CIHM Microfiche Series (l\/lonographs) ICMH Collection de microfiches (monographies) 111 Canadian Inatitut* for Historical Mlcroraproduction* / Inttitut Canadian da microraproductions MMoriquat 1995 Technical and Bibliographic Notes / Notes technique et bibliographiques The Institute has attempted to obtain the best original copy available for filming. Features of this copy which may be bibliographically unique, which may alter any of the images in the reproduction, or which may significantly change the usual method of filming are checked below. 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Laa Imagaa tuivantaa ont ttt raproduitas avac la plua grand (oin, eompta tanu da la condition at da la nattata da raxamplaira filml, at an conformit* avac laa condition* du contrat da fllmaga. Original copiaa in printad papar covara ara fllmad baginning with tlia front eovar and anding on tha laat paga with a printad or illuatratad impraa- aion, or tha back covar whan approprlata. All othar original copiaa ara fllmad baginning on tha firat paga with a printad or illuatratad impraa- aion, and anding on tha laat paga with a printad or illuatratad impraaaion. Laa axamplairaa originaux dont la couvartura an papiar aat imprimta aont fiimta an commancant par la pramiar plat at an tarminant loil par la darniira paga qui comporta una amprainta d'impraaaion ou d'illuatration. soit par la sacond plat, aalon la caa. Toua laa autrai axamplairaa originaux aont filmaa an commangant par la pramitra paga qui comporta una amprainta d'impraaaion ou d'illuatration at an tarminant par la darniira paga qui comporta una talia amprainta. Tha laat racordad frama on aach microficha ahali contain tha symbol ^^ (moaning "CON- TINUED"), or tha symbol ▼ (moaning "END"), whiehavar appliaa. Un daa symbola* suivanta apparaitra lur la darniira imaga da ehaqua microficha. salon la caa: la symbola -^ aignifia "A SUIVRE". la aymboia ▼ aignifia "FIN". Mapa. plataa. eharu, ate, may ba fllmad at diffarant raduction ratio*. Thoaa too largo to ba ontiraly inciudad in ona axpoaura ara fllmad baginning in tha uppar laft hand cornar, laft to right and top to bottom, aa many framaa aa raquirad. Tha following diagrama illuatraia tha mathod: Laa cartaa, planchaa, tablaaux. ate. pauvant itra filmto i doa taux da raduction difftrsnts. Loraqua la documant aat trop grand pour ttra raproduit an un saul clicha. il sst filma i partir da I'angia aupdrlaur gaucha, da gaucha a droita. at da haut an baa, an pranant la nombra d'imagaa nicaaaaira. l-aa diagrammas suivants illuatrant la mdthoda. 1 2 3 1 2 3 4 5 6 Maocorr •bouition test a4A»T (ANSI and ISO TEST CHART No. 2) J /1PPLIED IM/GE M RocHMttf. Nio Vofi" 1*609 US* (716) 482- 03OO- Phon. (716) 288-5989 -Fa. E)^RCISE m EDUCATION AND MEDICINE R. TAIT McKENZIE. B. A., M. D. Prnfessor o( Physii.il FduiJiion an I ft uiympic Uilure (oursc. St. L4>uis, ,004 mm 346 ILLUSTRATIONS PHILADELPHIA AND LONDON' W. B. SAUNDERS COMPANY 1909 - I /^^ >.>a;7: Copyrifht, 1909, by W. B. Saunden Companj MINTID IN AHCflIC* PRESD or m. ■. lAUNOERS COMFANY VHIUDILPMI* " Man i! the sum of his movenicnw."_F. H. Robertson pns.7^:;stt!;^=T^^-:;:-"-"--.«on,. lo .It 'M" ■' "•"''''""' ""'■ """"^ '""JHtaes may require exerrisc in „,der W.H, .im.e. .He .™. .r^j^,TXT-::;:r :j:^ - - PREFACE ..v.J"'' !""?"■'"" ''"''" "' addrcssi.rl to students and nracti dents of mcdicmc and to i,s practitioners, with the p r,K,se to give a comprehcns vf vieu- nf .i,„ . p-'"p"»- lo "1/ , r?;L"Tt''; *• "~" ,-' """-■""■ "Housn^s Bith which ih^ vvh^i T. ? "'""" ="P«'- The proKTi'ss of mcilial i|x'alinK for midical ins|H'ition of the children lo discover cor- rectable defects and to prevent the spread of ilisease. The pern cious influence of indoor life on growth has been proved, and measures are now taken to remedy it by exercise ami play; city slums are replaced liy play^roun-ls, cc.MeKes and universities are placing on their cuniculum instruction in physical education, l)oth practical and theoreiical, since the necesshy tor exact know- ledge of the physical charecteristics which dilTerenliate the child from the youth, and Imlh from the adult, has become patent to the thoughtful physician whose advice is so constantly iisked. Exercise and nassage have been used as remedial agencies since the days of .-Esculapius, but delinile instruction in their use has seldom been given to mwlical students. Perhaps a certain laziness which is inherent in Imlh |iatient and physician tempts to the administration of a pill or draught to purge the sy tem of what should be us«l in normal muscular activity, but there is a wide dearth of knowledge among the profession of the sco|x; and application of exercise in jMit-hologic conditions, and the neces- sity of care in the choice and accuracy of the dosage will be emphasized throughout the second part of this lx»k. 1 have endeavereil to acknowledge in the text the sources from which facts are culled, but I must especially acknowledge my indcbtctlness to the inspiring friendship of my colleague, Dudley A. Sargent, to E. M. Hartwell, from whose classic re- jiorts to the U. S. Bureau of Education, much of the historical data relating to gymnastic systems was obtained; also to Fred. E. Leonard, of Oberlin, whose historical researches on physical wlucation hav, been mined with rich results. The studies of Luther Halse; Gulick, on the development of plays among children, and G. Stanley Hall's work on Adolescence have been most serviceable sources of inspiration, while the chap- ters on exercise for the blind, deaf, anil mental defectives have been founded on the work of Edward Allen, Grace Green, MEFACE ».1 an.1 Mauncc Barr, in .heir n,,«,ive sptxial.ic. In .he section on m„hc. ,r.a,mc.„, I hav. striven .o crali, o.hcr w^rk ■ in he ncUwuh.h.. contributions , hey have ma.le, bu. mu.h of " .» my o«n ex,«rience, Kather.,! from a s,x.cial praciee in h " application of exercise. ' "" .his'clnderell!' TX'^u ""■■ ''.^■'" '" P'""' '''''"- "'^' l-f'-ion Cinderella ..f the therapeutic family in her true character. PHii..\i»Ki,i'Hr\. Pa. K. T. M. CONTENTS PART I EXERCISE IN EbUCATION T„. M CHAPTER I The Ukhnition and Class.kkat.u.v of Kxehcses ™^ T„ o t-HAPTKR II lat PaysioLoov of Kxkriisk ") ., CIIAPTIIR III MASSAOE AND PaSSI\ E MoTIONS -IS CHAPTKR IV tXERCISE BY Al'PABATUS 56 T, ,. CHAI'TKR V The German System of Physicai. Traimn, 74 ~ ,. CHAPTF.R VI The Swedish System of (;ymnastics «0 T„r ..t „ CHAPTKR VII r^^n^:::^'..r'c>;^-';,;^r: ••<-»- - Keeanat,on,.. and 104 .^ „ CHAPTKR VIII AGE, Sen, and Occupation 122 p,„ CHAPTKR IX Playgrounds and Municifai, (;ymnasiums '37 „ CHAPTKR X i-HvsicAL Education in Scaoois "58 „„, „ CHAPTKR XI I HVSICAt EDUCATION IN THE Co,.,.F,:E AND l-NIVEHSITY , ^^ T., „ CHAPTKR XII The physicai. Education of the Bund and the Deaf-mute ,„ CHAPTER XIII PavsicAi, Education of Meniae and Moral Defectives .,,.„„ >5 l6 CONTENTS PART 11 EXERCISE IN MEDICINE CHAPTKR XIV „^^ The Application op Exekcise to Patholooic Conditions 213 CHAPTER XV Flat-foot and its Theatment ^.g CHAPTKR XVI The Cause and Treatment of Round Back, Stooped and Uneven Shoulders 'SO CHAPTER XVH Scoliosis— Its Causes, Varieties, Diagnosis, and Prognosis 27, CHAPTER XVIII The Treatment of Scoliosis CHAPTER XIX Exercise and Athletics as a Factor in Diseases op the Circulation. ,,,5 CHAPTER XX The Exercise Treatment of Diseases op the Circulation 335 CHAPTER XXI Obesity— Its Causes and Treatment ,.5 CHAPTER XXII Other Disorders of Nutrition ,,g CHAPTER XXIII Exercise in the Treatment of Nervous Diseases 370 CHAPTER XXIV The Treatment op Locomotor Ataxia by Exercise 383 INDEX .W5 EXERCISE IN EDUCATION AND MEDICINE PARTI EXERCISE IN EDUCATION CHAPTER I THE DEFINITION AND CLASSIFICATION OF EXERCISES The term exercise, as here employed, comprises all movements, voluntary or pass.ve, including manipulations bv the hand of ar^ ZT7 ' " """"'' '"'■«"^'' '" "" °" '^"^ "-'-• 'he Mo,^ "'!!'*: 'he nervous system, the skin, and the abdominal orj-an,. and^tfeffi "'" '"'T^" " ""'-^"^^ '" ~™^ ''^ "Pl-'i-'ion and Its efficacy as a medicinal agent. It naturally falls into the t™ main divisions given bv Plato- active and passive. ■ """^ I. Active exercise requires a defmite exertion of the will power, whether in its more complicated form of games and gvm- nasucs, or ,n s.mple duplicate directed movements with assistance or resistance by tha hands of an operator or by a machine ooJp'r T.™ ™'"''' ''°'' ""' '"1"'^^ ^"y ^^^'o" of "ill po«er. The v-ar,ous manipulations of massage, bv means of the ttctT ' """''■"" "' ^^"^" ""^ ''"'"^' by«hich con- tracted hgaments or muscles are stretched and nourished, local nuwion improved nerves stimulated, and the abdominal organs aff^ted, are restful rather than exhausting to an overwrought . st^rrr'^ """■ ^" "-'^'"''"^"^ '"'°' ''^^'' 'h°^e involving a smgle ./«,/ of one or more muscle groups, such as lifting a weight or performing a feat on the parallel bars; and. second 3 * i8 EXERCISE IN EDUCATION AND MEDICINE exercises of endurance, consisting of motions rhythmically repeated without great muscular expenditure for each one, and depending for their effect upon continuous repetition. Exerciser of effort may be more or less violent in character or compound in motion, each one starting from and ending with rest. They are in endless variety, from simple movements of lifting and throwing, to the complicated combinations on the parallel bars and horizontal bar. In them the element of skill plays a leading r6le, and what would be . mild exercise for the expert may be a severe strain to the beginner, whose inaccuracy means the clumsy employment of many muscles that help little in its accomplish- ment, the contraction of some groups actually retarding success. Even in the accurate performance of an apparently simple move- ment, the distribution of muscular effort is wide, and increases tremendously with the difficulty of the feat. In pushing a heavy dumb-bell to arm's length above the shoulder, the extensors of the elbow-joint are the ones usually considered, but the entire muscular system shares in the effort. The grasping muscles of the hand are required, also the muscles that raise the shoulder and rotate the scapula. These are attached to the spine and ribs, which in turn must be supported by the pelvis, steadied on the hips, while the balance of the body is preserved by the muscles of the thigh and legs. .\ single, simple effort, then, may give rise to fatigue of more than the muscles most obviously employed. Education should be directed to teaching skill in the per- formance of such movements— skill that tends to economize the amount of effort required — for it is the common experience of shot- putters to find that their record performance is accomplished with the greatest ease, owing to the smooth, accurate applica. ,n of group after group of muscles at the ])roper time; and the perfec- tion of balance and speed of the body's movement. However skilful the performer may be, the whole muscular system participates in any violent exercise of effort. During the intense concentration so necessary for success, the chest-walls are fixed ; the glottis is closed, the lungs acting as an air cushion THE DKFIXITIO.V ANI, CLASSIFICATION OF EXERCISES ,9 there IS an explosne discharge of nervous energy, the intensity of^^«h,ch .s _ni,rrored in the muscular rigidit/ of the atw":^ S:ed^^vrr^ra:;'S;;^tj- no?- . '"'' "PP" ''P '"'™ » ^''^''■ng expression the ao EXBRCISE IN EDUCATION AND MEDICI SE .ands out along the neck like cord, ^he general impre.^^^^^^^ ih,. face is repulsive and corresponds closely to the face oi ra« exposed, presenting the appearance of one m readiness o' seizing the enemy. f^!r^!^„ „, „Tor, ,e.n in .hrowi„« the hammer^ in his drawing of ra,. Sir Charles Be.P sho.. a face corre- heart -""^ '^^''f „^ , ",To L po-t of seriously endangering drives up the blof .he Emolion, in Man an.l Animals. ' ' " Expression of the Emotions.' THE DEFINITION AND CLASSIFICATION OF EXERCISES 21 into action wherever violent effort is performe.1, as in deliverinL- a blow, and sometimes even in testing the grip by the clymimo. moter. It is the muscle of emphasis. Gam..s and feats of speed, in which many movements must be repeate,. as .juickly as possible in a certain limited time, may well be classed as exercises of effort, since practically all the conditions of a single effort apfily to them. In a loo-yard dash, occupying about ten seconds, the con- centration of attention is continued at its highest ,x.int throughout. The breath is held, and the whole muscular system is convulsed with supreme effort, while the bloo,l-pressurc rises, much as It does in the single effort of throwing the hammer or putting the shot. If, however, the rate be reduced and the runner be allowe.l twenty seconds or more to cover the loo yards, the nervous tension disappears; the blood-pressure is but little affected- there IS no nervous explosion, and the face remains calm and smiling. J he same exercise becomes, under these conoisc of the head is backward, the chin thrust forward, and the neck strained or convulsed. With the refeitablishment of e(|uilibrium lictween the produc- tion of waste and its elimination, the urgency of breathlessness fades and the runner gets what is called his "second wind." The look of distress disap|wars from his face. The lungs regain fresh power to expand, the head becomes clear, ,ind the muscles act with renewed vigor and elasticity. He can now continue running until he feels the symi>toms of general fatigue. If the pace has been slow enough, the runner may escape the acute |)oisoning shown by breathlessness, but sotmer or later the Fin. 4. -The typiial cxprMsion of breathlcssncM is sern in llip last man. products of tissue waste accumulate, the heart beats fast and weak, the nervous system is stu[)efied, and the muscles relax. This may, in extreme cases, end in death from overcxhaustion, as has Vjeen reported in soldiers after long and forced marches. The same condition may be studied in the face of the runner during a long distance race. .After the urgency of breathlessness has passed, the expression of his face changes. The eyebrows show a slight frown, and the eyelids are heavy, as with sleep; the upi^r lip is still retracted from the teeth, giving a slight look of pain to the cheek, otherwise relaxed and flaccid. The mouth is half open, the jaw drops, and the lower lip hangs loosely over the parted teeth. The general expression is one of vacancy. As fatigue becomes more profound, his effort is centered in an endeavor to prevent the eyes from closing, as a consequence of the niE DKFIN.noN AND ClASSIPICATION OP tXKRC.SES JJ increasing paralyHisofthe rau»clc-» of .he- up,«..r eydi.U. The S -^'^.—J wrinkles across .he leheLi of 'ms "'^'■Iv tig. 71, which shows advance! fatigue, or the last *age of exhaustion, are usually associated „ith the e-.ress^In of surprise and astonish- — ment, but here they illu trate the cmleavor to rais the drooping eyelid. The nostrils arc dilated, the lips are drawn downward and outward, the lower part of the face expressing the distress of failing respira tion. The head is thrown l)acl;ward and the chin thrust forward in the en deavor to balance the head without muscular effort, Both pose and facial ex jjression are characteristic of the last effort to fight off collapse. When this last effort is exhausted, the muscles of expression cease lo act, the circulation fails the color becomes pale, the lips livid, and the runner falls in a faint. The effec: of this general fatigue ,loes not usually pass away for a clay or two The bo: l^ich .H. an»un. .. enauran. :T The ex uX tt .