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MECHANO-THERAPEUTICS
IN GENERAL PRACTICE
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MECHANO-TH ERAPEUTICS
IN GENERAL PRACTICE
BY
G. de SWIETOGHOWSKI, M.D., M.R.G.S.
FELLOW OF THE ROYAL SOCIETY OF MEDICINE
CLINICAL ASSISTANT, ELECTKICAL AND MASSAGE DEPARTMENT
KINO'S COLLEGE HOSPITAL
WITH 31 ILLUSTRATIONS
LONDON
H, K. LEWIS, 136 GOWER STREET, W.CJ.
1914
TO MY WIFE
PREFACE
THERE is, unfortunately, still a barrier between a large
number of men in general practice, and the application
of mechano- therapeutics : the object of this book will
be to break down this barrier.
The main reason for the indifference on the part of
medical men with regard to this important adjuvant
in therapy is probably their ignorance of it, which is
largely due to the fact that this subject is not compulsory
in the curriculum, and is altogether neglected by the
medical schools. So that if there is any knowledge of
it among the profession in general, it is only owing
to the industry and pluck of a few individuals who
freed themselves from the " recognised " ideas and
theories.
The fact that in the past the carrying out of these
" unapproved " methods largely rested in the hands
of scientifically untrained people, naturally helped to
bring into discredit everything that was connected
with them. Though a great watchfulness in dealing
with a new " cure " is always necessary on our part,
yet it appears that a passive attitude of the profession
towards mechano-therapy only results in losses to the
vii
viii PREFACE
doctors as well as to their patients, leaving, as usual, a
tertius gaudens — the quack.
Attempts will be made in the following pages to
point out where mechano-therapy is likely to prove
useful ; a word will also be said about the technique.
My leading idea will be to make the whole concise and
clear, that it should serve as a practical guide to massage
in general practice.
THE AUTHOR.
NEW CAVENDISH STREET,
LONDON, W.,
June, 1914.
CONTENTS
PAGE
PREFACE vii
GENERAL CONSIDERATIONS .... 1
INDICATIONS AND CONTRA-INDICATIONS . . 3
I. SURGICAL . 5
A. FRACTURES . . . ... 5
THE UPPER EXTREMITY . . .12
Clavicle 12
Humerus ..... 14
Shoulder 14
Elbow 19
Wrist (Colles) .... 21
Metacarpals ..... 24
Fingers 24
THE LOWER EXTREMITY ... 27
Femur 27
Patella 29
Leg 32
Ankle (Pott) . . . 34
Metatarsals 39
Toes 40
ix
CONTENTS
PAGE
B. SPRAINED JOINTS AND DISLOCATIONS . 41
Shoulder 42
Elbow 43
Wrist 43
Hip 44
Knee 44
Ankle 45
C. CHRONIC ARTHRITIC CONDITIONS . . 47
Osteo-arthritis 47
Traumatic synovitis .... 47
Teno-synovitis ..... 48
D. INJURIES TO SOFT PARTS ... 48
Contusions ...... 48
Sprains . . .... 50
E. CHRONIC INFLAMMATORY CONDITIONS OF
SOFT PARTS ..... 50
Muscular rheumatism (Fibrositis) . . 50
Torticollis 52
Lumbago ...... 52
Sciatica ...... 52
Ulcers 53
Bed-sores ...... 54
Catarrhal prostatitis .... 54
F. DEFORMITIES 55
Scoliosis 55
Kyphosis (Round shoulders) ... 67
Genu valgum and genu varum . . 68
Flat feet 70
Wry-neck 73
Sprengel's shoulder , 74
CONTENTS xi
PAGE
II. MEDICAL . 75
A. CIRCULATORY SYSTEM .... 76
B. RESPIRATORY SYSTEM . .87
Hypostatic pneumonia . . 88
Chronic bronchitis, etc. ... 89
Catarrhal laryngitis and pharyngitis . 90
C. DIGESTIVE SYSTEM .... 92
Gastrectasis 93
Constipation ..... 94
D. CONSTITUTIONAL DISEASES ... 99
Gout 99
Diabetes 99
Adiposity 99
Debility . . . . .102
Anaemia ...... 102
Rickets 102
E. URINARY SYSTEM .... 103
F. NERVOUS SYSTEM .... 104
ORGANIC 105
1 . Locomotor ataxia . . .105
2. Progressive muscular atrophy . 108
3. Acute anterior polio-myelitis . 109
4. Cerebral haemorrhage . . 112
5. Neuritis 114
6. Lesions of the peripheral nerves . 115
(a) Cerebral nerves . . 115
(6) Spinal nerves . . .117
7. Neuralgia . . . .118
xii CONTENTS
PAGE
F. NERVOUS SYSTEM — Contd.
FUNCTIONAL 122
1. Paralysis agitans . . .122
2. Chorea . . . .123
3. Occupation neuroses . . .124
4. Hysteria and neurasthenia . .125
III. SPECIAL 127
A. GYNECOLOGICAL AND OBSTETRICAL . 127
B. OTOLOGICAL AND OPHTHALMOLOGICAL . 130
C. RHINO- AND LARYNGOLOGICAL . .131
D. DERMATOLOGICAL 133
E. DENTAL 133
CONCLUDING REMARKS . . . . .135
REFERENCES 137
INDEX . 1 39
LIST OF ILLUSTRATIONS
FIQ.
1. STROKING (EFFLEURAGE) . . 9
2. KNEADING (PINCHING, PETBISSAGE) . . .15
3. KNEADING (GRASPING) . . . . .16
4. HACKING (TAPOTEMENT) . . . . .16
5 and 6. A CASE or VOLKMANN'S ISCH^EMIC CON-
TRACTTJRE OF THE HAND . . . facing 20
7. FRICTION (DEEP KNEADING) . . . .23
8. PASSIVE PRONATION AND SUPINATION . . 23
9. CENTRIPETAL STROKING OF FINGERS . . 25
10. STROKING (EFFLEURAGE) OF THIGH ... 30
11. MOBILISATION OF THE PATELLA . . .31
12. PASSIVE MOBILISATION OF THE FOOT IN FRAC-
TURES OF THE LEG ..... 33
13 and 14. A CASE OF FRACTURE OF THE TIBIA . 34
15. MASSAGE OF THE ANKLES . . . .36
16. TIP-TOEING ....... 37
17. A CASE OF A TREBLE FRACTURE OF THE ANKLE 39
18 and 19. A CASE OF SUBCORACOID DISLOCATION OF
THE SHOULDER, AND FRACTURE OF THE
TUBEROSITIES .... facing 42, 43
xiv LIST OF ILLUSTRATIONS
FIG. PAGE
20. FORCIBLE KNEADING OF THE ELBOW REGION . 51
21. KNEADING OF THE TRAPEZITJS . . .57
22. A CASE OF POSTUBAL RIGHT DORSAL CURVATURE
facing 60
23. " SITTING SIDE BENDING," WITH PRESSURE ON
THE CONVEXITY ..... facing 60
24. " SITTING FORWARD BENDING " . . .61
25. BREATHING EXERCISES IN LYING ... 66
26. WALKING ON THE OUTER BORDER OF THE FEET . 71
27. WRIST ROLLING ...... 82
28 and 29. NECK MASSAGE. STROKING . . 90-91
30. NECK MASSAGE. SAWING MOVEMENTS . . 117
31. EXAMINATION OF THE ORBIT IN HEADACHE . 120
MECHANO-THERAPEUTICS
IN GENERAL PRACTICE
GENERAL CONSIDERATIONS
IT is, perhaps, wiser to start with the description of
clinical conditions calling for the application of mechano-
therapeutics right away, than to follow the usual way
of describing all the manipulations first. The under-
standing of those seemingly occult and mysterious
performances will become much easier when described
in connection with the complaints which they are
intended to remedy. This will avoid the meaningless
explanations at the beginning of most books on this
subject of such terms as effleurage and petrissage.
Following the general rule adopted in medicine, the
disorders will be divided into medical, surgical, and
special. This classification has been chosen as one
to which every medical man has become accustomed
through his hospital training. The following up of
this method will facilitate the reading, as well as the
exposition of the wide and manifold application of
massage, and thus it will not be necessary to create a
new system of pathology in order to do it justice.
1
2 GENERAL CONSIDERATIONS
To comfort those who think many costly appliances
necessary to carry out this kind of treatment, I can
only say that here, as well as anywhere else, the best
results are achieved by few and simple means. We
must always remember that the treatment has often
to be administered in private houses under great diffi-
culties. A couch and a pair of skilful hands are all
that is really indispensable : they are as important
in mechano-therapy as in operative surgery. We often
prefer our own fingers to the most wonderful instru-
ments.
Skill is required everywhere. But the skill of an
average medical man is quite sufficient to start with,
if shyness could only be overcome. Those who play
the piano or the violin will find it a useful talent
in this respect too. Those who cannot rely on their
fingers should leave massage alone altogether, rather
than have recourse to vibrators, pulsators, and other
similar instruments. It is infinitely more difficult to
know what we are doing when we are applying a motor,
which is always a clumsy, irresponsive object, than when
employing our fingers alone. Those of the profession
who have some experience in trephining will, no doubt,
agree on this point. But here, as well as there, machines
render great services in experienced and reliable hands.
They also save a great deal of energy to those who
have to do this kind of work during the best part of
the day. There is such a variety of vibrators that no
one ought to experience the slightest difficulty in satis-
fying his taste.
With regard to the couch, it is advisable to have it
GENERAL CONSIDERATIONS 5
not too low, and, if possible, covered with some rough
material, such as plush. This prevents the patient
sliding about, and it feels warmer. Leather or its
imitations are less suitable as covering materials,
because they are cold, and rather unpleasant for the
patient. One or two hard cushions complete the
necessary outfit.
No lubricants are really important in massage. They
do not reduce the pain, if it is the want of skill that
causes it. I should only advise their use in very rare
cases in which the skin is very sore.
Those who visit Sweden, the motherland of gymnastics
and massage, will be surprised at the simplicity of most
of the mechano- therapeutic institutes of Stockholm.
And yet the best work is supposed (rightly or wrongly)
to be done there.
INDICATIONS
On the whole : injuries, such as fractures and sprains,
deformities, simple and chronic inflammatory conditions,
and constitutional diseases, are those in which mechano-
therapy will be found useful, and in most cases more
helpful than any of our drugs. The use of drugs,
however, is never incompatible with massage, and the
two can be safely combined.
CONTRA-INDICATIONS
No acute inflammatory conditions and no tumours
should ever be directly treated by massage. Tumours
4 COKTRA-INDICATIONS
include here all the types of granulomata, such as
syphilis, tuberculosis, and actinomycosis, as well as the
true forms of new-growths, benign as well as malignant.
Rest, the knife or some other applications, are still the
best remedies here, in spite of the attempts of some
enthusiasts to regard massage as a panacea for all
complaints. The latter practice will always bring into
disrepute methods otherwise very useful.
Hcemophilia, leukaemia, and aneurysm also belong to
this category.
I. SURGICAL
A. FRACTURES
FRACTURES of the limbs are the only class of fractures
that may become subject to mechano-therapeutic
treatment. Fractures of the skull, the vertebral column,
and those of the pelvis are either fatal in most cases
or heal best under absolute rest, which is imperative with
regard to the important organs that might be injured.
Once satisfactorily united, they are not likely to leave
any such undesirable traces which could have been
prevented. These fractures are also comparatively
rare, and are mostly treated in hospitals or nursing-
homes, therefore they do not concern us here.
On the other hand, anybody, however little acquainted
with general practice, will find sufficient reason to com-
plain about the bad results of some of the commoner
fractures of the extremities. Anybody will recall to
his memory some case of Pott's or Colles's fracture he
has recently met with, which he could not cure by any
means.
Most of these cases might have taken an entirely
5
6 FRACTURES
different course if properly seen to from the first. These
patients so often complain about pain and stiffness long
after the time considered necessary for the broken bone
to regain its continuity and its former strength had
passed, that in most cases the injured limbs remain
quite useless for another month or two, or even longer.
The fault lies in the old-fashioned method of putting
up all kinds of fractures in splints, and leaving them
to their own fate, once a satisfactory apposition of
the fragments had been achieved. We all know that
an accurate position of the bone fragments does not
always guarantee subsequent free use of the limb, and
I have seen limbs that were crippled in spite of the
radiographs showing perfect results. The fixation
method, though, perhaps, more convenient in the be-
ginning, will nearly always cause disappointment after
a few weeks.
Fractures are becoming less and less a noli me tangere.
A treatment which was taboo not so very long ago is
now making its way through the world. Two great
surgeons, Championniere in France, and Bennett in
this country, were amongst the first pioneers of the
new movement. They were soon to realise the import-
ance of the early application of massage and movements
in the management of fractures.
The main object of the new treatment is to prevent
stiffness and pain, the two remote symptoms of all
fractures, which are both so tedious in practice. The
way in which these complications arise is a very natural
and simple one ; and so is also the way in which they
may be prevented. What we really aim at is the
FRACTURES 7
dispersion of the extra vasated blood, since it is the
hcematoma that afterwards causes the unpleasant
results.
Blood naturally becomes organised and replaced by
connective tissue. Ligaments, muscles, tendon- sheaths,
and joint-capsules, in fact, any structure, become hard
and inelastic from excess of scar-tissue. Our chief
object, therefore, must be to hasten the absorption
of the extravasated material by driving it into the
lymphatics. In that way we shall also improve the
circulation in the peripheral parts of the injured limb,
which so often suffer from imperfect blood-supply,
caused partly by the swelling at the site of the fracture,
and partly by splints and bandages.
It is a well-known fact that the joints and tendon-
sheaths in the neighbourhood of fractures, though not
actually involved in the injury, swell and form effusions,
which are often followed by great discomfort, thus
complicating the situation still more. This symptom,
however, is frequently overlooked at the time of its
occurrence, and is only noticed when the patient begins
to complain of pain at an unexpected place.
The following lines contain a general plan of treatment
of all fractures. Perfect reduction, being of first import-
ance for the subsequent results, should be insisted upon
in every case where there is any displacement at all.
When a fracture is seen on the first day, and there is
present a sufficient amount of displacement of the
fragments to necessitate reduction, this may be found
impossible without an anaesthetic, owing to muscular
spasm and pain. In such a case one should always
8 FRACTURES
try to relieve the spasm by means of very gentle
(centripetal) stroking carried out over the contracted
muscles. One will find that such manipulations have
a remarkably soothing effect on the patient, and often
render the administration of anaesthetics quite un-
necessary. The spasmodically contracted muscles be-
come relaxed, and the pain, which to a great extent
is caused by the cramp, is markedly diminished. If
now the attempt to reduce the fracture be repeated,
it will be found considerably easier.
In order to achieve a complete relaxation of muscles,
massage has to be applied for at least fifteen to twenty
minutes. The limb is then placed on a splint, preferably
a removable one, which would permit of an easy and
frequent access. As soon as the swelling has ceased
to increase, which generally happens on the second or
third day, by which time the shock has also subsided,
the splints are taken off and the limb submitted to
regular massage.
Care must be taken to avoid displacement. The
limb should be placed on a flat surface : the leg on a
bed, and the arm on a table. A hard mattress on the
former, and a cushion on the latter, will suffice to
diminish the pain without favouring the displacement.
Gentle upward stroking of the skin above and below
the site of the fracture will have to be applied in all
cases, and it is carried out with both palms alternately.
The parts in contact with the patient are the thenar,
hypothenar and the palmar surfaces of the thumbs and
fingers, which all try to embrace the limb (Fig. 1).
There ought to be as little pressure exercised as possible,
FRACTURES 9
the movement being more a gliding than a pressing one.
The aim of stroking is only to empty the superficial
veins and lymphatics in the vicinity of the extra vasated
FIG. 1. — STROKING (EFFLEUKAGE).
In this and the following diagrams the supporting
cushion has been omitted, so as not to obstruct the
view of the limbs.
blood. The fluid follows the negative pressure thus
created in the blood-vessels, and becomes sucked in and
pressed out. This, however, does not in any way in-
crease the discomfort of the patient, as the actual
site of the fracture is left untouched. On the con-
trary, by reducing the tension in the tissues, it
diminishes the pain very markedly. If done skilfully,
this stroking may be carried out from the very day
of the injury, and should be given for about fifteen to
twenty minutes, at the rate of about twenty strokings
a minute, which roughly corresponds to the breathing
rate of a normal person. The first few days the
treatment should consist of this and nothing else ;
movements of the limb might easily produce a new
hsematoma.
After each application of massage the splints have to
be put back into their original position. The more
extensive the primary swelling was, and the bigger the
10 FRACTURES
part in which the fracture occurred, the longer has this
mild and expectant treatment to be carried out. Where,
however, the dimensions are smaller, another point
frequently arises which necessitates an early introduc-
tion of movements into the scheme. This is the im-
portance of preserving a good function in places where
stiffness is very likely to occur. The hands and feet,
and joints in general, when directly involved into the
injury, require from the beginning a more energetic
treatment than a fracture through the middle of the
humerus or of the femur.
The presence of tendon- sheaths, joints, and ligaments
near a fracture calls for an early application of passive
movements in addition to stroking. Adhesions, which in
the first few days consist of fibrin alone, are thereby
broken down and not allowed to become fibrous. I
need hardly add that before the consolidation of frag-
ments has taken place, all these manipulations must
be carried out by the surgeon himself, and no one else.
Otherwise there will be always a great danger of a
displacement, which might be easily overlooked and
neglected. The surgeon must be positively sure of the
good position of the fragments each time he reapplies
the splints. Should a slip have occurred during the
daily manipulations, it is corrected without delay ;
and only a surgeon can decide whether the bones are
in the proper position or not.
When available, the use of X-rays facilitates our
task considerably : a radiograph taken before and after
the reduction, and, if possible, during the first week
or ten days, helps to disperse any doubt as to the
FRACTURES 11
satisfactory progress of the case. This, however, being
scarcely practicable in general practice, must necessarily
become limited to rare cases presenting some particular
difficulties, such as the intra-articular fractures.
In order to facilitate the return of venous blood,
fractured limbs should be kept elevated during night-
time, and during the best part of the day as well. The
application of ice and other cooling substances, specially
near the joints, is not advisable. Some authors (Cham-
pionniere) go so far as to make this even responsible
for subsequent chronic arthritic changes in the joints,
which persist long after all the traces of the injury
have disappeared.
Active movements, that is movements carried out by
the patient himself, can be commenced as soon as the
passive ones, that is those which are carried out by
the surgeon, have become easy and painless. Active
movements are, of course, begun earlier in fractures
close to joints, such as the ankles or the ivrists, but
especially in such parts as the hands and feet. Move-
ments in such cases have to be carried out as completely
as possible, that is they must be performed within their
widest range. It is a good method to let the patient
do as much of the movement as he is able to actively,
and then to finish off every movement passively until its
limit is reached. This will easily help the patient to
overcome the difficulties of performing active movements
within their normal range, and will thus prevent the
limitation of movements frequently resulting in these
cases.
Cases in which a wiring or plating operation has been
12 FRACTURES
performed, are obviously included in our considera-
tions, because massage can and should be carried out
in these cases on precisely the same lines, as long as
the wound is protected from contamination by a
dressing. The results of these operations are always
much more brilliant when combined with mechano-
therapeutic measures ; all the secondary stiffness in
joints below and above the wired bone is thus easily
prevented.
__ A
Ununited fractures are equally "more often benefited
by this kind of treatment than not, as the slight friction
exercised at both ends of the fragments against each
other largely favours the formation of callus. The
effect of it is generally seen in a week or two. This is
also the reason why fractured ribs unite well, non-
union in these cases being almost unknown. Here
the fragments are kept moving by the respiratory
movements. The same applies to most cases of frac-
tured clavicle if there is not too much displacement.
Occasionally rest intervals of a few days, interposed
between two courses of massage, are found useful, when
the formation of callus is much retarded.
Passing now to the discussion of individual fractures,
we shall mainly dwell upon the commoner types, such
as are more likely to occur in general practice.
THE UPPER EXTREMITY
Although the treatment of a fractured clavicle does
not as a rule offer any difficulty, yet the period of
recovery from such an injury is often unnecessarily
THE UPPER EXTREMITY 13
prolonged by the stiffness of the shoulder joint. This is
quite intelligible to us, and must always be expected
after a few weeks of fixation, which is commonly
practised.
Instead of this, the arm ought to be moved from the
first day. The surgeon should steady the acromial
fragment of the clavicle with his corresponding hand,
and should carry out slow and gentle passive movements,
mainly consisting of circumduction in the shoulder joint.
The arm is firmly grasped above the elbow with the
other hand.
The limb is fixed for the rest of the day by means of
a strip of adhesive plaster or a bandage, following
Duncan's or Wharton's method, but all these remedies
are discarded after a few days, and the arm is supported
by a sling alone. As a matter of course the strapping
is taken off every day to permit of a free access to the
shoulder joint, and is reapplied afterwards. If there
is much swelling round about the fracture (which, of
course, must be reduced if there is any appreciable
amount of displacement), this has to be gently stroked
on both sides of the clavicle, but the collar-bone itself
must not be massaged upon. The subcutaneous position
of the clavicle would render such manipulations very
painful, and might, under circumstances, even injure
the thin layer of soft parts covering the bony fragments.
During the third week, however, gentle kneading or
friction (see Fig. 7) applied by the finger-tips to the
mass of callus helps to produce a firm union and
alleviates the pain.
With such a programme of treatment the period
14 FRACTURES
of complete recovery will in reality not last longer than
three weeks, and there will be no necessity for any
after-treatment.
Fractures of the humerus in its upper third would
certainly yield better results, if not left to themselves
for six weeks. Though the use of the triangular (Middel-
dorpf's) splint is recommended, it should not in any
case be worn longer than a fortnight, and should be
replaced by a sling at the end of this period or even
earlier. Massage is commenced on the second day after
the injury, and within a week movements are introduced.
In carrying them out, the arm is supported by the
surgeon with both his hands below and above the
fracture. Even should an operation have been made
necessary, considerable improvement of function is
obtained by a combination of operative and mechano-
therapeutic measures. Especially when the wound has
healed up, movements can be carried out with more
vigour, guided, of course, by careful considerations.
