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.





Light And Psychotherapy Lumbago And Sciatica facebooktwittergoogle_plusredditpinterestlinkedinmail

Feedback