_Lack of Air and Exercise_.--As they usually have no exercise of any kind, do not get out into the air, and have very little diversion of mind, it is easy to understand that neurotic or hysterical symptoms develop, that they lose all confidence of recovery and make themselves even worse than they are by dwelling on their condition. The only way that this group of symptoms can be treated is by favorable suggestion, by encouragement, by mental rea.s.surance and by occupation of mind.

I have always felt that the condition of affairs which developed in a family immediately after the occurrence of an apoplexy usually makes a very unfavorable environment for the treatment of these cases. It is practically impossible for those who come to visit the patient or for the members of the {520} family for some time to wear anything but the resigned air that indicates that they fear the worst.

_Sympathetic Care_.--After the stroke at once when survival is a.s.sured comes the question of the management of the patient. A devoted daughter seems to be able to do more for an apoplectic father than anyone else. Somehow her youth appeals to him sympathetically, and he has not that feeling of sadness mixed with a little envy that comes so readily to all men when they find themselves slipping out of life while their contemporaries and friends and relatives are left behind.

It is as if the idea of his daughter being young and strong, even though he has lost vitality, docs not touch him poignantly because he has always expected that she should have health and strength after he was gone. On the other hand, a daughter is not always a good nurse for a mother. Just why, is hard to say. A hired nurse must take, as a rule, the place close to the mother which, in the case of the father, so naturally falls to the daughter. These ideas may be founded on too few cases to generalize very much about, but I have discussed them with many physicians, including some women physicians, and they agree with them, in general principle at least.

_Trained Attendance_.--As a rule, then, the first thing that has to be done for a patient who has had apoplexy and who is beginning to recover, is to have trained attendants near him who talk professionally to him and rea.s.sure him and do not make him feel constantly the possibility of an approaching end. If his improvement has begun his family must not be allowed to bother him, his affairs should not be talked over and, as far as possible, some occupation of mind should be secured for him. He needs new interests at once. These must be gradually awakened and he must be made to feel as early as possible that though he may be more helpless than before and most of his ordinary occupation in life may be cut off, there are still many interests in life which he may thoroughly enjoy. I shall never forget hearing Thomas Dunn English, the dear old poet to whom in his earlier years we owed "Sweet Alice, Ben Bolt," say at an alumni dinner of the University of Pennsylvania that he used to think that all the good things of life were somehow contained in its first eighty years, but that now since he had past his eightieth birthday (he was at the time in his eighty-third year) he was beginning to agree with Bismarck, who declared under similar circ.u.mstances that he had found many interests in the second eighty years of life. At the time English was quite blind, was almost completely deaf, had been seriously ill for several months, and had suffered a rather severe stroke some years before; and yet he made the best speech at the dinner that evening and had the youngest heart of us all--joyous, uplifting, encouraging, optimistic.

_Outlook_.--Men who have been great workers are p.r.o.ne to think that a stroke of apoplexy means the end of all serious work. Of course, it means nothing of the kind for the majority of patients. Many men find not only enjoyment in life after their recovery from even a serious stroke, but also possibilities of accomplishment sometimes better than they had done before. It has even been known that men who had been occupying themselves with things scarcely worth while, with the mere acc.u.mulation of money without any purpose, were awakened to a sense of their responsibilities to life and to their fellowmen by a stroke and planned in the after years inst.i.tutions or aids to {521} existing inst.i.tutions that did much to make life more livable for others.

Nothing makes a man face life in a better mood to do really effective service for mankind than the prospect of possibly soon having to go out of life.

_Encouraging Examples_.--On the other hand, many men have been able in spite even of a severe stroke to go on after a time with the work they had been at before and, though feeling its effects, accomplish the best achievements of their lives. A typical example is the case of Pasteur, the great French bacteriologist, to whom we owe most of our modern preventive medicine and to whom Lord Lister frankly attributes the germ idea of the antiseptic theory. When little past fifty, Pasteur after years of hard work and worry suffered from a severe stroke of apoplexy followed by several of slighter character. It seemed absolutely the end of his labors. For more than a year he was able to do nothing. For all his after life he was seriously lame as a consequence of his stroke. In spite of this, which would seem to preclude the possibility of great intellectual work, Pasteur's most important discoveries were developed after this time and he continued for over twenty years to be the leader of biological science. Had he died at the age of fifty or given up his work we would scarcely know him for the great scientist that he afterwards proved.