-.naiiy con.cs on i, ''ow- b- more Ihc acute form, correc.cl by a (e v mmu - r^U^ ' ^^^ r r a::rSy: .He n,u..e. .o. 'Heir^i^ JH.. ^ =;trtr;r;r==.::o/or.e power to louse himscU from liis letharRy. Fi,. 6,-Both (are. .how the tyr.ic»; exprr..ion o( l.ti«uc. Recovery from chronic fatigue, or prixluiid. anil his rfsourci's husliunilcd for the moment when cx|KTicme teachc!! him he can exert all hin latent iwwer in the Cmal spurt. This is so timed that the finish line will find him completely breath- less anil exhausteil. A mile race is. then, I an exercise of endurance th^ou^hout most of the ilis- | tance. and at the finish exercise of cflort. the I change showing by the ex- pression r)f the face. It is in 'mdinj; out the pace and I tlie ]K)int at which effort must be(?in that the genius of the true athlete is set or the skill of the trainer i; shown. Exercises of endurance, I then, have much more pro- found influence on the Ren- eral system than exercises | of effort. In the typical exercises I of effort, such as feats of | stretigth or skill, the result- ing fatigue is principally a ' local one, and includes soreness of the muscle most strongly in action, which refuse to function when the effort becomes too great. In exercises of endurance the constitutional fatigue is greater and powerfully affects the heart, lungs, general muscular and ner- vous systems. Passive exercise finds its widest field of usefulness in conditions of fatigue, where the elimination of waste matter must be assisted, Fir. 7.— The typical f.itc of cxhaustio jusl Man collapse in a litslailrt- race (mixlektl from life l>) the author). 28 EXERCISE IN EDUCATION AND MEDICINE and where nutrition of the part is impaired or destroyed. The patient remains inert and is acted upon by the operator or his, mechanical substitute. Muscles can be improved in size, tone, and nutrition, ligaments stretched and strengthened, the general circulation quickened, and overloaded veins made to disgorge Fig. 8.— The finish of a r ', showing effort on the right, exhaustion in the center, and collapse on the left. their blood. The digestive tract can be stimulated to more active habits, and overwrought nerves soothed and relieved of their hypersensibility. The full and detailed description of the typical movements of massage will, however, require a chapter to itself. CHAPTER II THE PHYSIOLCXJY OF EXERCISE Bodily movements affect ])rofoundIy the motor apparatus. the vessels which supply it with nourishment in the form of I)loo« -^ite cells that , arteries with a more powerful sfrnkp Ti,„ An additional amount of m ^on k„ i- • power of elimination can th-s be acauir^H , ^^ .^"""^^«' » EXERCISE IN EDICATION AND MEDICINE ears, dizziness, and a feeling of suffocation, wliile accompanying the thirst for air is mental anitiety, confusion, and even uncon- sciousness. The facial expression of the breathless man has been already described. This physical distress is preceded by a period of stimulation in which the eye becomes bright, the skin flushed, and a warm glow is felt from the dilatation of the capillaries. This dilatation of the capillaries is a sign of the increased power of the heart-beat, Fig. lo.— Stanton's sphygmomanometer; i, Leather cuff in place on the arm; a. bulb grasped in hand tor pumping air into the tube under the cuff to obliterate the pulse ; 3, glass tube graduated to show the height of the column of mercurj' required (Da Costa). which exalts the tension throughout the whole arterial system and drives the blood with quickened stream through vessels which at rest are almost empty. Blood-pressure is also raised by any obstruction of its return to the right side of the heart. The causes of raising or lowering it will be considered more fully in an analysis of the influence of exercises of effort and endurance on the circulation. The measurement, then, of arterial tension is exceedingly important. This is done by a sphygmomanometer, such as Stan- THE PHYSIOLOGY OF EXERCISE ^5 ton's modification of the Riva-Rocci instrument. Tl,e brachial artery ,s compre^ by strapping around the arm . lea her co^ four mches ,n w.d.h, beneath which is a rubber tube, the a bdnJ pumped mto .t until the radial pulse is obliterated. The _ of pressure requ.red .0 do this is measurd by the heUrof a column^of mercury forced into a graduated u^ight ^ It The normal systolic pres.sure, according to Janeway who him H r: '" '"'"™''"' '' '^^- ""■■'""'=«-- Any ii u„dT; 160 he does not consider abnormal. *' Sir Lauder Brunton's observations give 120 as nnrm,i f young adults and from r.5 .0 r^o for men m dd e Te Z ons.ders anything above 150 us abnormal, although h no 'ha" mg found men apparently in good health with a pressure Z' C;t"o "' r'"'- '" "= '■" '^ I—o- condition. by Dr T E '^ f ""?" '''™ "■'■"' ""= ^""«''" --hine, by Dr. A t. Newton and myself on college students IvinJ 2'ne, shows an average of X35, „hich is Ler an jt" Zra-dlr' ''' ^-^ - '-" ^-^- «™"-'^ "^ — The observations of O. Z Stenhpn= ■ ,„ showed the following mean pre^l^s^^a "di g^'!:: r;r;' ;^«ne, ,50.4; head down, .,,,, Wght lataf, .3;.5 ^^ In e.erci.^s of effort or speed, such as lifting a heavy weight Chest wall that ass.st m supporting the arm and shoulder come Z.T": ^™'^^f-'P---ns on the elastic cushion otl ' "Journal Aw. Med. Asxt,." On. , ,„ , 3* EXERCISE IX EDl-CATIOX AND MEDICINE ishment to the heart, are compressed, and the circulation of the heart-muscle partially arrested, while the refilling of the thin- walled auricles is hindered. The bloal i„ the arterial system is dammed back by the resistance in the engorged veins, and the superficial veins of the neck, temples, and forehead swell up like cords (see Fig. i), and the complexion becomes first red and then dusky. The blowl-pressure mounted to over 300 mm. in a series of experiments by xMcCurdy' in a back and leg lift in which the effort was maximum, but the bloal-pressure fell at once when the ob- Mnltft. '*m* l-JaiiHMAn ll«w. *m- •tr UlM. ^- Ul. Pi*. cmj PidM Ik n ID IM M in lU „ » 11* n in> lU «* Dft X at 1:1 n M 1« n s*. a la a 100 1T( « " n 173 n 114 in n " in V 117 197 10 « «t iw n m m n HL » «• HI »4 MO 154 ■0 w » «'l It is to exercises of e^lr 1' ^"'' ''"'■"• '" -^"""Pleteness. .ematic '.evelopm:„rof s ^ra rrJ.""' '°°l '" '"^ ^>^- --xn mild, rhythmic si::;:m:;-:::«- normal much more slowly h' ^h ,' ""'^ ""=" "^^P '° ^b- nses abruptly, remain hi h '^ P"'^^-^^'«- The pulse-rate of the exeLi; Du:^/^'^. • :i'™|;^ -^''-ly a. the end on with increased force and IpdTbut-r'""'" " ^""'«' (Fig. 12). '"''"^"y' ''"t without great overstrain ^^ potent influence than resistance in raising this 3» EXEKCISE IN KDLCATION AND MEDICINi: Owing to the profound influence of exercise on constitutional vigor, It should be regulated with great care in relation to the age of the patient. According to Benlse's sUtement, the volume of the heart in children is to the diameter of the arteries as 35 to » in adolescence it is 140 to 50, after full maturity, ago to 61. During this iwriod the volume of the heart is increasiti twelvefold, while the diameter of the arteries is increased only threefold. If the length of the body be considered as 100, the heart volume would be from 40 to 50 in the child, while the heart of a mature person would be 190. The child's growth then would be in relation to and dependent upon this development of the heart, and upon the possibility of increased pressure of the blood in the arteries caused by their proportionate narrowing. "Athletic training is mainly heart training.'" Exercises of endurance distribute the activity widely, and gradually approach the maximum without interfering mechanically with the respi ratory movements. They do not r«iuirc supremo efforts, but they accelerate the activity of the heart and lungs, at least so long as the exercise lasts. The aggregate of work done is very much greater than in exercises of strength. Such exercises must however, be active enough to provide for the free circulation of the lymph, which is carried on mainly by the massage of muscular contraction. If a walk be listless enough, there may not be suffi- cient movement of the muscles to thwart the pernicious influence of gravity acting on the column of blood contained in the veins of the belly, thighs, and legs, and the vessel walls may still become permanently stretched and varicose. Massage mechanically excites the vessels to action, empties the lymph-spaces, and hastens the circulation. It usually raises the general body temperature' as well as the part manipulated, and through these means it removes fatigue products, increasing the muscle irritability lost from overwork or disease. Many mo;ements may be chosen because of the automatic massage given to the larger vessels by the action of the limbs as "Weir Mitchell, "Fat and Bloud." " TWE wnrsioiooY or exmcme 39 thigh b^ turned "nl^Xd fl'L Th"! V" ""f"'''"i "• " ""^ vein wall connected ^T i^ 'TJ '^"^^ 'T''' '''' enlarging it. „ .he th.Kh .« „2 cotple ,y fl'e^ r''"'""^ pressure in again exerted on the vein Thl?^ .u '"'""^' lower centers in the hinH K . ^ , *"' °' ""em is turned over to .he High, reii^^d'-cirn^rrdtrrrHr-"^^"^ coord nations that arp n.,™ / ■« "•^voiea to those accessory -o™ehahi.ua^!!:^r™5;^^^^^^^^^ than"^ r ~"f ^*f •'■'•r • '^ '^^'"'"^ °' '' ^ -- --er this connectTon! "^ '"'"' '" '^^ "' '"^ -P"a'ely i„ nis.ic%oups?hrhr:;e:;raSatr^^ ='"■'''"'''«''- movement is unfamiliar, this c^ntrac iontw^l h 7"" J' " "'^ ate instead of unerring ' 'T ' f ^ J"''>' *"« r«rio con.mue,! af.e br™ Ute^ h! p'" '''''^''; " runner soon begins ,o notice a Jnl.i™ of^ " < '«PI«ar«l, ,he him, shown by an increasin„ iTth "'^'""''^ "'^^•P"'K "ver power. His L.C';ZZ i^LuoC S "' ''' ''" to his will; each effort require, a ^T,Z "'''°"'* attention. This lassitude KrZlly rtlL- """"'"" "" "' ■"' of muscles refu.se ,o perform heXtru'lilT"' '" T"" with relaxed grip, yielding ankle f,n- "*'«"'' "'""« Repeated attacks of fatigue nro'^"'"'""' 55 deKrecs. The- bollom of the curve: „-6, sul.jc^ a"'e^„ 7 .• ^""" " "'"'""' "> ■"'""'" «■ the waki„„ curve; at ,, breath held iu quiet ..xoiraHon'Tt/""'!' "' '• ■* """"' "'''"'• ''-■■ ject be„in, ,„ breathei/-j, curve sh„«s rn^H "'■'^^.\'"l!= ■"•Piralio,, when sub- .he breath. ..t *, he ™ »rtl a eep ef c^ed hT ' '°',l°'""« "" '■""'•"' "< ope,, his eyes and did so. He w.as not starded !,? ' '""■ "' ""» '"''' '" movement (Warren P. Lombard) "" ""' "■'" '" "'"'" ^'"J' ""'" In Kig 14 the preliminary stimulation of the poison, already- referral .0. .s seen n the higher cur^e of contraction found t the potson..! muscle at the lower part of the diagram This horma" the other unde/ th Tfl ''""^"T ^^""'""''- "■""le, of the fr„«, one contractions, .he o^er cuilt are"Z Al'^"- ''""''■ '^'" "^'"' ■>'■ ■" '^"<" tion is reco,;jed (Frieric S l"' ""'"""' """'''■ ^'"' ''"'"" """»- Stimulation soon gives place to the slo«- and lowered line of the upper part of the diagram. 44 EXERCISE IN EDUCATION AND MEDICINE It Still remains to speak of the function of the kidneys Before a^ after the Marathon race, of twenty-four ntiles, at'st. Lol h^^i '"fr''''""''"'"""'^"'--'«''™(PerrecrumT^ showing a nse of from . to 3? degrees. This rise, also r.tTby Bowen (F,g „), ;,, j believe, constant, although i may no show if the mouth temperature be taken Th„ f„ • nephritis lasting ^veral Z^T.J^l Te^SSo^ removed by the ktdneys are water, uric acid, urea, oxalates lithates, and numerous other substances. These show as reH^nv,' deposits (principaV, uric acid) in the urine esZiluv of hn ^ Habituat«l to fatigue, but quickly disappea; X 3^1:^'^^ In the understanding of the place occupied by c^ditianm, and elnnmation we have not advanced much, even TTZ he» 1/ ^'T f" ""'^ '''"' themselves, the bo■"'"> of two second.. 1-.K. .6.-rurve of the „me muscle, with the -ame weight and rhythm, after n„us,,agc for three mmutes (after Maggiora). massage (Figs. 16 and 18). Maggiora also discovered that exten- sion of the period of massage did not produce any greater results m the capacity for work, five minutes obtaining all the neetlful ettect. His experiments on the comparati-e value of the various manipulations proved that little difference existed in the effect of friction and percussion. There was a greater increase of work- ■ng capacity after the use of petrissage than from either of the other movements, but the best results were obtained by alter- nating all three. The effect of mas^^ge upon the muscles ' liraham, " Xecent Derelopments in Manage." 1 i ! 48 EXERCISK IN EDICATION AND MEDICINE weakened by fasting was .uch as .0 restore the-, temporarny to her normal condition. It also restored a normal fat.^ue un^ that „,s reduced and shortencl by a wakeful night (Fi." o rsln th r T '■"'™^" '""'""""' ■■"'ellcc.ual strain of nc hours m the final examination of medical students, Maggiora's fa .gue curve was one-fifth of the normal. An hour a ' after ten minutes of massage, the fatigue curve ralmol; completely restored. Perhaps .he mos't intere ti g S gior;,). • »-'«'"K- " "gill, 3 kilos ; rhythm, two si-conds (Mag- Obtained were in his studies of artificial anemia of the muscles 01^^^ ™Zr7com ''"^'"" "'^^' ''' '"^" -"'<» "™ I MASSAGi: AM) PASSIVE MOTIONS 49 moWn« Iht |«Mnm,- |,rrr«:eccl m the same genera 5» KXIKCISK IX EUfC.vriON .\M, MKDK IXI: 3- P.trl...g,, pinching, or gr.iping i, pirformcl bvpick- inj,' up the skin an.l sulK-utanmus tissue l,ct«trn the thumi, anf th.- Ji;ipkN. movement shoukl he performed bv the tins of ,', r cai.in™,unt:^Lr.,rs:;:r;ctr'"' '-ise the muscle an,l pr'X ^ ^ '/l:' t? '■"""«" I" used m cases of paralysis, neuralgia, a^^^inti!' '^ """™""'^ -.orr..nremr:;:---:rr:-- 54 EXEICUE IN EOUCAHON AND lltBICINL General massage i. l«s, given at an hour mM„ay l«tween meals, and never immerlialelv after eatinu TK '7'. '*'"'«" the manipulations are Ki,e„ is as folln» T. " '" "'"''' lubricated with cocoa-blltte r al "^o a JdT "" ""' which may follow the friction of atat urf^e Th '" '" ihnml 1 <■ ' ""*" ''™" covcrec. With the thumbs and fingers, the small muscle, of the foot are kneadLl specal attention being .levoted to the interosseo" gZ ' whS foot The leg ,s next treated by circular friction with the fingers 3^^ir^^'t^^c:;r---r5 5-Ke^:^^r:^:a^^a^s;^— -t bs A?h ^,"' ™""* ""•^"^ "'<' ^"^hions of the finger- unee, to lavor the flow of venous blood-riirr™.= tu is carried on for the hands and hT^trT Esirr: '-"""^ g.ven to themuscles of the loins, back and neck u^A k- ""^ to Actions kneading, and strikin;^^ S t^r'^rlS back, the same manipulation being directed downward and MASSAGE AND PASSIVE MOTIONS j, out«arn should be carefully covered af.e^ treatment. Weir Mitchell, in his treatment of neurasthenia by rest overfeedmg,and general massage, found a constant rise of tem,«ra ure after each treatment, and not«l a rapid improvement iithe tone and reaction of the whole muscular system oJul "'Tr '""" 'r «'""« "''^^^ '^ """ '«> ""•'h i^ given at onc.,me-Magg,ora-s experiments prove that the maximum effect on a part ,s obtamed in five minutes. Another mistake isTn employing too heavy a hand: a patient should never feel bru Jd riiuitrfft:"^™''^ - ■"--"' ■-'-"^ '^ - "^ -^^ ^t Mas.,age should be avoided in certain skin affections, as eczema act^e, and other skin eruptions, in wounds, bums, and ery^-X' m tumors and purulent inflammations, and in acute diseZ rf he bone t,s.sue. It should not be used in the acute stag^ori- re cons .tutional or local diseases, where complete restTncL^v an ,. should be allowed only with great pr'ecautiot in p^^' and m the presence of renal disease. Its place in the treatment II sprams, fractures and other surgical conditions, and Hie .n^med,cme w.U be considered more fully i„ ,He appropriate CHAPTER IV EXEROSE BY APPARATUS The application of exercise and massage by mechanical means has been considered from two points of view-firstly, from the Fig. jj.