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Locomotor Ataxia





How much can be done for organic nervous disease by attention to the
individual patient and by favorable suggestion is illustrated in
locomotor ataxia. This is, of course, an absolutely incurable disease.
We know definitely that certain tracts of nerves in the spinal cord
are entirely obliterated and their functions can never be restored.
Occasionally the disease gives rise to severe localized pains called
crises, for which even our strongest anodyne remedies are of little
avail. As a rule, the patient grows more and more helpless and though
he may live for twenty or thirty years after the beginning of the
disease, and usually dies from some intercurrent affection rather than
from any direct effect of his disease, the condition is burdensome and
the outlook is most unfavorable and depressing. It is for locomotor
ataxia, however, that the irregular practitioners have succeeded,
apparently, in working wonders. Some of them, indeed, have made quite
a reputation for the cure of the disease. This was not because they
did the impossible and cured genuine cases, but because individual
patients can, in many cases, be so much improved by attention to
particular symptoms, and so much can be done to make life more livable
for them, that it is no wonder that so many of them are ready to
proclaim that they have been cured, though only certain symptoms, are
bettered and their underlying disease remains in essence unchanged.

One thing that constantly happens in the progress of locomotor ataxia
is a yielding of joint capsules and attachments so that there is more
motion permitted in joints than is possible in the normal individual.
As a consequence of this relaxation of tissues around the hip joint
the leg may be stretched up along the trunk when the patient is lying
down, the foot being placed over the shoulder almost as a gun is
placed at carry-arms. Patients often walk with a distinct "back knee"
because of the yielding of the tissues around the knee-joint. The
ankle nearly always yields and a specially severe form of flat foot
develops. This causes muscles to act at a disadvantage and produces
great fatigue and even a painful muscular condition when the patient
stands much on the feet. This form of flat foot is hopeless so far as
cure is concerned, but it can be greatly relieved by the wearing of
flat-foot braces or even, to a greater degree, by the wearing of
specially fitted shoes. This does not seem much to do for a patient
suffering from the serious organic nervous disease of locomotor
ataxia, and yet a lot of patients for whom properly fitting shoes
were made, thought themselves so much improved and relieved by
this simple measure that they allowed themselves to be persuaded that
their locomotor ataxia was cured. In some cases, where the brunt of
the disease was borne by the feet, this relief really did so much to
afford the patients freedom from most symptoms of their affection that
they thought themselves on the road to recovery.


Value of Favorable Suggestion.--If once the idea of the awful
hopelessness of their cases is removed from locomotor ataxia patients
they will suggest their own betterment so powerfully that they easily
persuade themselves that their affection is considerably improved. It
is evident, then, that the regular physician must take advantage of
this wonderful power for the relief of human suffering and depression
that proves so helpful to the irregular. We cannot cure the tabes of
the spinal cord. We cannot re-create the nerve tracts that have been
obliterated. We realize that there is no use trying to do so any more
than there would be in trying to make an amputated finger grow to its
full size again. We can treat the patient, however. We can remove many
symptoms that sometimes bother him more than those necessarily
connected with his spinal affection. We can relieve annoyances of all
kinds that add to his misery and as a consequence we can give him
hope, keep him from brooding about himself and thus perform the proper
function of a physician. We shall not forget that we can only rarely
cure, but we can almost always relieve pain and we can always help the
patient in some way. The ataxic patient needs consolation, and this
can be given without in any way deceiving him. The loss of sight seems
an irreparable ill to those who see, yet the blind are quite happy,
are much more cheerful than many seeing people, and have learned to
stand their affliction not only with equanimity but really without
much depression. In the olden times, before proper care was taken of
the blind, they had little occupation, they had nothing to do with
their hands, the future was blank and they suffered severely from
depression. As a rule, they did not go out enough and their bodily
health suffered and the disturbance of their functions still further
heightened their depression. All of this happens now with the ataxic
patient. A host of symptoms not at all necessarily connected with his
spinal affection develop and prove sources of annoyance. Many of them
can be removed entirely, all of them can be ameliorated. If, while
doing this, we succeed in impressing a discouraged patient's mind with
our power to benefit in spite of an underlying incurable disease, we
have another triumph of psychotherapy.


