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THE thi;rape[itic uses of exercise. 
 
 BY 
 
 R. TAIT MoKENZIB, B.A., M.D., 
 Instructor in Gymnastics, McGiil University. 
 
 Reprinted from the Montreal Medical Journal, February, 1894. 
 
I 
 
 <^ 
 
 m- 
 
4i 
 
 THE THERAPEUTIC USES OF EXERCISE/ 
 
 By R. Tait MoKenzib, B.A., M.D., 
 Instructor in (gymnastics, McGill University. 
 
 In a recent lecture Dr. Wm. Osier told a popular audience 
 that a desire to take medicine is the ^reat feature that distin- 
 guishes man from the other animals, and he went on to say that 
 instead of relying on " a tablespoonful three times a day," he 
 should pay more attention to the principles of hygiene and their 
 application. 
 
 Investigation has brought to light new facts from which laws 
 have been formulated. The vital processes are becoming better 
 understood, and diet, heat, cold, rest and exercise, have sup- 
 planted to a great extent the exclusive treatment by drugs of 
 most forms of disease. The prescription of drugs is becoming 
 largely supplementary to these other and more important agents. 
 "As a paysician advances in age," said the late Sir Andrew 
 Clarke, " he generally places less confidence in the ordinary 
 medicinal treatment than he did, not only during his early but 
 even during his middle period of life." The modern doctor 
 does not as often attempt to perform what Voltaire wittily de- 
 fined as the miracle of reconciling health with intemperance. 
 
 The marvellous progress of the comparatively new science of 
 Bacteriology has directed the attention of the medical world to 
 the importance of preventing the dissemination of disease germs 
 by the agency of earth, air or water. Experiments have shown 
 the tepacity to life of the tubercle bacillus, its life, history and 
 most favorite soil. May we not, in our eagerness to destroy 
 these insinuating sources of disease, by methods which are too 
 
 * Read before the Montreal Clinical Society, November. 1893. 
 

 apt to include the patient in a common fate, be apt to neglect 
 the best preventative we have, best because the most under our 
 control ; I refer to the rearing of a strong and healthy array 
 of phagocytes begotten of good food, sufficient rest, and plenty 
 of exercise. 
 
 The most fertile soil for the insidious microbe, is a puny and 
 debilitated organism in which the life processes are slow and 
 feeble ; on the other hand if there be strength and activity, dis- 
 ease will not obtain its first foothold or even if it has already 
 entered the body, will be attacked and speedily ejected from a 
 system ready and able to combat such a danger to its well-being. 
 " The physician is only the servant of nature ; not its master." 
 He can give the most favourable conditions but the healing 
 power of nature does the rest. Fixity to a broken limb while 
 repair goes on. Rest to the stomach while the ulcer heals. 
 Extra nourishment or stimulants till the system again takes up 
 its accustomed work. 
 
 It is along these lines that progress has been made in the 
 past, and will be made in the future, rather than by the dis- 
 covery of the Elixer of Life, the search for which has occupied 
 so many great minds even to the present day. This search 
 however, may be productive of as great good to humanity as 
 was that for the philosopher's stone whose magic touch was to 
 turn everything to gold. From that vain dream the science of 
 Chemistry received its greatest impulse and may not the 
 equally fantastic search for this life-giving compound incidentally 
 reveal the great physiological laws that govern the life pro- 
 cesses ? So with increased knowledge we may determine the 
 proportions of water, food and exercise, the three ingredients 
 of the true elixer vitae, 
 
 " He who eats without taking exercise cannot be well," said 
 Hippocrates nearly four hundred years before Christ, and his 
 statement of the case has not been improved upon or refuted 
 since. Galen merely restated the same truth when he said : 
 " The greatest danger to health results from complete inactivity, 
 in the same manner the greatest benefit results from moderate 
 exercise." It is this one Therapeutic agent in its various 
 applications that I would take up for discussion. 
 