— The pdymarhjiioil of Caolain rh,'~.. A ■ standpoint of the physical educator, who kouW obtain rapid ..evel- opmentof the entire muscular system by specially designed ap- EXERaSE BY APPAHATtrs lecreased for frequent rapi.lly repeated motions; hTlZ^ nor res,s.ance is necessary; weight must be lifted ormoved ■f the best qua hfes of the muscle are to be developed Many so-caUed free exercises, such as deep knee-bending, use the body weight for resistance. Dumb-!,ell3 have been used since the time of the Greeks for the purpose of shortening the period required to de- velop a muscular group. Their appli- cation ,s crude and limited, however m comparison to the accuracy and ver- satility of machines employing the prin- ciple of the lever or the pulley weight. Jhe direction of a dumb-bell's pull is always downward, whereas, with the shoulder attachment of the puUey- weight, the drag is lateral, and the high attachment of the pulley reverses the direction of the force of gravty. By changing the position of the pulley it is thus possible to isolate the action of all the important muscle groups. We have records of Captain Chiosso, as early as iS,n .» u ^rt:;-ir:;^>---'-.r=::i:r^ .mpor. haUtma with '"T '"'"i'"' '"' '"' ''^'"^ "' ^ "«'« and its heaut7,; ".!"'; ^ '='"P'°^"' •" "'' -binary room "- heauty „f hne, the elegant and ornamental structure of the Fig. J6.-Dr. Sargent's first design for the pulley-weight, mlh adjusuble weighu in wooden boxes. 58 EXERCISE IN EDUCATION AND MEDICINE whole fits it for a prominent position in the dining-room, library, or boudoir." In spite of these advantages it did not make a permanent impression as an exerciser, an article of furniture, or as a means of p- - _ treating the dozen maladies for which it rV ^ was claimed to be most beneficial. Other machines, designed on this prin- ciple, have been constructed and used for the last fifty years, but the improvement of their' design, their systematic application to gymnastic training, and their wide em- ployment in physical education are un- doubtedly due to the efforts of Dr. Dudley A. Sargent, of Harvard, who has perfected the numerous developing appliances that are known by his name, and every gym- nasium is now supplied with a more or less complete set. In its simplest form, the pulley-weight shows one pulley attached to the wall at the shoulder level, over which runs a rope with a handle at one end. The other end of the rope is fastened to a weight carrier, steadied by guiding rods, which may be loaded with iron plates (Fig. 27). This rope may be compounded by means of another pulley attached to the weight carrier, so that its excursion is half that of the arm (Fig. 28, A). In this way the height to which the weight is lifted is halved, allowing twice the range of movement with the same length of guiding rod. A further elaboration of the pulley-weight uses a floor attach- ment, the rope turning about the pulley at the level of the floor, making a downward resistance (Fig. 28, B). A third variation, called the intercostal attachment, uses F^'K- '7- — Thepcrferted pulley-weight machine (Narragansett Co.), with weights attached by mov- ing a foot lever. Single. EXERCISE BY APPARATUS the overhead puUey, which draws the arms upward (Fig 28 C) Fie. .8.-Triplf, pullej-.riKhl (Narragaiuoll Co) o. me neck may be developed; also for the foot, to exercise the muscles of the leg and thigh. e^rcise the The quarter-circle is a modification of the regular pulley-weight 6o EXERCISE IN EDUCATION AND MEDICINE machine for keeping the trunk overextended during the arm movements. * Pulley-weight machines have been designed by Dr. Sargent for strengthening the flexors of the fingers (Fig. 30), and for the pronation and supination of the forearm. -Quarlcr-cirtie (Si>alding). Others are used for practising the movements of pushing down- ward on the parallel bars (Fig. ,:) and chim>ing the horizontal bar In these machmes, the bars are set on sliding rods and balanced by counter-,ve,ghts, while the resistance may be increased with the strength of the user. They are designed for the man who is EXERCISE BY APPARATUS 6l Fis. 30.-l-i„|(er marhini- to develop floors „f Ihc lingers and Sraapins [loviiT (Sialding). Fig. ^..-Traveling ,„„„« (Narraganse.. Co.), invented. by D. A. Sargen, tord.ve.o,. ing purposes. EXERCISE IN EDLCATION AND MEDICINE 62 z^Jt '" ™T K ""^ "'"^'^ "'^^''^^ °" '"^ P"""^' ''"d hori- zontal bars, and by their assistance, he is enabled to develop gradually strength sufficient for the usual feats shown •!"^'"-°"' "PP"^''"'"' °f 'he pulley-weight principle is sho«n m an mvenfon by George E. Goldie, in which the body- we,ght replaces the conventional iron plates. The gymnast lies upon a padded table running on a sliding frame. Four handle are attached to cords, a, the top and bottom, so that resistanc: I may be obtained from above or below. The upper end of the frame ,s ra.sed and hooked over the rung of a ladder, fixed to h wall. Ten.s,on on any of the handles draws the table up the inclined frame, so that the body-weight is the resistant force Thisr "sN ance may be made as shght as desired by having the frame attached o the lowest rung, and may be rapidly augmented by increasing omb? ' : 'r""" ""^''^ ''" ""= ^'"Sle movements ani combmafons of the pulley-weight machines mav be obtained ^ the use of the upper or lower pair of handles alternately or EXERCISE BY APPARATUS 63 duced. They n.e cl but Imle coordination, and may be repeated ■' mdel.nitely without great mental exhaustion. The repeated con- tracting and relaxing pumps the blood through the muscles, which rapidly increase in size, but if the entire muscular system be developed to Its physiologic limit, a very con- siderable drain on the vitality is •^'K- .1.1-— Exlreme muscular dc- vi-lopmfni wilhoui a rarTO|»ndinK "imase i„ hran and lun,, |„„.<.r. Iki» man could n„i float i„ sea «alcr and did prcmalurclv. „, , _, — . f^* " -The naui.cal wheel in action, 'vMhou ac."n 7" '"''-\''-- Powerful muscular development ci s s ou, t™' r " T' """■°" '^'«- ^3)- These'exer- end^rance ' """"'"''' "''"' °"'^- -l"-"^ ^X'" and The simplicity ot the movements is such that they are easily 64 EXERCISE XX EDICATIOX AND MEDICINE mastered, and the interest in them soon flags. It needs a slronK determination, buoyed with the hope of increased strength, tc continue their use. In order > help the imagination, as well as to form a preliminary training for special sports, apparatus has been designed to imitate the movements of paddling, rowing, sculling, and bicycling, using the principle of the pulley-weight or lever. Others employ friction to give resistance to the stroke of the oar or the turn of the wheel (Fig. 34). In the inomotor Dr. ^argent has devised a machine capable of developing all the muscular system, while allowing the exclusive use of selected muscle groups. For this purpose he uses the prin- ciple of the lever as applied to rowing and bicycling. The machine -The Sargent inomotor. consists of a pair of levers, connected, Ijy four adjustable rods, to a sliding seat and foot-rest, which are, in turn, joined by rods to a clutch gear or sprocket wheel. In the diagram A-B is the framework of steel tubing. i.the hand lever pivoted at P, F the traveling foot-rest running on the track, Pt; S, the traveling seat, moving on the track. Si. II' is the gear or sprocket wheel, connected to foot-rest and seat by rods FPR and SPR. The hand lever is connected with the foot-rest by rod C, and with the seat frame by rod D. The other imiwrtant parts are the toe straps, T.t. and seat back, SA. .\ftcr taking his seat, the operator grasps the handles and pulls. As he braces his feet the foot-rest moves forward, turning the wheel W. M the same time the scat is forced backward by EXERCISK BY APPARATl'S (,. Straightening the thighs, ami al.so serves to turn the wheel through ..s connectmg ro,l, SPR. When extension is compIete.T e s^^^n, half of the movement begins, and the wheel is .u'me, l.ysh^^ng anoh ':''"f^''"<^ P""'""« 'h" 'oot-rest and seat toward one anoher by flexmg the legs. The ,«wer thus obtained mav L apphed to large flywheels, as in the illustration (Fig. 36) oTth^' machme may be mounted on -oilers geared down ^' tha i moves only a few inches for every stroke. In this way th'imere of a long race may be obtained in a small room. The k'- " r TiK. 36.— The Sargrnt inomolor with flywhcrl obtamed. The general exercise is always sufficiently active to give valuable training for the heart and lungs It B capable of infinite variety in its construction and applica- Tans or" r,'-''''''"''^ T' °' ""■^'^P'"" ^"'--'-' «-- means tor propulsion on land or water. I 66 EXEICUE IN EDUCATION AND MEDICINE The use of mechanical means for the treatment of disease was first systematized and employed in a complete way by Dr. GusUve Zander, of Stockholm, about 1857. He there esUblished and directed the first Zander institute, and has been actively engaged in the practice of medicomechanical gymnastics, lecturing on the subject at the medical school of Stockholm until his recent retiremcn;, when he was succeeded by his eldest son. Zander has devised ; nearly one hundred ma- chines to give his exercises and manipulations, and his system of mechanotherapy has enjoyed a wide popu- larity in Europe, and has a considerable, following in I America. Zander institutes are found in Boston, Balti- more, Philadelphia, St. Louis, San Francisco, and elsewhere, while over seventy sanatoria are sup- plied with some of his apparatus. The machines are in three series; First Series. — Apparatus set in motion by the mus- cular power of the patient. Second 5fr».j.— .Apparatus set in motion by means of some motor. Third ^frifj.— .\pparatus exercising, by the weight of the patient's body or by mechanical arrangements, a cmective pressure or tension. They are classified, according to their physiologic effects, into four sections: 1. Apparatus /or Active Movements.— To exercise and develop —(a) Arms; (b) legs; (c) trunk, and (8- j;.— Machine for Sexion and extf the foieamu. EXERCISE BV AWA«ATM ^ flexion. Its action may be rcvcruvi -., i ■ extension. A nun,™ of o7h u "*'' '° '"^''»« '"'""n ~en. i, ,Ven the .at ,y ^otor ,»,S;; J jj;:^, "^ :*: :ir^- -- - <"' "><= ™-'es o^ .„« ,oi„s a„d elevation. ThT ma:hine L '^e ^di i:";' ™'"'™' ^"' ^^'"^ passing notice. It is call^ .h! ^^ ^'°" "^'■"^ ""^e than n.oven.ent is perfo™Jl^..f „,^-;; (^■■«- 38). and the beneath the a^-pit, and L..^:tt'^^X::i^2 « EXUCIRE IN EDt'CATIUN AND HEPICINE chest is thrust fomard rhythmjcally by a cushion appliwl against the back of the patient, as shown in the illustration. The rate is set to correspond with normal respiration, and the thoracic walls are expanded and stretched by its use. 3- Apparatus for Mnhanieal Operalions, including Vibra- lum, Perrussion, Kneading, and fw/ifw.— Vibration is ({ivcn to the whole body by the jolting movement of a saddle-shaped seat Fig. 30.— The "hone," lo give vibnuion of Ihc whole liody (ijllinK laddlewayj,). (fig- 39). and the Zander vibrator is adjusted to give about 500 strokes a minute to the feet, legs, chest, or abdomen. Four machines are devoted to percussion: Fig. 40 is pro- vided with four beaters for tapotement along the spine. This machine has been called the "digitalis of the medical gymnast," from its action in slowing the heart-beat. One machine is devoted to kneading the abdomen and six to friction of the arm, fingers, leg, foot, back, and abdomen. 4. The orlhopedir apparaitts are eleven in numbw, and are designed for suspension, rotation, and lateral pressure. EXEICISr. BY APPAIATl'S 69 A comiJete ou.fi, require, a. Ie.„ 3000 square feet of ,,„cc, The resistance is .,u,,pli«l by a weight an.l lever instead of a pulley-weiKht m all the machines re.,uirinK vo|untar>- action from l^iJr, T "".'* a"«ment«l by moving and damping the «e,ght at any pomt of the graduated scale market on the lever. Fi«. 40.— Zander's hark pcrcussor. c™17 ""^u^'f '" '""P'^ "■'■"' ^'-"•"""'^ '"«• "f -"Uvular rit "'k, "' ''''" """ ""•' '""-^'"S -"'action the muscle ,s able to accomplish less work. The resistance is then nude o d,mm.h during the latter half of the movement, a princip e rS r ''I'^^'ru^^ -•^•--e is furnished bvfrictio!: of th.; : " "'^ "^^'"^ '"' developing flexor power of the leg upon the thigh the greatest resistance occurs wheTthe TO • ExransE js EDPCAnoN and medicine 5i™!^"' '!;?"' '° 'T"' '""^ '""P'"" «'--■"». «"'^ being esfmated as the pomt of greatest power in the knee flexors. ove come by employing these machines; the amount of relSLce ■s always constant, and can be diminished or increased as defred accordmg to the strength of the patient. ThTdose trt accurately prescribed, and the uncerLnty of the humaaTand can be eliminated. The pmount of resistance forms a curve, the Fig. 41— The Z«nder vibnitor. apex of which is at the point of greatest physiologic efficiency ^^rt^^X^. "-''«-•" ''^ -■-- -" 'He var^g (rf^r""^' "' '™''" '^'^'""^ ^""^ ''^*''«"«' by C. F. Taylor 1869), and numerous modifications have been made to simphfy the somewhat cumbersome mechanism of the originals. ^^ rhe Zander vibrator gives a rate of from 500 to 900 strokes rocL^o— ' sir '"^"' "-'- -"^ '^^ -«^ ^-'^^^ There are three types of vibrator now in use: the rigid arm vibrator, of which the Zander machine is an e.^mplc; th"Yex^" EXEKCISE BY APPARATUS j, S pLT"' "' "" '"""'"' '"'""°'' '""'""''' '" "" '='«'™- lenlT*, T""'"^ 'u°"''' ''' '''"'"'y '"'J"^"''"e i" rate and much hT 1"'k'"Tu"- ^'"= ^"«''' °f '"« ^'brator has beea much discussed but Eberhart, of Chicago, happily compares them o various sized hammers: " If one wishes to drive a smaTl naT he could do so with either a sledge hammer, an ordinaiy hamTer or a tack hammer. The ledge hammer would driv^it aT^ne h m'mer ^h'/""" '' '""•^'' ^P^^"""- P°-^; '"e ordina" hammer would drive it in four or five ..rokes; the tack hammed would po^.yy require a do«n blows. The fi^al result w. uTd be the driving of the nail." Mechanotherapy has obtained its greatest hold in .America through the vibratory treatment. The power of properly appM vbraton. movements to quiet pain, to make a rapid and excH heart beat ^ow and steady, and to reach, through the sp^ nerves, the deep-seated organs presided over by the symL het nervous system, is well established. 5ymp8.hetic Three points must be carefully considered in the app/ication of this treatment: ^z) The length of the stroke; (,) its rate (^) limite, and modified in their effects by the applicator us^ the bril^'t^rr 'r " -"^-g^^d machine' being a rub^ .hTthr:.^d , =^2 T""' '""' ^ ^'""' '''' °f -"'rubber fc fh-it Tk 1 1 ^"^^ ""'^'^ "^'''' ''■■''= 'he erector spin^- a hollow rubber ball for the treatment of the eye; a flat dfsc a v^uum cup, and special vibratodes of hard and ^.ft rub^r for wTon r™- ""■"= '""^ ^''""■'^^ ^- P'-te'™. ■■" his ime W Stimuli; 7> I™"''"""' ^'''"''''" ""= "-^-^"'^ 'n'o (I) Stimulation; W vibratory stimulation; and (3) vibration. St mulation is produced by a milium stroke and light pressure, wuhth brush attachment, for increasing the bloo/supply to a ulation. ^ application should last from three to seven seconds. Vibratory stimulation is applied by the rubber ball with a 71 EX£KCIS£ IN EDUCATION AND llEDICINE medmm stroke and deep pressure, the treatment lasting from eight to twelve seconds over one spot. This is recommended for^ m wh,ch the viscera are to be reached by acting on the spinal nerve-roots. "^ uble r„dicatt v««,n^r area. SimuUHo^ ,1, """" ""^ ,^'" "^ "™» '" *« .ma,.c,.h.