Removing Unfavorable Suggestions.--The general experience with those
suffering from locomotor ataxia has been that the depression
consequent upon the announcement that they have the disease and the
stigma that is supposed to attach to it in our day leads them to a
great extent to avoid going out into the air. This adds woefully to
their depressed condition. Take a healthy man, let him stay inside a
great part of the time without any exercise, seeing no new faces,
without any interests in life, and at the end of three months he will
have a set of neurotic symptoms on a basis of depression that will
make him supremely miserable. This will be true even though he has not
the threat of an incurable disease hanging over his head. He must be
made to realize that every neglect of any law of health in his
condition is even more serious in its effect upon him than it would be
were he in good health. Above all, it must be made clear to him
that while his neglect of hygiene may perhaps not shorten his life, it

will greatly add to the mental suffering, much more unbearable in its
way than the physical suffering which he will have to endure during
the progress of his disease.


Treating Accessory Symptoms.--Nearly every ataxic patient who is not
directly and almost constantly under the care of a physician, is a
sufferer from two conditions that are so constantly present that they
are sometimes thought to be consequences of the primary affection.
These are loss of appetite with consequent loss of weight and
constipation. Almost without exception neither of these symptoms or
syndromes are at all connected with the locomotor ataxia. They are the
result of the unhygienic life that the patient is living and of the
depressed state of his mind and lack of diversion. They are mutually
connected, for a man who does not eat enough will not have regular
movements of his bowels, and constipation reacts to produce further
depression. A vicious circle in pathogeny is formed and the patient is
likely to get into a very debilitated and depressed condition. Both of
these troublesome symptoms may be corrected to the manifest
improvement of the patient by proper advice and ordinary care for his
well being.

Appetite is largely a function, as the mathematicians say of something
that depends on something else, not of exercise, as is often thought,
but of fresh air. In the tuberculosis sanatoria patients with fever
are not permitted to take exercise, yet if they are out in the air
most of the day and if their rooms are well aired at night, they can
eat heartily and digest their food well. Of course, appetite is
largely a psychic matter and the thoroughly discouraged man will have
no care for food in spite of abundance of air. A little persuasion,
however, of the necessity for making the best of a bad job will
usually arouse even a locomotor ataxia patient in the early stages of
his disease to the necessity for eating a reasonable amount. If he has
suffered from gastric crises and fears that eating normally may
precipitate these, he must be persuaded that this is not the case,
that the presence of food, or its amount, or quality, has nothing to
do with the initiation of these painful attacks so far as we know, and
that even though at the beginning of his affection before his
locomotor ataxia was recognized, his gastralgia may have been declared
by his physicians, as is so often the case, to be connected with some
form of gastritis or indigestion, that idea may now be given up and he
may eat plentifully with confidence that it will not increase his
pains. On the contrary, limitation of food seems to have a distinctly
unfavorable effect in increasing the number and severity of these
attacks.

The same thing must be made clear to him as to intestinal and rectal
crises. It seems likely that tendencies to constipation by irritating
peripheral nerve endings may have some effect in bringing about the
explosion in sensory nerves which have been called intestinal or
rectal crises. In general, however, these are dependent on spinal and
not peripheral conditions, and no thought of any connection must be
allowed to disturb the consumption of a proper amount and variety of
food. It seems clear that when patients are much run down, have lost
considerable in weight and are in a generally depressed condition,
their nervous system is much more irritable than it would otherwise be
and they are likely to suffer more frequently from crises of various
kinds. Once a patient is made to understand that his general
nutrition may affect not only the course but the occurrence of
symptoms in the disease, as a rule it is not difficult to get him to
eat enough and to do so with the definite feeling that it is going to
do him good. Even though it should be necessary to use tonics, and
often they will have to be prescribed, it is clear that this treatment
of the patient's general condition is the physician's first duty,
though it does not and cannot affect the specific disease.


