. effects of, on urinary pigments, 126. general effects of, 124. in obesity, 128. in obesity with anaemia, 128. Karell on, 120, 128. precautions in using, 123. sleepiness from, 125. stools during use of, 125. urinary changes from, 126.

Morphia habit, treated by rest, etc., 137, 154, 165.

Movements, co-ordinate, in ataxia, 204. in paralysis agitans, 231. in paraplegia, 223. in spastic paralysis, 226. Swedish, 92.

Neurasthenia. Vide Cases.

Nurse, choice of, 53.

Obesity, milk diet in, 128. with anaemia, 128. with anaemia. Vide Cases.

Ovarian disorders treated by rest, etc., 47.

Paralysis agitans, 231.

Paraplegia, ataxic, 223. spastic, 228.

Partial rest, 63. schedule for, 64.

Peculiarities of American race, 17, 21, 32.

Phthisis, gain of weight in, 35. Pollock on, 35.

Playfair on nerve-prostration, 12, 150.

Quetelet on gain of weight at different ages, 17.

Rest, 57. definition of, 62. effects of, on menstruation, 149, 193. in ataxia, 203, 210, 230. in neuralgia, 58. in spinal disease, 58, 197, 230. Jackson on, 58. length of, 66, 68. mental, 71. mode of terminating, 63, 78. moral uses of, 69. partial, 62. reasons for, 61, 70, 182.

Schedule for partial rest, 64.

Seclusion, 50.

Selection of cases, 33, 60.

Soup, raw, mode of making, 139.

Spine, irritable, 163, 178.

Syphilis preceding tabes, 198, 201.

Tabes. Vide Ataxia.

Temperature after electric treatment, 110, 116. after massage, 93.

Treatment, season for, 53. selection of cases for, 33.

Urinary pigments, changes in, during milk diet, 126.

Weight at different ages, Bowditch on, 17, 23. gain or loss of, 14. loss of, relation to an anaemia, 15. Quetelet on, 17.



THE END.

FOOTNOTES:

[Footnote 1: The Systematic Treatment of Nerve Prostration and Hysteria. London, 1883.]

[Footnote 2: The Pennsylvania Orthopaedic Hospital and Infirmary for Diseases of the Nervous System.]

[Footnote 3: Sur l'Homme, p. 47, et seq.]

[Footnote 4: Growth of Children, p. 31.]

[Footnote 5: See a valuable paper by Dr. Gerhard, Am. Jour. Med. Sci., 1876. Also Lectures on Diseases of the Nervous System, especially in Women. S. Weir Mitchell. Phila., 1881, p. 127. See also the papers by Dr. Morris J. Lewis on the seasonal relations of chorea, analyzing seven hundred and seventeen cases of chorea as to the months of onset (Trans. Assoc. Amer. Phys., 1892), and Osler On Chorea (1894).]

[Footnote 6: Statistics (Anthropological) Surgeon-General's Bureau—1875.]

[Footnote 7: This excess of corpulence in the English is attained chiefly after forty, as I have said. The average American is taller than the average Englishman, and is fully as well built in proportion to his height, as Gould has shown. The child of either sex in New England is both taller and heavier than the English child of corresponding class and age, as Dr. H.I. Bowditch has lately made clear; while the English of the manufacturing and agricultural classes are miserably inferior to the members of a similar class in America.]

[Footnote 8: Zeitschrift fuer Biol., 1872. Phila. Med. Times, vol. iii., page 115.]

[Footnote 9: Letheby on Food, pp. 39, 40, 41.]

[Footnote 10: Am. Jour. Med. Sci.; Proc. Phil. Coll. of Phys., 1883; Phil. Med. News, April, 1883.]

[Footnote 11: Chorea. See Lancet, Aug. 1882.]

[Footnote 12: "Nurse and Patient." S. Weir Mitchell. Lippincott's Magazine, Dec. 1872.]

[Footnote 13: See Philip Karell's remarks on the use of treatment by milk in cardiac hypertrophy. Edin. Med. Jour., Aug. 1866.]

[Footnote 14: Trans. Obst. Soc. of London, vol. xxxiii.]

[Footnote 15: Seguin Lecture, op. cit.]

[Footnote 16: "Pinch" is used to avoid the use of a technical term, but should be understood to mean the grasping and squeezing of a part with the whole hand, using the palmar portion of the fingers to press the grasped mass against the "heel" of the hand. Fuller technical details of the massage process and consideration of its effects will be found in the excellent "Handbook" of Kleen, in the works of Dr. Douglas Graham, Dr. A. Symon Eccles, and in an article in Professor Clifford Albutt's "System of Medicine" (1896), by Dr. John K. Mitchell.]

[Footnote 17: Dr. Symon Eccles in "The Practice of Massage" recommends this order.]

[Footnote 18: Some care is needed not to overwork patients. For details I must refer to manuals of Swedish Gymnastics.]

[Footnote 19: See also page 91.]

[Footnote 20: A number of observations in late years have been made upon the effect of massage upon elimination. Among the articles to which the practitioner desiring further to study this subject may be referred are,—

Edin. Clin. and Path. Jour., Aug., 1884.

Jour, of Physiol., vol. xxii., p. 68.

Centralbl. f. Inner. Med., 1894, No. 40, p. 944.

Munch. Med. Woch., April 11 and April 18, 1899 (Influence of bodily exercise upon temperature in health and disease).

Numerous articles by Mosso, Arbelous, W. Bain, Lauder-Brunton, Lepicque and Marette, and Maggiora.]

[Footnote 21: American Journal of the Medical Sciences, May, 1894.]

[Footnote 22: Numerous examinations made since have quite uniformly agreed with the former remarkably constant results.]

[Footnote 23: J.K. Mitchell, loc. cit.]

[Footnote 24: Most induction batteries are without any arrangement for making infrequent breaks in the current.]

[Footnote 25: In the extreme constipation of certain hysterical women, good may be done by placing one conductor in the rectum and moving the other over the abdomen so as to cause full movement of the muscles. This means must at first be employed cautiously, and the amount of electricity carefully increased. It is doubtful if any movement of the intestinal muscle-fibres is thus caused, but that it is a useful method of stimulation in obstinate cases may be taken as proved.]

[Footnote 26: Harvey on Corpulence.]

[Footnote 27: The management of the morphia or chloral habit becomes much more easy under a milk diet, massage, and absolute rest, and I can with confidence commend their use in these difficult cases. Massage in the morning is liked, and general surface-rubbing without muscle-kneading at night very often proves remarkably soothing, while the rest in bed cuts off many opportunities to indulge in the temptation to secure the desired drugs.]

[Footnote 28: I have found that this may be usefully replaced by one of the numerous peptonized foods described in the pamphlets issued by the manufacturers of the peptonizing powders. The ready-made peptonized preparations vary very much, like some of the beef extracts, but a trial will discover which of them is best fitted for an individual case.]

[Footnote 29: Nerve Prostration and Hysteria.]

[Footnote 30: It is worth mentioning that where ataxic patients have to use canes, a crutch-cane with a base some six or eight inches long and well shod with roughened rubber is far more useful and safer than the ordinary stick.]

THE END