„^„,™,.Sh,^T^:r"u'5e'V,SiSXt"dti4"^^^^^^^^ ■.K^lu'^u°°.'"f P"^"'"^ ^^ " ''""■y ^'"^^ »"d deep pressure with the hard-ball attachment. It should not be given for more than fifteen or twenty seconds, and is used to inhibit a nerve that ■s givmg pam. Pilgrim especially warns operators against over- sfmulafon, which, while not permanently harmful, is never considered desirable. EXERCISE BV APPARATUS ^ IS that all functions and organs of the body are controlled -r,rne^r:zr ;r^ ■•^'^-^•- - -^ shows senslfVeness .hen r/distlrhLeTfur e^rj nerves from the spinal canal. When the nerve is vibrated ,hZ pa-nful po.n. tends to disappear, and coinciden^lirrrstlLn Fig. 41. icml vibratory Rubber brush; ment (rubber) CHAPTER V THE GERMAN SYSTEM OF PHYSICAL TRAINING It is to Germany that modern physical education n,.,st look for one of the most powerful influences in its development, and tho somewhat acrimonious discussions thnt fill gymnastic litera- ture, between its supporters and the foUowers of Ling, the Swede have done much to clarify the principles on which the German system is based. It is necessary here to review briefly the origin and growth of German gymnastics and their introduction to America To Basedow belongs the honor of first combining physical and mental education in the general training of the European youth In 1774 he founded, at Dessau, the " Philanthropinum," to realize Rousseau's method of nature, "so that the training of the mmd and body shall serve to assist each other." He em- ployed the knightly exercises of riding, fencing, vaulting, and dancing in educating the sons of the burghers. He also drew h.s exercises from popular German sports, rowing, swimming skating, and games of ball, and copied from the gymnastics of the Greeks, notably the " Pentathlcn, " which consisted of weThte' ^'""'''"^' ^'™'"'''^' ^^^^^^' *"<* '^"y'"'S heavy Among his disciples were Salzman and Guts-Muths, lahn and Spiess m Germiny, Pestalozzi and Fellenberg in Switzerland Nachtegall m Denmark, and Ling in Sweden. Salzme^i, one of Basedow's assistants at Deaau, established a school .t Sch»epfenthal, near Gotha, in :jS^, and here Guts- Muths received his inspiration. As he himself writes: "I entered, when still a youth, the school of Schnepfoithal THE OM«AN SYSTEM OF PHYSICAL GAINING 75 He afterward wr^lwl on 1 T """"'" "'g^'™-'-. ain,s,whfchmaybesta(^Thr ^"'^-^""'^ '""^ '«■" distinct *iia^ uc siaieq m his own worHs ns *< /^x nr i . Fr;»H-;,k T J . T , P ' ™ '"^ second. W He wa:;"!/''" ™^ ""^ '■" '"8, in the village of d.-spositio„ Zcl T^J 3--. .-"ess, and .If-sufficient career as a student rswHdandT'J'T" 'V" ™*'"«- «'^ with the n,en,ber. of^i „' Sl^' rHaTl '"J"''"'^ wanderer from university to unive^^ Fertile K^"' ' Jena, where he was forced to leavlt;^ ^^ ''^"' *° private tutor direrti„rv . , ""■^rsity and become a appeared in i8oo Ld sS h ""t. P™"°"°" °f patriotism, agS. For^Le next tin V ^ ' '" '"'"«" '" '"P"'" 76 EXEKCISE IN KUUCATIUN AND MEDICINE word siwcial costumes were adopted. Their badge liore the "Turnkunst," and the figures "9-919-1519-1811 " /.■• TumkiKist . \ 'S"> , These figures served as reminders of Hermann's rout of the Roman legions, under Varus, 9 a. d., the introduction of tourna- ments into Germany, 919 A. D., the last of the German tourna- ments, 1519 A. D., and the revival of "Turnen," or turning in 1811. In a year the number of turners rose to 5C0. Jahn and Friesen organized a German union, hostile to all foreign rulers, and ex- tended it to the students of various German universities. In the war of liberation members of this union were the first men enrolled in the famous free corps of cavalry, where Jahn commanded a company recruited by himself. In the five years preceding 1816 he latjorcd incessantly, writing and publishing his book, "Die deutschc Turnkunst," which sums up his aims and accomplishment. In speaking of the beginning of his work he says: " Love to my fatherland and my own inclina- tions made me a teacher of youth. During the beautiful spring of i8io a few of my pupils began to go out with me into the woods and fields on the holiday afternoon of Wednesday and Saturday. The number increased at the various sports and exercises. Thus we went on until the dog-days, when the number was very large, but soon fell off again. But there was left a select number and nucleus who held together even during the winter, with whom the first turning ground was opened in the spring of i8n in the Hasenheide." In this work he pays willing tribute to Guts-Muths, the main source of his inspiration. In 1819 plans were perfected for establishing turniilg grounds throughout Prussia in connection with the schools, but because THE GERMAN SYSTEM OF PHYSICAL TRAININC. 77 Of a murder committ«l by one of the turners, to which ,K,litical significance was attachecl, the student societies and Turnverein were put under the ban as being hot-beds of liberalism. Jahn was arrested, as well as Francis Lieber, a youth of nineteen, one of h.s oldest and most favorite pupils. Lieber was exiled, and chose the tnited States for his new home in 1827. He came with a recommendation from Jahn for the express purpose of taking charge of a gymnasium in Boston, where he also established a swimmmg school. Fig- 44. -IVo|,le throwing flower, lo Ihf Amerieaa Turners at Ihrpara'c whTTT" the Tumfesl of .goK, in Friinkforl. Jahn's case dragged on for nearly six years, but he was acquitted m 1825, although with certain restrictions. In 1840 he was finally released and awarded the iron cross in recognition of his service durmg the war of liberation. Though he issued many pamphlets showmg his continued interest in turning, his declining years were passed m poverty and obscurity. His last publication appeared in 1848 entiUed "Schwanenrede" (swan song), closing with these words : "Germany's unity was the dream of my awakening life, the THE GEMIAN SYSTEM OF PHYSICAL TSAININO 79 morning glow of my youth, the sunshine of my manhood, and is now the evening star which guides me to eternal rest." The formation of gymnastic societies, however, continue.! to grow, and Tumfests were celebrated, until in i86i nearly 6000 turners took part in the festivals. At present it is as common to find a Tumverein among German colonists and peoples of German e«raction as cricket and athletic sports among Englishmen li\ing abroad. The Tumfest at Frankfort, held in July, 1908. had 30000 turners m line, drawn from every land to which there has been German immigration. America's numbers exceeded that of any nation outside of Germany. The hold of turning upon the German people was evident by the enthusiasm displayed during the parade of the visiting turners on the opening day. Flowers and wreaths were showered upon them by the spectators along the route The exercises, which continued for six days, opened by a mass dnll of about 20,000 men. The illustration shows about Sooo men rehearsing for this event. Although all the societies drawn from distant lands, had never performed together before the exhibitions were faulUess. On succeeding days group com- petitions and drills were given by children (Fig. 46) and by picked squads representing their societies, with individual and group competitions on the horse, horizontal and parallel bars running, and vaulting. Prizes in the form of wreaths and diplomas were given to the successful societies and competitors. The turners place great emphasis on mass work, and the social side has not been neglected. They have long ceased, however, to be political clubs, holding themselves entirely aloof from the consideration of party questions. They are divided into two main sections: boys from seven to sixteen years and men. Classes are subdivided in squads each squad being led by a "foretumer," whose business it is to make the members of his squad as expert as possible, and, above aU^to secure to each an erect form and aggressive carriage of the The introduction of the German gymnastics into the school 8o tXZlCISI W EDDCAnON AMD HEOlaVE •yrtem was the work of A.UJph Spies., a Hessian, born in 1810. He was influenced liy Pestalozzi, and trained in the methods of Guts-Muths. In 1829 he became acquainted with Jahn, and in the following year, whHe still a student, formed a class of boys at Giessen, and made a beginning by teaching what is known as com- mon exercises, the simultaneous performance of movements in re- sponse to the word of command, either with or without the aid of apparatus. He is sometimes called the creator of gymnastics for FiR. <6.— A naaa drill of ichool-rhildrfn at the Turnfc«t, Franktort, .908 girls. These gymnastics he introduced into the public schools of Burgdorf, in SwitzerUnd, where he became acquainted with Froebel. They include free gymnastics, dumb-bell drills, exer- cises on the suspended ladder, and see-saw, besides running, jumping, and swinging. In 1848 he returned to Germany, and at Darmstadt carried on special normal classes to train assistants for his work, until his death in 1858. He was highly successful in teaching gymnastics to the girls of his schools. THE CE«MA.V SYSTEM OF PHYSICAL TRAININO 8l rjTo r:i •°/)'»'ema.- German gymnastics and .o Ip. Uiem to pedagogic purposes and methods. ^ iTussian army, was placed at its hrarl d„.u . • parti/an of ih^ <:,„J^ i, Rothstcin was a warm a^d srrr t '"™"^ ''"^^-'^^^^^^^^^^^^^^ sy" te,; and 1: K^ .. ', "■''° """"^'^'^ ''^'<'"''"' "-e German pupl'' rrv"' "' ""'""^ "^^'"^ '" "''= "(Se and sex of the gymnastic machines. These erirrr "" exercises on the and difficult fnr J «efciMs grow more complicated «?yn,nastiXt^ct"n." ^ ' '^ """"' ^'"^^'^ ™""^-^ -"> 82 EXEICUE IN EDl-CATION AND HEPICINE Outdoor gsmo have been accorded a place in the Gennan system from the first, but interest in them has increased to an extraordinary degree from the year idyi, when the Central Com- mittee (or the Promotion of Youthful and Popular Sports in Germany was organized under the presidency of Baron E. von Schenlcendorff. Facilities for school games have been provided, and provision has also been made for their management and maintenance. The movement resulting in the American Play- ground Association may be traced to the labors of this committee and its distinguished president. The introduction of Ger- man gymnastics in .\mcrica Ijegan with the arrival of Dr. Follen, a German exile, at Harvard, in i8j6. The Bos- ton Gymnasium in Washing- ton Gardens seems to have been the first public gymna- sium of any note in the United States. In 1837 Dr. Francis Lieber, already referred to, succeeded Follen. Gymnastic grounds were established at Yale, Williams, .Amherst, and Brown about the same time, while a dozen or more schools followed suit. This movement, how- ever, was short-lived, and closed about 1830, when both Dr. Follen and Lieber left the field and followed other pursuits. The subsequent history of German gymnastics in America is that of the growth of German immigration and the establishment of the Tumgemeinden in large American cities, such as St. Louis, Milwaukee, Philadelphia, and Cincinnati. The Xormal College of the North American Gymnastic Union, established in 1861, and now conducted at Indianapolis, is employing educated FiR- 47. — Typical pair En Orrman wand drill. THF. OK.MAN SYsrrll OF PHYSICAL TKAINLNO 83 teacher, «aine.l in ,hi. „.,„.„, by „„^ „,^„,,i four yca« and ,he official orsan of the movemen,, a monthly calle. ".Mm,, and B.-l,," earric. on an active can„»iKn ,0 mtro. uee physical traininR into the school system, ami dis'.minate knowledge on the subject. William \. Stecher. its editor and director of ,.hy. i, ., , ,, , ,„ f .'nn m the school., of Philadelphia, divides the German m h , ,„. siv lar|{c groups or classes: Fin. ,K -Typicnl .wing and b.-,l«„co „„ciV on ,hr p,r.-ill<.| !»„. 1. Tactics, embracing marching in all its forms 2. Free exercises, embracing all forms with hand apparatus, hke short and long wands, dumb-bells, rings, and clubs 3. Dancing steps, principally for girls, including all the move- ments from the simple gallop to the most complicated forms executed by expert dancers. 4. Apparatus work on the horizontal bar, parallel bars, long a, EXERCISE IN EDUCATION AND MEDICINE and side horse, buck, suspended rings, ladder, jjoles, roijc, round swing, sec-saw, balance board, swinging board, pulley-weights, storming board, and vaulting table. 5. Track and field work, such as high, broad, and deep jump- ing, hop, step, and jump, running, hopping, putting the shot or stone, throwing the javelinordiscus, lifting and putting up of iron weights and stones, pole-vaulting, swimming, skating, fencing, boxing, wrestling, and shooting. 6. Games and plays, the enumeration of wiiich would take too long. The first collection of games was published by Guts- Muths in 1793. The exercises for children are divided into six or eight grades, to correspond with the number of years in the common or grammar schools. Inclusive as it is of almost all forms of indoor and outdoor activity, the characteristic apparatus that will always be asso- ciated with German gymnastics, because invented and most largely used by them, are the parallel bars, where the typical exer- cises are those in which the weight is supported by the arms in \-aulting and balancing. The horhonlal bar. the glorified liml) of a tree, in which the weight is also supported hy the arms in circles THE GERJIAX SYSTEM OF PHYSICAL TRAINING 85 and levers; ami the z^aMng horse, borrowed from the days of ch,valry, on which circles, vaults, and pirouettes are practised and carr.«l to a high ,»int of development, the weight being again supported by the arms. Exercise on these machines emphasizes the development of he muscles of the shoulder-girdle by the almost constant use of he arms m supporting the body weight, an,l in this, together with the large use of music to govern the rate and rhythm of the free exerc,s.