 The body has been looked upon hy many, in fact by most of 
 the medical profession as a chemical compound, and disease has 
 been treated by the administration of chemical substances to 
 restore the stability of the compound. This view of the body 
 has been held almost to the exclusion of its other aspects and 
 the natural reaction has swung the pendulum of thought into 
 the mazes of Psychical research. Schools have sprung up in 
 which disease is looked upon as a mental state. Healing is to be 
 accomplished by faith, accompanied by the laying on of hands, 
 bottled electricity or infinitesimal globules. The body is the 
 expression of the soul, which controls its workings absolutely, so 
 that disease is merely the imperfect expression of the spiritual 
 element in man 
 
 Another view of the body sees it as a complex machine, toler- 
 ating a good deal of interference and abuse with comparative 
 impunity, with this advantage over the ordinary machine 
 that it always tends to repair injuries to itself. It has within it 
 the capacity of self-renewal as well as that of dissolution and 
 unlike any other mechanism, the more it is used within physiolo- 
 gical limits the better will it work, and the longer will it last. 
 
 Bodily movements are among the most potent measures that 
 keep the human machinery in working order. The active use 
 of the various muscle masses affects more than their own tissues. 
 There is pressure on the abdominal contents, stretching of con- 
 tracted chest walls, and removal of excess of blood from the 
 head and torso out to the periphery where it circulates in the 
 extremities. 
 
 A brief resume of the principal effects of exercise would per- 
 haps express the idea I have in mind with greater clearness. 
 
 The two-fold function of muscular tissue is to be noted. 
 Each muscle acts as a reservoir for blood, and also as a means 
 for producing heat and motion. Exercise acts as a stimulant 
 to the heart, and " every active muscle," says Weir Mitchell in 
 his book on Fat and Blood, " is practically a throbbing heart 
 squeezing its vessels empty when in motion and relaxing to 
 allow them to fill anew. Thus both for itself and in its relation 
 to the rest of the body its activity is functionally of service." 
 
I 
 
 6 
 
 " The vesaels unaided by change of posture and by motion 
 lose tone, ... so that defects of nutrition occur and with 
 these defects of temperature." 
 
 There is a physiological law, known as the Law of Trever- 
 anus its discoverer, which may be briefly stated thus : — Each 
 organ is to every other as an excreting organ." In other 
 words to ensure perfect health, every tissue, bone, nerve, ten- 
 don or muscle should take from the blood certain materials and 
 return to it certain others. To do this every organ must have 
 its period of activity and of rest so as to keep the vital fluid in 
 a proper state to nourish every other part. This process in 
 perfect health is a system of mutual assurance and is probably 
 essential to a condition of entire vigour of both mind and body. 
 The excretory organ that we most persistently neglect is the 
 skin, extra work is thus put on the intestinal and renal systems 
 with the consequence that they are overworked and become 
 diseased. 
 
 The skin is stimulated to increased excretion, most fully and 
 naturally by the various forms of physical exercise. By the 
 term physical exercise, I would include passive as well as active 
 movements ; from massage in which the will power of the 
 patient plays no part whatever to the most complicated and 
 delicate voluntary movements in which the training is more for 
 the nerve centres than for the muscles. 
 
 In massage the tissues of the body are exercised by the 
 operator for a therapeutic purpose by stroking or rubbing, 
 kneading, pinching, rolling and beating the muscle masses and 
 through them the underlying organs. " By these means are 
 the muscles exercised without the use of volition or the aid of 
 the nervous centres, while increasing mechanically the flow of 
 blood to the tissues which they feed." 
 
 In duplicate movements, the will power of the patient is used 
 in resisting or performing under resistance, movements of 
 flexion, extension, circumduction, etc. These movements also 
 require an operator, but Dr. A. Zander has invented a series of 
 machines by which flexions, rotations, vibrations, etc., can be 
 administered without the necessity of an operator. An institu- 
 
 •i 
 
^ 
 
 ■i 
 
 tion ill which tlieae machines form the exclusive treatment has 
 been founded in New York. 
 