Massage of the deltoid is all-important in every case
of a fracture of the humerus. The deltoid is the most
important muscle of the arm we have to deal with in
our work, and it has only one rival in the quadriceps
of the leg. They both undergo a most rapid atrophy
following a complete immobilisation of the limbs by
splints, and the functional impairment resulting there-
from is often appalling. We have to do all that is in
our power to preserve their strength, if we do not
want quite unnecessarily to prolong the period of
recovery for many weeks after the osseous union has
taken place. We must substitute massage and passive
THE UPPER EXTREMITY 15
movements for the active normal movements which the
patient is now unable to perform, and which kept his
muscles in a fit condition up to the moment of the
injury. All the arm muscles, but particularly the
deltoid, should be thoroughly kneaded and hacked as
well as stroked at the commencement and at the end
of each daily sitting.
Kneading is done by pinching the muscles up between
the thumbs and fingers, both hands alternately
squeezing the tissues gently, and at the same time
\
FIG. 2. — KNEADING (PINCHING,
PETBISSAGE).
moving along the belly of the muscle (Fig. 2). In
addition to this, the whole of the limb may be grasped
with both hands, and kneaded as if it were dough in a
bread-pan (Fig. 3).
Hacking is done with the ulnar borders of the hands,
and chiefly of the fingers. The little fingers alone are
in direct contact with the parts treated, the other
three falling down on the little fingers the moment
they touch the body of the patient, thus adding to the
force (Fig. 4). The hacking movements have to be
16
FRACTURES
accomplished by frequent and rapid ulnar flexion in
the wrist joints alone, the elbow joints being kept
FIG. 3. — KNEADING
(GEASPING).
motionless. This renders the hacking more elastic,
and at the same time more penetrating, so that it exerts
an influence on the deeper layers of tissues, and is less
FIG. 4. — HACKING (TATOTEMENT).
fatiguing. It is advisable to start at the insertions
of the muscles in our case it will be the insertion of
the deltoid — and to move upwards towards the origin
THE UPPER EXTREMITY 17
of the muscles, because in that way we empty the
blood-vessels better, and thus remove the waste
products more readily.
My experience with cases in which smaller portions
of bones were separated, such as the tuberosities or the
coracoid process, taught me, that it is of infinitely more
importance to preserve the good function of the limb
than to maintain its morphology.
The latter, though possibly an ideal we should strive
after, must sometimes be disregarded in the interest
of our patients, who in these cases desire but a useful
limb. Therefore little attention should be paid to
the character of such injuries, and their treatment
should resemble that of simple sprains or dislocations,
which will be discussed in a separate chapter (see Figs.
18 and 19, facing pp. 42 and 43).
Applying splints to a case of an avulsed tuberosity
of the humerus would resemble killing flies with cannon-
balls.
A case of an ununited fracture through the middle
of the humerus in a man I had some time ago, may be
perhaps of some interest to the reader, especially as
it illustrates two points together. Though an opera-
tion was decided upon in this case, I obtained per-
mission to apply massage first. Within a fortnight there
was so much bony union that the idea of an opera-
tive intervention was abandoned. A few weeks later
the patient was off the sick list, and able to do his work.
Even if one is not at all of a hostile disposition towards
operative measures, one cannot help thinking that many
operations of this kind are performed without sufficient
2
18 FRACTURES
understanding of facts, which, after all, ought to be
pretty obvious. According to the text-books, most
cases of non-union are due to malnutrition of the limb,
and therefore people have tried thyroid extract and
Bier's treatment. Not in vain also have we known
plating operations being performed three and four
times without success ; because many of these cases,
if operated upon, are bound to give bad results, and to
bring the operative methods into discredit, having
suppuration, and finally amputation, a disappointing
sequel. Interposition of soft parts is no such serious
mechanical obstacle as is often imagined. It happens
very frequently that the operation confirms the absence
of any such hindrance, and even should this be present
during the first few days, it need not remain there
for months, since a great deal of it becomes absorbed in
the course of a few weeks. Operative treatment of un-
united fractures ought to be undertaken only after all
the other methods have failed, and even then it ought
to be aided by massage, which, as generally understood,
helps to raise the vitality of the injured parts by elimi-
nating waste products, and increasing the blood-supply.
The only direct indication for an immediate opera-
tion is given by the bone fragments being displaced
to such an extent that this is quite incompatible with
anything like a good function later on. This must,
however, be confirmed by a radiograph, taken after
the bloodless correction has failed. If all the operations
were always carried out according to this strict indica-
tion, the results would be probably a little more satis-
factory on the whole.
THE UPPER EXTREMITY 19
In the above-mentioned case a Gooch's splint was
found very useful, and the patient had to wear it until
the union was completed. As long as the callus was
still soft, there was a great danger of a displacement,
which had to be watched very carefully. Massage was
given to the deltoid, the biceps, and the triceps ; the
shoulder was moved every day so as to prevent stiffness
and atrophy of the shoulder muscles, and shrinking of
the joint apparatus ; the humerus was well supported
above and below the fracture, whilst these evolutions
were carried out.
More freedom should be given to the arm in cases
of supra-condyloid fracture, in which there is always a
considerable danger of muscular or nerve paralysis, if
splints are applied too tight, and the circulation
neglected. IschsBmic contracture of the hand is very
common in cases where there was any pressure on the
forearm.
I have got under my care a girl, who, five years ago,
sustained a fracture of the lower end of the humerus,
and had a splint put on. The next day she developed
all the signs of Volkmann's paralysis due to defective
blood- supply, resulting in an absolutely crippled hand.
She was under treatment for a year and a half, and has
improved so far that she can do some sewing and
darning. (See The Lancet, May 17th, 1913, "A case
of Volkmann's Ischsemic Contracture of the Hand/')
(Figs. 5 and 6.)
Many of the different types of fractures of the elbow
region can here be dealt with summarily. Experience
has taught me that from the point of view of the treat-
20 FRACTURES
ment and of the subsequent recovery it is to a certain
extent immaterial what kind of fracture we have before
us. Be it a fracture of the lower end of the humerus,
where only a small portion of the bone has been separated ;
be it the head of the radius that suffered the break ; or
be it that one of the epiphyses of the elbow has become
separated — the treatment must be carried out with
the view of preventing stiffness and final limitation of
movements at this joint. An exact diagnosis, con-
firmed by radiographic examination, is, however, very
valuable, especially with regard to the prognosis and
duration of treatment.
Massage must be started immediately in these cases,
because the joint generally presents a very extensive
hcemarthros. Passive movements are carried out very
gently from the first, whilst the muscles of the arm
(mainly the biceps and the triceps) are gently kneaded
and stroked with the other hand, so as to obtain as
complete a relaxation of their spasm as possible. Every
day these movements are performed once or twice in
each direction : pronation and supination, flexion and
extension. Too much movement may favour the pro-
duction of an unnecessarily great amount of callus un-
desirable in a joint. (This applies especially to children.)
Active movements are commenced during the second to
third week. Splints are better not used at all than worn
too long, a sling rendering a sufficient protection, and
the arm is kept well flexed the first week or two.
Fracture of the olecranon, if without any too great
displacement of the fragments, is best treated by
massage and early movements, splints being quite
-JK
2P'
M
o
z
ass
THE UPPER EXTREMITY 21
unnecessary. A strip of adhesive plaster may be put
round the lower third of the upper arm to prevent the
upper fragment from being pulled upwards by the
triceps. Should the displacement be considerable, the
fully extended arm is fixed to a Gooch's splint by means
of a bandage and massaged daily, movements being
commenced after a week. Old-standing fractures of
the olecranon are best operated upon if the function
is impaired, and there is a wide gap between the frag-
ments.
Fractures of both ulna and radius, especially in children
where they are commonly of the green-stick variety, give
excellent results with massage and movements applied
early. Particularly important is the extension of the
fingers carried out simultaneously with the extension
of the wrist, which should be started on the first day.
The reason why stress should be laid on this particular
movement is the common injury of the flexors of the
fingers caused by the fracture, and this may become
noticeable only when the fingers are hyperex tended.
Considerable impairment of function may result in such
cases if the condition is not recognised early enough.
Other movements, and particularly pronation and
supination (see Fig. 8) are practised during the second
week. Stroking ought to accompany all these passive
movements, since it reduces the muscular spasm which
often interferes with a successful application of such
manipulations.
Colles's fracture, being decidedly one of the com-
monest fractures in general, is particularly frequent
in private practice. Although it only requires an
22 FRACTURES
ambulatory treatment, the results are often very un-
satisfactory. Here, again, pain and stiffness are the
usual complaints, deformity being unfortunately also a
common appearance.
In order to obtain constantly better results a complete
reduction on the very day of the accident must be
insisted upon in every case. Stroking of the forearm
should always precede the reduction, which will thus
be rendered easy in every way : it relieves pain and
reduces the muscular spasm which is one of the chief
obstacles to a satisfactory reduction. The forearm is
then placed on an ordinary splint, which ought to
reach as far as the middle of the palm. Gentle stroking
and full passive flexion as well as extension of the .
fingers, the thumb being the most important of them
all, constitute the programme for the first few days.
Such early movements of the fingers are absolutely
indispensable, because of the great number of tendons
and tendon- sheaths passing right over the site of the
fracture, and therefore directly participating in the
injury. Those belonging to the thumb are most in-
timately connected with the fracture by being, so to
say, embedded in the extravasated blood. Active move-
ments of the fingers and passive ones of the wrist
joint, particularly pronation and supination (see Fig. 8),
are introduced before the end of the first week. Ex-
tension of the wrist is the only movement which should
commence a little later, as it has been alleged by some
authors to favour backward displacement of the lower
fragment. (The same caution applies also to fractures
of the scaphoid.) The muscles of the forearm are every
THE UPPER EXTREMITY
23
day subjected to an energetic kneading to counteract
their atrophy.
By the end of ten days the splint is discarded, and
FIG. 7. — FRICTION (DEEP KNEADING).
only a sling used for another few days. Friction (deep
kneading) over the fracture (Fig. 7), and active movc-
FIG. 8. — PASSIVE PRONATION AND
SuriNATION.
In order to carry out these two most important movements
one hand must grasp the arm just above the fracture and
help to rotate the wrist, whilst the other hand controls the
patient's own hand.
raents against resistance may now be commenced. The
amount of resistance is regulated by the surgeon, accord-
ing to the strength of the patient, and ought not
24 FRACTURES
to cause too much pain (Fig. 8). It is essential that
patients should exercise their wrists at home as much
as possible and at frequent intervals.
By the end of three to four weeks most of the patients
treated in this way will be able to resume their occupa-
tions.
Some time ago I had a bad case, a labourer who
sustained a comminuted fracture of the lower end of the
radius, but who, nevertheless, four weeks after the
accident, was able to start his heavy work. He was
treated on precisely the same lines as all the other
cases of typical Colles's fracture. Considering the great
damage of the bone, and the kind of occupation of this
patient, the result must be called a very satisfactory
one, moreover, the length of time required being the
usual.
I have repeatedly found that patients with Colles's
fracture complain of an indefinite pain situated not at
the broken end of the radius, but over the styloid
process of the ulna, after the fracture has become
firmly united. This must be due to a laceration of the
ligament attached there, and ought to receive special
attention as soon as it has been recognised. Deep
kneading with both thumbs placed just over the radial
side of the ulna, and between the two bones as well,
soon relieves this pain, which often is the only cause
of the patients' inability to use their hands.
Fractures of the metacarpals and phalanges are fairly
abundant in general practice, and therefore must not
be left without due attention being given to them.
Here more than anywhere else the necessity of mechano-
THE UPPER EXTREMITY 25
therapeutic treatment is obvious, and its aims clear.
If the fingers are not too badly damaged, so as to make
amputation imperative, they should be treated in the
following way. After the splints and dressings (if any)
have been removed, the hand is placed into a basin
with warm boracic lotion, and passive movements are
carried out for at least twenty minutes, night and
morning. During the second week the patient is en-
couraged to perform active movements in the bath.
The third week is spent in practising flexion and extension
against resistance. Even if there is no laceration of
soft parts, a warm arm bath is found useful in the active
exercises which the patients have to do at home.
Flexion, extension, and rotation of the wrist ought to
be included in the daily programme.
As soon as the skin has healed up, massage in form
of centripetal stroking can be done as well. This, of
course, may be commenced on the first day if there
has been no external laceration, or in other words if
FIG. 9. — CENTRIPETAL STROKING OF FINGERS.
the fracture was a simple one. It is best done by
grasping the terminal phalanx of the injured finger
between the tips of one's own thumb, index, and the
middle finger and moving them along, towards the
knuckles (Fig. 9). This movement is often practised
26 FRACTURES
by surgeons who, having put on rubber gloves, attempt
to smooth out all the little folds on their fingers. Splints
should in no case be worn longer than a fortnight.
Reduction of displaced fragments is indispensable in
all cases, if good results are to be obtained. Fractured
metacarpals receive a good support from a pad in the
palm, and a closed-fist-bandage. Early movement is
essential on account of the extensor tendons running
across the fracture, and the possibility of their being
caught by the callus. Deep friction should be applied
to the inter-metacarpal spaces.
Bennett's fracture of the base of the first metacarpal
does very well with the splint bearing the same great
surgeon's name. Extension is indicated in almost all
cases. Contiguous fingers may be used as lateral splints
in cases of fractured phalanges. The sling should never
be worn longer than it is absolutely necessary, as it
does not the least encourage the patients to use their
limb.
One point is worth remembering when practising
flexion of injured fingers : the physiological limit of
this movement. When the patient succeeds in bending
his first (ground) phalanx to right angles with the
metacarpals, one should not force him to go beyond
that point in anticipation of achieving still better
results, as the right angle is the limit for the majority
of normal people. Any attempt to bend the fingers
farther still will only cause unnecessary pain, which
may easily be verified on one's own fingers.
All that has been said about the compound fractures
of the fingers applies with the same strength to all
THE LOWER EXTREMITY 27
compound fractures, with but very slight modifica-
tions.
THE LOWER EXTREMITY
Fracture of the neck of the femur in children and
adolescents calls for the application of massage and
movements for reasons different from those which apply
in the case of adults, and still more of aged people.
In the first group of patients it is the good function that
we want to preserve ; in the second it is the life. The
value of early massage in these cases is absolutely
unquestionable, and most of the text-books of a more
recent date recommend such practice emphatically,
advising us to induce the older patients to leave their
beds within a fortnight of the injury. The reason for
their doing so is by no means a trivial one. We all
know the great danger of hypostatic pneumonia from
prolonged rest in bed. Therefore we must do everything
we can in order to stimulate the sluggish circulation
of the older patients (see chapter on pulmonary troubles).
Besides the general applications, however, the leg must
receive full attention. It should be massaged from the
toes right up to the groin, and upwards stroking,
kneading, and hacking of the calf and thigh muscles
should be carried out every day. Movements of the
foot and knee (if possible) should be given in every case
as well. If not impacted the fracture is put up in
some kind of splint, preferably Hodgen's, because this
permits of an easy access to the limb.
Extreme abduction is maintained all the time, and
28 FRACTURES
e version is to be prevented. Impacted fracture of the
neck in middle-aged persons should be undone if the
shortening exceeds one inch ; if not, it should be
disregarded, and the patient allowed to carry out active
movements after a fortnight had passed since the
occurrence of the injury. He should get up after three
weeks, and use his leg in walking. If the impaction
had to be undone on account of a considerable shorten-
ing, a delay must necessarily take place with regard
to the union, as well as in the free use of the limb. In
these cases it is wiser to re- apply the splint for the
night, the leg being well abducted, until a complete
bony union has been established between the neck and
the shaft of the femur. This would counteract the
natural tendency of the soft bone to produce a traumatic
coxa vara.
Fracture through the middle of the thigh is treated on
much the same principles. Particular care must be
taken to preserve the strength of the quadriceps muscle
in the same way as was described in connection with
the deltoid in fractures of the arm. In stroking up the
thigh, one ought to lift one's hand up when approaching
the point of the fracture, in order to avoid unnecessary
pain. Passive movements and massage of the knee
are of great importance if one wants to avoid stiffness
of the whole leg for many months afterwards. The
reason for this is, that an effusion into the knee joint
very frequently accompanies fractures of the thigh.
It is best to put up the leg in full abduction, the
foot being absolutely vertical to the surface of the bed.
Bed-clothes must not touch the toes, but should be
THE LOWER EXTREMITY 29
placed over a wire cage ; otherwise they will invariably
tend to evert the foot. Any linear or angular displace-
ment is corrected at once, the leg being measured from
time to time.
Within three weeks from the day of the injury all
movements should be freely practised : flexion, exten-
sion, abduction, adduction, and rotation in the hip
joint. Within four weeks the patient is allowed to
get up and to walk on crutches, which are discarded in
a week or so, and he ought to be able to use his leg
normally six to eight weeks after the original injury.
In children, massage is employed with equally good
results. Here the suspension of the leg permits of an
easy access to the thigh.
Of great interest is the fracture of the patella. Al-
though the idea that good results can only be obtained
by operative measures seems to be prevalent amongst
the profession, yet there are certain points which often
necessitate the adoption of another mode of treatment
in some cases. There is, first of all, a certain number
of patients who for some reason or other do not want
to give their consent to an operation which is not of
the life-saving type. Then, there is the risk of a secon-
dary suppuration. However aseptically or antiseptically
the operation may be carried out, the mere presence
of a foreign body in the synovial cavity will attract
micro-organisms circulating in the blood. Silver wire
shares in this respect the fate of deep silk stitches. It
is a well-known fact that even an ordinary knock —
hardly deserving the name of a trauma — is often
responsible for the origin of a serious condition, such
30
FRACTURES
as osteo-myelitis, although no interruption of the
continuity of the skin had taken place. I saw once a
case of a wired patella which had gone septic six weeks
after the operation, and long after the wound had
healed up completely ; the empyema of the knee joint
that ensued remained uncontrollable for several months.
An alternative to the wiring operation is strapping.
Strips of adhesive plaster, about ten inches long, are
applied to the knee, alternately above and below the
knee-cap, in such a manner that the fragments are
brought close together. There are about four straps
fixed below and four above, their ends overlapping.
FIG. 10. — STROKING (EFFLEURAGE) OF THIGH
Note the position of the left hand, which in this case
steadies the upper fragment of the patella.
Massage of the quadriceps is taken up at once, but
upwards stroking is carried out very gently in order
not to pull the fragments asunder, and for this reason
also the upper fragment of the patella is steadied
by the other hand (Fig. 10). Kneading and hacking,
however, is done very energetically, as it is surprising
how quickly and to what an extent the quadriceps.
THE LOWER EXTREMITY 31
muscle undergoes atrophy if not properly treated. The
calf muscles and the foot, of course, are included. It
is of utmost importance to move the fragments of the
knee-cap to and fro, so as to prevent their becoming
FIG. 11. — MOBILISATION OF THE PATELLA.
adherent to the articular surface of the femur, since
this is often found to be the main reason of a subse-
quent functional impairment of the joint. Fragments
naturally are moved as one whole, and not separately
(Fig. 11).
During the second week gentle passive movements,
such as bending and stretching of the knee, are com-
menced, as well as friction around the joint. The third
week is occupied with active movements of the leg
in the hip, knee, and ankle joints, walking with a stick
being also allowed.
One of my cases, an elderly gentleman, was confined
to bed for five weeks before I saw him. Extension had
been applied to the leg all the time, and the patient
32 FRACTURES
not allowed to get up. The leg was in consequence
wasted ad maximum, and the mental condition of the
patient was that of great worry and distress. He
thought he would never get better. However, within
three weeks he was able to attend at his office in the
City, and on his way home he managed to walk up a
pretty steep hill in Hampstead. He was treated on
precisely the same lines as described above. I may
add that in his case an operation was refused on
account of the patient's age and his great nervousness.
Two months later the leg was still in good condition.
It would have probably taken much less time if there
had not been such a long period of immobilisation.
Many adhesions had to be broken down which might
have been so easily prevented by a few early movements.
Fractures of the tibia and fibula can be briefly dealt
with. It is of importance that the extensors and flexors
of the foot and toes should not become wasted. The
patient should, therefore, be encouraged to move his
toes from the first day, in spite of slight discomfort.
If there has been any effusion into the ankle joint,
a bad stiffness of the foot may result, and for this
reason movements should be carried out in that joint
as soon as possible. Massage is applied to the whole
leg in the same manner as was described in connection
with other fractures. To facilitate movements of the
foot the leg is supported by one hand placed under
the knee, which is kept slightly bent, the foot gently
resting on its heel (Fig. 12).
The fact that the fractures of the leg are very
frequently compound does not much influence our views
THE LOWER EXTREMITY 33
with regard to their treatment. The external wound
is protected by a dressing, and carefully avoided during
the administration of massage. If there have been no
FIG. 12. — PASSIVE MOBILISATION or THE
FOOT IN FRACTURES or THE LEO.
signs of sepsis during the first few days after the injury,
no danger can arise from such practice afterwards.
Six weeks ought to be the maximum time necessary
for complete recovery from a double fracture of the
leg, and I have actually seen cases taken off the sick-
list at the end of this period. Fractures of either tibia
or fibula alone require considerably less time (Figs. 13
and 14). The use of a removable plaster of Paris case
(Croft's splint) is commendable, as it permits of both
early massage and early walking long before the bone
has become completely united. The callus remains soft
and pliable for about five weeks after the injury, so
that any slight displacement can be easily corrected.
Some time back I had a case in which I could give
the bones any shape I liked up to the sixth week ; a
small weight on a pulley did in a few hours all that
3
34
FRACTURES
was necessary. It should be remembered that the
normal leg has a slight outward curve which, if possible,
ought to be preserved.
The next common fracture of the lower extremity is
FIG. 13. — THE SAME CASE AS FIG. 14, FOUR
WEEKS AFTER THE ACCIDENT.
The whole weight of the patient's body is put on the
toes of the injured side. There is no pain on walking
whatever.
Pott's fracture. This is probably the kind of fracture
that generally gives the worst results. Almost every
day we meet cases that have been unable to follow any
kind of occupation for months and months.
k
FIG. 14. — FEACTURE or TIBIA (Bov OF 11). SEE FIG. 13.