-s clone in classes, lies the main .lilTerence between the gymnastics that are krown as "German" and those derived from other sources. Singing and turning are inseparable, especially "■■th the children, and the system has become more cosmopolitan of ate years to fit the local conditions an.l national temperament m Amenca They now may be sai.l to include everything except he medical application of exercise and massage, which -has been left entirely in the hands of the Swedes. i mi ill CHAPTER VI THE SWEDISH SYSTEM OF GYMNASTICS The Swedish system of gymnastics had its first impulse from patriotism, as was the case with the German, but in the hands of its scholarly founder it became much more finished as a gym- nastic system, and comprises recreative and school gymnastics, military gymnastics, and, rhost distinctive of all, medical gym- nastics, or the application of movement to the treatment of disease. Peter Henry Ling, its founder, was born in 1776, two years before the birth of Jahn, in Smjland, one of the southern provinces of Sweden. A dreamy, imaginative boy, he entered the Latin school at Wexio, where he distinguished himself in his classical course by his mental ability, strong individuality, unyielding will, ani reckless enterprise. He was suspended or expelled from this school, along with some companions, on account of a breach of discipline. Leaving Wexio on foot, he seems to have wandered for some years in Sweden, Denmark, Germany, France, and even England, acquiring the languages of the countries in which he sojourned, and we find him, in 1801, enrolled as a volunteer in the naval defense of Copenhagen against the English. Here he remained for ten years, becoming a skilled fencer under the instruction of Montrichard, a French refugee, from whom he obtained a diploma endorsing his ability to give instruction in the art. While there he visited and attended the gymnasium of Nachtegall, and recognized the national importance of the new- art, striving to classify and develop its practice according to ana- tomic laws md to give it the precision of mathematics. In the fall of 1804 he returned to Sweden, to act as a sub- stitute for the aged fencing master of the University of Lund, whom he soon succeeded. He also taught gymnastics and riding, THE SWEDISH SYSTEIC OF GYMNASTICS 87 and applied himself diligenUy to the study of anatomy and physiology, putting his conclusions into practice in the system of fencing taught to his pupils. The new exercise became pop- ular, and it was not long before interest in it and in his gym- nastics spread beyond Lund. Invitations to introduce the double art were received from Gothenburg, Malmo, and Christianstead, where he gave instruction during the summer vacations in the arts of swimming, fencing, the saber, and gymnastics. The eight years of his stay in Lund were also fertile in literary activity, for it was then that he first began to know and love the Scandinavian mythology, and to compose patriotic poems in French, German, Danish, and Swedish. About this time he also wrote "Agned," a tragedy in five acts, which was presented on the stage at Stockholm. One of his poems, "Gyfle," deals with the loss of Finland, which the Swedes bitterly deplored. These plays and poems show the intensity of his patriotism and his desire to see his countrymen strong in body and soul, with power to meet her enemies. Fervid patriotism was the inspiring motive of his poems and his gymnastics alike, though in the latter he saw a practical means of restoring the health as well as of developing the physique of the race to defend the fatherland. During these eight years he thought out the principles upon which his later work was based, seeking, first, to understand the human body and discover its needs, and then to select and apply his exercises intelligently with these needs in view. He conceived the idea of opening in Stockholm a central institute based on the one already in operaUon in Denmark for the training of teachers of gymnastics for the army and school. He took as his pattern the institute of Nachtegall, in Copenhagen. His plan was successfully carried out, and the school was opened in 1814, in the northern suburb, Normaln, on the site occupied ever since. Here he equipped the necessary rooms, gymnasium, fencing hall, and offices, in some old buildings which had once belonged to a cannon factory. By increased grants from the Government he was soon furnished with an assistant, and two others were added from time to time, until, in i8jo, he had three. if 88 EXERCISE IN EDUCAnON AND MEDICINE L.ng believed that gymnastics had a rightful place in education medicine, and national defense, and almost from the start instruc- tion was given in these three branches. In spite of a good deal of jealousy and opposition he continued to teach fencing and gymnastics to the Swedish army, under the sympathetic encourage- ment of Bernadotte, who afterward reigned as Charles XIV When It was shown that the French and Prussian soldiers were being drilled m bayonet fencing, his method of teaching this exercise was investigated and chosen in preference to all others and It became an established part of their regular training In 1836 he published a manual of bayonet fencing for use in the army, and another of gymnastics, in which he found it necessary to limit the exercises to simple forms that required little or no apparatus. He commenced the development of medical gymnastics after the hrst year of the Institute in Stocliholm, against bitter opposition on the part of conservative physicians. His school gymnastics comprised only a few stretching move- ments, sometimes assisted or resisted by another pupil, but with little apparatus, the Swedish educational gymnastics in its present form being a comparatively recent growth. During all this time his literary activity was intense, and always m the realms of mythology and the ancient legendary history of the Scandinavian race. His literary labors were rewarded by membership in the Swedish .Academy, where he also received the grand prue. The title of professor was conferred upon him, and he was decorated with the Order of the North Star. His collected writings fill three large volumes, of which only about 350 pages have to do with gymnastics. From his first marriage he had one sur%'iving daughter Jetta and by his second wife, three of his seven children became teachers of gymnastics-Hjalmar, Hildur, and Wcndia, the first two at the Centra Institute. In ,839, after some years of impaired health he died and was succeeded at the C'entral Institute hy Branting and Georgii, who, in company with Dr. Liedbeck, one of his pupils, and husband of his daughter Jetta, arranged his literary THt SWEDISH SYSTEM OK GYMNASTICS 89 remains for publication. The year after his death they puMished hK prmcples of gymnastics in the incomplete and often frag- mentary form ,n which he left them, a treatise begun as far back as i»3i. Th.s book, after an o,«ning section devoted to the laws of the human organism, takes up in order the principles of edu- caional nuhta^., medical, and esth tic gymnastics, and closes w.th a few pages of miscellaneous suggestions and comment. Lmgs system was constructed in the light of the physiology of h,s day, wh,ch often sounds fantastic in the presence of modern discoveries. H,s physiology with regar.l to the nature of life, the laws of organic unity. an'""' ■--"^■■and include a u do range o subjec.s ,„ .heir curriculum. By a recen, arransemen orkof, r:^''™ ' "" ™'»^'^"' "-' "f 'he practical by I nt s 1; "T"""'" '""■ '"-■™ --'-'I-"'''.'- "KKlined hL : ^n 7'!"'' ''""'"''"^'J- ''>■ hi> son. .hede,elo|,ment has closely followcl the lines marked ou, bv its ori«ina.or complcc uccompnshmen.. He classified movements into irouns as .hey were ,],rec«ed to .he muscles of the .runk, head, arm or leg. makm. use of a table which was .he forerunner of the present ■ay s order. His first table consists of three order movemen.. seventh, an arm mo^ement; eighth and ninth, leg movements- ^.mh attd eleventh, arm movements - all of a respiratorv natt.rc.' H^- tables al,so show a forecast of .he progression which is .he o.her charac.eris.ic of .he Swedish svs.em. .„.'^'1'''T "l"^"™"^ '- '"i"'"*? military cade.s s.ronglv influ- enced .he character of his theories. E. M. Hartwell justly obsc■r^■es 94 EXEHCISK IN EnrCATION AM> MEDICINE that Swdish Kymnastics still l*ar witness to their scmimilitaty orJKin. LmK's |wculiar aims are more completely reflected ami h,s methods more fully emlKxIicd in the physical training of recru,ts and soldiers than in any other department of S«en«.ium (l-cfetore) 1. The day's order. 2. Gymnastic progression. 3. The use of the word of con.maa.! for movements instead of imitation. The exercises of the .lay's order are always arranged under the following ten classes, each of which can be made more difficult or complicated, as is deemed advisable by the progress of the pupil. The order is: I. Introductory exercises, class formations, facings, and marching steps (Fig. 55). THE SWEDISH SYSTEM or GYMNASTICS 55 rpr:iv;:;r'"'' ^'""' """^ '"'" -''^ - ""^•'- rh«,»!!r""^ movement,, .lesigncl to cultivate elasticity of the -Introductory exercise ixwition, neck firm. y>K- S''-— Arch flexmn at ihe stall Uirt. 4. Balance movements, or exercises of ecjuilibrium, reouiring h.gh coo.lmat,on, rather than force, and especially .3)- 10. Respiratory exercises, accompanied by movements to assist respiratory activity. They are designed to restore normal Fig. 61. — Latrral trunk movement. respiration after the more active work that has gone before (Figs. 64, 65). This order may be slightly varied by introducing, after the balancing exercises, marching and running, or by introducing a series of heaving movements after the lateral trunk movements, thus increasing the groups in a day's order to twelve. The order of exercises is the basis of the Swedish method, and may be depicted graphically by the following diagram, repre- THE SWEDISH SYSTEM OF GYMNASTICS 99 Kig. 6». — Leg movements. Fir. 63.— Leaping exercise. ipo EXERCISE IN EDUCATION AND llEDICINE Fig. 65. — Resptratoiy exercise No. a. THE SWEDISH SYSTEM OF GYMNASTICS loi senting a forty-minute lesson period, the height of the curve showing the intensity of the effect on the circulation an03 militar}' exercises, which are not exclusively Swedish- in character, but the medical gymnastics, which are so widespread in their apphcation, d.-senc a more careful consideration. Classification and practice of the movements of massage, described in another chapter, have been largely the work of Swedish practitioners, and all the duplicate movements were described and named by Ling with extreme exactness, so that a prescription of exercise may be written with clearness and accu- racy. All movements have a commencing, intermittent, and ter- minating position, the fundamental positions being standing. Fi(t. 68.— Dancing JKps to music (Boston Normiil Sciiool of Gymnastics) sitting, lying, and kneeling. In standing there are derivative positions of the legs, like flexed standing, or of the arms, like yard standing, or the hips firm position, or of the trunk, like curved standing. The similar derivative positions are described for sitting, kneeling, and lying. As these are usually self-explanatory and are employed in describing prescriptions in the section on Medicine, no further explanation need be made here. CHAPTER VII THE "SOFT BUSINESS OF JAPAN," THE "GOSPEL OP RELAXATION,- AND THE "DOCTRINE OF CONTRACTION" The rise of Japan to the position of a world's power has brought prominenUy to the attention of western readers an oriental exercise which has been elevated to the dignity of a system by some writers. It IS known as jiu jilsu, or, in its more modem form, jiudo. The origin dates back a^bout four centuries, when a certain Akiyama went from Japan to China to study medicine. While there, he saw a way of fighting caUed hakttda, consisting of various methods of striking and seizing. This he learned; also twenty- eight ways of recovering a man from apparent death (kuatsu). He began to teach it on his return to Japan, but with so little success that he went for help to the Tenjin shrine, and there worshiped for one hundred days. One day, while out walking, during a snow-storm, he observed a wiUow, its branches covered with snow. Unlike the pine, which stood erect and broke before the violence of the storm, the wiUow yielded to the weight on its branches, but did not break. Reflecting upon this principle, he began work and invented over 300 different holds, naming his school Yoshin-Riu, or the spirit of the willow tree. Jiu jitsu is the art of fighting without weapons, and was the exclusive possession, until about forty years ago, of the Samauri or swordsmen, of Japan. While it is probably Chinese in origin! It was developed in Japan, where it was practised by the Samauri for the defense of an unarmed man against 1 man of stronger physique, or one armed with a sword, club, or spear. Itspbject is to place the antagonist at one's mercy by the mere pressure of THE " SOFT BlUNESg Of JAIAN " 105 the finger or hand, to throw him by first disturbii ij his equilibrium, and then yielding suddenly to his struggle to regain it. It also enables one to place his opponent's joinU in such a position that they may U broken by his struggle to free himself. It includes rig. 6,.-P^ (rom . Iknch-book ol Hokuui (1760-im,) jhowing: ,, Defctu. ««n.l a man who icin, your (Keikogi) garnKn. by wri« and dbow hold; ,, bending finiah""" ""*"' ^" '"' '^ "'"' "" '" '''^' *• '"^ """^ beginning; 5, finger hold. numerous methods of taking strangling holds about the neck by the hands alone or by grasping the jacket. Some of these Holds are shown in the sketch-books of Hokusai as early as 1750. The art was jealously guarded by the Samauri, and marvelous io6 EXEKCUE IN r.DUCAnoN AND MEDICINE i ; talcs were told of their prowcw in it, but since the abolishment of feudalism, forty years aRo, the secrets have Income common property. It is now tauRht widely in Japan, and is part of the physical training of the cadets in the naval and military academ-s under the more modem name of jiudo. Its real merits have been 70.— Pajp? from Holcusai'a flki-tch-book iUuMratinK jiu-Jiizu. much obscured by the extravagant cUiras made for it and the exploitation it has received in America. One of the principal secrets of the art was " kuatsu, " or bringing bac, to life. .-Vn illustration (Fig. 71) from an old book on the subject will serve to show the principle on which this part of'the THi; "g^irr bisinem of japan" ,^7 art ««, U« tl>™ by J. ward just above the elbow, the anterior ligament will tear and the joint become disabled. In most of their holds on this joint Ill EXERCISE IN EDUCATION AND MEDiaNE the man's own weight is used as the downward force at the shoulder (Fig. 77). In another lock the arm is turned so that the bones of the forearm cross into extreme pronation. Power is then applied, Fig. jg-— «, Position o! the bones, sliowinc the crossinR ot llie radius anj ulna .nral llie direction of the twist; h, position ot the arm when the hold is well taken. so that the radius is wrenched out of its sock.,., or the wrist ligaments torn and the arm rendered useless (Figs. 78 and 79, a, b). The principles of these holds are comparatively few and simple, but their applications are many and difficult to acquire, THE "SOFT BUSINESS OP JAPAN" j,, even imperfectly. The holds are so arranged as to pass from one m.o another almost automatically, so that if one s succe^fuT res.sted, . e opponent usually struggles into a worse one Th y are d.fficult and even dangerous, to demonstrate with one who U unac,ua,nted with their possibilities, becauseanovice mayo tnu o rugg e when he should yield, and so do himself serioL injur" It IS most unlikely that a small, ' ' puny man could, by this means, become invincible when pitted against a powerful, acti\e ath- lete, but with anything like equal conditions, it is a most valuable means of defense. Fig. 8-!iell. the venous circulation, and instead of obstructing the circulation of the capillaries, would accelerate the blood in its course toward the heart. The use of one muscle to antagonize another is the prmciple upon which this and other systems are built. A typical exercise would be the simple flexion and extension of the arm, durmg which the attention is concentrated on the flexors of the arm (Fig. 85). The fist is tightly clenched, and the arm is slowly flexed ith intense resistance from the lengthening triceps so that during the movement the entire arm is in a state of tension' To mcrease the effect the subject stands with knees everted and slightly bent, and the muscles of the thighs in vigorous contraction. I lie EXMCME IN EDUCATION AND MEmciNE The cxerc.