 Simple active movements are made without either assistance 
 or resistance. The simphi and duplicate movements together 
 with the various positions have been grouped and classified and 
 named in the Swedish medical gymnastics. 
 
 The word " exercise," as usually employed would include 
 only light and heavy gymnastics, walking and athlet'cs. 
 
 In light gymnastics, movements are arranged in series with 
 perhaps light dumbells or clubs. Muscular developeraent is 
 quickly produced by these movements. Archibald MacLaren, 
 of Oxford, found while training a s<iuad of officers as instructors 
 to the British Army, that " the muscular additions to the arms 
 and shoulders, and the expansion of the chest, were so great as 
 to have been absolutely ridiculous and embarrassing, for before 
 the fourth month several of the men could not get into their 
 uniforms, jackets and tunics without assistance. In a month 
 more they could not get into them at all. One gained five 
 inches in chest girth." In this connection it may be well to 
 state the fact that in most leg movements the body acts as a 
 heavy weight, and the exercise is as severe as if a hundred 
 pound dumbell were attached to the foot the patient being on 
 his back. 
 
 The use of fixed apparatus for suspension and support, hori- 
 zontal and parallel bars, introduces another principle into gym- 
 nastics. The extremities are made the fixed points and the 
 origin of the muscle is thus made its insertion. An application 
 of the principle is well shown in the system of pully weight 
 developing machines, worked out so fully by Dr. Sargent, of 
 Harvard. By them, isolated groups of muscles can be exercised 
 in such a way that by varying the weights used, the do?e can 
 be accurately measured and governed. The machines can be 
 adapted to the strength of the strong, or the weakness of the 
 weak, that the greatest benefit may be obtained without the 
 danger of overstraining. 
 
 The value of athletic sports as a therapeutic agent is question- 
 able or a least very limited. The competitive element and the 
 
8 
 
 danger of strain and over-exertion would make them rather too 
 drastic to be much used in this way by the physician. Hut 
 there is an exercise that might be classed as athletic, the one 
 nearly always prescribed by physicians, 1 refer to walkinj^. 
 
 As usually taken, a walk does not exercise the muscles vigor- 
 ously enough to produce very much effect. The skin is not 
 stimulated sufficiently to act as an excretory organ, and the 
 man comes in dull, heavy and tired out, instead of having the 
 bright warm sensation of strength that is felt after a half hour 
 of brisk hard work, followed by a rub down. The great advan- 
 tage claimed for walking, is the open air ; that is good, but a 
 shorter time given to more vigorous and more evenly distributed 
 work will give better results. 
 
 There are three effects of exercise that would commend it as 
 a therapeutic agent. 
 
 Ist. It relieves congestions by equalizing the circulation. 
 
 2nd. It acts as a sedative to the nervous system probably 
 through iiis action on the circulation. 
 
 3rd. It strengthens and enlarges muscles, bones, and liga- 
 ments, and would thus apply to all conditions caused by weak- 
 ness or inequality of developement. 
 
 If the education of a child could be begun as suggested by 
 Oliver Wendell Holmes, 100 years before its birth, there would 
 probably be no necessity for the application of exercise in ther- 
 apeutics and even now its necessity will be greatly lessened by 
 incorporating exercise in our educational systems By the 
 gymnastic garnes of the Kindergarten, children are made strong 
 and healthy from an early age and troubles arising from weak, 
 ness or malnutrition are prevented. 
 
 In schools where systematic physical training has gone hand 
 in hand with mental throughout all grades, the marked improv- 
 ment in the physique of the children is sufficient to commend 
 such training to all who have the welfare of the race at heart. 
 This improvement will not be universal however until there is 
 as much attention paid to the proper breeding and rearing of 
 children, as there is to that of horses and dogs. 
 
 The good effect of a course of exercise on even confirmed 
 
 •* 
 
 V 
 
9 
 
 J. 
 