It is worth while to be able to tell the stories of such lives as examples to patients who are dispirited and downhearted after a stroke. Of course, men must be prevented from doing hard work or from worrying during the time immediately following the hemorrhage of the brain, and, indeed, for some months. Work and worry, though worry much more than work, might easily hasten a recurrence of the seizure. It has always seemed to me, however, that it is impossible to keep the human mind utterly unoccupied. Men must think about something during their waking hours, and if they have not some interests close at heart they worry about themselves. Of the two things, worry is much harder on the tissues, raises blood pressure more, disturbs the circulation of the brain to a greater degree than does work. Anything that a man will interest himself in, then, should be allowed to him, provided, of course, that he is kept from getting into the state of mind which precipitated the rupture of the artery in his brain. It is a change of mental occupation above all that is needed and this is secured by deliberate attempts to interest his mind in various ways and keep him from dwelling on himself and his ills. This injunction cannot be repeated too often.

_Change of Mental Interest_.--I have already insisted in the chapter on Diversion of Mind that so far as we know at the present time different portions of the brain are occupied with different subjects in which we may interest ourselves. When a man by business worries, occupation with financial affairs, or with political troubles, has apparently worn out one portion of his brain, he may still use other portions to decided advantage. Hence the necessity for finding new interests for the apoplectic after their attack. The best interests for them are those a.s.sociated in some way with their fellows, because these are accompanied by feelings of consolation, of encouragement, of desire to live and do good to others. These do more to take men out of their moodiness, their morbid introspection, and their self-centeredness, than anything else. With the help of a good nurse, herself of broad interests, this must become the main purpose of the physician's treatment.

{522}

_Misplaced Sympathy_.--After the first few days, when the shock is over, a strong, healthy man who has been suddenly taken down with apoplexy, then rendered helpless as a consequence of the lesion in his brain, rather resents the sympathy and, above all, the frequent expression of the feelings of his friends towards him. Time is needed for him to recover, there is no way of hastening it, he is already impatient at the delay and words of sympathy do him very little good and often add to his impatience. He is to be taken absolutely with professional calm, made to understand that time is the most important element in his cure, provided he will not worry and will have patience to wait and to help as far as he can. I nearly always feel that it is better for these patients to be away from home as soon as they can be moved with safety. This enables them to avoid without much difficulty what they are apt to consider the intrusive and obtrusive sympathy of friends. Especially is this true of business friends, themselves in good health, who come to offer their condolences.

Their hysterical condition is largely influenced by the fact that they are indoors and have so little diversion of mind. Just as soon as possible they must get out of doors. Over and over again I have found that patients did not care to expose themselves to the inquisitive gaze of neighbors and preferred to stay in the house, though the outing would be of much benefit to them. Hence the necessity for getting them away from home, among people whom they can observe without attracting too much attention themselves and, above all, without being the subjects of such obtrusive pity as will disturb them. None of us likes to be pitied and least of all the strong, vigorous man who often has had nothing the matter with him all his life and is now suddenly stricken. It requires years of experience to enable one to take sympathy properly and without resenting it.

_Outings and Human Interests_.--When patients care for carriage riding I have found that the city park is an excellent place for patients suffering from the effects of apoplexy, who require outdoor air and diversion of mind, yet without exercise or much exertion. The children in the park, if they play around, serve as a better diversion of mind than almost anything else for elderly people thus stricken, for they seem to renew their youth at the sight of the little ones.

Grandchildren make the best possible consolers even when they seem to probe deep into old wounds by asking questions and by talking about death. The talk of death from young lips has not the same disturbing effect as from older people. The games of children interest the old once more, and if there is occasional music and the chance to see the pa.s.sing throng of carriages and motor cars and the pleasure boats and all the rest there is refreshment and reinvigoration in it all that soon brings back to the patient deep, satisfactory, even dreamless uninterrupted sleep at night, and appet.i.te and strength. At first there will usually be some objection to being thus treated as an invalid, but only a few days of experience are needed to convert even the most morbid to the idea that this outing will do them good. As a rule, friends must be warned not to spoil the effect of it by fearing lest the patient should be lonely and so go to the park to entertain him. If the drive, the lake and the children, as well as the pa.s.sers-by, do not suffice to give the patient sufficient diversion of mind, the visits of friends will not have any favorable effect. As a rule, it is better for them to see the {523} patient at home and even that not too often unless they are of his immediate family.