34]
THE LOWER EXTREMITY 35
I have to think of a chauffeur whom I saw recently,
and who could not put his foot on the brake for several
months. Though there was a perfect bony union, so
much pain was evolved through the slightest pressure
that the patient had to undergo a long course of massage
before he could resume his responsible work.
Next to the pain, and just as intractable, is the
colossal oedema that nearly always accompanies bad
Pott's fractures. This can only be explained by a
very defective circulation, partly caused by swelling
of the joints in the first few; days after the injury, but
greatly due to a diminished tonus of the blood-vessels
as the result of muscular inactivity. Both stasis and
pain can be prevented if massage and movements are
commenced immediately after the injury.
No matter what type of fractured ankle we have
before us, whether it be the classical Pott, inverted
Pott, or Dupuytren, the chief point is the same in all
cases, namely effusion into the ankle joint as well
as into its vicinity, and therefore they all have to be
treated in a similar fashion. After the displacement has
been duly corrected, massage of the swollen joint should
be applied without delay. The right foot is placed on
the surgeon's left knee, leaving the heel free. The
surgeon places his right thumb behind the internal, the
rest of his fingers behind the external malleoli, thus in
a way embracing the Achilles tendon, and carries out
stroking movements in the centripetal direction alone
(Fig. 15). The surgeon's left hand steadies the foot by
holding it across the instep. (The left foot is treated
in the reverse way.) The hand being now pronated,
36 FRACTURES
the dorsum of the foot is massaged likewise, also the
calf has to be stroked and kneaded. The gentlest pos-
sible movements ought to be applied in the beginning,
as the pain is generally very intense.
Within three days the swelling will have subsided
so far as to permit passive movements, and flexion
and extension, adduction and inversion, are those to be
practised first. Abduction and e version need not be
encouraged, since they are apt to favour displacement
FIG. 1 5. — MASSAGE OF THE
ANKLES.
so characteristic in fractures of the ankle, which leads
to the deformity known as traumatic flat foot.
In order to carry out passive movements, one hand
steadies the leg above the ankle, and the other holds
the foot, preferably placing the thumb on the dorsum,
and the other fingers on the sole of the foot. Active
movements of the same kind, with similar exceptions,
are begun during the second week. Special stress
should be laid on good adduction and inversion, so as
to maintain a good arch of the foot, and to strengthen
THE LOWER EXTREMITY 37
the tibial muscles. Plaster -of -Paris splints, though very
practical with regard to early walking, are not advisable,
as they do not permit of any movements and massage,
unless they are made removable. If neglected, the
muscles are bound to become atrophied and weakened.
Kneading of the ankle region, with finger-tips directed
towards the ends of both malleoli, will stimulate the
formation of callus, and disperse the oedema ; the latter
will also improve considerably if the foot be kept
elevated during the night.
Splints should not be applied longer than ten days,
after which period the patient is allowed to get up, but
not to put his foot to the ground. Walking is com-
menced only when there is no more danger of the foot
being displaced outwards, and this would not be safe
Fio. 16. — TIP- TOEING.
before the fourth week, especially in heavy people.
Patients must be reminded that once they start
walking, they should place their feet parallel to one
another.
Exercises against resistance (adduction and inversion,
flexion and extension) should be persevered with for
38 FRACTURES
another fortnight. Tip-toeing with the feet inverted
(Fig. 16) should be practised by the patient himself
every morning for another month or longer. It will
be found that the results of Pott's fracture will be much
more satisfactory if treated in the above manner, and
will not disable the patient for longer than six weeks.
A special point to be observed during treatment
is the finding out of tender areas in the neighbourhood
of the fractures. Some of them are more constant than
others. There is, for instance, nearly always an ex-
cruciating pain elicited by pressure right in the middle
of the calf, between the heads of the gastrocnemii,
probably due to a ha3matoma close to one of the bigger
nerves. Also the parts along the Achilles tendon are
frequently found to be tender, which is most likely
caused by an extravasation of blood in the sheath of
this tendon. Other spots are scattered all over the
leg, often situated between the extensor muscles. Deep
kneading relieves pain so rapidly, that tenderness often
disappears completely within a day or two.
As a parallel to the case of the chauffeur, I might
quote that of a pianist of over seventy, whom I treated
quite recently. Five weeks after the injury this patient
walked without any support whatever, and could bend
his knees whilst standing on tip-toe. No trace of pain
or oedema, no limitation of movements, no displacement
in spite of a treble fracture. Two fragments of the
tibia, and one of the fibula, were chipped off the lower
ends, as confirmed by the radiograph (Fig. 17). The
age of the patient had not the slightest effect on the
length of the time required for his recovery.
THE LOWER EXTREMITY 30
Complete reduction of the fracture on the first day
under an anaesthetic, and an early application of mechano-
l/t<r<i/)eutics, are the only factors responsible for the
di (Terence between these two cases.
Fractured metatarsals require considerably less time,
FIG. 17. — TREBLE FRACTURE OF THE
ANKLE.
since they do not upset the mechanism of the foot so
much as Pott's fractures do : the architecture of the
foot is maintained by the other metatarsals in spite of
one of them being broken. Massage of the foot, which
consists, besides stroking, also of kneading with both
thumbs placed on the dorsum, and the fingers on the
40 FRACTURES
sole will soon establish normal circulatory conditions.
Exercises include tip-toeing and transverse bending of
the foot, along an imaginary line, running parallel to
the metatarsals. Walking will thus be made possible
during the third week.
Fractured toes are treated exactly like fractures of
the fingers, as described above.
In concluding this chapter I must add a word on
the objections that have been raised with regard to
massage and movements in fractures.
The formation of excessive callus had been alleged to
be one of the consequences of early massage. It is a
fact that massage does favour formation of callus, and
for this reason we apply it in cases of ununited frac-
tures. But, personally, I have not seen one single case
in which the just-mentioned complication should have
occurred. Evidently, those cases in which an abnormal
amount of callus thrown out caused an impairment of
function were either cases of what is called " exuberant
callus," which happens even in fractures treated by
the old methods of prolonged immobilisation, or the
massage was applied incorrectly, to say the least.
I dare say the majority of those whose views on the
latest management of fractures are sceptic, have never
carried out massage themselves, and judge only by the
results of some third person's work, or they would
have undoubtedly come to a different issue.
It has also been alleged that pulmonary embolism
was a much feared complication of massage ; this,
however, is absolutely denied by men of such wide
experience in fractures as Sir William Bennett.
SPRAINED JOINTS AND DISLOCATIONS 41
There is one more point I want to draw the readers'
attention to, and that is the psychic influence of our
treatment on the patient. It helps the patient to
overcome his timidity of using the injured limb more
gradually, and it gives him more confidence, through
his being able to watch the daily progress of his case.
B. SPRAINED JOINTS AND DISLOCATIONS
The treatment of what is popularly called sprains
does not differ essentially from the treatment of frac-
tures. There are, however, two points to remember.
Firstly : no sprains should ever be put up in splints ;
and secondly : active movements should be commenced
on the first day, besides the usual employment of mas-
sage. If both these points will be adhered to, the
period of recovery will be considerably shorter than
it is in cases in which splints and a long rest are
prescribed. By immobilisation of ordinary sprains we
only lose time, and miss the chance of preventing the
formation of adhesions. It is always a risky thing to
leave a haematoma alone there, where good function
is particularly desirable.
Everybody who has attended post-mortem examina-
tions, and has had to remove the lungs himself, knows
to what an extent adhesions can form in serous cavities ;
and he will realise that if such firm bands and strings
can originate in the thorax, despite the respiratory
movements, how infinitely more likelihood of their
formation there must be in such serous cavities as the
immobilised joints.
42 SPRAINED JOINTS AND DISLOCATIONS
I remember hearing once a colleague relate about his
experience of the two different methods as applied to
himself. He once sprained one of his ankles whilst
skiing in the Alps, and the Swiss doctor who was called
in, immediately started massaging the sprain. A few
days after he resumed his sport. Some three years
later he sprained the other ankle, playing football in
England, but this time he was, unfortunately, put to bed
for six weeks, and the result was that he was unable
to use his foot for three months. This is precisely what
happens in our work almost every day.
Of great importance in these cases is the right diag-
nosis : if there be any suspicion of a fracture, the sprain
would be better treated as a fracture ; but, with the
X rays becoming more and more popular, a radiograph
can be easily obtained after the injury, and this will
decide one way or the other.
In dislocations, which differ from sprains only in the
degree of damage done to the joint apparatus, greater
care should be exercised with regard to the active move-
ments than need be done in simple sprains. Those
movements which caused the dislocation would in the
beginning favour its recurrence, and should therefore be
avoided, until all the signs of the injury, such as swelling
and discoloration, have disappeared, and all the other
movements can be practised with complete ease.
One of the commonest examples of this type of injuries
is a sprained shoulder joint, which requires the follow-
ing treatment. Stroking and kneading of the deltoid
towards the trunk, as well as stroking of the whole
arm right up to the axilla, is carried out with the
FIG. 18. — A CASE OF SUBCOBACOID DISLOCATION OF
THE SHOULDER COMPLICATED BY A FRACTURE OF
THE TUBEROSITIES.
Before reduction.
FIG. 19. — THE SAME CASE AS FIG. 18, AFTER REDUC-
TION, ALSO SHOWING THE FRACTURE.
This patient, a male typist of about 30, was discharged five weeks after the
accident, completely cured.
[43
SPRAINED JOINTS AND DISLOCATIONS 43
object of preventing atrophy of the muscles. Gradual
rotation of the humerus outwards, until the hand can be
easily put on the back, and inwards, until the elbow can
be placed on the middle of the chest, prevents the forma-
tion of such adhesions which might produce a limitation
of these two very important movements. In a case of a
simple sprain, the abduction of the arm must be insisted
upon from the first, but this exercise must be very
moderate in cases of subcoracoid dislocation, because an
extreme abduction would each time force the head of
the humerus through the rent in the joint capsule,
and thus favour the establishment of " habitual dis-
location."
The sling should not be worn longer than three days,
its object being only to take the weight of the arm off
the shoulder joint capsule and ligaments, until the
effusion has begun to abate, which generally happens
within two to three days. All the movements should
be practised so long, until the patient himself has
learned to perform them within their full range, and
without experiencing any pain whatever. Should some
stiffness of the joint persist in spite of that, this can
easily be remedied by friction of the joint capsule at
places where it is accessible to the fingers. The treat-
ment can advantageously be given twice daily (Figs.
18 and 19).
In sprains of the elbow and of the wrist, great stress
should be laid on good pronation and supination, as
these two movements are usually impaired. Massage
is given in the usual way, consisting of stroking and
friction, which is chiefly applied to the radio-humeral
44 SPRAINED JOINTS AND DISLOCATIONS
articulation in the elbow, and to the styloid processes
in the wrist.
Sprains of the hip joint are less easily influenced by
direct manipulations, the joint being only accessible
in front. Movements should, therefore, be encouraged
in all directions : flexion, rotation, abduction, adduction
(by crossing the legs), and extension are done first
passively, then actively, and finally against resistance.
In iliac dislocation adduction is to be avoided ;
abduction being restricted in pubic dislocation.
The leg should always be carefully measured in these
cases, this being especially important then, when a
radiograph cannot be obtained.
Most common are the sprains of the knee joint.
Sport and football par excellence, play a prominent
role in the history of injured knees. Putting aside
cases of displaced or fractured semi-lunar cartilages
which, unless operated on first, are not suitable for
mechano-therapeutic treatment, there still remains a
large number of cases which are greatly benefited by
mobilisation and massage. The knee joint is readily
accessible, especially when distended by fluid. The
parts which may be directly attacked are the upper
synovial pouch above the patella, and the two recesses
to both sides of the knee cap, bulging out when fluid
is present.
The surgeon places his hand almost flat over the
swelling, and gently presses it upwards, continuing the
movement as far as the groin, and repeating this for at
least twenty minutes. Absorption of the fluid takes
place very rapidly, so that passive bending and stretch-
SPRAINED JOINTS AND DISLOCATIONS 45
ing of the leg can in most cases be commenced on the
next day, and on the third day the patient is told to do
it himself, being only aided by the surgeon. In most
cases there should be no difficulty in walking within
two or three weeks. Strapping or bandaging and still
less splinting of the joint is hardly ever indicated. If
some tender area be revealed in the course of treat-
ment— as it sometimes is the case on the inner aspect
of the knee or below the patella — they should be
rubbed and kneaded. Flexion "should be carried out
in such a manner as to reach as soon as possible its
physiological limit, which can be tested by comparing
the injured limb with the normal one, whilst the patient
is lying on his face.
Sprained ankle is undoubtedly the most common
injury of a joint met with amongst all classes of people.
It is sometimes very difficult to differentiate it from a
Pott's fracture, a useful guide in that respect being the
exact localisation of pain. In Pott's fracture the
greatest tenderness is experienced just over the tip of
the malleolus, that is over the site of the fracture. In
a sprained ankle the pain is most intense lower down,
where the ligaments have been ruptured ; an extensive
swelling, however, may obscure the anatomical picture
so as to make this test impossible. Then, of course,
crepitus, deformity (mostly outward displacement of
the foot), and finally a skiagraph, will help to establish
the right diagnosis. If an X-ray picture is not obtain-
able, and doubt exists whether the case be a simple
sprain or a fracture, the case should be regarded as a
fracture, and treated on the lines indicated above.
46 SPRAINED JOINTS AND DISLOCATIONS
Ordinary distortions of the ankle must under no cir-
cumstances be immobilised. The only result of complete
and prolonged rest will be the formation of adhesions
in the joint, as well as in the surrounding tendon-
sheaths, the last practically always participating in
the general effusion. Massage is given once or twice
a day, lasting each time fifteen to twenty minutes, and
movements are begun on the first day, being quickly
though gradually increased in range. Flexion and
extension of the foot have to be practised by the patient
himself, being particularly important.
Massage ought to be soothing, not painful. The
swollen parts should be gently stroked upwards, includ-
ing the calf, right up to the popliteal space. A more
detailed description of how massage should be done
in these cases was given under Pott's fracture. Walking
is allowed on the third day, cycling and every other
kind of exercise being encouraged.
There is one point which ought to be remembered in
connection with the treatment of fractures and sprains
of the lower extremity, and this is limping. Experience
has taught me, and, no doubt, the majority of the
profession will agree, that limping is in most cases an
outcome of the patient's timidity in using the injured
leg. This, though fully justified in the beginning of
the treatment, soon grows a habit difficult to eradicate,
and therefore it should be early counteracted by re-
peatedly drawing the patient's attention to the fact,
that there is nothing to account for the limping.
CHRONIC ARTHRITIC CONDITIONS 47
C. CHRONIC ARTHRITIC CONDITIONS
Cases of osteo-arthritis are generally benefited by gra-
duated exercises, if the extent of the trouble does not
render them too hopeless. The progress is, in most
cases, a very slow one, improvement being noticeable
only after some months of treatment. It is the general
health that ought to receive special attention, and not
the condition of the limbs alone. More detail on this
subject will be found lower down, where constitutional
diseases will be dealt with, since, in all possibilit}^
osteo-arthritis has to be counted amongst them.
The prognosis is much better in patients who suffer
from articular stiffness and pain, following injuries, such
as intra- and peri-articular fractures, dislocations, and
sprains, when they were not properly treated at the
time being (traumatic synovitis). Most of them have
adhesions caused by prolonged immobilisation and want
of exercises. If the surgeon is unable to break them
down by means of ordinary passive manipulations, he
has to effect it under general anaesthesia, which is
followed by a course of massage and active exercises,
necessary to strengthen the muscles, often highly
atrophied. In order to render the result of such an
operation really satisfactory, the surgeon must not
forget any movements possible in the joint, under
normal conditions, and moreover he should carry them
out within their fullest range under an anaesthetic.
Cases are often met with where, for instance, only one
particular movement of the arm is found to be painful,
and only when the patient attempts to reach for some
48 CHRONIC ARTHRITIC CONDITIONS
object, which requires a complete action of the joint,
such as buttoning up braces on the back, combing the
hair on the back of the head, putting on boots, or
taking a book off the shelf, and the like. The presence
of adhesions as a possible cause of such symptoms ought
always to be borne in mind, when considering the
treatment of cases with a definite history of a trauma.
Operations of the kind described must be performed
with a light, yet a steady hand. The amount of force
to be applied can never be estimated beforehand, but
it ought to be just sufficient to sever the adhesions
without injuring the joint apparatus. The best method
of doing it is that of slight jerks, the amplitude of
which is gradually and speedily increased. This simple
procedure, under the name of " bone-setting," is
practised by many quacks, and constitutes the alpha
and omega of their skill.
Similar treatment is applied in cases of teno-synovitis,
which often results in bad stiffness, unless appropriate
steps have been taken at the right moment. Massage
and movements are to be commenced as soon as the
acute stage of teno-synovitis has abated. Should
incisions have been made, it is wiser not to wait with
the mobilisation until the wound has healed up com-
pletely, but to carry out movements in a warm anti-
septic arm bath, such as boracic lotion, a few days after
the operation.
D. INJURIES TO SOFT PARTS
Contusions of soft parts, popularly called bruises,
require immediate treatment by massage. Rest and
INJURIES TO SOFT PARTS 49
lotions have become quite obsolete. It is quite obvious
that besides numbing the pain for a moment, they
cannot have any lasting effect whatever. Adhesions
which result from serous or haamorrhagic effusions taking
place between muscular fibres, are just as injurious to
the function of a muscle as they are in a joint or a
tendon-sheath to the function of these structures. It
is a well-known fact that the increase of fibrous tissue
in a muscle impairs its contractility and thus reduces
its strength. Another fact about scars is that, under-
going a certain amount of contraction, they are likely
to entangle nerve filaments. This constant pressure
and dragging on the nerves is the cause of the dull
pain which so frequently persists after injuries of soft
parts.
Massage is carried out on the first day as painlessly
as possible, and is given with the object of dispersing
the extravasated blood or serum, and thus preventing
adhesions. The swelling need not become smaller at
once, though the discomfort of the patient may be
greatly reduced after the first application. It is a good
practice to commence massage with stroking of the
parts above the bruise, then gradually to encroach upon
the swelling, and finally to massage the parts beyond
it. Free exercises should be encouraged from the
first, and should be particularly insisted upon if the
injured parts are situated near a joint cavity, or if
the tendon-sheaths are involved in t he injury.
The above method is equally applicable to contusions
of the skin and subcutaneous tissues as well as to
contusions of the periosteum itself : in cases of a haema-
4
50 INJURIES TO SOFT PARTS
toma of the periosteum, the formation of traumatic
nodes is thus prevented. The pain caused by the
pressure of the effusion which raises the periosteum off
the bone, is often very intense, but it is greatly alleviated
by massage, which also considerably hastens the absorp-
tion of the fluid.
If a sprain has been caused by an over- straining of a
muscle at sport or at work, that particular movement
which caused the injury is to be avoided for a few days.
There is a long list of complaints, known under various
names derived either from different kinds of sport,
or from occupations in which they occur, such as
" sculler's sprain/' the " golfer's back," etc. Massage,
first stroking and kneading, then hacking and gentle
exercises, constitute the treatment of these cases.
E. CHRONIC INFLAMMATORY CONDITIONS OP
SOFT PARTS
The first place in this group — as far as frequency of
occurrence is concerned — must be given to the condition
popularly known under the name of muscular rheuma-
tism, which, however, some call fibrositis.
Though the nature of this widespread complaint is
still somewhat obscure, its treatment appears to be
well defined at present. Patients generally complain
of dull pain at one or more places of their body, the
trunk and upper arm being chiefly involved. Exacer-
bations of pain described as being similar to the pain
experienced after a bad bruise coincide with certain
atmospheric changes, such as damp or windy weather.
CHRONIC INFLAMMATORY CONDITIONS 51
The parts thus affected feel heavy, and if, for instance,
the arm be the seat of the trouble, the patient may
become unable to use it at all. Some movements are
particularly painful, such as lifting the arm sideways, or
upwards, as in combing hair or pouring out tea. There
is generally a long history of many similar attacks,
usually called by the patients attacks of rheumatism
or neuralgia, the pain being often fallaciously referred
to the nearest joint, most frequently to the elbow and
the shoulder joints.
Clinically, on examination, one finds that the pain
can nearly always be localised. In the case of pain
in the shoulder, the greatest tenderness is elicited by
FIG. 20. — FORCIBLE KNEADING
OF THE ELBOW REGION.
* Note the position of the thumbs.
pressure on some parts of the deltoid. Should pain in
the elbow be complained of, the tendon of the triceps
or the supinators are found to be tender. The move-
ments in these joints are quite painless when carried
out passively by the surgeon. Very careful examina-
tion by well-trained hands reveals areas which feel
slightly firmer than healthy muscular tissue does. If,
however, great pressure is applied to them, which can
be done by placing both thumbs one on top of the
52 CHRONIC INFLAMMATORY CONDITIONS
other (Fig. 20), these areas pit, like an old chronic
oedema. The pain is only bad at the commence-
ment of pressure, but is generally relieved a few
moments after.
Pathologically, little change can be found to explain
the comparatively well marked clinical disturbances.
Serous, sometimes cellular, infiltrations of muscles have
been described as the only findings in these cases.
The pain must therefore be attributed to pressure on
nerve endings, caused by serous exudation. If after
a time a certain amount of fibrosis takes place, the
complaint becomes still more tedious, and hard nodules
may then be felt along the muscles, fasciae, and tendons,
likened by some authors to rows of beads. They are
often encountered in the cervical region in the trapezii
and the sterno-mastoids. Situated near the exit of the
occipital nerves, they give rise to occipital headache
(see chapter on headache, under Neuralgia).
Torticollis is often produced in the same way through
an irritation of the spinal accessory nerve.
Lumbago may persist as long as the lumbar nerves
are pressed upon by the infiltrations occurring in the
quadratus lumborum.
Sciatica is just as frequently caused by the same
kind of changes in the glutaei, which, however, is a
fact not often recognised.