Neurotic Complications.--There can, of course, be no doubt that the
crises of locomotor ataxia represents extremely poignant attacks of
pain. But on the other hand, anyone who has seen many of them is prone
to think that not a few of them are really attacks of pain resembling
those which occasionally develop in hysterical subjects. The pain of a
gastric neurosis may, indeed, so simulate the gastric crises of
locomotor ataxia as to make what is only a case of hysteria seem
beyond doubt one of locomotor ataxic. Locomotor ataxia patients are
prone to think much about themselves and to fear the recurrence of
these painful crises once they have had experience with them. As a
consequence they sometimes suffer from what are pseudo-crises, that
is, from neurotic painful conditions which simulate genuine crises
mainly in the amount of reaction they produce in the patient. True
tabetic crises yield more readily to ordinary anodyne drugs than do
these pseudo-crises. Nearly always the true crises are associated with
and exaggerated by neurotic symptoms due to the depression of the
patient, the yielding to his feelings, the conclusion that his pain is
inevitable and is going to be worse each time, while successive crises
are, as a matter of fact, often milder until they disappear for good,
and this element in the case must always be borne in mind. Much can be
done for the relief by psychotherapy, that is, by making the patient
see the realities of his condition, suggesting to him that succeeding
crises are less painful and that if his general condition is as good
as it should be he becomes better able to stand the pain of his crises
and the shock of them is not so disturbing to his system.


Mental Attitude.--Prof. Oppenheim, in one of his "Letters to Nervous
Patients," advising a patient suffering from an incurable organic
nervous disease, evidently locomotor ataxia, though that is not
explicitly stated, outlines emphatically the favorable side of that
disease. This is absolutely needed. Ever so many unfavorable
suggestions with regard to his affection find their way to the
patient. The very fact that it is pronounced absolutely incurable is
disheartening. Prof. Oppenheim's words, then, may be a precious help
and to have them repeated from time to time renews the suggestion:

Now, however, we neurologists know that that disease frequently runs
a very mild course, that a man showing certain early symptoms of
such a disease may for ten to twenty-five years and even longer
retain his capacity for work and enjoyment. This for a man of thirty
to forty years is almost tantamount to the expectation of a whole
normal lifetime. But on the other hand, what danger to the peace of
mind, what destruction of happiness in life may be caused if the
knowledge that such a disease has begun to develop is imparted to
the patient without being combined with the consoling information as
to the nature and course of the benign forms of this trouble! In
unceasing anxiety and fear, in daily expectancy of some fresh
symptoms, of some increase or aggravation of his troubles, does the
poor man waste his life; and I have frequently found that this
wretched apprehension and excitement cause a nervousness and mental
depression which in their effects are much more momentous than is
the commencing spinal disease.

From this miserable condition I desire to protect you, and I would
ask you to take this advice deeply to heart: do not bear
yourself as one who is condemned; as one who, affected by a
progressive, incurable disease, will soon fall a victim to
paralysis. On the strength of my own experience I give you the
assurance that your condition of health will not necessarily in ten
years' time be essentially different from what it is at present. But
I would also strenuously exhort you to observe all the precautionary
rules laid down for you, to avoid all unaccustomed strain or
indulgence such as can only be undertaken with impunity by a man in
full vigor and absolute soundness of health. I would advise you also
to be thoroughly examined once a year by an experienced physician.
But apart from these restrictions, you should as far as possible
feel yourself and bear yourself like a healthy man, remaining
attached to your work, and not withdrawing yourself from the
pleasures of social intercourse.


Relearning Muscular Movements.--Perhaps the most interesting evidence
of how much may be done for organic nervous disease in spite of the
fact that the underlying lesion is absolutely incurable, may be
obtained from what is accomplished by Frenkel's method of treating
locomotor ataxia. As is well known, by reteaching the movements
necessary for walking, ataxic patients regain control of the movements
of their limbs to a marked extent. As a consequence, bed-ridden
patients are enabled to walk once more even though they may have to
carry a cane and be supported, and patients who have had to use two
canes get along with only one, or may even eventually be able to walk
without any artificial support.

Just how the improvement is brought about we are not quite sure. It
seems probable that the eyes become trained to replace the muscle
sense to a noteworthy degree, but there is in addition apparently a
re-education of the muscle-sense. Perhaps there is also a transfer of
the function of certain degenerated nerves to other tracts than those
in which muscle impulses originally traveled. The improvement in
muscular control originally obtained is a striking illustration of how
much nature is able to compensate for even organic lesions and is a
lesson in the necessity for never ceasing to try to do something even
when the case seems hopeless. Certainly locomotor ataxic patients
would seem the least likely to be benefited by training in movement
and yet this movement therapy for tabes has had some wonderful
results.