^ « never complicated or el.l«niU-. They arc Although there is Imlc oriKinallty in their ,lc,ig„, ,l,„c is a novelty m he manner of their statement that appeal., to the uninformed »n.! (lartly mformed with the force of a new truth. The advantage of such movements to a busine«, man who i., not aml>,t,ous to excel in g«ne» or s,x,rts, l,ut who wishes to get «nd leg muwiea. " his necessary exercise in "tabloid" form, is evident, and it is to h>rn tha, such a pro,x«i,ion makes its appeal. Great numbers can be treatecl at the.r homes, through written r to l,f,, ami tnc .Iru.lKcry of it U not without its koo,I .K.inlH Tc^ exercises will ,„,ckly develop the muscuH f ^ merest for a fme many who woul.l no, otherwisl- take any Zir 1-. "' ">"«"'" ""vements of every -,lav life ami her ab,l,ty to «i,e all-arouml .levelopment, is anmher ma, e In th,s respect they ,lo no, stan.l the test well. In such a » r^ there are no movements rerjuirinK fme or complicate,! c^rla i 1 an- "f of an exercise J ndiij .^ "'"'"'r? ^"'' ^■■-"''"'•™" increase in .he l.lood-presfure a,^ „I" »' '-athlessness and The chief characterful -ritt: 7 " """''"■ necessary for success in s„.h ^ ™"'"'"' '''^Petition and the^age Unr:::^t^i:':^zf^^ ''--^ ^^o^^m., placed in the last but one The tim ~J" '""^'"^'^ are leaving off any exercise mnsf ''' '" '^^•^'""'■"g ""'I '- the ages mL:rr:rr: ,:irSe::r^ '-•'^■''!-'' ^r His conditionrrri";:;! rSeii: :r ^-"tr of receivmg guidance from this chart ' '"'"'''" sports as cricuTSb , ^[J^ '"tZl' ''"■' '" ""'' has been continued with regu artv f ' n, 'T' '" " ^''°" 136 EXERCISE IN EOUCAnON AND MEDICINE CLAS^FICATTON OF ATHLETICJIAMES AND EXERCISES. Bi>w)inK. BoxinK. Cricket. Cross coun- try running. Right or Irft /ore- arm, shoulder, and the whole muscular system lo a lesser deKTce, Right farearm. arm. shoulder, and bjiclt. All at forearm.aiTTB, ■houldera, chest, back, and thighs. The whole muscu- lar system mod- jTately; right or left forearm, arm, and shoulders. Thighs iind legs. , Moderate. Accuracy. I speed, and I agility. Extreme. Great. Dundng. Thigh, and legs. ] Extreme, i Great, Slighl. Accuracy and strength. Great, i Alertness, agility, strength. Moderate. Accuracy, speed, and agUity. Extreme. | Endurance, speed, and strength. Eoduiance and agUliy. Football. (socker). Football. (Rugby). Thighs and legs. ■ Moderate. J Qreat. I Hammtr- th rowing. Hand-ball. Hockey. Jumping (high). Jumping (hnntV). I^cr(>sse. The whde muscu- I lar system. , The whole muscu- I lar system moder- I ately. Shoulders and back, also arms and thighs to ft lesser _ degree. The whole muscu- lar system, par- ticulariy the back. The whde muscu- lar system, espe- ciiilly the back and right (or left) forearm. The whole muscu- lar system, espe- cially the alxtom- inala,thj(hs. ham- strings, and calves. Thighs. I'.wer back, and shmilders. Thighs, calvc. kick, and shoulders. All the muscles of the legs and ortna. Extreme. Extreme. Extreme. fireat. Agilil}. speed, and strength. Accuracy, endurance, speed, and i agility. Slight Accuracy. 1 ia-30. Amount of exercise depends on the posi- tion played; pitcher . has his [Etching arm i ccnslanUy over-' ' worked. 14-60. , 16-40. «hSo. Depends nn position ; plaj-ed; exercise ob- tained by bowler is j different from that of the fidder. i8-as- A severe lest ot the ' heart. 14-40. Clog and soft shoe I exercise only the ! legs, but many acro- I batic postural an<; ! esthetic dance: i bring in the trunk and arms. "-.(5- In this game the ImII j is not touched by the bands, but is kicked by the feet and butted by the I head only, 16-30. The moat severe field I game on the heart I and lungs. ii-60. The walking inter- rupted by the strokes of the game make it peculiarly valuable tor those living a sedentary mdow life. 16-S0. !A difficult feat of co- • ordinatitm as now ; practised, i.e., from : a j-foot circle. 1-40. la-as. An extreme test on I the heart and lungs, 16-3.1. The hi^h hurdles (i ft. 6 in.) require great accuracy. I Jumping without a I run cultivates ;igil- ity onlv. ia-30. A running game. AGE, SEX, AND OCCl'PATION "7 j Influcnre Ewr.be. f hW region! ./ .he ' r»«nami ; '?,P^«- txidy UMcd, dffliS" "Si^t:' '■-■ »■' '"'«'"■ plralinn, Extreme. Phydca] characlcr- irtlri rulti. valed. BcM use for ] IJrar i ti The whole muscu- j Extreme, lar system, very moileratdy. Arm flexors and all of forearm, ' Right for left) fore- arm, triceps, shoul- ders, back, and thighs. The whole muKu- lar system. I -a^ A severe lest on the heart and lungs. -as- A severe test on Ihe I heart and lungs. Slight, i Extreme. Strength Wlsht. Moderate, endurance. Endurance. Slight. Accuracy. 1 Great. slight. Moderate, (ireat. Tennis, Walking. Water polo. Wrestling. I The whole muscu- lar system, eape- j c;ially right for left) forearm and arm. ! Strength. speed, and agility. Endurance ! and strength. 1 T^vha _.. eully unused, except ,f. ^ i,*;*'"he sliding scat. 16-60. |\alue depentra on tramping over ir- ' regular ground and ' open air. "4~6o. >6-,W. Great. .\foMem. n r«ially legs, thighs, and lower trunk. f1«ors nt linaers. Mudcr,,- u- t,. ' wnst. and Rwe- '"""'" ^- W'Bht. arm. flexor* ,rf arm, all .rf shoul- der, and aWo- 1-^' "(rf forearm, arm. ami shoul- ders; ihighs. and legs. Agiliiy, ac- curacy, and endurance, Strciwth t*iilantL'. Hexnrs of hand. I wnsi, forearm, arm. shoulders, Horizontal Fw"^^"!'"^'"'- arm. pectoruls. la- tiwmusdorsi.and , abdominal mus- cles. I All of f.jre irm. i arm, shoulders, j abdnm.-n, thighs, and legs. j AU of forearm, arm, ! shoulders, abdo- I men, Ihighs, and I legs. Hone - '««. and so de- velop thighs and legs more than side horse, I highs and legs de- ^■eioped in the ap- proach and finish, but much less than arms and shoul- = An excellent cxer- uRcfor developing all muscles above [ the pelvis. 1- Influence w, co- ordination >lei«nds greatly on the in- I Incucy of the excr- ases practiseil. ■ 'Me set of exertises are for equilibrium I ,'.™>;, another are like the typical hori zpnlal fKir exer- nses in their t-ffrct. One ,4 the bcsl all- around exercises. i I30 EXERCISE IN EDUCATION AND MEDICINE V Here, again, it must be borne in mind that, in addition to the circles on the horizontal bar, the swinging exercises on the flying rings, vaults on the horse, and balancing exercises on the parallel bars, the same exercise may be interchangeable from one piece to another. For the healthy boy or girl of eighteen or thereabouts the best development would be obtained by a judicious mixture of gymnastic and athletic exercise in the open air. .\ course should be designed so as to employ all the activities of the muscular system — strength, accuracy, speed, agility, and endurance — as naturally as possible. .\ periwl of gymnastic exercise should begin with a ten-minute drill, including movements for both arms and legs, with special emphasis on correct carriage of the body and on deep breathing. This should be followed by, exercises in rope climbing, on the parallel bars, horizontal bar, or flying rings, in which the arms are used ; following this, exercises of agility, like vaulting over bars or the German horse, and simple ground tumbling. Each lesson should conclude with running or with a gymnpstic running game of sufficient speed to test the endurance. The period sb""ld occupy one-half to three-quarters of an hour, and should be repcied at least three times a week. If alternated with walks or out-of-door games, the maximum development and general education o! the physical powers should be obtained. The mental exhilaration ari - ing from the emulation and competition that is found in a large class is an influence by no means to be neglected, especially in the young, although exercise will have its effect whether this be pres- ent or not, just as surely as iron or castor oil. For those of mature age and a sedentary life, exercise should be directed principally to the muscles of the arms and trunk, care being taken not to overtax the circulation. Such exercises as throwing the medicine ball, — a large ball weighing from seven to twelve pounds, — hand-ball, and other ball games, combined with simple apparatus work, are usually effective and interesting. If combined with the fresh air obtained in a game like golf, tennis, or a brisk walk in the country once or twice a week, the result AOE, SEX, AND OCCIPATION ,,, b^omTt ■ °' "''""""« >•'■"" "«-• "^■^«^»»ity for exercise spo":'=:::';:;^-:it£-^-^~we.r tion of life- ^ ixtrcii* for the i)rolonga- once or t«,ce a day. and have Rraduaily increased the exercises to ten mmutes or a quarter of an hour. The deuth of L!-h i lo„ 1 • ■ . ""^^ ''*'^'' act may be graduallv Dro and raise the body several times during the exniration Rv ,K- a ternate bending and raising of the body we c nrmlT^tren:. 'en .ti:?::c^rr"' '"^^-^ ''■■^' ™fVUzt "Another useful combination with the respiratory exercises diterna ely, „,th deep msppr.tions, from left to right and wi.h exp,rat.ons, from right to left, the arms being h ff Ls^d t th.s movernent we bring into action some of 'he muL'" of thl pme which are apt to be only imperfectly used by mo pers^S n advanced years, and the stiffness of the neck and spi^ TZhe tendency to stooping, so common in old persons, can b 'to Ime degree corrected by this kind of movement. I commelc^Tn good time and practised regularly and thoroughly, s"^ t e '3> EXERnSE IN Eni'CATION AND UEDICINE arms around the »houtder-jojnt is likewise useful, and other combinations with muscle and joint movements will occur, but they should have accustomed themselves to these respiratory movements. The latter ouRht always to have our principal atten- tion, since to them the lienelicial effect on the heart and lunj^s is mainly due. In addition to the influence on the circulation, the respiratory movements keep up the nutrition ami efficiency of the lungs, which undergo in old age a kind of atrophy. The walls of the smallest divisions and air-rells become thinner, and a kind of senile emphysema is develo|)ed, which, by this exercise, is to some degree prevented. "Another im|X)rtant influence consists in maintaining the elasticity of the chest-walls, which are apt to become stiff in old age, and thus to interfere with free movements of the lungs and the pleura. If, for some reason. i the erect |)Osition should be incon- venient, respiratory movements can be made also in the horizontal and sitting positions." In addition to these exercises, taken regularly every morning, he strongly advises a walk lasting from a half to three hours, part to be taken in the morning and part later in the day, and once a week he recommends a day of more prolonged exercise, and a holiday once or twice a year spent in a walking or climbing tour of three or four weeks. Occupation should have equal weight with age in choosing exercise. In the natural occupations of man, like farming, fishing, and lumbering, a great deal of muscular exertion in the open air is required, and the need for it is thus naturally provided for. During the last hundred years, however, the ])ro|)ortion of city dwellers has risen from 2 to nearly 60 per cent., and the artificial and confining conditions of a crowded city life must be faced. The segregation of masses of people limits the amount of space and air for each, and the necessity of further economizing energy by the use of machinery reduces muscular activity to a mini am. This ap))lies especially to the most "civilized" part of a civilized community, so that there has arisen a whole series of defects and diseases due to this suppression of the ACE, SEX, A.ND OCCUPATION >jj natural muscular activity, or to its concentration on a few move- menu. School-children are taken for live hours a .lay from their natural occupation of out.loor play an.l confmt.l more or less strictly to a sittinK or standing jxnition, makin;- their Uxlies fertile soil for the growth and .levelopment of |K«tural defects. It is necessary then, that exercise in the of^n air for city children of he .school age shoul.l Ik' ol.taine.1, by playgroumls, situated in ttie more congested districts. The construction of roof ganlens, recreation piers, an.l other otK;n.air breathing spaces is also .iirecte.! by this same nee.1, an.l the gymnastic exercises for school-children |)antus for the average business man of mature age and sound constitu- tion has lieen undertaken by D . Luther Gulick, in his "Ten Minutes' Exercise for the Busy Man," and by J. P. Mullcr, of Klampenborg, Denmark, in his "Fifteen Minutes' Work a Day for Health's Sake," where the first eight movements terminate in a bath and are followed by ten exercises n self-massage, and the following list has Ijecn compiled and foiiml of proveS »3S .rn» into ,upin..ion; cxicn.l nc-ck (FIk. 8g,. Holrl .his ..W.ion for a m„„em and then rcver. nbuly Uck ... „ar.i„« ,Li.i„„. :V<«r.-Wh,,, the lingers cannot !« kq.t in thi* ,K>»iiion, start by holilinK a loo|. of cord in the hands instead of intcrlockinR the lingers. Re- pral turnly limes. n»- ««. n«- 90. Extrcis, j.-Position: Lying on back, hands on hii« i, tourT'^L'*'"''* '""' """'' """"""'y "'■"' '«^^'" "^n- 'ill L L " "'\'L'!^'""'"- ^l^^P »«"«'« around leg, and press in on theaMomen (Fig. 90). Relax. R,pea, l^rnly limes. i..Vfr<:(j<- 4._Position: Stand- ing, hands behind head. Movements; Bend siflew,iy, to right, then forward, then to left (Fig. gi), and then back- ward, circling five times each way. Keep feet together and the knees straight. Get far down on each side. Repeal Iwenly limes. Exercise 5.— Position : Stand- ing, hands clasped behind head (Fig. 93). Movement: Force the head and elbows back strongly. Relax lettmg the elbows come forward. Repeal Iwnly lim.' Exercise 6.— Legs thirty inches apart, arms at s. -. Movement: Raise arms above head, bend forward and touch Fig. 91 Fig. 9a. n I 136 EXERCISE IN EDUCATION AND MEDICINE floor with both hands (Fig. 93). Rise slowly and bring hands to position. Repeat twenty times. Exercise 7.— Position: Arms forward (Fig. 94), then out and then up, stationary run. fig- 93- Fig. 94. — Stationary running. Fig- 95- Movement: M the rate of fifteen steps in five seconds. Take fifty steps for each position of the arms. Exercise 8. — Position : Standing, hands clasped across abdomen. Movement: Inhale, pressing in abdominal wall (Fig. 95). Exhale, relaxing abdomen. Repeat twenty times. Exercise 9.— Position: Sitting on stool or on side of bed, hands clasped behind the back. Movement: Trunk rolling, forward to right; backward and then to left (Fig. 96) ; then up to start- ing position. Repeat twenty limes. Exercise 10. — Position: /°^ Standing. 1 \ Movement: Arms side- /i5^ ways, raise, upward stretch, inhale. Forward bend (Fig. 97) and rise. ,\rms side- ways lower. Exhale. To Finish. — Wring out a Turkish towel in odd water. Take it by both ends and rub hard back, chest, abdomen itnd thighs. Fig. 96. Fig. 97. CHAPTER IX PLAYGROUNDS AND MUNICIPAL GYMNASIUMS The segregation of city life, with its attending evils, weighs most heav,ly on the children of all but the very rich and the surv,val of a strong and healthy race depends on pLid ng b" L h ing spaces and free play for them ^ :;o^:^for;c. ' ' "'"' "''^^^^ ""■ " -" '^^ ^-^^ ^--— In New York, according to the statistics of ,900, about «oo persons hved on one city block, in about rjoo roomT;oo of wh c" had no w,ndows and no outside doors. The commiu^ on ptv ground organ-nation made a map of the city, show.ng the r5s and playgrounds by green squares. Then they called in Se cap ta,ns from different districts, and asked them to fx^in ouMhe parts where restless boys gave the most trouble. In evl^y case parks, or trees. The committee then put a red sign on each of Oiese troublesome places. Other policemen, who said , hi , he boys gav-e them no trouble, pointed to their districts, which I le always close to the parks. The committee ne« stucL pins in the map o show w.here the schools were and where the chilXen v thickest This map was sent to the Mayor, and with it a copy of the State law which reads: -'Hereafter no school-houses fhd £ umrsTe.""