All cases of fibrositis are greatly benefited by a course
of massage, which should consist of a very vigorous
kneading of the parts affected. Deep and forcible pres-
sure should be exercised on the infiltrated areas in
order to bring about the absorption of the inflammatory
CHRONIC INFLAMMATORY CONDITIONS 53
products. This is best done by grasping the limb
with both hands, and placing both thumbs on the
painful spot. In these cases it is advisable to use an
electric vibrator, with a small rubber applicator, as
manual treatment may become rather fatiguing,
especially if different parts require similar treatment.
Hacking and stroking are here useful adjuvants, and
help the circulation to eliminate the waste products.
As the surrounding muscles are more or less weakened
through the patient not using them properly on
account of pain — exercises in all directions should be
encouraged. Slight exacerbations of pain are not
uncommon in the beginning of the treatment, which
has to be applied daily, during four to six weeks on
an average. Some patients find also the application
of heat very soothing, such as hot poultices or radiant
heat. Others, however, cannot bear it at all.
Massage has unfortunately been seldom adopted in
ulcers. Chronic ulcers, resulting, or favoured by a
torpid circulation, as in the case of varicose veins, or
originating from traumatic and thermic causes in anaemic
subjects,1 are all cases which obviously require stimula-
tion of the parts thus affected. If we succeed in
relieving the venous stasis, we necessarily benefit the
ulcer, as in that way we influence the nutrition of
tissues. The affected limb — which is in most cases
the lower extremity — should to this effect be kept
elevated during the best part of the day and the night.
The vicinity of the ulcer, which is always very painful,
1 To this class the complaint known under the name of
Raynaud 'a disease belongs.
54 CHRONIC INFLAMMATORY CONDITIONS
— especially the parts beyond it — is gently stroked
towards the trunk of the patient, thus emptying all the
veins and lymphatics.
To rub the ulcer itself, though advocated by some
authors, is not commended on account of the great
tenderness, and the risk of destroying the granulations.
This may, however, be tried as a preliminary step
carried out once in the beginning of the treatment, as
an alternative to scraping or curetting. In such a
case the surface of the sore is covered with a piece of
boracic lint, and the thumbs are placed on top of it.
The prevention of bed-sores is so important that it
need hardly be emphasised. It should become a
routine measure that in all cases of long illness the
prominent points, such as the scapulae, sacrum, and
the heels, should be inspected every day, and long
before any signs of sores appear, these parts should
be submitted to a daily friction with such stimulants
as methylated, or pure spirits of wine. The general
application of mechano- therapeutics in such cases will
be considered later, when the treatment of debility
is discussed.
There is one more trouble belonging to the inflam-
matory conditions of soft parts to be mentioned, and
this is catarrhal prostatitis, one of the most troublesome
complaints known. It is very little influenced by the
ordinary methods, and it runs a very chronic course.
It thus becomes most tedious to both the surgeon and
the patient. The latter becomes affected physically, as
well as psychically, if the prostatorrosa is not radically
attacked by means of rectal massage.
CHRONIC INFLAMMATORY CONDITIONS 55
The patient is placed in the knee-elbow position.
The index finger, protected by a rubber finger-stall,
and lubricated with some indifferent ointment, is
introduced into the rectum. The prostate in these
cases is generally found to be enlarged and granulated.
The treatment consists of gentle stroking manipulations
in a downward and forward direction, and is carried
out with the pulpy part of the finger, so as not to
injure the rectal mucous membrane. This is carried
out once or twice a week, and it is followed by an
immediate improvement. After each sitting, a con-
siderable amount of thick milky fluid escapes from
the urethra. Within a few weeks of regular treatment
the size of the prostate is found diminished, and the
amount of discharge considerably lessened, or completely
arrested. Massage acts here as a stimulant to the
glandular tissue by emptying its secretion and supply-
ing it with fresh blood instead. This can hardly be
achieved by any other means, owing to the inaccessible
situation of this gland.
F. DEFORMITIES
The deformity most frequently observed in general
practice is scoliosis. Probably a hundred per cent, more
cases would come under observation if every young
subject complaining of pain in the back and general
weakness were stripped at the first consultation, and
thoroughly examined. If this routine measure were
carried out conscientiously by every medical man in
the country, the incurable hunchbacks would disappear
56 DEFORMITIES
in less than a quarter of a century. Ninety-nine per
cent, of all curvatures could be prevented or cured, if
attacked early, before gross bony changes had taken
place. The age of eight to twelve is most commonly the
time when the trouble begins, many more girls being
affected than boys. Their relation varies between 5*1,
and 9*1 (see the author's " Spinal Deformity in
Schoolgirls," School Hygiene, February 1914).
It would go far beyond the scope of this book to
discuss the various theories of the formation of spinal
curvatures. Our object here is only to state how far,
and in what way, mechano-therapy in general practice
is applicable to these cases, and what good it may be
expected to do.
Assuming that scoliosis nearly always, and in the
first place, is due to weakness of the whole frame or
its parts, such as bones, muscles, and ligaments, other
factors, such as weight and faulty position, playing
only a subaltern role, all our efforts must be directed
towards the strengthening of the spinal apparatus.
We have three ways of doing this by mechanical
means : exercises, massage, and appliances. These
factors should never be used separately, though the
last-named one may often be left off altogether ; their
combination, however, depends on the kind of the
case under treatment. Slight cases, with little de-
formity and little subjective symptoms, such as pain or
fatigue, do well with exercises given mainly, massage
being used as an adjuvant. Those cases in which sub-
jective complaints are predominant require chiefly
massage, exercises being administered very cautiously.
DEFORMITIES 57
Very advanced cases, with a great amount of deformity,
pain, and respiratory and circulatory disturbances, obtain
considerable relief from supportive jackets, worn during
the daytime. Massage is employed here as in all other
cases, and exercises, mostly passive ones, are directed
towards improving the circulation, as well as respiration.
Massage of the back consists of stroking, kneading,
and hacking. Stroking movements are carried out in
three stages : along the upper part of the trapezius,
from the back of the neck towards the shoulders ; along
the lower part of the same muscle from the shoulders
towards the loins ; and finally along the latissimus
dorsi from the axilla down to the iliac crests. Both
FIG. 21. — KNEADING OF
THE TRAPEZIUS.
hands are employed at the same time, each of them
massaging the corresponding side. Kneading is done
by placing the hands flat on the patient's back, and
moving the skin over the muscles ; the hands are not
moved over the skin, as is the case in stroking. The
upper part of the trapezius being accessible to the
58 DEFORMITIES
fingers is pinched up, and kneaded in the ordinary way
(Fig. 21). Hacking is very useful as a means of stimu-
lating the erectores spinse, and is best carried out trans-
versely to the course of these muscles.
It is necessary to devote at least five minutes to
these manipulations each time. In cases where massage
chiefly is indicated, these sittings should, of course,
last longer, fifteen to twenty minutes being an average.
The patient lies on a couch, his back being exposed ;
the person administering massage is standing or sitting
by, facing the upper part of the patient's body. When
combined with exercises, massage is given during the
rest pauses, which must necessarily be made in these
cases.
With regard to exercises we may point out that their
object is a threefold one. Firstly, loosening of liga-
ments and stretching of the shortened muscles on the
concave side of the deformity. Secondly, correcting
the deformity itself. Thirdly, teaching the patient
what the normal position of his spine ought to be, and
how to maintain it.
It would be almost impossible to give a complete list
of exercises to be practised by scoliotic patients, but
it may be accepted as a general rule that any move-
ment of the body, no matter whether a passive or an
active one, tending to undo the curve, is of value, and
may be used as an exercise.
Movements are often combined with different atti-
tudes of the body, and more complicated movements
may be constructed out of two or three simple ones,
thus offering us an unlimited variety to choose from.
DEFORMITIES 59
Out of this large number we select a few exercises
especially suited for the particular case under treat-
ment, and we carry them out every day, increasing their
amount gradually. They all must be performed slowly,
the fullest attention of the patient and the surgeon
being concentrated on them all the time. They should
be carried out within their widest range, that is to say
as far as the anatomical barriers permit. The number
of times each movement should be practised varies so
much in every case according -to the amount of energy
possessed or spent on other exercises, that it cannot
be fixed beforehand. We generally begin with six, and
increase the number up to twelve, but there is no
reason why certain patients should not perform twice
as many.
There is only one factor that must be punctiliously
observed, and that is fatigue. The moment we notice
that the patient fails to carry out the movements with
his usual alacrity and precision, the exercises must be
interrupted, and a rest period of five minutes interposed,
during which massage is employed. Some of the
commoner signs of fatigue are swaying of the body,
or changes of the rhythm with which the exercises
are usually practised : patients first hurry, and then
slow down and tumble. Another sign of fatigue is a
faulty respiration, which ought to be closely observed
throughout the treatment. The expression of the
patient's face should be carefully watched, as it often
indicates the moment of his exhaustion.
Passing now to the description of individual exercises,
we shall consider more fully only those which are
60 DEFORMITIES
applicable to cases of right dorsal curve, this being the
commonest type of scoliosis. Eor cases of left dorsal
curve all movements should be reversed.
The patients start with simple exercises, and are very
gradually taught to do more complicated ones. To the
simple exercises belongs " sitting side bending " of the
trunk towards the convexity of the curve, which in our
case will always be the right one. The patient sits
either on a high plinth, his legs strapped down to it,
or on an ordinary stool, his feet twisted round the
legs of the stool, so as to add more to his security. He
places both his hands on the back of his head, expanding
his chest, and raising his chin. The side bending
movement is carried out slowly, and the respiration is
watched. Bending and raising of the trunk to the
original position should occupy at least ten seconds
altogether, a slight pause being made before the exercise
is repeated. One ought to reckon one minute for
every four movements, and three minutes for a dozen.
This exercise can be rendered stronger, that is of more
effect on the spine, if the surgeon places his right hand
on the convexity, and his left hand under the patient's
left elbow (or under his arm), thus assisting in the
flexion of the trunk (Figs. 22 and 23).
Another useful exercise is " sitting forward bending "
of the trunk, which can be done without the patient
changing his former sitting position. The patient lifts
his left arm straight up in one line with the spine, and
places his right hand on the convexity of the curve,
the thumb looking backward. The right hand exercises
pressure on the curve, and the left arm is forcibly
II
H fc
H O
s'S
*Is
DEFORMITIES 61
stretched out, thus rotating the shoulder, which pulls
the spine over to the left side. The surgeon helps to
correct the deformity by grasping the patient's left hand
FIG. 24. — THE SAME CASE AS FIGS. 22 AND
23. " FOBWABD BENDING " : SITTING,
WITH PRESSURE ON THE CONVEXITY AND
TRACTION OF THE LEFT ARM.
above the wrist joint with his left, and placing his
right hand on or above the patient's right, which is
pressing on the " hump." The surgeon pulls the
patient's arm upwards and at the same time exercises
62 DEFORMITIES
pressure on the curve (Fig. 24), especially at the moment
when the patient begins to raise his trunk to the original
position. Full expiration is made during flexion, and
a deep inspiration during extension of the spine.
" Crawling exercises " — introduced by Professor Ru-
dolph Klapp — have the great advantage of correcting
the deformity, whilst the weight of the body is taken
off the spine. The patient crouches on all his fours
in such a manner as to keep both his right extremities
as close to each other as possible ; the left leg and the
left arm, however, are stretched out. The patient
performs crawling movement in as small a circle as
possible, all the time endeavouring to maintain the
same relation of his limbs. The hands are protected
by gloves, and the knees are wrapped up in some
flannel. Also small square pieces of thick felt may be
fixed to the parts exposed to pressure by means of an
elastic bandage. The left arm has to make far-reaching
movements forward, and the left leg has to remain
far behind its fellow. The patient moves along only
in the direction of the curvature, so that if it is a case
of right dorsal curve, the direction is identical with
that of the hands of a clock. Left dorsal curve becomes
straightened out through the reverse. Crawling exer-
cises are to be practised by the patients at home for
at least fifteen minutes, night and morning.
A double curve or S-scoliosis requires a different
arrangement of the limbs, which in that case must be
stretched out crossways : the right arm and the left leg
or vice versa.
" Side lying " on the side of the concavity is a posi-
DEFORMITIES 63
tion in which the weight of the body is used as the
correcting factor. This posture should be habitually
assumed by the patients when resting, or even when
sleeping. The real advantage of this correcting position
is that it influences the spine during a great part of
the day.
If compensatory curves have already developed
markedly, combined movements are of more use than
simple ones. For instance, in the case of right dorsal
curvature, the compensatory curves being left lumbar
and left cervical, I find the following exercise very
useful.
The patient places both hands on the back of the
head, which is kept bent to the left, thus undoing the
cervical curve. The legs are kept wide apart, and the
weight of the body is thrown on the right foot, thus
undoing the lumbar curve. The right knee is now
bent, and at the same time the spine flexed to the
right, the dorsal curve being thus undone. Rotation
of the vertebras, always present in more advanced
cases, is overcome by a slight twist of the trunk towards
the convexity, achieved by the patient facing his
right knee, when bending over it. In this way a treble
curve is corrected by one exercise, which, though rather
complicated, is easily learnt by degrees.
Extension and flexion of the arms forward and side-
ways in standing or sitting, with the spine held in a
correct position, help the patient to train his muscular
sensation, and to get accustomed to perform the every-
day movements in a good erect posture.
" Side hanging " is a powerful means of correcting
64 DEFORMITIES
spinal curvature in the dorsal region. The patient is
placed with his convex side right across a well-padded
boom, the head and the legs being slightly supported
by the surgeon. If the person treated is a child, which
is mostly the case, any soft object, such as the back of
a sofa or that of an easy chair, will do for this purpose.
Care must be taken lest the deformity should become
aggravated by compressing the ribs. It should, there-
fore, be remembered that pressure is to be applied to
the top of the " hump," and not to the parts beyond it.
These aie just a few examples of spinal exercises
which can easily be applied to the typical cases of
total or C-scoliosis in general practice. Most cases of
slight curvature can be cured, if treated by the above
exercises alone.
The following are a few class exercises, that is exercises
which can be done by several patients together. They
are suitable in very slight cases showing just the be-
ginning of a deformity, and can, of course, be combined
with the above-mentioned ones. In all of them great
stress is laid on deep respiration and on the correct
position of the shoulders as well as of the rest of the body.
Standing arms parting ;
Standing arms stretching upwards, sideways and
downwards ;
Heels raising and knee bending, with hands on the
hips;
Knee up-bending (alternately), with hands on the
hips ;
Standing arms circling ;
Standing arms flinging ;
DEFORMITIES G5
Standing arms rotating outwards, head extending.
Advanced cases of scoliosis require special attention,
and celluloid jackets are often necessary in order to
reduce a certain amount of deformity and compression
of the viscera. Simple celluloid jackets can be made
by any medical man without difficulty. The main part
of the work is the cast. First, a negative is obtained
of the patient's back. This is done by putting several
layers of plaster of-Paris bandages on the extended
back, and cutting them open at one side. The body
has been previously well anointed with vaseline. A
bottom is made to the negative, and another bandage
carried round the whole, so as to close all the rents,
and thus to prevent leakage. As soon as it is dry, it
is well rubbed with some grease inside, and filled with
plaster-of-Paris. In a day or two the negative is cut
open again, and the positive taken out. The cast thus
obtained represents the patient's back in a corrected
position. On this model, first a woollen vest is placed.
On top of that a layer of book muslin is wrapped round.
This has to be previously cut up into strips of about
a yard in length, and about six inches wide, because
this facilitates the shaping of the jacket. The muslin
thus prepared, and placed on the cast, is painted over
with a solution of celluloid in acetone. As soon as
this gets dry — which takes place in a few hours —
another layer of muslin is wound round the first layer,
and painted again. In such a manner about a dozen
or more layers of muslin and celluloid are placed on
top of each other. When perfectly dry, the jacket is
cut open in front. Leather straps and buckles are fixed
5
66
DEFORMITIES
to it after it has been removed from the cast, and small
pads of cotton wool fastened to those points inside the
jacket which are in contact with such prominent parts
as the sacrum and the top of the curvature. If the
deformity is very marked the jacket should be applied
in a recumbent position by the patient himself.
FIG. 25. — BREATHING EXERCISES IN LYING.
Photograph shows the moment of deepest inspiration and maximum extension
of the arms.
Celluloid can be made non-inflammable through the
addition of certain salts.
Respiration is generally very defective in scoliotic
subjects ; therefore special respiratory movements should
be practised every day, at the beginning of each sitting.
The following movement is very useful because it com-
bines expansion of the chest with stretching of the spine.
The patient is lying on his back, his hands by his
DEFORMITIES 67
sides, the surgeon sitting beyond the patient's head
holds both the patient's hands in his own corresponding
ones. The surgeon gradually draws the patient's
arms upwards, whilst the latter is told to take a deep
breath. Having reached the limit of extension, the
surgeon ceases to exercise traction on the arms, and
the patient begins now to draw the surgeon's hands
downwards to the original position. Full expiration is
made during this period. Both these movements have
to be carried out, as far as possible, in the plane of the
body of the patient, who must be told to keep his elbows
all the time in contact with the couch. The whole
movement is repeated about a dozen times. As the
patient gains strength, this exercise is gradually rendered
more difficult by adding resistance on the part of the
surgeon, and by allowing the patient's legs to hang
over the foot end of the couch, thus increasing the
extension of the spine (Fig. 25).
The last-named exercise is also very helpful in the
treatment of kyphosis or round shoulders, especially
when slightly modified. One or two cushions placed
just under the most prominent part of the spine, and
acting thus as a fulcrum, considerably increase the
extension of the vertebral column. This, however,
must be done with caution, so as not to cause any pain
or discomfort. Similar exercises are given in sitting
posture, the back of the patient resting against the
surgeon's knee. " Sitting flexion and extension " of
the trunk, with the patient's hands placed either
on his hips or on the back of his head, ought to be
always done with a certain amount of resistance
68 DEFORMITIES
applied to the "hump." Swimming movements are
generally very useful, especially if accompanied by
deep breathing.
A point of great importance in all these exercises is
the carriage of the head. The patient must be constantly
reminded to lift his head up as high as he can, because
only then a deep inspiration can be made, and a proper
expansion of the thorax take place.
Cases of kypho- scoliosis will of course require a com-
bination of both kinds of exercises, described under
scoliosis and kyphosis.
It is taken for granted that in all cases in which
scoliosis is due to an inequality of the lower extremities
(with regard to their length), the shorter leg will be
lengthened, either by a thickening of the sole of the boot
outside, or by an elevator inside, or both. As it was
repeatedly found that a large percentage of scoliosis
cases is caused by often very trivial differences of the
legs, every case of spinal curvature should be carefully
examined in this respect in the beginning of the treat-
ment.
Spinal deformities originating from an empyema
especially require breathing exercises.
Genu valgum as well as genu varum in children under
the age of six to seven are to a great extent amenable
to mechanic treatment. The application of splints alone
is never satisfactory, as it only helps to weaken the
limbs, favouring atrophy of the muscles. Although it
is very important indeed not to allow rickety children
to run about, yet it would be a great mistake not to
give them any exercises instead. Active movements
DEFORMITIES 69
cannot always be carried out properly by children of
that age, so that passive ones have to be chiefly relied
upon. Besides flexion and extension of the knee,
special movements tending to undo the deformity are
practised night and morning. The child's thigh is
grasped with one hand, and the leg with the other, and
bending as well as stretching movements are carried
out, whilst an attempt is made to straighten out the
curve. By such manipulations the ligaments become
loosened on the concave side, and the soft cartilage,
covering the bone ends, undergoes a transformation
which is necessary to correct the faulty architecture of
the joint. General application of mechano-therapeutic
measures in such cases will be considered lower down
under rickets, in the chapter on constitutional diseases.
Knock-knee and bow-legs in adolescents are past that
stage at which softness of the structures would permit
of a bloodless correction. But if an operation has
been carried out, massage should be employed from
the first, and movements carried out in the knee joints
should follow within a few days. Otherwise great
stiffness will result. The same applies to such an
operation as the subtrochanteric osteotomy, performed
for the correction of coxa vara. A case of this kind
in which massage and movements were only adopted
six weeks after the operation taught me how unwise
it is to immobilise the whole extremity for so long a
period. The patient's knee became so stiff and painful
that one might have thought it was Macewen's opera-
tion, and not a subtrochanteric division of the femur
that had been performed in this case.
70 DEFORMITIES
The importance of early movements after Murphy's
arthro- plastic operation or after joint excisions is, I
think, obvious enough, so as to render all further explana-
tions superfluous. Mobilisation of limbs must, however,
take place a few days after the operation, if it is to
be of any use whatever.
A very common complaint is flat foot. If every
medical man could take the trouble to examine all his
patients who suffer from pains in the feet, he would
find that 99 per cent, of them represent flat feet of some
kind or other. Mostly it is the first or second stage of
pes planus that the general practitioner has to deal
with. And it is just these two first stages that can
be cured by exercises alone.
The first stage is pain without deformity. The second
stage is pain plus deformity, which, however, can be
corrected by manipulations of the surgeon. In the
third stage deformity can only be corrected by great
force under anaesthesia.
There are two kinds of exercises for flat foot. Some
may be practised by the patients at home, the others
require assistance of the surgeon. Patients ought to
make it a rule to put their feet parallel when walking,
and not to evert them, as most people do. This is one
of the first causes of flat feet, probably provoked, or
favoured, by ill-fitting shoes. Peasants in certain coun-
tries of Europe, for instance in Poland, who never wear
boots except on rare occasions, always place their feet
parallel, and flat foot is scarcely at all known amongst
them. The same is reported of natives in tropical lands.
Besides following the example of primitive people in
DEFORMITIES
71
this respect, flat-footed patients should practise walking
round the room on the outer border of their feet, heels
raised off the ground, until they get tired (Fig. 26).
FIG. 26. — WALKING ON THE OUTER
BORDER OF THE FEET, HEEI.S
BEING RAISED OFF THE GROUND.
Tip-toeing, with heels kept wide apart, and the toes
turned in, should be repeated at least twelve to twenty-
four times, morning and evening (see Fig. 16). This
can be modified and rendered more difficult] by not
allowing the patient to touch the ground with his heels.