 ■I 
 
 V 
 
 criminals has been studied hy Dr. Wey, of the Elmira Reforma- 
 tory. He says : — " The stimulation of the physical powers a 
 year ago in the cabe of three impressed their mental organiza- 
 tion to a degree that enabled them to earn their release upon 
 parole, whereas if left to themselves their min<l8 would never 
 have been quickened as a reflex of an improved (ihysical state." 
 
 The late Dr. Scguin, by the systematic training of the hand 
 and eye gave understanding to an idiot brain and Dr. Luther 
 Gulick re[)ort8 three cases in which feeble minded children have 
 been marte bright, intelligent and active by a course of special 
 exercises calling into active use the will and attention. 
 
 Organic disease of the heart has long been treated by the 
 Swedish movement cure, and Oertal of Munich has established 
 an institution in which diet and exercise are the chief agents 
 used. " The heart being a muscle, should be developed in the 
 usual way ; " if it be weak he advises walking on the level and 
 then hillclioibing. The patient should walk till violent palpita- 
 tion is brought on. He then is required to stand still till that 
 has abated and until the shortness of breadth is satisfied by 
 voluntary long deep inspirations. 
 
 Oertel treats in this way even those who have not sufficient 
 compensation, and repeats the treatment at intervals, according 
 to his judgment. This he couples with baths and a diet rich in 
 albumen, [)receding it by a course of Swedish gymnastics and 
 baths. Frantz claims that the ventricles can be more com- 
 pletely and efficiently emptied by exercise than by digitalis, 
 and that the benefit is more lasting. 
 
 In cases ol infantile paralysis, exercise in conjunction with 
 electricity has given satisfactory results in both increased size 
 and usefulness of the groups of muscles affected. 
 
 The importance of movements in the treatment of sprains is 
 sometimes overlooked. In speaking of this in his book on that 
 subject, Mansell Moullin says : " The sooner movement is beyun 
 the better. As a rule passive movement may be commenced 
 from the second day with the certainty of preventing adhesions. 
 I have repeatedly seen the most severe cases treated in this way 
 recover so completely in the course of a few days that unless 
 
10 
 
 there is an exceptional amount of walking to be done the patient 
 could follow his ordinary occupation without danger and without 
 pain." 
 
 Constipation is most amenable to treatment by movements 
 and exercise. Negative evidence on this point is seen in every 
 hospital ward where the daily notes show complete inactivity of 
 the bowels in nearly every case following rest in bed. May 
 not its frequency in women and those of a sedentary occupa- 
 tion be due to this cause ? In no other condition is the power 
 of massage so quickly or so surely seen. Swaying movements 
 and flexions of the trunk are natural forms of raassi^ge for the 
 abdomenal contents ; even in deep breathing the intermittant 
 pressure of the draphragm lind abdominal muscles is a physio- 
 logical massage. 
 
 In chronic dyspepsi' cise is one of the best means of 
 
 treatment. In one v.. came under my notice lately, half 
 
 an hour, three times a , .... was quite sufficient lo relieve the 
 most distressing symptoms. The patient like many another is 
 accustomed to eat more than he uses and without this work the 
 unused nourishment acts as a burden on the system, and even 
 as a direct poison. The following experiment shows the effect 
 of certain movements on the stomach. With feet iixed, body 
 lying supine raise the trunk upright by contracting the ab- 
 dominal muscles and the flexors of the thigh. If repeated very 
 often a sensation of nausea will be produced in most people, even 
 to the extent of causing vomiting. If such a powerful effect can 
 be produced Ky a simple movement repeated often, surely less 
 violent or less prolonged action could be used to obtain a thera- 
 peutic effect. 
 
 In speaking of obesity and its cure Blaikie remarks, " While 
 the spar-- man may be benefited by a course of moderate sivm- 
 nasties the corpulent man must," and he cites the case of a 
 man who in five months reduced his weight 90 ibs., from 805 
 to 215 by exercise alone. 
 
 The accumulation of fat in the muscles of the abdominal 
 wall makes them weak, and the tendency to use them as little 
 as pOaaible uceomes confit'iijcd. 
 
t 
 
 l! 
 
