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