The story of how this mode of treatment came into existence is
interesting and instructive as an illustration of how happy chance in
our time, as so often with regard to drugs in the past, came to assist
the rational development of therapeutics. A German professor wished to
demonstrate to his class the varying inco-ordination of a series of
tabetic patients. Some of them had their main inco-ordination in the
legs, others in their hands. He went over the cases in his wards so as
to arrange the demonstration for the next day. He told each patient
that he would ask him to perform a particular set of movements before
the class which would illustrate strikingly a particular phase of
muscular inco-ordination. His patients were interested in the
announced demonstrations and during the afternoon they went over the
movements that they were expected to perform. They practiced them as
assiduously as their condition permitted for the exhibition. As a
consequence the most striking features of their inco-ordination
disappeared. After having practiced the movement for a certain length
of time they could do it ever so much better than before. The special
feature of the professor's demonstration was spoiled, but a great
contribution to our knowledge of nature's compensatory powers
was made and fortunately the hint of its significance for treatment
was taken and developed.


Effect of Favorable Suggestion.--How much can be accomplished for the
relief of the general symptoms of locomotor ataxia and for the placing
of patients in an attitude of mind that makes most of their symptoms
of vanishing importance, can be judged from some recent experiences
with a new cure for the disease. This consisted only of some rather
conventional treatment of the urethra by applications and dilatation,
yet patients were relieved so much of the symptoms of locomotor
ataxia, or at least persuaded themselves that they were, that both in
this country and in Europe the discoverer of the new "cure" soon had
scores of patients. The active therapeutic agent undoubtedly was the
fact that patients who had been told that their disease was incurable
and who had settled down in a state of discouragement and apathy in
which their power over their muscles, their general health and their
strength and vitality were at the lowest ebb, and their tendencies to
discomfort emphasized and made poignant by the supposed hopelessness
of their situation, became aroused to new vitality by the promise of
cure and then, under the repeated suggestion of a treatment said to be
sure to cure them and that had cured others, became so much better,
that is, released so much latent energy, that they felt better, ate
better, walked better, got out more and had their general health
improved, and all to such a degree that their disease seemed cured.

Another interesting illustration of what would seem to be the power of
suggestion over the symptoms of tabes occurs in a recent article in
the Archivos Espanoles de Neurologia Psyqiuatria y Fisioterapia of
Madrid [Footnote 39] on the improvement of tabes dorsalis by
antidiphtheritic serum. It is quite impossible that the serum should
affect favorably any of the underlying lesions of the disease any more
than that these should be ameliorated by the wearing of shoes of
special character or operations on the urethra. The patient in this
case, however, was distinctly improved in many ways after the
antidiphtheritic serum was injected. There were some interesting
sensory manifestations, pains in the arms and legs after the
injection, but these were removed by santonin or methylene blue. Both
of these drugs are eminently suggestive in their action, so that one
would be prone to think the pains rather neurotic than actual. After a
dozen injections had been given, the patient's sensations improved,
his power to pick up small things was better, and the sense of walking
on carpet had disappeared to a marked extent and he was able to walk
much better than before and without support. Probably any attention
given to him to the same degree would have produced like results.

[Footnote 39: Tomo 1 No. 7, July, 1910.]

We have had previous examples of this kind in the history of the
treatment of locomotor ataxia. Certain drugs when given in the past
with the definite promise of cure and pursued for a good while with
frequently repeated favorable suggestions, have often seemed to
benefit patients, though subsequent experience has shown their total
lack of value to modify the disease. Nitrate of silver was one of
these in the old days and many locomotor ataxia patients acquired an
argyria as a consequence of the amount of silver absorbed and
deposited in the skin. Arsenic was another and some of the aluminum
compounds were also used. When we recall the suspension
treatment and its reported good effects--and failure, the
over-extension treatment with the same history and many others in the
past, the real place of the mental in the therapeutics of tabies is
revealed. Once this is practically realized, we find that we have
ready to hand and easy to use, the one really efficient factor in all
these treatments--that is, the influence on the patient's mind. It is
for the physician to devise thoroughly professional ways and means of
using that in each particular case so that his patients may be
benefited as much as possible. Certainly it would be foolish for us to
leave to the irregular practitioner the use of this extremely valuable
remedial measure, when we may do so much good with it, for the relief
of symptoms at least.





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Previous: Cerebral Apoplexy



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