 11 
 
 The burning out of this superabundant fat is best accom- 
 plished by the voluntary use of these muscles in movements 
 often repeated and graduated in violence to suit the special 
 case. The loss of weight during muscular exercise is much 
 more considerable than one is apt to realize. 
 
 In a two mile lace I have known ot a man losing nearly 
 tv,'o pounds ; quite a diflFerence for ten minutes ; and in a 
 recent prize fight the difference in weight before and after, in 
 one of the contestants, was seven ponnds. 
 
 To be most efficient, a dry diet, rich in albumen, should be 
 combined with gymnastic exercise and walking. 
 
 From a series of measurements made by Dr. Geo. H. Taylor, 
 it was found that the average expansion in consumptives was 
 about an inch in place of the normal two or three. He claims 
 that the tendency to pulmonary affections is in the inverse ratio 
 to the amount of respiratory power. 
 
 In a recent case of my own, an increase of 3f inches in a man 
 21 years of age was found after five month's work, and this is by 
 no means exceptional or even above the ordinary. In another 
 case, after special movements, practiced for a month, the in- 
 crease in expansive power or chest mobility was 1^ inches, 
 while the method of breathing was much improved, and this 
 with an expenditure of half an hour three times a week. 
 Suppose that at each respiration one cubic inch of air were 
 added by proper breathing, the result would be an increase of 
 15 cubic feet of air used to oxygenate the blood every twenty- 
 four hours. That is well within the mark. 
 
 May it not be that in the search for a specific we are over- 
 looking the natural method of controlling pulmonary tuberculosis 
 and that we are unable to understand the language of nature 
 because it is so simple. 
 
 In children who have poorly developed chests with hereditary 
 tendencies toward tuberculosis, a course of special exercises 
 would be valuable, conducted somewhat as follows. Take care- 
 ful measurements of the chest and extremities, strength tests, 
 lung capacity, heart and respiration. With this data in mind, 
 give a course designed to act more particularly on the respira- 
 
12 
 
 tory system, deep breathing with special exercise for the 
 external respiratory mtiscles, correct positions in standing 
 walkmg and sitting. Repeat the tests every month or two, and 
 at the end of a course, the patient can go back to the physician 
 with the progress shown in black figures, which are worth a 
 dozen opinions. 
 
 By carrying on work in this way, facts would accumulate, 
 general rules would shape themselves, and the whole question 
 would be put on a firm scientific basis very different from the 
 disjointed results and inaccurate observations it has had so often 
 m the past. 
 
 Wm. A. Edwards advises massage and movement in chorea 
 He says : If the child be violent it should be held supine upon 
 a mattress for 10 or 1.5 minutes, while a masseur applies gentle 
 strokmgs with the palms over the entire body, gradually in- 
 creasing the time to an hour, repeated every three days. In a 
 short time passive movements, added to overcome tension of 
 antagonistic muscles, and in from eight to ten days voluntary 
 movem^^ts, next week gymnastic exercises should be intro- 
 duced, simple in form, combined with simple voluntary move- 
 ments of the limbs and trunk. The patient should imitate the 
 movements of the masseur, so as to exercise the will power • 
 rhythmic movements, timed by music, are of inestimable value' 
 
 tor the exercise of the child's will and brain The 
 
 case requires much kindness, persuasion and encouragement. 
 Blache states that of 108 cases of chorea in childhood treated 
 as above, not one relapsed. 
 
 Almost every surgeon who has investigated the subject of 
 lateral curvature of the spine, has endeavoured by a theory 
 differing from that of his predecessors to account for thr-J 
 almost constant facts :-l. Rotation of the vertebrae. 2 Con- 
 vexity of the dorsal curve to the right, and the lumbar to the 
 left. 3. 90 per cent, of cases are in girls. 
 
 Lonsdale, beside mentioning debility and faulty habits of 
 dress, lays great stress on the greater expansion of the right 
 lung and the solid resistance of the underlying liver as being a 
 cause of rotation of the ribs. 
 