^ " "- '-' -"- ^'---- '38 EXERCISE IN EDUCATION AND MEDICINE Wherever the pins were thickest on the ma)), showing the most children, the red signs were thickest too, and it has since been proved that the putting of green spots into these regions will drive the red spots out. This was a graphic method of showing the in- fluence of play on juvenile crime, so much of which is due to lack of a proper out- let for the natural impulses and instincts of the healthy child. So long as the surround- ings are normal for the best development of a child's neuromuscular system, the choice of play and its con- duct may be left to the natural instincts of the child, but in a city these normal instincts are thwarted, and if exercised at all, his games of ball or tag, his hunting and fighting games, bring him into conflict with the police, and land him in the juvenile court, accused of such crimes as destruction of property, disorderly con- duct, and burglary. One of the strongest pleas for the establishment of playgrounds is made from this social side rather than from that of physical education proper. It was proved that juvenile crime decreased over 60 per cent, in each district Fig, 98. — City conditions showing need of playgrounds (Playgrounds Association of Phil- adelphia). PLAYGEOLNDS AND MUNICIPAL GYMNASIIMS Fig. 19 -A typical east side .tree, in New Yorli city. Where .he H,ht .o p,a, and a „.ace .o p,a, .as «.v. given to the Fig. too.— A; ■mprovised sho,„.b.,h (PUyg™.„d. A«„iati„„ o, PhiMelphi.,. i il- I! r I II I40 EXERCISE IN EDUCATION AND MEDICINE In the ])oor and crowded districts ^f the city the condition of the homes is such as to make free play impossible; the children have not even room or opportunity to run or bathe, and the city must provide them with both. The necessity of teaching the language and tne ideals of their adopted country to the hordes of foreigners who yearly immigrate to such cities as Chicago or New York make the playgrounds and municipal gymnasiums a most valuable means of education, and the experience of Chicago among the Bohemians, Lithuanians, and Poles has been such as thoroughly to justify the large annual expenditure. The introduction of playgrounds in American cities has usually been the voluntary labor of private committees, cooperating with the school boards, obtaining the use of certain school yards and open spaces by donation or purchase, equipoing them, and PLAYGROLN-nS AND MUNICIPAL GYMNASIUMS 141 demonstrating their usefulness to the city, an^l so bringing on tlie council the influence of the people directly benefited, and finally securing purchase of the ground and permanent supervision by the municipal'ty. Playgr-^unds should be of three distinct tyi,es^smal!, mclium and large. ' 142 EXERCISE IS EDl'CATION AND MEDICINE lii Type /.—Numerous small pieces of ground are usually obtain- able by utilizing vacant lots. These can be transformed into playgrounds for small children of both sexes, and should be equipped with a few small swings, see-saws, a sand pile under a canvas awning, toilet facilities, and a shelter for rainy weather. If ix)ssiblc, a shallow wading pool wi.h sand or concrete bottom should be provided. T"ie expense of sucli an equipment need not exceed fifty dollars, distributed somewhat as follows: I. Ten-foot double swing frame with triangular ends, braced, and two swing.s— ten to twenty-five dollars. ' 2. Children's six-foot swings, with canvas scups for little chil- dren to swing or sleep in, well protected from the sun— ten to thirty-five dollars. (See Fig. 103.) 3. Two or three see-saws with 14-foot boards, at five to ten dollars each. 4. Sand-box, varying in size and shape according to the space, filled by one or two loads of fine white sand— five to fourteen dollars. 5. .\vvning for protection against the midday sun and shelter for rainy weather— ten to sixty dollars. There should also be connec- tion with the water-supply of the city. Much of the equipment is frequently obtained from interested supporters of the movement. The back yard may be turned into a playground of this kind, as has been done in Philadelphia by Dr. Talcott Williams and others. The arrangement of apparatus would be as in Fig. 104. ^■ig- 103- — Construction of a swing for little children in the playground. PLAVOHOUNDS AND UIN.CIPAL GVM.NA.SU MS 143 these .mali playgrounds, but they should be scattcrl/alu, at d stances o not more than three or four blocks from the homes of the children who have to use them. Small children cann!^ go more than a few hundred yards to their playground ^a^d fo m 144 EXERCISE IN EDUCATION AND MEDICINE m I that reason the city parks are unavailable except on a holiday o, other great occasion. Type //.—The second ty|)c of playground should consist of a piece of ground, from two to ten acres, with a more substantial shelter, containing toilet-rooms, shower-baths, and an office for the supervisor. The ground itself should be provided with a wad- ing pool, a .sand pile, or court for young children, and a swim- ming pool for those who are older. OS-— Type I of playground (Elizabeth Rafter). The sand ])ilc here may be extended to the dignity of a ganlen or court, fenced in. and provided with simple toys, buckets, shovels, and building bIock^. These are frequently carried off, but this was prevented in one playground by an effective checking system. The child wanting a pail or shovel deposited his hat, which was returned when he returned the tools. The sand should be eximsed to the sun and rain, and great care should be exercised to prevent the spread of communicable diseases through this medium. PlAVC.«0,-.Nns AN,, „,.N,c,p,, ovMNASIUMS '45 : y^'iV^Mmfi ;v.t,^. 'I r Fis- .o6._A wading pool in lairmounl P,„ $^t:*-' LUmi Fi,. ,o;.-SanH pile (W.,e„iew Park, G.™.„,o„„, p, , it H Im 1 ^ ^H him 1 1 u 146 EXEBCISE IN EOl'CAnON AND MEDICINE Tig- loR.^An up-(o~ditte playjirouncl rqulpmrnt for M-iund ty]>r ol playKround. is large enough, there should be a running track surrounding the field. These playgrounds aire necessarily fewer in number than Fig. left). — .Apparatus in use ((iymna^iium, Washington Park, Pittsbunfh}. the first, but should not be more than half a mile apart in the crowded sections of the city. They are intended for boys and mVO«ot»DS AND «™,C,P« CVMNASIUM. „, 148 KXfcRClSK IN KOt'CATlON AM) MKimiNK Typ*' Ill.—'Vhv third tyi>c i>f pluy^nniml should In; found in the outskirts of the city, usuully conntxtcd with the park system. These playing fields, like Boston Common or Belmont Plateau in I*hiladelphia, should lie of such si/c as to allow of two huselmll FiK- til- — I.urKC municipal playitruund plan (Elizalivth Rafirr). diamonds or foot-l)all fields, a (|uarter-mile running track, the out- door apparatus described in the second type, and a large gym- nasium hall and dressing rooms. municipality and have the necessary (i>nvenienri-s already installed, with the I><>ssit)ility of using the Ijusemt-nt in rainy weather. The yards arc already endosed and the janitors can look after the apparatus when the ground is not in use hy the children, thus preventing the wanton destruction of pr«»i»erty that is s*> frequent. The field apparatus can also 1* used all year and not in the summer only, and the cost of administration is thus greatly lessened. If the school yards are used, Utards of education are encouraged to huy neigh- iKiring property tn enlarge them, as has already been done in Philadelphia antl elsewhere, and both municipality and schtxvl lx)ard profit from the combination. PIAYOROUNDS AND MIMCIPAL IJYM.NA8I11IS MO *;| 11! 15° EXE8CISE IN EDUCATION AND MEDICINE In the building there should be shower baths, and close by a swimming pool with deep aiid shallow divisions, and also a wading pool for the small children and girls. In some cities, notably in Chicago, this type of playground has been made a social center, the permanent building containing a large auditorium for lectures and various social gatherings of the people of the quarter. Every attempt is made to encourage these gatherings, as well as the specific physical training for which these playgrounds were origin- ally designed. Play in itself is essentially neither good nor bad, but it has great possibilities for good in the hands of a capable director, and the profession of playground supervisor is a distinct specialty in physical education, requirtag unusual natural gifts and careful preparation. The supervisor of the smaller playgrounds for young children should be familiar with kindergarten methods: she should teach them the simple kindergarten games and direct them in their play in the sand heap, having story-telling hours and other occupa- tions most interesting to children of that age. This may well be combined with visiting the children's homes and tactfully instilling in the parent's minds the importance of cleanliness and personal hygiene. The larger playgrounds require a man to give at regular hours a definite amount of gymnastic exercise in the form of marches, setting-up drills, and apparatus work. He should organize gym- nastic and athletic games, of which there are many specially designed to be played by a large number of players in a small space. DeGroot's playground ball is popular with the boys of Chicago, and ideally suited for these conditions. He should ilso organize among the boys athletic contests and games extending to interplayground contests, in which loyalty to their section or even to their city is taught, and the spirit of fair pUy and clean sport is instilled in their youthful minds. A period of exercise should begin with marching, light setting-up movements, and then exercises on the fixed apparatus, in which the possibilities of each piece are shown. .\s a rule, less emphasis PtAVGROUNDS AND MMICIPAI, GYMNASIUMS iji is laid on the form in which a feat is accomplished than indoors The apparatus IS considered much more casually This should be followed by an athletic game or contest like the wheelbarrow race, run by two boys, one grasping the aniles of h^ companion, who runs forward on his hands; the three legg«i race; obstacle races; relays; jumping and vaulti'ng Ld ^e of the many games with the basket-baU or medicine balL El V ' •52 EXERCISE IN EDUCATION AND MEDICINE The wading ikmI can be systematically used for games of tag, leap-frog, tub-racing, and the like, the children, of course, being suitably dressed or, rather, undressed. Of these sports children never tire and the spectators are entertained not a little. Many children learn to swim instinctively or arc taught by companions, but the teaching of swimming should be part of the playground activity, and games of water polo and water basket-ball, as designed by Dr. A. E. Garland, of Boston, arc much in vogue. Certain days should be set apart for girls if they cannot have their own pool, but the playground instruction for them would differ in certain important particulars from the course most suitable for boys. The round games are alvvays popular with them, especially singing and marching, the salute to the flag, and, above all, dancing. Most of the European races are rich in folk-dancing, and the exhibitions of these dances of Scotland, Sweden, Russia, Spain, and Bohemia at the playground congresses have alvvays attracted deep interest. From such sources American folk-dancing is being evolved. The contra danses of .America, English in origin, are widely used as quadrilles, and the Sir Roger de Coverly, or Virginia reel, with modern embellishments, is always popular. Dancing has almost entirely replaced athletic contests in the girl's branch of the Public School Athletic League of New York, with the greatest advantage. Here, again, is shown the necessity for special training of teachers who are to take up this profession of playground super- visor. Where playgrounds cannot be otherwise obtained, the school playgrounds are used with great advantage, both for the first and second grades, as already described, and the regular school-teachers are frequently employed as supervisors after a course of training to fit them for this specialty. The need for playgrounds and breathing spaces in the crowded wards of ihe great cities jumps to the eye, but it also exists in the country village, the town, and in those parts of a city where poverty is unknown. While the usual attack on the problem is made by PLAYCHOLNDS AND MUNICIPAL GYMNASIUMS .53 Ifterward'th?"' "'.'l'-^'"™""* ''-'. -" Mymnasiums and baths afte vvar,l, the provision of systematic exercise for city resi.lent, has ,«.en approached in the reverse way, in at leas, one city lot the slum is non-exisfant n„,\ ,u ■ ■ '"- "-'V' nncrc wealthy. community is prosperous and for Jcl^he'l.h' "r"-"''' •''''^-^•'"-'"^. '-K- the campaign equipped with showers, dressing-rooms, and a large swimming Fi«. M4.-Th... „,!„ „erd„ hall „, ,he B^Une .„„ici,:;^IZ!rZr E in^'tho ^'™'"T '■" r'"""''"« ^™^ «''^- '° --'ents of the ifi »S4 EXERCISE IN EDUCATION AND MEDICINE windows and skylight, making a height of forty-five feet in the center. This hall is equipped with a complete outfit of gymnastic apparatus, and contains a running track, also used as a gallery for spectators at the exhibitions. The climbing and fixed apparatus are in sets of four, arranged so that the floor may be rapidly cleared. A small gymnasium, 74 feet by 34 feet, having a height of 32 feet, is equipped with Swedish apparatus, and is used for the overflow from the children's classes. Fig. 115.— The small aerdlc hall of the Brookline municipal gymnasium and baths. There are special rooms on the fourth floor and in the basement for private instruction and for games and corrective apparatus. All the regular classes in the gymnasium are free to residents of Brookline and non-residents are admitted on the payment of a fee. Preliminary medical examination, while not obligatory, is strongly recommended. The schedule of classes in the annual report of Mr. J. Leonard Mason, the director, shows the scope and variety of a week's work: PLAVOROUNns AN.. UV,UC1P.,L CVMNASIUMS Women'. af,emo„„ ,,.„ Mo.ndav. Men's afternoon iUm 3:45 Men'i erening class 5: 15 8:00 Women's morning djs, Tuesdav. GW, under fourteen year,,' .,,„„,«,„ ,„^ '<>= 3<. Girls over fourteen years, aftem™,„ ,H^ '■■>! Men s afternoon class 5: 45 Women's ewning class 5: 15 Public sch..,l teachers' class '^'•""'^•'" Boys under fourteen years, aftern,.,„ da,. ^^ ~ Boys over fourteen years, afternoon d,ss" ''^ 5° iroung men's evening class 3^45 Women's morning dass Thursday. Women's afternoon dass. 