Lifting oneself up on the outer borders of the feet
without letting one's heels touch the ground is equally
good.
Apart from these very important exercises, patients
have to perform movements with their feet in all
directions except one. Flexion, extension, adduction,
and circumduction, are carried out first without, then
with, resistance ; abduction, however, is left out on
account of its favouring the flattening of the foot. Resis-
tance is effected by the surgeon's hands, one of which
grasps the leg just above the ankle, and the other across
the metatarsals.
Massage in these cases consists of stroking of the
72 DEFORMITIES
calf of the leg upward, as well as of the dorsum of the
foot. Kneading is done by placing both thumbs on
the dorsum, and the fingers on the sole of the foot.
The region of the calcaneo-scaphoid ligament is attended
to with special care, this being the most tender spot
of the foot. Should the arch be flattened, the foot is
bent repeatedly into the proper shape.
Pain is the first symptom to abate during such treat-
ment; after this follows the deformity. If the case
requires an application of plaster-of-Paris for the sake
of correcting the deformity, movements and massage
are employed as soon as the plaster is removed. The
plaster must not be left on too long, a fortnight being the
maximum, on account of muscular atrophy which fre-
quently occurs. Rest in bed is sometimes necessary in
cases where pain is unbearable, or where there is a
great deal of muscular spasm in the peronei.
Congenital flat foot, just as other congenital defor-
mities, such as club-foot or talipes equino-varus, always
requires individual consideration, so that the treatment
will be a different one in every case. It is, however, impor-
tant to remember that during the first month of life, as
well as after tenotomies, or plaster-of-Paris redressments,
massage and movements alone, or combined with light
splints or orthopaedic boots, are of an enormous value.
The same is to be said about paralytic deformities
such as those resulting from infantile paralysis and
others (see nervous disorders). It is to be borne in
mind that only exercises can really strengthen a muscle
• — rest can only weaken it ; this is a physiological fact
which nothing can alter.
DEFORMITIES 73
Massage should always be adopted as early as it can be,
because it has been noticed that the paralysis goes back and
muscles recover to a greater extent if properly attended
to without delay than if left alone until contractures
begin to appear. Paralytic conditions, due to injuries
or tight splints, are on the whole treated similarly.
In old-standing cases, or in cases where one group of
muscles is entirely paralysed, splints are of great service.
They help to overcome the action of those muscles
which were left intact, thus preventing contractures.
How far even very inveterate cases are capable of
improvement may be seen, from the two pictures
illustrating the case of Volkmann's ischsemic contracture
of the hand, referred to above (Figs. 5 and 6).
Traumatic congenital torticollis, due to rupture of
the sterno-mastoid during delivery of the head, seen
soon after birth, can be greatly improved if attacked
at once by manipulations. To hasten the absorption
of blood, massage in the shape of very gentle kneading
is applied to the torn muscle, by pinching it between
the thumbs and the first and second fingers. Later
on energetic passive movements of the head, which
put the damaged muscle on stretch, tend to prevent
cicatricial shortening. To that end the infant's head is
grasped by the surgeon with one hand, the other being
placed on the shoulder of the affected side, so as to
steady the child's trunk. The head is first rotated in
the opposite direction, and then extended in order to
overcome the action of the contracted sterno-mastoid,
which is a double one : flexion and rotation. Too
much force must not be employed, because of the risk
74 DEFORMITIES
of a fresh rupture. The treatment should be continued
for several months to prevent relapses.
Also in adults mechano-therapeutic treatment is most
advisable after an operative division of the tendon.
Movements of all kinds should be employed with great
perseverance, here again with the object of preventing
recurrence. An elastic bandage may be worn for
some time to keep the head permanently in a correct
position — also a poroplastic collar may be tried, but
should not be relied upon as the only measure.
SprengeVs shoulder, if noticed shortly after birth, can
be considerably improved by gymnastic exercises,
tending to increase the expansion of the chest. Swim-
ming movements, breathing exercises, bracing the
shoulders, in fact, every kind of movement mobilising
the scapulae, bringing them down and forcing them back-
wards, are of use. Should, however, a bony bridge be
present between the upper angle of the shoulder-blade
and one of the vertebrae — which is frequently the case —
this must be severed by operative measures, and the
exercises just described started without delay, and
carried out for months. The older the deformity, the
greater the difficulty of correcting it, and the more
energy and perseverance has to be put into the treat-
ment in order to obtain satisfactory results.
II. MEDICAL
THE application of massage in internal disorders requires
so much care and consideration — more even than is
necessary in most of the surgical complaints mentioned
above — that the author cannot help realising the great
responsibility resting with all those persons who are
left in charge of the administration of this therapeutic
agent.
Whereas the group of disorders referred to in the
first part of this book consisted mainly of troubles
affecting easily accessible and less vital parts, such as
limbs and other peripheral structures, all internal
diseases have a distinct bearing on the whole organism,
most of the parts thus affected being of first importance.
In the majority of cases now to be considered, the
diseased organs can only be indirectly influenced by
means of cautious manipulations, the effect of which
can only be defined by careful clinical observation.
It is clear therefore that no one who does not possess
some knowledge of both, manipulations and observa-
tion, should treat such cases.
Being fully aware of his own responsibility in re-
commending mechano-therapeutic treatment to others,
the author has a strong desire to collect only reliable
75
76 MEDICAL
material, as far as this is possible, and to avoid the
quotations of some too enthusiastic writers.
Those who have grasped the true meaning of mechano-
therapeutics — which, in fact, is suggested by the name
itself — will understand that only such diseases can be
directly and successfully influenced by massage and
movements, whose origin is due to some derangement
of the mechanical forces governing healthy organisms.
Hence it is not very likely that massage would have
any direct effect on such troubles as fevers or parasites.
Nevertheless, by improving the circulation, they may
help to eliminate toxic material and waste products,
and benefit the patient in this roundabout way.
Constitutional disorders, due to a slow or defective
metabolism, can also be influenced by our means, as
far as an increased amount of physical work is capable
of hastening and increasing the exchange of matter.
The dangers of rubbing a malignant tumour, or an
abdominal abscess, and causing metastasis all over the
body, are too obvious to require any further explanation.
It is, however, another question altogether if a patient
suffering from cancer wishes to be kept alive as long
as it is only possible, and massage is applied to his
limbs in order to preserve their strength ; but then
of course, the aim is here totally different.
We pass now to the discussion of individual systems.
A. CIRCULATORY SYSTEM
The main object of physical treatment in cardiac
diseases is to support the function of the heart, as that
CIRCULATORY SYSTEM 77
of a pump. The more of its work we can take over, the
better. The heart is an organ that cannot be put to
rest for so and so many hours a day, and then made
to perform some exercises at will ; yet it requires rest
when overworked, just as much as any other muscle
does, and it also must be helped to get stronger when
weakened through disease. Physiology, however,
teaches us that the only means of strengthening a muscle
is exercises. Hence it is perfectly clear that in order
to satisfy all these points we have to pump for the
heart on the one hand, and on the other hand to train
the cardiac muscle.
We can put this theory into simple words, and
explain it in the following way.
Supposing we had before us a system of pipes filled
with water and corresponding to the circulatory system
of the human body ; and in the centre of this system
one big pump to keep the water going round and round,
in order to supply different parts. Supposing this pump
was breaking down, and required a thorough repair,
but at the same time it was not possible to remove it
to the workshop. The best way of maintaining the
water supply under such circumstances would be to put
up a few smaller pumps in different places ; since it
does not much matter whether the pumping is done
in the centre, or at the periphery of the system, as long
as the amount of work carried out is the same. This,
however, is precisely the thing we intend doing in a
cardiac breakdown, because, after all, our circulation
is nothing else but a process of pumping blood from
one place to another, and if our pump goes wrong
78 CIRCULATORY SYSTEM
everything goes wrong, the health of distant parts
suffering most.
With regard to the effect on the circulation, it is of
no importance whatsoever whether the breakdown of
the heart is due to weakness of the cardiac muscle or
to vegetations on a semi-lunar or a bicuspid. Just so
little it matters to the water supply whether the
stagnation is caused by a defect in the cylinder or a
valve.
As far as the treatment is concerned, it is not of
much importance whether the case before us is one of
myocarditis or endocarditis. The more exact diagnosis
may, however, be of value when the prognosis is being
considered.
The moment we notice signs of incompensation we
have to step in, and do part of the heart's work, just
that part which appears to have become too much for
its strength.
Let us now consider what results are actually achieved
in these cases by drugs, and let us take digitalis as a
cardiac remedy par excellence. We know that its chief
effect is that of a stimulant to the cardiac action by
making the systole more complete, and by lengthening
the diastole. As one part of the diastole of the ventricles
is the only time during which the heart is really resting,
any prolongation of that period must benefit the heart
itself, and on the other hand any increase of its energy
during its contraction must benefit the circulation. All
this seems very logical until one realises the fact that
sooner or later the effect of both these actions is bound
to become nil : whatever strength is gained by the
CIRCULATORY SYSTEM 79
heart through the prolongation of its rest time, is spent
on the increased force of its systole.
The medicinal therapy has another drawback besides
the one just mentioned, and it does not much matter
which drug is administered. Cardiac stimulants merely
exhaust the organ, which, being spurred on, does its level
best, only in order to collapse after a short while, as
there is no such stimulus which would not be followed
by reaction. If we want to tide the patient over a
short critical period, reckoning on a natural solution
of the situation later on, we need not take this point
too seriously into consideration. Things are, however,
different when we know by experience that the period
of defective compensation is going to last for weeks, if
not for months ; to administer stimulants then, and
thus to exhaust the neuro-muscular apparatus of the
heart in a short time, is, to say the least, unwise. It
would be just as unreasonable to correct the action of
a bad pump whose valves are broken or whose piston is
crooked, by putting on more steam.
It is a well-known fact that muscular action promotes
arterial circulation in that part of the body which is
being moved. This can already be deduced from the
appearance of the skin alone. The contraction of a
muscle acts like a pump, or, still better, like a great
number of small pumps, because each fibre in its way
exercises pressure or suction on the neighbouring blood-
vessels. There are other signs of an increased circulation
besides, such as, for example, warmth — partly also due
to other processes — and the increase of volume of the
parts observed, which swell and become softer and more
80 CIRCULATORY SYSTEM
elastic, on account of a greater amount of fluid in the
blood-vessels. This latter condition is so different from
an oedema, where the fluid has left the vessels, and
has accumulated in the tissues around, that they can
readily be distinguished from one another by touch.
It is commonly observed that a quick stroking move-
ment carried out with a finger along a cutaneous vein —
especially in a centripetal direction — flattens the vein
for a period lasting considerably longer than the move-
ment itself. This shows that stroking of the skin presses
the blood out of the cutaneous veins, thus producing
negative pressure in the blood-vessels, and that such
manipulations suck the blood from the periphery to the
centre.
In these two agents — muscular action and centripetal
stroking of the body surface — we have examples of
mechano-therapeutic factors which, by means of
peripheral pressure and suction alone, help to restore
normal conditions in a perturbed circulatory system.
Besides these, however, there are other equally im-
portant and helpful factors. The enormous influence
of the respiration on circulation can be utilised to the
same end. There are particular movements of certain
joints which undoubtedly help pumping blood to and
from the limbs. Also kneading of the extremities assists
in the absorption of oedemata by pushing the transu-
dates out of the lymph-spaces into the lymph-vessels,
thus driving the fluid back into the system.
Finally, there is at our disposal the use of that large
reservoir represented by the abdominal Hood-vessels,
which we can fill with the overflowing fluid, and so
CIRCULATORY SYSTEM 81
relieve the circulation. To give an idea of the capacity
of these vessels it might be mentioned that cases of
sudden death have been reported in which the unex-
pected end was found to be due to cerebral anaemia,
caused by a too rapid tapping of ascites, and the conse-
quent sudden dilatation of the abdominal blood-vessels.
Artificially, we can, to a certain extent, produce a
similar effect by irritating the splanchnic nerves through
manipulations, such as abdominal massage in the shape of
very deep kneading. The obvious signs thus produced
are : an increased temperature of the abdomen, a more
or less marked drowsiness of the patient — due to a
slight anaemia of the brain — and a slower pulse as the
result of reflex stimulation of the vagus.
The effect of deep inspiration on the circulation has
been so thoroughly investigated by physiologists that
it is unnecessary to describe it here at any length. It
suggests, however, one more way of relieving the over-
burdened heart by deep inspiratory movements of the
thorax, which create a considerable negative pressure
in the big trunks of the venous system, and thus suck
the blood from the periphery with an enormous force.
In order to achieve a still greater pumping effect,
breathing movements may be considerably deepened
with the aid of the physician, the patient himself making
no efforts in this direction at all.
The anatomy and the mechanism of certain joints
show us another way of assisting the flow of blood
by means of passive movements. The blood-supply of
joints is, in general, very abundant, but some joints
possess particularly extensive anastomosis, such as, for
6
82 CIRCULATORY SYSTEM
example, the hip joint ; the number of veins round the
ankle joint is very great too, and quick rotatory move-
ments carried out at these joints by twisting, stretching,
and compressing the blood-vessels pump the blood very
effectively. Flexion and extension of the thigh have a
similar effect by compressing the femoral artery and
vein against Poupart's ligament. This latter action has
been compared to some one treading rhythmically
on a garden hose, and making the water squirt out with
a still greater force.
Based on the foregoing considerations we can easily
outline the plan of treatment in cardiac diseases, though
the kind and the amount of manipulations adopted in
every case must necessarily depend on the condition
of the heart. In bad cases great caution should be
exercised, and very slow progress only can be ex-
pected.
FIG. 27. — WRIST ROLLING.
If the patient is very feeble, we begin with stroking
and kneading of his extremities alone. The calves and
the thighs, as well as the forearms and the upper arms,
are methodically massaged in order to reduce the
CIRCULATORY SYSTEM 83
oedema, and to relieve the discomfort produced by
it. Passive exercises, such as foot rolling and wrist
rolling (Fig. 27), plus flexion and extension in these
joints, are gradually added.
It is absolutely necessary to watch the pulse, by taking
it before, during, and after the daily treatment.
Gradually, hip rolling is introduced, though this may
be started with right away, if the condition of the
patient allows it, and if these movements will not have
any deteriorating effect on the pulse. Hip rolling is
given quite passively, and is done by the physician,
who with one hand grasps the patient's foot, placing
his palm under the sole, and the thumb on the dorsum,
and with the other hand gets hold of the leg just above
the knee, which is kept bent. Circumduction is carried
out in the hip joint without any assistance of the
patient, who must learn to relax all his muscles, so as
not to exercise any resistance whatever.
Arm rolling is a much stronger movement, which is
given in a sitting posture, and therefore only applied
to lighter or more improved cases.
Abdominal massage — which will be described in more
detail in the chapter on the digestive system — ought
to be employed in every heart case. Besides the influ-
ence on the circulation it has a definite effect on the
digestion, which is often out of order in these cases.
Trunk exercises are of a great variety, and should be
practised according to the strength of the patient. We
begin with the lightest one.
" Trunk lifting " or " trunk raising " is carried out
without in the least disturbing the patient. The
84 CIRCULATORY SYSTEM
physician stands at the head of the bed and takes hold
of the patient's shoulders by placing his palms over
the shoulders and under the armpits, the thumbs on
the acromion. The patient is told to breathe deeply,
and with every inspiration the physician pulls the
shoulders upwards as far as it is possible, and then lets
them return to their original position. After a short
pause, lasting until the next inspiration, the movement
is repeated. Should any unpleasant symptoms, such
as giddiness or palpitation, occur during exercises, these
have to be either interrupted, or carried out with less
force. Gradually, other breathing movements, like those
described in connection with scoliosis, may be added,
and are, as a rule, found here very useful.
As soon as the patient is able to sit up, " trunk
rolling " is indicated, and the patient is now, to a
certain extent, expected to assist the doctor. The
patient sits on a stool, his hands resting on his hips,
and the physician, placing his hands on the patient's
shoulders, makes him perform rotatory movements in-
volving the upper part of his body. The pulse must be
taken every few minutes, and, should tachycardia be
observed, the patient must immediately lie down to
rest. Trunk lifting can also be done in sitting.
The effect of all these manipulations is precisely the
same as that of digitalis : the pulse becomes fuller and
more regular, its rate approaching the normal ; the
effect, however, is here a more lasting one. This is
explained by the fact that the heart's work has been
actually diminished, instead of being increased — as is
the case with most cardiac stimuli. Such treatment
CIRCULATORY SYSTEM 85
gives the pumping organ a good chance to recover,
and, by lowering the blood pressure, makes cardiac
failure from overwork practically impossible, provided
that no new aggravating factors supervene.
Mechano-therapy possesses another, more direct,
method of influencing the cardiac action, by either
increasing or decreasing the pulse rate and the blood
pressure. This is effected by a direct application of
certain manipulations to the cardiac region. The
experiments of Levin of Stockholm, who took about
8,000 pulse measurements, showed that stroking and
gentle vibration of the cardiac region reduce the blood
pressure and the pulse rate (by 10-20 heart-beats).
Hacking, and a more vigorous percussion of the thorax
over the heart, produce raising of the blood pressure
and an increased pulse rate (8-10). As this, however,
is not always equally well borne by all patients, it
should not be indiscriminately insisted upon.
Abdominal massage also reduces the pulse rate con-
siderably ; this is most likely due to a stimulation of
the vagus, which has a depressory influence on the heart.
(The author succeeded in lowering the blood pressure
in one sitting by 10 Hg., this having been the effect
of very gentle vibrations applied to the cardiac region,
and carried out with the hand alone.)
All the manipulations described above are applicable
to cases with a more or less marked loss of compensation^
since they are all meant to reduce the heart's work.
Should this help on to a complete return of compen-
sation, measures must be taken in order to strengthen
the cardiac muscle so as to make it capable of performing
86 CIRCULATORY SYSTEM
the usual amount of work expected from a normal
organ, and not merely of maintaining the circulation
under such favourable conditions as rest in bed and
daily massage. This can only be achieved by active
exercises.
Gradual increase of work strengthens the heart muscle
as it strengthens other muscles. This, however, is only
possible after a prolonged period of cardiac rest in the
beginning of the treatment just described. The plus
work consisting of exercises is, of course, not carried
out all day long, but during a very small part of it only.
The active exercises here adopted are even more
numerous than the passive ones. Besides those already
mentioned, which can also be done voluntarily, there
are many others, comprising, in fact, every possible
movement of the body. All of them can also be per-
formed against resistance. This circumstance gives
us means of regulating their force at will, and thus
enables us to have a direct control over the heart's
work.
Movements involving the extremities are less fatiguing
for the patient than those of the trunk, on account of
their smaller weight. Thus, requiring less muscular
action, the legs and the arms should first be commenced
with ; flexion and extension, abduction, adduction and
rotation of the feet and wrists, as well as movements
of the elbow and the knee, shoulder and hip joints, are
employed either in lying, sitting, or standing. The pulse
is, of course, taken frequently to prevent unpleasant
complications.
Though practised by the Swedish gymnasts long before
CIRCULATORY SYSTEM 87
Schott, most of the resisted exercises were included in
what is nowadays termed the " Nauheim treatment."
They are of beneficial influence in cases of dilatation of
the heart, tending to diminish the area of cardiac dulness,
as proved by percussion. Also irregularities of all kinds,
especially those following infectious diseases, are often
completely cured. Patients suffering from a simple
nervous palpitation, or from some other kind of an
abnormally agitated cardiac action, always express
their satisfaction at the soothing effect of massage and
movements, and find that each sitting steadies their
heart, and relieves the oppression in the chest. Cases
of valvular disease are helped to maintain a satisfactory
compensation, or to regain it if the latter has been lost.
Little definite can be said of the duration of the
treatment, as it always depends on the individual case.
However, a lasting effect can be obtained already after
a course of six weeks, shorter treatment being of use
only in very mild cases. Another course of six weeks
is sometimes required after an interval of a few months,
and there is, of course, no objection to a prudent adminis-
tration of drugs in conjunction with physical therapy.
B. RESPIRATORY SYSTEM
At first sight it may perhaps seem strange that
mechano-therapeutics could have any bearing whatever
on this group of maladies. Experience, however,
furnishes us with ample evidence that the application
of mechanical treatment in selected ca,ses is undoubtedly
88 RESPIRATORY SYSTEM
of great value. Thus, we have in Sylvester's method of
resuscitation of the drowned the best proof of the efficacy
of mechanic measures as applied to cases of asphyxia.
The value of artificial respiration will hardly be ques-
tioned by anybody who has had to adopt it in critical
moments.
Massage plays an important role as a preventive
measure against hypostatic pneumonia in old or very
debilitated persons, who have to be confined to their
beds for a long period. The only cause of this trouble
is — as suggested by the name itself — a defective circu-
lation, such as a stasis in the big pulmonary blood-
vessels.
In the foregoing chapter means were described with
the aid of which bad circulation could be improved in
cardiac diseases. Hypostasis of the lungs, being only
a symptom of deficient cardiac activity, and not a
disease in itself, must be treated on the same lines as
all the other circulatory troubles. To avoid unneces-
sary repetition, readers are referred to the chapter on
circulatory system.
An addition now worth making is the clapping of
the thorax with both hands as well as shaking : two
movements which hold good in all pulmonary troubles
treated by massage. They are done by placing both
hands flat on the patient's chest, and clapping it sys-
tematically all over, whilst the patient is either sitting
or standing. The physician then, without changing
his position, turns his hands over, and does the same
manipulation on the patient's back, moving up and down,
and to the sides. The clapping has to be carried put
RESPIRATORY SYSTEM 89
extremely gently, and must not cause any pain or dis-
comfort whatever.
The shaking, one of the most difficult movements that
exists, is carried out in the recumbent posture as follows.
One slips both one's hands high up under the patient's
shoulders, palms upwards (the patient lying on his
back), then, lifting the patient's trunk slightly off the
bed, his thorax is shaken by gentle vibratory move-
ments, whilst the hands are sliding in a downward and
outward direction towards the hypochondriac region.