Where people are able to go away and, above all, where they can have some pleasant companionship, a seaside resort is an ideal place for those recovering from apoplexy. The long ride in a wheel-chair on the boardwalk at least several hours in the morning and afternoon soon acts marvelously. There is constant diversion of mind at any season of the year, for there are lots of people to be seen in all sorts of costumes and the shops and the shows and the pa.s.sing throng all have their interests. Then the sea air is bracing and tempts to sleepfulness and just as soon as sleep improves courage comes back. I have known patients so hysterical that they were crying every day and that seemed to have given up all hope, improve so much in two weeks at Atlantic City that it seemed little short of marvelous. What is needed, however, is not a stay of a few weeks but of several months.

Prognosis of Strokes.--While, of course, any single stroke may be fatal and no one can tell anything about the prognosis of a rupture of a brain artery, there are many favorable things that can be said to patients, and they are so p.r.o.ne to think of all the unfavorable things that this better side should be presented to them at once. The physician is tempted to present the worst side of the case lest it should be thought that he did not realize how serious the condition was. All the seriousness of it may be impressed upon friends, but the patient must be told all the possibilities of good. I have always felt that the tonic quality of hope was worth more in preventing further damage and in encouraging the beginning of repair than any drug that we have. If patients have been unconscious, just as soon as unconsciousness disappears, they should be told that very probably this is the beginning of recovery and that the great majority of people who have a stroke recover. The more rapidly the symptoms disappear the better is the ultimate prognosis. Many a man who has had a stroke has done years of good work afterwards and very few men who recover fail to accomplish something that is of supreme satisfaction to them. They have a new outlook on life as a consequence of the near vision of death.

Those who have had one stroke usually die in a subsequent one, though, of course, some intermittent disease such as pneumonia or some organic complication may antic.i.p.ate the second stroke. Those who have had two strokes and survive are often much worried by the old tradition that a third stroke is always fatal. I am reasonably sure that many old men have not survived their third stroke when they felt its premonitory symptoms and knew just what was coming from their previous experience, because they had given up hope on account of this old tradition.

Ignorant people or those of the lower cla.s.ses who have not heard this axiom often survive their third stroke and I have seen a man who had suffered from seven apoplectic seizures.

Complications.--Occasionally a patient, especially if of the educated cla.s.ses, may be much worried by the fact that while one side is distinctly lamed after his stroke, yet there is also a p.r.o.nounced weakness on the other side of the body. This sometimes gives rise to the rather appalling thought that there was perhaps a simultaneous rupture on both sides of the brain. It needs to be explained to such patients that this slight weakness, sometimes quite distinct, however, on the side opposite that which is most affected is extremely {524} common. Ordinarily the rupture of an artery on one side of the brain causes a paralysis on the other side of the body. This paralysis or loss of control over muscular action is due to disturbance of the motor tracts of nerves through which muscular action is controlled and directed by the brain, and these normally cross to the other side on the way to the periphery. In nearly everyone the tracts remain uncrossed to some slight extent. In some so much of the pyramidal tract remains uncrossed that there may be decided weakness on the same side as the lesion in the brain.

CHAPTER III

LOCOMOTOR ATAXIA

How much can be done for organic nervous disease by attention to the individual patient and by favorable suggestion is ill.u.s.trated 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 pract.i.tioners 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 {525} 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 {526} 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 appet.i.te 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.

Appet.i.te 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, appet.i.te 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 {527} 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 p.r.o.ne 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 p.r.o.ne 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 a.s.sociated 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 Att.i.tude.--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 p.r.o.nounced 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 {528} 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 a.s.surance 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 ill.u.s.tration 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 ill.u.s.tration of how happy chance in our time, as so often with regard to drugs in the past, came to a.s.sist the rational development of therapeutics. A German professor wished to demonstrate to his cla.s.s 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 cla.s.s which would ill.u.s.trate 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 a.s.siduously 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 {529} 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 att.i.tude 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 ill.u.s.tration 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 p.r.o.ne 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. a.r.s.enic was another and some of the aluminum {530} 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 pract.i.tioner the use of this extremely valuable remedial measure, when we may do so much good with it, for the relief of symptoms at least.