•. 
 
 18 
 
 Barwell put the blame on the exaggerated use of the right 
 serratus magnus, as well as faulty position and the carrj^ing of 
 weights by the right arm and shoulder. Brodhurst attaches 
 great importance to stays and corsets as a cause. Other causes 
 mentioned are spastic contraction, paralysis of muscles, weight 
 of the heart on the left side, debility etc. All unite however 
 m believing that one of the main causes, apart from those 
 purely mechanical, such as shortening of one leg, old empyema 
 or pleurisy ; is muscular debility, inducing faulty positions of 
 sitting and standing. The causes given are many, but the 
 number of methods of treatment is what Dr. Osier would term 
 " suspiciously large." Division of the erectores spinal muscles, 
 has been practised with disastrous results. Mechanical appli- 
 ances of all degrees of complexity and rigidity have been 
 designed, forcible extension, recumbancy, the prone position, 
 slings and sloping seats, have had their innings, elastic jackets 
 have been worn, while massage, calesthenics and gymnastics 
 have been used with varying degrees of success. 
 
 Before any treatment can be accurately tested certain meas- 
 urements and tests should be made to give a starting point and 
 enable the surgeon to check off his results. Lateral deviation 
 of the spinous processes at various levels, rotation of the ribs 
 and lumbar vertibrae ; flexibility in rotation should be ascer- 
 tained. 
 
 The difficulties in the way of getting accurate measurements 
 are great, but graphic tracings first described by Dr. Seaver, 
 by means of an adaptation of the pantograph may be obtained 
 which are perhaps more accurate than any means that I have 
 as yet seen designed. By this means cross sections of the body 
 at different levels can be obtained showing the rotation at these 
 
 levels. Lateral deviation is shown in such a way that a glance 
 
 will show its amount at any level. 
 
 Flexibility in rotation from side to side can be measured by a 
 
 graduated half circle placed on the sternum registering the 
 
 amount of lateral twisting to right and left. 
 _ By taking these with other set data, and repeating from 
 
 time to time, progress under any system of treatment could be 
 
 determined with comparative accuracy. 
 
14 
 
 The treatment would vary with the case, but certain broad 
 lines have been laid down by Bernard Roth, who published in 
 1885, (British Medical Journal), his results in a series of 200 
 consecutive cases. The main feature of his treatment is the 
 discarding of all mechanical supports and the strengthening of 
 the spinal muscles by special exercises. He corrects faulty 
 positions in sitting and standing, uses manipulation and dupli- 
 cate movements in the corrected position with free gymnastics 
 daily, all directed to equalize the developement of the spinal 
 muscles and improve the general muscular system. Under this 
 treatment the general health is found to improve, pain ceases, 
 and the maximum of improvement possible is attained in from 
 three to six months of daily treatment, lasting about three 
 quarters of an hour, followed by rest supine of ten minutes. 
 
 This course of treatment is followed by a home prescription 
 to be taken for a year to ensure permanence of the improve- 
 ment. He says :— " The conscientious carrying out of this treat- 
 ment for about one hour daily will enable surgeons to cure or 
 improve the vast majority of cases of lateral curvature of the 
 spine on an average in three months from the commencement 
 of the treatment." 
 
 The object of this paper is merely to indicate in outline as 
 briefly as possible the place that exercise should occupy in 
 medicine. In doing so, many things, important perhaps, have 
 had to be left out or barely noticed In a paper of this length 
 which has to cover such an enormous field, one can but touch 
 upon, without dipping into, n few of the most important principles. 
 These notes are like a skeleton which the hearer must clothe 
 for himself, with its sinews, muscles, nerves, and vessels, and 
 skin, before he can appreciate the fulness of its outlines. If I 
 have succeeded in stimulating an interest in this department 
 of medicine, too often left to the ignorant empiricist, the quack 
 and professional rubber, I shall feel that I have my reward.