This being reached, the movement is finished off by
a gentle compression of the thorax. Both these move-
ments, shaking as well as clapping, require practice
combined with some skill on the part of the adminis-
trator, and an absolute passivity and deep respiration
on the part of the patient. Clapping is done with both
hands alternately during the patient's expiration, as
well as during the inspiration, whereas in shaking both
hands are employed simultaneously, and only during
the expiration.
Clapping and shaking are successfully applied in those
pulmonary complaints where there is a great difficulty
of expectoration, in chronic bronchitis for example. This
is pre-eminently benefited by such manipulations, as
they loosen the tough secretion, and help to detach it
from the mucous membrane of the bronchi. How far
this is possible, anybody can test for himself, though
not suffering from any definite respiratory trouble :
after two or three such movements he will probably find
it necessary to clear his throat, if not actually to cough
up some phlegm, the source of which is not apparent,
90 RESPIRATORY SYSTEM
In fact, every chronic condition of the respiratory
tract associated with an abundant and thick secretion,
such as asthma, emphysema, bronchiectasis or fibrinous
bronchitis, is likely to derive benefit from mechanical
treatment.
That these methods are particularly called for in
cases where the pulmonary trouble has been caused
by a primary heart disease, need not be especially
emphasised. In cases of a compressed or collapsed
lung with old-standing pleuritic adhesions the exercises
are directed towards increasing the vital capacity, chest
lifting and trunk rolling being here particularly suitable.
Acute and chronic catarrhal laryngitis are to a great
extent curable by massage of the neck carried out with
the intention of reducing the congestion of the throat.
We can achieve this by emptying the jugular veins on
both sides of the neck, as well as by influencing the
lymphatics. This is best done by deep downward
FIG. 28. — NECK MASSAGE.
First Stage of Stroking.
stroking manipulations carried out along the anterior
borders of the sterno-mastoids in the following manner.
The patient sits with his neck exposed, and his hea.d
RESPIRATORY SYSTEM 91
is supported against the back of an easy-chair. The
physician stands in front of him, and places both ulnar
borders of his hands behind the patient's ears (Fig. 28).
Then, moving his hands downward, he presses them
FIG. 29. — NECK MASSAGE.
Second Stage of Stroking.
into the grooves in which the big blood-vessels are
situated. Arriving at the middle of the sterno-mas-
toids, he quickly turns his hands round, so that the
ulnar borders are replaced by the thumbs, which
continue the movement as far as the sterno-clavicular
joint (Fig. 29). This manipulation must be done firmly,
yet lightly and quickly, and should be frequently
repeated during five to ten minutes daily.
Besides this, vibrations should be applied, if possible,
to the larynx by means of an electric motor, placing
a soft flat rubber piece to both sides of the thyroid
cartilage. This helps to detach the secretions from the
mucous membrane, and at the same time it supplies
the affected organ with fresh blood. To do this kind
of massage with the fingers is extremely fatiguing,
though this was originally practised in Sweden. A
92 RESPIRATORY SYSTEM
small round rubber piece of a harder consistence than
the first one is used to influence the deep cervical
vessels and glands. Some go even so far as to massage
the axillary glands, which, however, is hardly ever
necessary.
That massage is most useful in cases of catarrhal
pharyngitis and laryngitis can be experienced by every
one who, when suffering from either of these complaints,
applies gentle rubbing to his throat : the unpleasant
feeling in the pharynx and the hoarseness will thus be
soon relieved.
It will be seen from the description of the following
case of mine how even inveterate cases may be benefited
by massage. A young singer for several years suffered
from catarrhal laryngitis, and though her voice was
otherwise considered very good she had to clear her
voice every few minutes, especially whilst singing. In
talking, her voice often broke down, and she had to
make great efforts in order to get rid of the temporary
hoarseness. During two months she received daily
treatment on the lines described above, practising being
quite forbidden for that period, and she improved so
far that at the end of the term, in spite of her missing
several months, she obtained a medal at the Academy.
C. DIGESTIVE SYSTEM
The main views expressed in the other chapters hold
good here, and we find that those digestive troubles
which are due to mechanical causes are benefited by
DIGESTIVE SYSTEM 93
mechano- therapeutic measures. Great improvement
may be expected from massage where the motility
of the intestinal apparatus is impaired, and where
the primary cause lies either in the atony of the
muscular wall of the viscera, or in the weakness of the
abdominal wall. Of course, cases in which the functions
of the bowels are in any way impaired by an acute
or a chronic obstruction, being unsuitable for massage,
will, as a rule, necessitate the adoption of operative
measures.
In cases of dilatation of the stomach, the gastric
contents, failing to be transmitted through the pylorus
into the duodenum within the proper time, must be
pushed along by mechanical means ; otherwise stasis,
fermentation, and great discomfort will arise. There
is no other way of emptying the stomach in the right
direction, except with our hands used as a substitute
for the normal action of the gastric musculature.
Particularly well suited for our treatment are vibra-
tions when applied to the epigastric region. They
may either be carried out with the hands, which are
placed flat on the abdomen, the fingers transmitting
the shaking movements on to the stomach, or a motor
may be used. In the latter case a soft rubber piece
is chosen, though manual treatment is much to be
preferred.
The treatment begins under the left hypochondrium,
where the cardiac orifice is expected to lie, and is con-
tinued towards the pylorus. The hands are held
slightly inclined towards the outlet, and they have
to perform such movements which tend to expel the
94 DIGESTIVE SYSTEM
gastric contents into the duodenum. These manipula-
tions, however, ought not to be performed too soon
after the patient has taken his food : one or two hours
after a light meal will as a rule suffice in order to prevent
all unpleasant sensations.
Dilatation of the stomach is often combined with a
general atony of the intestines resulting in constipation,
and therefore general abdominal massage is always
indicated in these cases. As, however, constipation is
a complaint in which nowadays massage has become
the most popular kind of treatment, advocated by the
highest medical authorities, special attention must
now be given to this widespread mischief and to
its cure.
Constipation is mainly due to a sluggish peristalsis
which causes an abnormal absorption of water, and
therefore an excessive inspissation of faeces. Hastening
of peristaltic movements, on the other hand, always
provokes soft stools. Most of the aperients used have
an accelerating influence on the intestinal action, either
through an irritation of the mucous membrane, or
through a stimulation of Auerbach's plexus. Other
drugs, such as opium, for instance, cause artificial con-
stipation by slowing down the peristalsis. Unfortun-
ately, the effect of drugs is in reverse proportion to
the length of time during which they are administered.
The excitability of the nerve centres as well as of the
mucous membrane of the intestines, becomes lessened
and replaced by an increasing indifference to such
stimuli. And, as the habit of taking aperients grows,
so the doses have to be enlarged. The result of such
DIGESTIVE SYSTEM 95
practice is, generally speaking, a total failure after a
few months, or years.
The proper and the most ideal treatment of consti-
pation would be that which would strengthen the un-
striped muscles of the whole intestinal tract ; but par
excellence it is the muscular coat of the large intestine
that has to be strengthened. Only those measures can
be really successful which tend to establish normal
conditions. Habitual taking of remedies, however, can-
not be called normal. The only method approaching
this ideal treatment is afforded by mechano-therapy ;
since in this case, as well as in all the others, the object
of our treatment is the strengthening of muscular tissues
through exercising them.
Massage of the abdomen consists in the first place of
bimanual kneading all along the ascending, transverse,
and descending colon in a circle, thus following the
physiological direction of the peristalsis. The patient
is lying with his head raised and his knees slightly
flexed in order to relax the abdominal muscles as com-
pletely as possible. The hands are placed one on top
of the other, the finger-tips being placed directly over
the large intestine. This can be distinctly felt when
containing faecal masses.
Some patients state that as soon as massage of the
ccecum is begun, they feel the necessity of emptying their
bowels, an effect which is probably due to a reflex of the
ccecum on the rectum. Manual treatment of this kind is
much more efficient than the rolling of a cannon-ball, as
advocated by some ; it goes much deeper, and it helps
mechanically to push along the contents of the bowel.
96 DIGESTIVE SYSTEM
There are other useful manipulations belonging to
abdominal massage. Such, for example, is .the knead-
ing of the whole abdomen, which is carried out much
in the same way as the colon massage, only including
the small intestines as well. Here both hands of the
manipulator grasp the whole of the stomach, the patient
being placed as above. The physician sits on the
patient's right, and puts his right hand flat above the
right iliac crest, and the left hand below the left hypo-
chondrium. The movements are carried out so as to
bring the two hands together in the middle, whilst
exercising pressure on the structures below. The same
is repeated after the hands have been reversed.
Massage of the abdominal muscles is done in the same
way as that of other muscles, kneading, however, being
mainly applied, since hacking would be very inappro-
priate on account of the unpleasant sensations thus
caused, as well as on account of a possible shock. Hack-
ing would also be quite useless without having any solid
background for the parts thus treated. In kneading,
the abdominal parietes have to be firmly grasped with
both hands, at right-angles to the recti muscles, and
treated as if they were dough.
We arrive here at a point where the condition of the
abdominal muscles ought to be considered, since that
is, in my opinion, as important as the intestines them-
selves. Indeed, there is no other factor that would
favour habitual constipation as much as the weakness
of the abdominal wall. Not without significance is it
that we find this complaint so much more common in
women, who wear corsets, and who do not over-indulge
DIGESTIVE SYSTEM 97
in exercises, than in men. Stays and want of physical
training produce atrophy of the trunk muscles, this
necessarily leading to great difficulty in emptying the
bowels during defcecation, as well as difficulty in
emptying the uterus during parturition. Comparison
is often drawn between civilised women and their
primitive sisters who still use their own strong muscles
as a natural support, instead of the ridiculous product
of our fashions.
Ploss and other great authorities on women's customs
and habits, as well as travellers, state that to most
native women a confinement is just as easy and quick
as an act of defsecation, which can rarely be said of our
patients. These would, however, be greatly benefited
in both respects by appropriate exercises, directed to-
wards the strengthening of the abdominal muscles, and
particularly of the recti muscles.
Besides massage, patients suffering from constipation
ought to perform the following movements : lying on a
bed, couch, or floor, they raise their trunk, whilst the
hands are kept by the sides. The legs should be strapped
or held by the person administering treatment, this
rendering the exercises easier for beginners. Another
exercise consists of " leg raising," whilst the trunk is
kept quiet. The knees can either be bent (easier) or
kept straight (more difficult) . These exercises may be at
first performed passively, by the medical attendant, or
voluntarily, by the patient himself or herself, or against
resistance, according to the strength of the patient,
and the progress that has been made. Resistance is
effected by placing one's hands flat on the patients'
7
98 DIGESTIVE SYSTEM
back and chest in the case of "trunk raising," and on
the knees in the case of " leg raising." Each exercise
should be performed slowly, and should be repeated
six to twelve times. Slight pain may be experienced
in the recti muscles after the first day or two, which,
however, promptly disappears. It will be surprising
to find how very few women can do " trunk raising "
without assistance— a movement which, as a rule, does
not present any difficulties to men.
" Trunk bending " in a standing position, the hands
being here placed on the hips, as well as " trunk rolling "
in a sitting position, are both most useful exercises which
can be practised in addition to the first-mentioned
ones, combined of course with abdominal massage.
A very good, though rather complicated, movement
is the following. Ihe patient rests both hands on a
mantelpiece, or, in fact, on any object on a level with
his shoulders, the arms being kept at full extension
all the time. The manipulator places one of his own
hands on the patient's chest, and the other on his back.
The patient is told to raise himself on tip-toe, and to
push his trunk forward without bending the arms.
The second part of this exercise consists of the patient
bending his knees completely, without getting down on
his heels. The third part consists of pushing the trunk
backwards and straightening out the knees. Finally
the patient returns to the original position by putting
the heels to the ground. During the first half of the
exercises the administrator effects resistance, preventing
the patient from bending his legs by a slight upward
movement of his (administrator's) hands, and during
DIGESTIVE SYSTEM 99
the second half of the exercise he does the contrary
by a downward pressure.
A treatment carried out on the principles outlined
above is the best that can be directed towards a
cure of the causes of intestinal stasis. It is most
beneficial in cases of toxaemia of alimentary origin, and
is certainly helpful in such condition as flatulence.
This applies not only to adults, but also to infants.
Personally, I have seen very good results from vibra-
tions and gentle kneading applied to breast babies.
A relief of that common yet so very embarrassing
complaint (caused in most cases by swallowed air)
follows promptly after a single sitting.
Several authorities who took part in the recent dis-
cussion on alimentary toxaemia, held by the Royal
Society of Medicine, expressed themselves strongly in
favour of abdominal massage as a treatment of con-
stipation.
D. CONSTITUTIONAL DISEASES
The main cause underlying all constitutional troubles
is defective metabolism. Either it is a faulty meta-
bolism of fats, or that of carbohydrates, or proteins,
the result of it being either adiposity, diabetes, or gout.
Anything that would stimulate the sluggish process
of transformation of these matters would necessarily
bring benefit to those who suffer from the above-men-
tioned disorders. We all know that there is no other
natural way of raising the metabolism but muscular
100 CONSTITUTIONAL DISEASES
action ; in this factor we have a kind of stove in which
we burn our materials otherwise wasted. Everything
in the way of food taken must be either used up in
the stove, or stored up somewhere in the body, or
else it is wastefully eliminated. In a healthy subject
either the whole amount of the introduced material is
burnt, or a little of it is left over, and deposited as a
reserve to fall back on in case of need.
Constitutional troubles arising from the third possi-
bility, namely, from taking too little nourishment, are
not often met with, and can as a rule be readily dealt
with. In fact, diabetes, gout, and adiposity are gener-
ally accompanied by an excessive introduction of fuel
which cannot possibly be all burnt in the normal way.
Restrictions with regard to food are thus of first
importance, and they cannot be replaced by any other
measures. However, in order to help the organism in
dealing with matters under the abnormal conditions
created by the disease, we must attempt to keep up a
bigger fire in the stove, since this will enable the patient
to get rid of the abnormal bulk of fuel which is not only
useless, but can become positively dangerous. In other
words, we have to break through the vicious circle
set up in these cases : want of muscular action leading
to an excessive accumulation of foodstuffs, and the
excessive accumulation of foodstuffs leading to a
decrease of muscular action. The best results will
be achieved by interrupting this circle at two places :
cutting off the excessive import of fuel by reducing
the amount of food, and increasing the fire by introducing
exercises and massage.
CONSTITUTIONAL DISEASES KM
It would be impossible to describe special treatment
for every constitutional disease. All that can be said
is that the treatment here has to be general, as general
are the diseases. It has to include all parts of the
body, as we do not really know where the seat and
the origin of the disease lie. Local applications will
thus be rarely called for, if at all.
General massage in constitutional disorders consists,
briefly, of the following manipulations: kneading and
clapping of legs and arms, as well as kneading and
hacking of the back ; abdominal and neck massage ;
foot, leg, arm, and trunk rollings ; breathing exercises.
Flexion, extension, circumduction, and adduction plus
abduction in all the joints where such movements are
practicable, should be carried out passively, voluntarily,
and against resistance, according to the patient's state
of health.
Breathing exercises are especially given at the begin-
ning and at the end of the daily sittings. Abdominal
massage and trunk raising are particularly commended
in adiposity, which is always accompanied by weak
trunk muscles. Such treatment is here followed by
a decrease of fat and an increase of muscular tissue.
The main object of mechano- therapeutics is thus to
increase the oxidation of the heating materials, and
the function of breathing exercises may thus be com-
pared to a Bessemer furnace which enables us to main-
tain a high temperature which is necessary for the burn-
ing of excessive fuel. This certainly applies to fats and
carbohydrates which are par excellence coal and wood
in the body's household.
102 CONSTITUTIONAL DISEASES
Similar ideas lead us to the application of massage
also in those constitutional maladies which result from
insufficient fool absorption and assimilation due to
an abnormally low consumption. This is the vast
number of cases classed under the headline of debility.
We shall always be in the position to benefit these
cases as long as we succeed in raising the consumption,
and in maintaining a proper metabolism. We have
to increase the body economy on rational lines, which
means that nothing should be wasted either by being
thrown away, or by being stored up.
By stimulating the appetite with physical factors
such as massage and exercises, we assist the debilitated
organism in a better assimilation of food. This is the
reason why mechano-therapeutics are so often advo-
cated by high authorities as a suitable after-treatment
in cases of prolonged and wasting diseases, whatever
their nature may be. The results achieved by massage
in these patients are often astonishing, and this is also
perfectly clear, since all we are aiming at is to find
here a substitute for the physical actions of the body.
This point ought to be always considered as soon as the
normal metabolism of an individual is upset on the
one hand by the disease, and on the other by want of
exercises.
All that has been said about debility applies equally
to ancemia, and other allied conditions, springing from
a defective metabolism of salts (ashes), such as, for
example, rickets.
It is true that we know very little about the inner
mechanism of our body, and still less about its ups and
CONSTITUTIONAL DISEASES 103
downs. This, however, does not justify the adminis-
tration of tonics alone, which, after all, are by the
majority our profession believed to be practically useless,
and it also does not at all justify the disregard for other
more normal measures, here described.
It may be added that in stout patients mechanical
treatment can be applied very vigorously, and the fat
parts subjected to an energetic kneading, hacking, and
clapping ; the condition of the heart, however, must be
carefully watched so as not to throw on this organ
more work than it can comfortably deal with.
E. URINARY SYSTEM
Though a direct influence of mechanic measures on
the kidneys can hardly be effected, indirectly, so far
as the improvement of the circulation is concerned,
these agents prove to be of great value. Our interest
must be in the first place directed towards relieving
the heart's task, which is markedly increased in nephritic
cases, so that everything which had been said in the
chapter on cardiac diseases applies here.
By massage and movements we reduce the oedemata,
and help the heart to cope with its work under such
difficult conditions as high blood pressure.
Vesical troubles, such as incontinence and retention,
are more or less directly amenable to manipulations.
The treatment consists in these cases of massage of
the bladder through the abdominal parietes, or through
the rectum, or both. The patient assumes a half -lying
and half-squatting position on the couch, his knees
104 URINARY SYSTEM
being drawn up towards his chest, and his head being
raised as high as possible. The index finger of the
right hand is introduced into the rectum, and the left
hand influences the bladder through the abdominal
wall, in other words, the massage is bimanual. The
patient may, as an alternative position, be seated in
a chair, his arms supported so as to relax the belly
muscles completely. Both hands are pushed into the
pelvis just above the fundus of the bladder, the fingers
being slightly bent, though kept rigid. Downward
pressure is exercised on the bladder, which, if contain-
ing too much urine, has to be catheterised previous to
treatment. The patients should be warned that the
muscles may be a little tender for the first few days.
The object of this kind of treatment is fairly obvious.
When incontinence is caused by a weakness of the
sphincter, this muscle will become strengthened by
mechanical stimuli, just as any other muscle would.
When, on the other hand, retention is due to a relaxa-
tion of the detrusor vesicse, a similar effect resulting
in a better function of this muscle may be expected.
If a cramp of the sphincter be the cause of retention,
urine will be forced through by manipulations.
This treatment is not suitable in acute inflammatory
conditions of the urinary tract ; chronic catarrhal
cases, however, may be greatly benefited by massage.
F. NERVOUS SYSTEM
The application of massage in nervous disorders has
become so wide of late, and the results have been so
ORGANIC 105
encouraging, as compared with other methods, that a
more detailed consideration of mechano-therapeutics in
connection with this class of maladies will be required.
For the sake of facilitating the survey, the usual
classification of nervous diseases will be adhered to.
ORGANIC
1. LOCOMOTOB ATAXIA OB TABES DOBSALIS
The credit of the introduction of mechano-therapeutic
treatment of tabes into the wider medical world is due
to Frenkel. It was he who first made an attempt to
put these methods on a more feasible basis, though
Swedish people still claim their priority with regard
to this invention, and it is very likely that such treat-
ment was practised in Sweden long before the Swiss
doctor published his ideas.
The quintessence of his scientific elucidations of what
his methods in particular are meant to achieve, and in
what way he thinks that they are better than all the
others, could be expressed in a few words. Personally,
I have not perceived any substantial difference between
the various systems, but I am rather inclined to believe
that the result of any of them will always be satisfactory,
when carried out intelligently, no matter whether the
methods be Swiss, Swedish, or English.
The counteracting of the main part of the trouble
will always be the chief object of every kind of treat-
ment. The main feature of ataxia being the loss of the
sense of co-ordination, anything that assists in regaining
the lost muscle sense must be here of value.
106 NERVOUS SYSTEM
A patient in the atactic stage of tabes is like a little
child that cannot walk properly. In both the equilibrium
is impaired by a defective sense of co-ordination : the
first one knew it, but lost his knowledge ; the other has
not learnt it yet. And just as a child by constant
exercises learns how to use his limbs co-ordinately,
so the atactic patient has to learn how to re-educate
his limbs by constant exercises. In order to do that,
however, it is not absolutely necessary that the patient
should rigidly adhere to the exercises described by
Frenkel, and which are carried out with the aid of his
ingenious appliances, because these can easily be replaced
by our own hands and fingers.
As the chief idea of mechano-therapeutic treatment
of tabes is to teach the patient how to develop his
muscle sense — in other words, to teach him to walk
as other people do, and to grasp with his hands objects
of ordinary life as normal individuals do — these every-
day movements must be practised above all. To make
the patient's task easier in the beginning of the treat-
ment all those movements, apparently simple, have to
be divided into their components, and such elementary
movements practised first. Leg exercises can be prac-
tised in bed, and arm exercises at a table. The patient
is told to place his heels or his toes precisely on a spot
indicated by the teacher, whose hands and fingers are
substitutes for Frenkel's appliances. The movements
thus practised are, once flexion or extension, then
abduction and adduction or rotation, their range
being gradually increased, and this is gone through
every day to make sure that what the patient has
ORGANIC 107
learnt has not been forgotten. Each limb is first
practised separately, then both legs or arms together
are made to perform the same or different movements.
Walking is taught with the aid of footsteps, drawn
with chalk on the floor. The steps should be small
in the beginning, the interval between each being
gradually increased. The same applies to the upper
extremities.
Frenkel advises his patients to practise piling up
round pieces of wood (not unlike draughts) or putting
their fingers through small holes on a kind of chess-
board, or placing small bits of wood into these holes,
the latter performance being similar to the work of a
telephone exchange official. But, in fact, many new
exercises can readily be invented, and they will all be
found useful if they only fulfil one condition, namely
that of educating the sense of equilibrium.
In bad cases, that is in such cases in which the inco-
ordination is far advanced, one has to start with passive
movements which help to train the nervous tracts to
receive the right reflexes, and to make the limb obey
the impulses of will. As far as the accuracy is con-
cerned, voluntary movements can become possible only
by degrees.
Whether a complete and radical cure of ataxia can
be achieved is rather doubtful. Great improvement,
however, is the rule, and bedridden patients are often
enabled to rise, and to get about. It is well known
that the presence or absence of ataxia does not
yet decide the fate of the patient. Other symptoms
may come more to the foreground, and may cast a
108 NERVOUS SYSTEM
shadow on the improvement of inco-ordination gained
by mechano- therapy.
Bladder symptoms can greatly be ameliorated by
manipulations described in the chapter on the urinary
system.
Sensory disturbance, such as the lightning pains or
the weakness of the patient, call for a general appli-
cation of massage, consisting of kneading and hacking
of the limbs and of the trunk.
General paralysis, but especially its form called tabo-
paralysis, should be treated in a similar way.
2. PROGRESSIVE MUSCULAR ATROPHY
(Amyotrophic lateral sclerosis]
Muscular dystrophy and spastic paralysis of infants
(Little's disease), though presenting an insuperable
obstacle to any other kind of treatment, are nearly
always influenced by massage and exercises which are
applied to the parts thus affected.
The spasm of the muscles is best overcome by passive
movements, which have to be carried out energetically,
though painlessly. Once the range of movements of
the limbs has approached the normal, active movements
will be found to be considerably easier.
The sooner commenced, the better results can be
obtained by such measures, and also, had an operation
been performed with the object of tendon transplanta-
tion to the spastic muscles, mechano-therapeutics form,
nevertheless, a very important adjuvant to the after-
treatment.
ORGANIC 109
3. ACUTE ANTERIOR POLIO-MYELITIS
(Infantile paralysis)
This is probably the only spinal disorder in which
massage, as proved by the highest authorities, has
always given excellent results, not even to be compared
with those of electricity.
The general scheme of management of infantile
paralysis ought to be the following.
Directly the febrile stage has passed, and loss of
power in the limbs has been noticed, the paralysed
parts must be daily subjected to rubbing, pinching,
kneading, and hacking. It is of first importance that
the treatment should begin as soon as the acute stage is
over ; otherwise hopeless deformities will result. The
intact muscles contract considerably and stretch the
paralysed ones, thus not leaving them any chance of
recovery.
We do not possess any better means of preventing
such undesirable consequences of paralysis than massage
and movements. Very often the overstretched muscles
are not totally paralysed, and have not completely
lost their excitability and contractility at the time of
the active disease, and only underwent an extensive
atrophy as a result of disuse. Exercises therefore are
indicated which stretch the contracted muscles and
contract the stretched ones. Should contractures have
developed before the treatment begins, splints or other
orthopaedic appliances must be made use of, as the
shortened muscles have a great power of resistance.
Especially during night-time light splints may be worn,
110 NERVOUS SYSTEM
which are frequently readjusted as the improvement
progresses. During the day-time massage and exercises
have to be carried out as often as possible, and with
great perseverance. The treatment should never be
given up before six months are over, because some
muscles recover very late.
When splints are used, the limb should be placed in
an over-corrected position, so that, for instance, when
the flexors of the wrist are contracted, and the extensors
paralysed or paretic, the hand should be put up hyper-
extended.
Celluloid splints have the great advantage of fitting
every shape of limb, and are made precisely in the same
way as celluloid jackets described above under the
treatment of scoliosis.
The splint should be worn for a considerable period,
and if left off must be reapplied as soon as there are
any signs of relapse.
The paralysis resulting from anterior polio-myelitis
tends to go back of itself to a certain extent in the first
few weeks after the attack, leaving some groups of
muscles completely paralysed, others only paretic ;
some that were powerless in the beginning recover soon,
even without treatment. This fact might possibly
sustain the belief that the whole of the paralysed area
will recover in the course of time. This, however, has
not been proved by experience. A certain number of
muscles do not and cannot recover without adequate
treatment, for the reasons stated above, the main
reason being the tendency of the antagonistic muscles
to become contracted.
ORGANIC 111
Taking for granted the fact that a muscle can develop
through practice, and that only muscular tissue possesses
the quality of generating new muscular tissue, we can
expect good results from all those muscles which have
not completely perished. Where some few muscular
fibres have remained untouched, there the benefit of
massage and exercises is evident. Electrical treatment
can, of course, be carried out simultaneously, but, if
we may quote an authority like Osier, it cannot be
compared in its results with the effect of the other
treatment.
There are two kinds of resisted movements recog-
nised in Sweden— co ncentric and excentric. One of them
is considered to be particularly helpful for restoring
muscular power in paralytic cases ; both are executed
by the patient as well as by the person administering
them. In concentric exercises the patient performs
the movement, resistance being executed by the gym-
nast ; in the excentric this process is reversed. The
difference between these two movements is that in the
concentric exercises the amount of the resistance is
determined by the gymnast, whereas in the excentric
ones it is the patient himself who, according to the
strength of his muscles, offers resistance.
The effect of each concentric movement is a shortening
of the muscles, whilst the resistance is overcome. The
effect of the excentric movement is an elongating of
the muscles, caused by their yielding to the resistance.
It is held by many Swedish authorities that the
excentric movements have a particularly strong restora-
tive effect on paretic as well as contracted muscles.
112 NERVOUS SYSTEM
4. CEREBRAL HAEMORRHAGE
In treating cases of cerebral haemorrhage it is essential
to avoid everything that might possibly aggravate the
condition of the patient by unnecessary shaking of the
patient's body. But, when all precautions against a
renewed bleeding have been taken, it is of great import-
ance from the first days of the illness to prevent the
formation of contractures. Gentle upward stroking of
the affected arm and leg, and very gentle and slow passive
movements, performed without disturbing the rest of
the patient, reduce the muscular spasm. Later on,
when the danger of another apoplectic stroke has
become considerably smaller, a more energetic treatment
can be carried out. It will be found that much better
results can be obtained easily when the necessary
measures, as described, have been taken immediately.
No time and energy are thus wasted on the correction
of contractures, which, if neglected, become a source
of annoyance to the patient as well as to the medical
attendant.
This is particularly the case with the upper extremity,
which generally becomes readily deformed, probably on
account of the greater range of movements possible in its
joints, as compared with those of the lower extremity, and
on account of the different groups of muscles affected.
In the arm the chief muscles paralysed are the exten-
sors, therefore the resulting deformity will take the
shape of a multiple flexion ; at the elbow, wrist, and
finger- joints. In the lower extremity it is the flexors
of the thigh and the extensors of the foot that suffer
ORGANIC 113
most. The issuing contracture is here never so great
as in the arm, but the knee is mostly extended and
the ankle flexed, causing the characteristic dragging
of the foot, and swinging it round in a half-circle in
walking.
Should the tendency to contractures be great in spite
of all the steps taken, the application of light splints
will be indicated, and the limbs should be put up in
slightly over-corrected positions. Massage is, of course,
applied daily.
The use of paralysed limbs in these cases can to a
great extent be reacquired by an adequate education
of the nervous tracts, because there is no primary
atrophy of muscles, the lesion being that of the upper
neuron. Muscular atrophy in these cases is a secondary
symptom, produced exclusively through want of proper
exercises.
Speech disturbances, often met with in cases of right-
sided hemiplegia, require similar attention. The pro-
nunciation of single consonants must be practised with
great perseverance, the use of a mirror being here of
considerable service, as it shows the patients how to
shape the mouth.
Though the extent of hemiplegia may become reduced
within a month, the picture described above shows
what commonly remains as a permanent result of
cerebral haemorrhage, if nothing has been done to coun-
teract the deforming rigidity of the limbs.
Exactly the same may be said with regard to a
hemiplegia following thrombosis or embolism, due to the
softening of the brain, or even with regard to certain
114 NERVOUS SYSTEM
cases of brain syphilis, as I had an opportunity recently
to observe.
5. NEURITIS
In neuritis there is hardly any other way of relieving
the pain and counteracting or combating the atrophy
that is as reliable as massage.
The stroking and passive movements here applied
must be of the gentlest kind at the outset, but as soon
as the tenderness has been lessened, and atrophy has
begun to make its appearance, massage, exercises, and
nerve vibrations must be carried out energetically, in
order to prevent deformity from contracture, which
may attain considerable dimensions.
Nerve friction or nerve vibration as practised in
Sweden, and advocated by some specialists as being
eminently useful in restoring nerve function, should be
applied in every case of peripheral or central palsy.
This manipulation consists of pressure exercised on the
nerve trunks and on the bigger nerve branches, by
placing the tips of one or two fingers on the nerve, and
thus exciting vibratory movements, and rolling the
fingers over the nerve, if it is a superficial one, such as
the ulnar nerve near the trochlea, or the peroneal
nerve close to the capitulum fibulae, Vibrations are
applied all along the course of the affected nerve or
nerves. It is plain, however, that this cannot be a
very easy performance, even to an accomplished
anatomist. Benefit may chiefly be expected when
the nerves treated are situated at such places where
ORGANIC 115
they cairbe directly felt, such as the two just mentioned
ones, and where they can be pressed against the bone.
Muscular reaction can sometimes be obtained by this
kind of mechanical stimuli in cases where the electric
excitability is practically extinguished.
Nerve friction of the type described must be repeated
every day at least a hundred times, if it is to be of
any use.
In neuritis massage may be advantageously combined
with the application of radiant heat.
6. LESIONS OF PERIPHERAL NERVES
(a) CEREBRAL NERVES
The facial and the spinal accessory are the only two
cerebral nerves which, when paralysed, may successfully
be treated by mechano-therapeutics.
A case of facial palsy I treated some time ago
convinced me of the great usefulness of exercises in
lesions of the seventh nerve, even in very obstinate
cases. The patient contracted a cold, and developed
Bell's palsy. Several months elapsed between the
occurrence of the nerve trouble and the time I saw
the girl. The nerve did not react at all to either of
the electric currents ; the affected muscles responded
very sluggishly to galvanism, being quite indifferent
to faradism. No voluntary contraction was possible
in this case. In spite of a regular treatment by com-
bined current during a few months the reaction of
degeneration would not improve. Attempts were
116 NERVOUS SYSTEM
therefore made to teach the patient to exercise her
facial muscles before the looking-glass. In order to
counteract the tendency of the sound side to a dis-
figuring deformity, and at the same time to give the
paralysed muscles a chance of resting in the contracted
position, strips of adhesive plaster were applied to the
face so as to bring the two ends of the overstretched
muscles together. Battery treatment was carried out
simultaneously, and it was applied several times a
week.
Within a few weeks after the patient had begun
to practise her mimic exercises, consisting of shutting
her eyes, lifting the corner of her mouth and drawing
her mouth to the affected side, her facial muscles com-
menced slowly to react to faradism, and the patient
progressed so favourably that the treatment could be
stopped after another two months had passed ; the
condition of the face had then become almost normal.
There was a slight difference in the promptness of
electrical reaction as compared with the sound side,
but nobody who did not know the girl could tell on
which side the face had been paralysed. Whistling,
showing the upper teeth, closing the eyes, and all the
emotional movements were performed quite correctly.
Of course, there was no deformity whatever when the
treatment was finished, although there had already been
a marked deviation of the mouth when the case was
first seen.
Cases of paralysis of the spinal accessory should be
treated on similar lines. Here the exercises comprise
shrugging of the shoulders, respiratory movements, and
ORGANIC 117
elevation of the arm, as well as rotation of the head.
Massage, consisting of kneading and hacking of the upper
portion of the trapezius (see Fig. 21) and the sterno-
mastoid, as well as sawing manipulations carried out
with the ulnar border of the hand (Fig. 30), should be
given every day.
FIG. 30. — MASSAGE OF THE
NECK.
Sawing movements, which are carried out
with one hand, whilst the other one steadies
the head of the patient.
When an operation has been performed with the
view to establish nerve anastomosis, then the indication
for subsequent passive and active exercises is quite
obvious.
(b) SPINAL NERVES
Hie methods employed in cases of peripheral nerve
lesions are similar to those applied to neuritis. Massage
of the affected muscles and nerves as described above,
plus passive and voluntary movements, should be
regarded as infinitely more important than the electrical
treatment. However, the best results will be obtained
by a combination of the mechano- and electro-thera-
peutic measures.
us NERVOUS SYSTEM
The importance and the absolute necessity of pre-
venting contractures so frequently resulting from peri-
pheral nerve lesions must always be borne in mind
when treating these cases.
Operations for nerve suture or nerve anastomosis in
cases of nerve division should always be followed by
exercises of the corresponding muscles, as there is no
contra-indication to mechanic treatment whatsoever.
7. NEURALGIA
Most of the neuralgic pains are often associated with
rheumatism, and in many cases the nerves themselves
are found to participate in the inflammatory process ;
it is best therefore to discuss neuralgia jointly with the
organic nervous diseases, and not to consider these
complaints as purely functional disorders.
Pain in most of these cases is due to a pressure on
the nerves, exercised by the inflammatory exudations,
which are actually found in and around the nerves,
and are proved by anatomo-pathological investigations
to consist mainly of serous infiltrations and cellular
elements. In old-standing cases there may be even a
certain amount of fibrosis.
Amongst the commonest localisations of this trouble
are the following :
Cervico-occipital, involving the posterior branches of
the upper cervical nerves, especially the inferior occipital.
There is usually a tender point at the emergence of
this nerve, midway between the mastoid process and
the first cervical vertebra. The occipitalis major and
ORGANIC 119
minor as well as the auricularis magnus nerve are also
often painful at their exits from the occipital fascia.
Pain in these cases is situated at the back of the
head and of the neck, and forms one of the types of
headache.
Hard and tender nodules are frequently discovered
on careful examination, corresponding to the points
where the nerves become superficial. Massage of these
painful areas is recognised to be the most efficacious
mode of treatment, and though gentle at first, it must
be energetically applied, until a hard pressure exercised
on the points does not produce more than the normal
sensations of pressure on a nerve. Those, however,
are entirely different from the heavy dull aching and
gnawing or boring pain in neuralgia. The treatment
may require several weeks, especially if the case is
inveterate.
In patients complaining of frontal headaches I found
the supra- trochlear nerves affected. The trochlea of
the superior oblique muscle of the eye appears to be
a common seat of infiltrations in rheumatic subjects.
Such infiltrations must necessarily cause pressure on
the neighbouring nerve branches (see The Practitioner,
June 1913 : " Headache and its Treatment").
Vibratory massage applied t.o the inner part of the
orbit by means of a motor, whose shaking movements
are transmitted through the hand of the person adminis-
tering treatment, tends to hasten the absorption of the
inflammatory products, and thus relieves the pain. The
number of cases I examined before and after my first
publication on this subject referred to above, is so con-
120 NERVOUS SYSTEM
siderable that I cannot sufficiently emphasise the great
usefulness of massage in frontal headaches. Nearly
all my cases showed great tenderness of the trochlea
to a slight pressure, and were markedly relieved after
a comparatively short treatment (Fig. 31).
FIG. 31. — THE ABOVE DIAGRAM SHOWS
THE POSITION OF THE THUMB WHICH
ENABLES ONE BEST TO EXAMINE THE
TROCHLEA OF THE SUPERIOR OBLIQUE
M. IN ONF.'S OWN SELF.
The supra-orbital and the infra-orbital nerves are
also often involved in facial neuralgia. This, however,
is to my knowledge not nearly so often the case as
compared with the supra-trochlear nerve. Pressure on
these nerves at their emergences is always followed by
relief, which is more obvious and lasting than that
obtained from a sole administration of salicylates.
Forcible kneading of the tender points, executed by
the tips of both thumbs, will be found very helpful
in most cases.
In brachial neuralgia it is most commonly either the
circumflex or the ulnar nerve that is at fault. In the
first case the pain is situated in the deltoid ; in the
second, tenderness is complained of about the elbow
ORGANIC 121
joint just at the point where the ulnar nerve winds
itself round the lower end of the humerus. It is often
met with in cases suffering from muscular or arthritic
rheumatism, or in those patients that sustained a trauma
at some time or other. It is then most likely due to
an extension of the trouble from the vicinity, or to the
pressure of the exudates on the nerves.
Massage is always found to bring relief to those pains,
but the period of recovery is sometimes extended over
months, particularly when the case has been neglected.
In sciatica the pain is either caused by neuritis of
the great sciatic nerve, or it may be due to infiltrations
of the glutaei muscles, the swelling pressing on the
big nerve trunk. Massage requires here considerable
physical strength on the part of the person in charge
of the case. Kneading of the buttock and of the thigh
is best executed by the knuckles of the fingers of both
hands, the fist being firmly clenched. The patient
assumes a recumbent posture, lying on his face.
Exercises comprise here those of the trunk, such as
bending, and of the leg, such as flexion of the thigh
with fully extended knees. The range of these move-
ments is steadily increased with every day.
Coccydynia, which as far as its obstinacy is con-
cerned is one of the worst complaints known, often
results from a cold or a bruise. Manipulations tending
to loosen the coccyx, and to help to disperse the residue
of either inflammatory or traumatic origin, will be found
very helpful. The forefinger of one hand is introduced
into the rectum, the other hand steadies the bone from
outside.
122 NERVOUS SYSTEM
Podalgia, or painful feet, is in the majority of cases
caused by a weakening of the arch, thus representing
the first stage of pes valgus, sive planus, and as such
it is directly amenable to mechano-therapeutic agents.
Massage of the foot and leg muscles, and exercises
which were described more in detail under the treat-
ment of flat-foot, will in most cases bring a prompt
relief.
The same should also be practised, and given a good
trial, in cases of metatarsalgia, before recourse is had
to an operation.
FUNCTIONAL DISEASES
1. PARALYSIS AGITANS
Cases of Parkinson's palsy have been reported which
were greatly ameliorated by gymnastic treatment com-
bined with muscular kneading and stroking, though
this condition has so far defied any other kind of treat-
ment. The only case I treated showed signs of im-
provement with every day, but, unfortunately, treat-
ment in this case did not last very long, the patient
being unable to continue attendance at the hospital.
Whether the effect of mechanic treatment is purely
suggestive, or whether it has a real therapeutic value,
cannot and need not be decided as long as the nature
of the disease itself is obscure.
Resisted movements were found of the greatest use
in this case as a means of steadying the tremor.
FUNCTIONAL DISEASES 123
2. CHOREA
The method of treating St. Vitus's dance with gym-
nastics is becoming more and more popular, but great
care must be here exercised both with regard to the
selection of suitable cases, as well as to the kind of
treatment. One rule must be unconditionally adhered
to, and this' is individual treatment of every child, away
from school, but never together with other children.
We know that the psychic moment in chorea is of
great significance. We often cannot even determine the
extent of its importance as long as the patient is not
entirely separated from the atmosphere of the school
and its home. This alone categorically demands an
interruption of school work. On the other hand,
choreatic individuals differ so much from one another
that it is quite impossible to treat them all on exactly
the same lines. They differ very much physically as
well as psychically, and therefore the measures applied
to them must vary accordingly.
The more severe cases of chorea ought not to be
treated by gymnastics, but should receive massage alone.
General massage should be carried out in the way
described under constitutional diseases. Stroking of the
limbs is very soothing, having a remarkable sedative
influence on the inco-ordinate movements. If possible,
the child should be confined to bed for a few weeks and
secluded from the rest of the family. The effect of
massage combined with absolute rest is always much
more prompt than if given under the ordinary un-
favourable conditions.
124 NERVOUS SYSTEM
Lighter cases should receive mechano-therapeutic
treatment in a less restricted form. Resisted move-
ments will then be found most useful. The degree of
resistance must, of course, be exactly proportionate
to the physical resources of the child, so that no undue ,
fatigue shall be caused. The resisted movements, more
than any others, force the patient to direct his full
attention to the muscular actions performed, and teach
him to carry out voluntary movements with more
precision.
Complications of chorea, such as endocarditis in
children or pregnancy in adult women, obviously re-
quire special consideration.
3. OCCUPATION NEUROSES
Writer's cramp is undoubtedly the commonest
representative of this group. Much can be done to
avoid aggravation of this condition by correcting the
position of the arm in writing. The elbow must always
be supported on the table, and must serve as the centre
from which the movements originate ; neither the little
finger nor the wrist should be used in that sense. Some-
times the change of the penholder may bring an im-
provement in lighter cases — a thick penholder instead of
a thin one, or vice versa. Occasionally it is found that
placing the pen between different fingers unaccustomed
to hold it brings relief.
Unless scrivener's palsy is due to some mental causes
still obscure to us, it appears to be frequently a sign of
over-fatigue of those muscles which are involved in the
FUNCTIONAL DISEASES 125
process of writing. Hence a temporary amelioration
generally follows the above-mentioned suggestions.
A more rational and a more effective treatment, how-
ever, consists of complete interdiction of any writing,
and of massage applied to the whole arm as far as the
shoulder, resisted movements in the finger, wrist, and
elbow joints being carried out daily.
The patient is gradually allowed to resume writing
within a fortnight or three weeks.
Masseur's palsy — which, strangely enough, not only
exists, but is said to be pretty frequent, especially in
Sweden, where some work almost incessantly for ten
hours daily and even more — affects mainly the shoulder
muscles. It manifests itself in a feeling of fatigue and
pain all around the shoulders, and an inability to per-
form movements which entail a strain on the shoulder
muscles.
Treatment consists of rest and avoidance of all those
actions which cause dragging of the affected muscles.
The ideal treatment of these cases is rest in bed and
application of massage to the overstrained parts.
Gradually gymnastics are allowed, but great caution
is to be observed lest the pains should return. In
these cases the use of electric vibrators ought to be a
boon to the patients just as the use of typewriters in
the foregoing complaint.
4. HYSTERIA AND NEURASTHENIA
The significance of the therapeutic effect of massage
in these two troubles was fully realised by Weir Mitchell,
and also constitutes an important part of his method.
126 NERVOUS SYSTEM
It is intended to stimulate the metabolism, and by
regulations of diet to lead to an accumulation of fat
in the body. With regard to neurasthenia, and par-
ticularly with regard to such forms of it as are
characterised by a marked loss of flesh and disappear-
ance of fat — instances of which we have in Glenard's
disease (enteroptosis) and in the movable kidney — the
beneficial effect of such treatment is obvious.
In more serious cases, rest in bed is of great help when
massage alone should be applied to the whole body.
This is given in the way found suitable in constitutional
disorders, which undoubtedly resemble neurasthenia very
closely.
Exercises are prescribed as soon as the patient's
physical strength will allow it. In the beginning very
gentle and passive, later on active and resisted, they
have to be given for several weeks or months.
Breathing exercises and abdominal massage should
always be practised, because of their direct influence
on metabolism.
III. SPECIAL
A. GYNAECOLOGICAL AND OBSTETRICAL
THE following points, though being well known to
every man in the profession, may be mentioned in
connection with this chapter.
One is the mechanic stimulus widely adopted in
obstetrics and applied to the uterus, consisting of
rubbing of the womb through the abdominal wall, with
the object of preventing post-partum hcemorrhage. This
massage is carried out in order to effect a better con-
traction of the uterine muscle, and as such it should
be performed as a routine measure in every case : first
after the child has been born, and then after the placenta
has been expelled. One or both hands are placed over
the fundus, and quick rotatory movements are executed
with a fair amount of vigour.
The same manipulations are often applied in cases
of protracted labour, when due to defective pains, and
it is remarkable to what extent and with what prompt-
ness contractions follow this massage.
Another mechanic factor familiar to the obstetrician,
and frequently practised by him, is the resuscitation
of asphyxiated new-born children. It is based on the
principles of our breathing exercises, but at the same
127
128 GYNAECOLOGICAL AND OBSTETRICAL
time use is being made here of the law of gravitation.
When the infant is held up by the shoulders, his thorax
is fully expanded ; in lifting him up, his head down-
wards, the lower part of his body becomes suddenly
bent. The thorax thus becomes compressed, and a
deep expiration results. At the same time more
favourable conditions are created for the escape of
mucus from the trachea, by the body being turned
upside down.
The introduction of mechano-therapeutics into
gynaecology proper was accomplished by Thure Brandt,
the Swedish major, some forty years ago. It consists
of bimanual manipulations in which the index and the
middle finger of one hand introduced into the vagina
steadies the portio, whereas the other hand influences
the fundus uteri through the abdominal parietes by a
kind of kneading and pinching movements. Brandt
and his followers practised gynaecological massage in
cases of prolapse., uterine displacements, as well as in all
chronic inflammatory conditions of the uterus itself, and
of its vicinity. In the first-mentioned complaint the
manipulations are intended to strengthen the uterine
ligaments. In the endo- and para-metritis they are
meant to hasten the absorption of inflammatory pro-
ducts from the affected areas, and to loosen the
adhesions. In metritis it is to relieve the venous
congestion, and thus to improve the circulation in
this organ.
Though in itself quite plausible and useful in suitable
cases, T. Brandt's methods have not found a wider
application, especially in this country, on account of
GYNECOLOGICAL AND OBSTETRICAL 129
certain objections raised here and there by the medical
profession. The objections are not very convincing to
those who consider the freedom of science and the
well-being of their patients of infinitely more vital im-
portance than misdirected ethical scruples. Certain
precautions directed towards the protection of the
profession as well as of their clientele, are always indi-
cated. On the other hand, however, there is no essential
difference between the ordinary work of a conscientious
gynaecologist, and that of a conscientious man, as Thure
Brandt himself undoubtedly was. At any rate, this was
the impression I gained from a perusal of his private
notes in MSS. to be found in the Library of the Central
Institute in Stockholm.
It would be wiser to afford more opportunity of re-
habilitation to a method which, though not always
approved by some authorities, cannot otherwise but
appeal to common sense, and which has been vindicated
by its own results.
Massage can be used in the last stages of pregnancy
as a preventive of skin cracks (stride gravidarum) ,
otherwise readily forming on the abdomen, and some-
times even on the thighs. The skin alone ought to be
here the subject of very gentle kneading executed with
the tips of the fingers. Also the nipples of the breast
require similar attention, being very liable to suffer
from the process of suckling, if not previously hardened
by rubbing with such stimulants as methylated spirits,
which should be commenced about six weeks before
the confinement and practised every day.
With regard to the lower extremities, which often
9
130 GYNECOLOGICAL AND OBSTETRICAL
suffer a great deal from oedema, pains, and even open
wounds as the result of varicose veins, it must be
emphatically pointed out that stroking and kneading of
the legs are strictly indicated in order to cope with the
congestion. Exercises of the legs and of the trunk help
to restore normal circulatory conditions of the body,
and may rightly be expected to diminish the risk of
thrombosis of the femoral veins, this much dreaded
complication of the early stages of puerperium. Later
on, trunk exercises and abdominal massage are of
great service as restoring the strength of the abdom-
inal muscles, which in most cases are extremely
weakened. In fact, gentle exercises, such as voluntary
contractions of the ,recti muscles whilst lying in bed,
should be practised from the second day after par-
turition. Also small sacks filled with sand may be
placed on the stomach after a few days, and the patient
told to lift them by contracting the abdominal muscles.
The perineal muscles may be trained even before the
confinement by voluntary contractions, imitating those
which generally accompany the act of defecation and
those which serve to keep back the contents of the
rectum. This may be practised several times a day,
the object here being prevention of subsequent relaxa-
tion of the perineum, which favours prolapse of the uterus.
B. OTOLOGICAL AND OPHTHALMOLOGICAL
MASSAGE has found its way even to such special branc'hes
of our science as otology and ophthalmology. Obviously
it has here but a limited scope. Nevertheless, it is the
OTOLOGICAL AND OPHTHALMOLOGICAL 131
ear and eye specialists themselves that advise the
application of massage in certain complaints.
Vibratory massage applied to the mastoid process
by means of an electric motor is advocated by some
as beneficial in cases of otosclerosis. The aim of the
treatment is here loosening of the ossicles, and it
appears that massage is the only way of influencing
this dreadful disease. Vibratory massage can also be
advantageously applied in cases of chronic otitis media.
Massage used to be applied by oculists in cases of
immature cataract in order to hasten the degenerative
process going on in the lens by rubbing it with Daviel's
spoon through the cornea. A few days after the lens
could be extracted.
C. RHINO- AND LARYNGOLOGICAL
SOME troubles affecting the throat such as laryngitis
and pharyngitis have been dealt with jointly with other
affections of the air-passages in the chapter on the
respiratory system, and therefore need not be described
here again.
With regard to the nose troubles, one or two things
have to be mentioned.
Firstly, massage has been applied to the nasal mucous
membrane in cases of atrophic rhinitis with the aim of
stimulating the regeneration of the tissues. Gentle
friction has been exercised on the mucous membrane
by means of a probe, whose point has been protected
by a small quantity of wool. It is obvious that such
treatment can yield more satisfactory results only after
a. certain period,
132 RHINO- AND LARYNGOLOGICAL
Secondly, we adopt mechano-therapeutics in the after-
treatment of cases which have undergone an operation
for tonsils and adenoids. The object of these measures
is mainly an improvement of breathing, which is
always more or less impaired in these cases, owing to
the obstruction of the naso-pharynx. The resulting
abnormality is here a double one : breathing becomes
shallow, and the air passes through the mouth instead
of through the nose. What we have to do is, there-
fore, to teach these subjects (mostly children) how to
breathe deeply and through the nose.
Breathing exercises such as have been described
under scoliosis treatment and also in connection
with respiratory troubles, are applicable here. Class
exercises 1 can be adopted with a greater benefit than
elsewhere, since this type of patient as a rule does
not require much individual attention. Such exercises
will consist of the said movements carried out while
standing, and deep inspiration to be performed through
the nose, followed by expiration through the mouth
without holding the breath between the movements.
Breathing exercises must necessarily be performed
slowly, though regularly, and according to the instruc-
tions of the teacher.
The effect of this kind of treatment is a more complete
ventilation of the lungs, an increased vital capacity of
the thorax, and at the same time it helps to exterminate
the faulty habit of mouth-breathing.
In order to achieve better results, breathing exercises
must be performed daily.
1 As described on p. 64.
DERMATOLOGICAL 133
D. DERMATOLOGICAL
OUT of the vast number of skin troubles only a few
can be influenced advantageously by massage.
Alopecia, when not of parasitic origin, is amenable
to a treatment of which the object is to raise the vitality
of the scalp. This is effected by manual kneading and
friction applied with the tips of the fingers in order to
loosen the scalp, to produce an active hypersemia, and
thus to stimulate the hair follicles, and to promote the
growth of the hair. If possible, massage of the scalp
should be practised every day once or twice, the patients
being often able to administer it themselves, when
properly instructed.
Massage of the face is nowadays more and more
adopted as a rational treatment of acne. What had been
termed " plastic massage " by some French authors
should be applied to the face in order to reduce the
amount of blackheads, and to prevent the formation
of pustules. This massage consists of gentle pinching
and kneading of the face between the tips of the fingers.
The skin has to be lifted off the cheeks and off the chin,
as well as off the forehead, and carefully submitted to
the above-mentioned process. This is very beneficial
as a means of opening the many cutaneous glands which,
being blocked by the accumulated debris, give rise to
the formation of the two above-mentioned symptoms.
E. DENTAL
MASSAGE has been advocated by eminent dentists in
cases of chronic gingivitis, a condition much more wide-
134 DENTAL
spread and important than is generally supposed. The
main features of this complaint are a loss of tonus in
the gums, leading to a weakening of the teeth, and a
state of chronic sepsis in the mouth.
Massage here is prescribed with the object of strength-
ening the gums and in assisting a free elimination of the
discharge. This is effected by a vigorous kneading of
the gums, the tips of the fingers performing gliding
movements in an upward direction in the case of the
lower jaw, and in a downward direction in the case of
the upper jaw. The fingers are from time to time dipped
into pure spirits of wine, the latter adding still more
to the hardening of the tissues.
This kind of massage ought to be practised every
evening by the patients themselves after a thorough
cleansing of the mouth has been performed. Person-
ally, I had the opportunity of convincing myself of the
efficacy of this treatment.
CONCLUDING REMARKS
SHOULD the foregoing pages have succeeded in raising
the interest of some of their readers, and in directing
it towards a closer and more unprejudiced, but a per-
sonal study of mechano-therapeutics, the author will
feel that his efforts have not been quite futile. For it
always was his intention to acquaint a wider circle of
his colleagues with a therapeutic factor which has
been badly neglected by the profession.
Massage has up to quite recently been in the hands
of quacks and unqualified persons, and on that account
medical men have been accustomed to look down upon
it as something beneath their professional dignity. This
is, however, not the right way of tackling a new
method. Some two or three hundred years ago surgery
was in the hands of barbers, but nowadays this does
not prevent anybody from considering it one of the
most favourite branches of our work.
The larger public was of yore inclined to believe in
the efficacy of massage, and the quacks must have un-
doubtedly been of some service to them. Although
the results were sometimes anything but satisfactory,
such failures might have been easily avoided, if the
medical profession had thought of a thorough investi-
gation of this matter, instead of pronouncing them-
135
136 CONCLUDING REMARKS
selves far above it, and treating massage as a quantite
neglig cable.
Lack of scientific training obviously" made ignorant
people apply exactly the same treatment in all cases
without discrimination, and though they obtained
excellent results in some, they had disastrous failures
in other cases, since massage, harmless as it may
appear, can sometimes cause very sad complications.
Pyaemic metastasis has occurred after an abscess had
been submitted to rubbing, and a general peritonitis
followed the massage of an acute appendicitis. Gross
displacement of bone fragments resulted in fractures
treated by people who had no knowledge of surgery.
A case I saw once exhibited osseous union of the femur
at an angle of 120°, as proved by a radiograph.
The results of mechano-therapeutic treatment would
become positively excellent if medical men would take
up this work themselves, and rely less on others. It
would be a greater benefit to the public, as well as a
greater advantage to the profession, if the motto
"More medicine in massage, and more massage in
medicine," were generally adopted.
REFERENCES
THE literary material dealing with our subject is so copious
that it is only possible to consider here the main sources
of reference, and only those of a more recent date.
BENNETT, SIR W. : Lectures on the Use of Massage and
Early Passive Movements in Recent Fractures and other
Common Surgical Injuries. 3rd Edition. London, 1903.
ESTRADERE : Du Massage, ses Effets physiol. et therap.
These de Paris, 1863.
FRENKEL, H. S. : The Treatment of Tabetic Ataxia by Means
of Systematic Exercises. English Translation by L.
Freyberger. London and New York, 1905.
HOFFA, A. : Lehrbuch der Orthopifdischen Chirurgie.
Stuttgart, 1898.
JOSEPH, MAX. : Handbuch der Kosmetik. Leipzig, 1912.
KELLETT-SMITH, : Lateral Spinal Curvature and Flat Foot
and their Treatment by Exercises. London.
LOVETT : Lateral Curvature of the Spine and Round Shoulders.
London, 1912.
LUCAS- CHAMPIONNI ERE : Precis de Traitement des Frac-
tures par le Massage et la Mobilisation. Paris, 1910.
MOSENGEIL : Ueber Massage, deren Technik und Indication.
Langenbeck's Archiv. filr klinische Chirurgie. Band 19.
NORSTROM : Muskel-Rheumatismus.
OSLER, SIR W. : The Principles and Practice of Medicine.
London, 1909.
PENZOLDT and STINTZING : Handbuch Spezialler Therapie.
Band 5. Jena, 1896 RAMDOHR : Allgemeine Gym-
nastik und Massage.
137
138 REFERENCES
ROMER, F., and CBEASY, E. : Bone-setting and the Treatment
of Painful Joints. London, 1911.
THOMSON and MILES : Manual of Surgery, Vol. I. and II.
Edinburgh and London, 1909.
THORNE THORNS, LESLIE : Nauheim Treatment of Diseases
of the Heart and Circulation. London.
WIDE, A : Handbuch der Medicinischen Gymnastik.
German Translation. Wiesbaden, 1897.
INDEX
ABDOMINAL exercises, 97
Abdominal massage, 95
Acne, 133
Active movements, 11
Adenoids, exercises in, 132
Adhesions, pleuritic, 90
Adhesions after bruises, 49
Adhesions in traumatic syno-
JVitis, 47
Adiposity, 99
Alopecia, 133
Amyotrophic lateral sclerosis,
108
Ansemia, 102
Ankle, fracture of, 34
Ankle, massage of, 35
Ankle, sprained, 45
Anterior polio-myelitis, 109
Arthritic conditions, 47
A trophic rhinitis, 131
Bedsores, 54
Bell's palsy, 115
Bennett's fracture, 26
Bladder troubles in ataxia, 108
" Bone-setting," 48
Brachial neuralgia, 120
Brain syphilis, 114
Bronchitis, chronic, 89
Bruises, 48
Callus, excessive, 40
Catarrhal prostatitis, 54
Corvico-occipital neuralgia, 118
Chorea, 123
Circulatory system, 76
Class exercises in scoliosis, 64
Clavicle, fracture of, 12
Coccydynia, 121
Colles's fracture, 21
Comminuted fracture of radius,
24
Compound fracture of leg, 32
Concentric movements, 111
Concluding remarks, 135
Congenital deformities, 72
Constipation, 94
Constitutional diseases, 99
Contracture, Volkmann's, 19
Contractures in cerebral hae-
morrhage, 112
Contractures in neuritis, 114
Centra-indications, 3
Contusions of soft parts, 48
Coracoid process, fracture of,
17
Debility, 102
Deformities, 55
Deltoid, massage of, 14
Dental, 133
Dermatological, 133
Diabetes, 99
Digestive system, 92
Dislocations, 41
Elbow, fractures of, 20
— sprained, 43
Elevation of limbs, 11
Embolism, cerebral, 113
Embolism, pulmonary, 40
Enteroptosis, 126
Excentric movements, 111
Excessive callus, 40
Exercises in scoliosis, 58
Exercises in tabes, 106
Exercises in tonsils and ade-
noids, 132
139
140
INDEX
Facial neuralgia, 120
Facial paralysis, 115
Femur, fracture of neck, 27
Femur, fracture of shaft, 28
Fibrositis, 50
Fibula, fracture of, 32
Flat foot, 70
Fractures, 5
Fractures of lower extremity,
27
Fractures of upper extremity,
12
Friction, 23
Frontal headache, 1 1 9
Functional diseases of nervous
system, 122
General considerations, 1
General massage, 101
Genu varurn and valgum, 68
Gingivitis, chronic, 133
Gout, 99
Gynaecological, 127
Hacking, 15
Headache, 119
Heart massage, diseases of, 76
Hip, sprained, 44
Humerus, fracture of, 14, 17
Hypostatic pneumonia, 27, 88
Hysteria, 125
Iliac dislocation, 44
Immature cataract, 131
Incontinence, 103
Indications, 3
Infantile paralysis, 109
Infiltrations of soft parts, 52
Ischaemic contracture, 20
Joints, sprained, 41
Kneading, 15
Knee, sprained, 44
Kypho-scoliosis, 68
Kyphosis, 67
Laryngitis, catarrhal, 90
Laryngological, 131
Lightning pains, 108
Limping, 46
Little's disease, 108
Locomotor ataxia, 105
Lumbago, 52
Lungs, massage in diseases of,
87
Massage, general, 101
Massage in chorea, 123
Massage in puerperiun, 130
Massage in scoliosis, 57
Massage of abdomen, 95
Massage of uterus, 127
Masseur's palsy, 125
Medical, 75
Metacarpals, fractures of, 24
Metatarsalgia, 122
Metatarsals, fractures of, 39
Muscular rheumatism, 50
Nerve vibrations, 114
Nervous system, diseases of,
104
Neuralgia, 118
Neurasthenia, 125
Neuritis, 114
Nipples, massage of, 129
Obstetrical, 127
Occipital headache, 52
Occupation neuroses, 124
Olecranon, fracture of, 20
Operations in fractures, 11
Ophthalmological, 130
Organic nerve trouble, 105
Osteo-arthritis, 47
Otitis media, 131
Otological, 130
Otosclerosis, 131
Pain in fractures, 6, 7
Paralysis agitans, 122
Paralytic deformities, 72
Patella, fractures of, 29
Periostitic nodes, 50
Peripheral nerve lesions, 115
Phalanges, 24
Pharyngitis, catarrhal, 90
Pleuritic adhesions, 90
Podalgia, 122
INDEX
141
Post-partum haemorrhage, 127
Pott's fracture, 34
Progressive muscular atrophy,
108
Prolapse, of uterus, 128
Prostatorroea, 54
Protracted labour, 127
Pubic dislocation, 44
Quadriceps, massage of, 28
Radius, fracture of, 21
Raynaud's disease, 53
References, 137
Resisted movements in chorea,
124
Respiratory system, 87
Resuscitation of the new-born,
127
Retention, 103
Rhinological, 131
Rickets, 102
Round shoulders, 67
Scaphoid, fracture of, 22
Sciatica, 52, 121
Scoliosis, 55
Scrivener's palsy, 124
Shoulder, sprained, 42
Special, 127
Speech disturbances, 113
Spinal accessory, 116
Spinal jackets, 65
Splints in fractures, 8
Splints in paralysis, 109
Sprained joints, 41
Sprained muscles, 50
Sprengel's shoulder, 74
Stomach, dilatation of, 93
Strise gravidarum, 129
Stroking, 8
Subcoracoid dislocation, 43
Supracondyloid fracture, 19
Tabes dorsalis, 105
Tabo-paralysis, 108
Teno-synovitis, 48
Thrombosis, 113
Tibia, fracture of, 32
Toes, fractures of, 40
Tonsils, exercises in, 132
Torticollis, rheumatic, 52
Torticollis traumatic con
genital, 73
Traumatic, synovitis, 47
Tuberosities, fractures of, 17
Ulcers, 53
Ulna, fracture of, 21
Ununited fractures, 12
Urinary system, 103
Uterus, massage of, 127, 128
Varicose veins, 130
Volkmann's contracture, 19
Wrist, sprained, 43
Writer's cramp, 124
X-rays in fractures, 10
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1000, 405. ; 500, 255.; 250, 145.; 100, 6s. 6d.; 12, is.
I EWIS'S CLINICAL CHART, SPECIALLY DESIGNED FOR USE
" WITH THE VISITING LIST. Arranged for four weeks,
and measures 6x3 inches. 12, 6d.; 25, is.; 100, 2s. 6d. ;
500, us. 6d. ; 1000, 2os.
I EWIS'S "HANDY" TEMPERATURE CHART.
L' Arranged for three weeks, with space for notes of case as
to diet, &c., and ruled on back for recording observations
on urine. 20, is. ; 50, 2s. ; 100, 35. 6d. ; 500, 145. ; 1000, 255.
Uniform in price with the " Handy " Chart : —
T EWIS'S FOUR-HOUR TEMPERATURE CHART.
^ Each chart will last a week.
LEWIS'S NURSING CHART. Printed on both sides.
LEWIS'S BLOOD-PRESSURE AND PULSE CHART.
T EWIS'S SMALL FOUR-HOUR TEMPERATURE CHART.
^ Designed by G. C. COLES, M.R.C.S. For two weeks,
giving space for Pulse, Respiration, Urine, and Remarks.
[ EWIS'S MORNING AND EVENING TEMPERATURE CHART.
J-* Designed by G. C. COLES, M.R.C.S. Each chart lasts
three weeks, and provides space for noting also the Pulse,
Respiration, and Urine, and general Remarks.
T EWIS'S POCKET CASE BOOK.
-L" For the use of Nurses, Students and Practitioners,
25 cases, 4 pp. to each case, with headings, diagrams, and
a temperature chart. Oblong 8vo, 8 in. X 5 in.,
is. 6d. net, post free, is. gd.
H. K. Lewis &• Co. Ltd., 136 Gower Street and 24 Gower Place, London, W.C,
05
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