'O' .?o Men's afternoon class 3:45 Men's evening dass 5:15 8;oo Friday. Gtrls under fourteen , -ears, aftem,.,„ class G.ris over fourteen years, afternoon dass "*' Women s evening class 3:45 8;oo Corrective gymnastics ^'"™oay. Cliildren under ten years class 9:,io Boys under fourteen years class '°-}° Boys over fourteen years dass. . . '-3° Voung men's evening class [[" ' *■ 'S 8:00 climbing, and gyLu.stic gam ^ClEfrr '" """"'■"«' acteristic of the German gymL.lsFn M ?T """"^ '^"- dancing steps to the ™,.i T ^"'' °^ ""« ^™« age Girls Lt'^folt: r^e : aTXn "^"^ ^"""°^^- Though they have passed fhrn n *' * ''P^™'^ '^'''^s- the childish plavstLTT^ '"'^" ^"^ ''"= -«" '"te^csted in games ut! ^ owS" "" '" '^"""^ " "'^ ^^ "'^ -8ged '55 I '56 EXERCISE IN EDUCATION AND MEDICINE This age division has not been found necessary among the boys, according to Mr. Mason. Women from twenty-five to sixty have their classes in the morn- ing, and begin their lesson with marching, setting-up movements, and the hght, graceful calisthenics requiring skill; women of this age are fond of balancing movements and of dancing, the slower rhythmic movements and relaxing exercises being used with great advantage. Violent exercises of jumping and vaulting, in which the body may be jarred, are avoided. The women's cla.sses are very popular, and have a distinct social value, which their members heartily appreciate. The afternoon class for women is attended by many school-teachers who arc mentally tired from their day's teaching. For them the exercises are rhythmic and given by imitation, all exercises requiring close attention by word of com- mand are avoided. The working-girls and women come in the evening, and require more strenuous work. They are fond of the apparatus and social dancing with music. In addition to what may be called the routine work of the gymnasium, an opportunity is given for the practice of swimming, wrestling, fencing, and gymnastics, and clubs for their promotion are organized. The senior boys take up the heavier apparatus work and indoor athletics, while the girls arc instructed in athletics, modified and reduced, some litde apparatus work, and dancing. The strenuous competitive games like basket-ball are not encouraged, although they are permitted. Business and professional men, varying in age from thirty to sixty years, do not tolerate work in which close continual attention is required. Music is thus of special value to accompany the setting-up exercise with which their class begins, and simple rhythmic dancing steps to music are very popular with them. The movements of boxing and games, like indoor baseball, also appeal to them strongly, and a favorite exercise is found in the medicine ball games, which invigorate the muscles of the arm and trunk overstrained or unused by many business and working men. PLAYGROUNDS AND MITNICIPAL GYMNASHMS 157 In a town like Brookline, of less than 30.000 jK^ple, the avcraKC weekly attendance at the gymnasium during the first year was 1473, of which over 800 were girls and women. An outgrowth of the movement for play has been the establish ment of summer camps for city children, frequently started by private benefactors, newspapers, or charitable organizations. In them provision is made for physical training, and the days are spent m roaming the woo,ls and hills or on the water. Large numbers of poor children are thus given the advantage of country Vi'"*"-?nt"/l'||' i'lfl Hi ".J Fig. ..6. --Morning gy„na,li<, at c.n>,, T^cunwh (Dr. Onon', „n|,). air and surroundings in the hot weather that is so fatal to the chil- dren of the city. The Young Men's Christian .Associations have been par- ticularly active in providing camps for their members, where they may live under canvas for July and .\ugust, and private camps have been established by Dr. George W. Orton, Dr. George L Meylan, and others in the mountains of Maine, New Hamp- shire, and elsewhere. _ In 1907 more than 25,000 boys were spending their holidays in this way. In ^dition to this over 5000 boys who were unable to afford the moderate expense were housed in the settlement camps. The first girls' camp was started in 1903, and four years later there were at least thirty such camps in operation. ' ii CHAPTER X PHYSICAL EDUCATION IN SCHOOLS More than 23 per cent, of the total population of America spends from three to 6ve hours a day in school, and with the extension of the public-school system the responsibility of educa- tional boards increases correspondingly toward the growing number of children under' their care. The normal life of a child during its waking hours is one of muscular activity, but if discipline is to be maintained in the school-room, the teacher must inevitably suppress a greater part of this restlessness so fundamentally related to growth. The lessening of natural movements by school limitations during the years of growth is harmful not only because muscular exercise is decreased, but because nervous tension and strain are more than correspondingly increased. This tension sho'old be repeatedly relaxed by periods of physical exercise designed with three objects in mind— first, to correct the physical faults and de- formities fostered by the sitting posture; second, to recreate the mind and body of the child, and, third, to develop his physique along natural and normal lines. In the building of schools the sanitary engineer should see that every school-room has 15 square feet of floor space and 300 cubic feet of air for each pupil, and a system of ventilation capable of supplying him with 30 cubic feet of pure air every minute. It is his duty to see that the light is abundant, the window area about one-fifth of the floor space, and arranged to come from behind or over the Iqft shoulder, and not reflected directly from the paper on the desk into the eyes; that the desks are designed to fit not only the child of normal size for his grade, but also those who are abnormally large or small. C. L. Scudder, in his investi- I5« PHYSICAL EDUCATION IN SCHOOIS ,55 gation of 8chool-«ating, in Boston, found girl, Hifferine seven cZ to L '"^'^- d»k' of such l,eigh, that the book Is forced ?eTslo;^tr.h'"'°'''rr"''*"'- Vm. .here are found oesks «> low that ,he round shoulders, the drooping heads and the flat chests of their occupants are sadly noticeable. F«. ..,._The G.rl,r d«k, ^Ju.t.ble b, .hc pupil. The relation Of the seat height to the desk height should be such as to permit the elbows to rest on the desk without sZpin. Z^U^Z r^:'>,-t\"''= ^•'-'"-. -d 'he desk edge 22 r P ' "''^' "^ ""^ '^'- I" '^ ^"^f^l'y appointed schc«r room at leas, one row of seats and desks should be InTde adjulul n order to fit pupils that are not of the regular grade size Bv h,s,s avoided .he unsuccessful and burdensle meS f havil' w iht :t """":'"" 7^7''^-'-'"^' -h.-ch adds an additiold weight to the teacher's already o,erloaded shoulders and is gen- J ;!? 1 Mi ( 1 III, 1 1 k M ■ i6e EXEBCISE IN EDUCATION AND HEDICINE erally neglected. Most of the difficulty in seating pupils can be overcome by a self-adjusting desk and foot-rest like that invented by J. P. Garber, of Philadelphia, which can be changed to fit by the pupil himself with little noise or loss of time, the two great objections to adjustable furniture (Figs. 117, 118). A perfect fitting seat and desk can guarantee only that the child shall be in the correct sitting position occasionally throughout the school day, for, however well the desks may fit, pupils rapidly slump unless study periods arc repeatedly interrupted by oppor- tunities for movement and exercise. The upper part of the body Fig. 118. — Showing mechanism for adjustment of the Garher dealt; to, Adjust- able top; 14, pivot of atuchment for adjustable portion of top; 19, lever piesscd up by fingers to overcome the spring 31 and release the rod 30 from the serrations 9. allowing the desk to be raised or lowerrd at will. leans forward upon or against the desk, constricting the chest, crowding the abdominal organs, and impeding the venous circula- tion. T : weight is supported by the arms, and the head, neck, and spine hang by the muscles of the shoulder-blades in abnormal curves. To relieve this overstrain of the back and shoulder mus- cles the pupil changes to a pose resting the entire weight of the trunk on the shoulder-blades and lower end of the spine (Fig. 1 1 9) . The back sags down in a single long curve, the chest contracts, the breathing is impeded, and the circulation made sluggish. This position stretches the muscles and ligaments of the spine, rounds the back and shoulders, and shoves forward the chin. PHYSICAl EDUCATION IN KHOOU ,6, The correct sitting ,x»ture i,, one in which the pupil ,i„ erect and the head po.sed «> a, to bring the center of gravity within a line r^fciom r "'"'"'"•'' '" ""'^' =""'•"«''■ ''"• "«= demand Ind lonJ'n. 1, 7"'^ '° "''* requirements ill-fi.ting deslcs ^k^^lT ',"""" '■" "'"■='' '""' P°^'"^ '«~"- habitual the mischievous result cannot long be in doubt. -Faully posture (Shaw). thJ^" ^fr^V' "'' ''"■''''^ ^"""'-"f^ ^'^""W "ot have more than one-dnrd of the time in confinement at the desk (Shi Short penods of s.tting, followed by double that time spentin muscular acfvty out of the seat, should be the rule. This ^tivi J exercse. I„ the kmdergarten the exercise is admirably combined «th mental culture by the teaching of imitative games in which the large muscle groups are exercised in hopping, jumping, and run ill }!• i6t IXEKCtSE IN F.nUCATION AND HKDICINE ninR, and in imitating with the arms thr flight of birds and insects. The circulation is stimulated, and postural faults are prevented, while at the same time the child is taught valuable lessons in natural history, in which his interest never flags. The names of these games are suggestive of the action: "The nindmill's fans around they go" (Blow), "Mow, mow the oats" (Hofcr). —A kimlergarteii game in thr sfho«>l yar "> ■> I^n.-up animal spirits, quicken their circulation, and relie,e the nervous tension caused by keeping still, and .so res. and invigorate al hd ulaX 'f """"''' ''''""■ '" "->• ^--'. however, par ularly in America, children see. ,„ have lost the know Jj/e of 4, 164 EXERCISE IN EDUCATION AND MEDICINE games and play and have to be taught them. This is attributed by Guh'ck to the lack of play traditions found in the mixed and constantly shifting population of American cities, where two gener- ations of children seldom grow up in the same place to pass down their customs and play rules to their successors. Special games have been designed and collected by E. H. Arnold, of the Boston Normal School, and others, adapted from old and popular children's plays for the use of the many children who have to occupy the confined space of the playground. These Fig. 133. — Mosher's poatui^s in standing. games should be taught and practised during the recess period, although it is not so much the number of games that is neces- sary, but the time and space to play a few good ones. The school-day of children in the higher grades should have two five-minute periods of exercise in addition to the purely corrective work of the three-minute periods, and the games of the recess aboVe described. These exercises should be designed to promote quick, strong muscular control; to expand and enlarge the chest for deep breathing; to bring the blood out into the extremities; and to teach the proper carriage of the body. In PHYSICAL EDUCATION IN SCHOOLS jfij SrlT'^';'""''''^ P"^'""' '"^ '-■=•■- should be on .he watch for the most frequent of all defects, that position where the weigh ,s hab,tually borne on the right leg, the^t being Set te and placed out to the side (Fig. 122, ,) ^ ^ It is not possible for a child to remain long at rest with the we.gh equal y on both feet (Fig. x«, .). and siL t tension on both legs IS the same, the child rapidly tires Th^ h.^; .Z^ .0 teach is that recommended by Dr^^h'^g -t ,^ inT l^^ one foot ,s placed slightly in advance of the oLr. h n^ng feet as the weight-bearing leg tires. ^ r.!*" ''^°fT'" '"'^ been the battle-ground on which the Sroronhe " '^" '°"«'" ""= "'°'' ^•'■^°">- -Sa gn daj^^^ work "'"'^"- r-- Both have a place in .he aay s work. The more purely corrective exercises, done to word ess itn. hf /!:!'. ''^'""^ •^'■"'°"^' "^^ f"""''-' "ore or less upon the Swedish system, while rhythmic exercises done .0 music and the teaching of movements by imim ion are "o e characerisfc of the Germans. Excellent systems of g^^e^ To^ face!'ete"^" '""'""""'• '° '"'"' "'^ ''"'='«'°"= "«>" ""d left arch'i:™ " "'""" '"^ ^"-'^ '-'"^"'' -din*^ or 3- Breathing exercises and'wStr '"""'' "" ^°'"""''"™' '"^ "^-'^"''■•"« 5- Back including shoulder-blade, movements for the spine and general carriage of the body '^ ' 6 Abdominal movements for the abdominal muscles. trunk ^ds^r' "''"' """"■"'■"^ '°^ '"' '^'-' "--'- of 111 ;* ' i66 EXERCISE IN EDUCATION AND MEDICINE 8. Breathing movements. g. Jumping movements, like the fall-outs, and springing move- ments, the most violent of the series, and repeated to the point of breathlessness. -Method of using the school furniture to replace gymnastic apparatus in Phil- adelphia schools. The "dip" between the seald. lo. Slow, deep respiratory movements, to calm the respiration and circulation and prepare for rest. Practically no apparatus is used, except the school seats and desks, and the alternate rows of pupils, who act as living supports in duplicate movements (Figs. 123 and 124). Fig. ia4. — *' Follow your leader" through the seats and aisles of the school-room. The alternate files in the picture should be reversed, and the game continues till the players are back to their own desk. In the Philadelphia i<:hools recreation drills are used in addition to the more corrective work, and sometimes the children are allowed to run freely in the school yard for one minute, or to take jumping and %'aultilig exercises, with the desks as apparatus. PHYSICAl EDUCATION IN SCHOOLS ,67 o^irSln.' ''"' ^™^''^ '■" "'"-'"' -' -- -P ^^o" to at7w'"' ''""'l^' P™"'"' "•'■''' '^ ^^™-'"'" '-g-^ enough ragether. Here the dressmg-rooms and lockers for each sex ner m,t a complete change of clothing, with the liberal uL of 1 shower-bath and swimming pool. The school gymnas.um shol be m a separate building, if possible, but when Zs is notTasibi w37:::t^,:rn:"--^'-ba^: ^acu Should L::^\tii/-vrg'";r s shotld t :"' ^""^7 ^'^"'"*' P"''"'^' -" horizontal bar ona 1 H """T "! ''"'" '""' '° ^'^' '° f'"-'"'«'e the handling of large classes and these should be set in the door sockets casHv removable, so that the floor maybe cleared for mass drlsr^rS' exerases, and games. Around the walls, chest weigh ^dS developing appliances should be set, with the bom and !ull ul and the dumb-belk, clubs, bar-beUs, and wands. The"e sho!ld ^ an ab d , ^^^ ^ ^^^^^ ^^ hounouM b^ made for the use of the room by boys' and girls' classes Th! equ-pment must var, widely wi.h'.he'conditions, andT reliab firm of gymnasium outfitters should always be c;nsulted or ,h design and mstalment of the apparatus in Z n^ " " f T^'"™' ^ere need be little or no equipment each pupU (Burnham), or a plot 300 feet by 100 feet for a school o tooo pup,ls; but if not, the ap,«ratus should be like thaTora playground cf the firs, or second class, already describS buildinTw"" ""'"" "' ""^ "' playgrounds about the school- New Yokt°""rT"' '"°" "'«^"'' """^ '■" Philadelphia and New York the roof „self is used, caged in by wire netting Th^ i68 EXERCISE IN EDUCATION AND MEDICINE roof playgrounds give the only opportunity a child may have fw engaging in outdoor athletics, and in New Yorli city, where the population is so dense, it has made possible the formation of the public School Athletic League, which is now over half a million strong. The Public School Athletic League of the city of New York was founded in 1903 by Dr. Luther Halsey Gulick, then Superin- tendent of Physical Education. He brought to the attention of the Board of Education the deplorable physical condition of the children attending the public schools, most of them living in many-storied tenements, each with a [wpulation as great as a 'f^&li' >»■i^ Fig. 135.- -A roof playground in a crowded section of New Vorit (PlayRrounds Association of New York). small village, with no playgrounds but the crowded streets and congested sidewalks. It was estimated that in the tenement district of the east side, Manhattan, there was a child for each running twenty-four inches of the street, which was emphasized as just the space required for a grave. The committee of the board approved the scheme, and incorporated the league. The organization was perfected by the election, as officers, of men in- fluential in the political and financial world, and by securing the cooperation of teachers and principals. The lirst athletic meeting was held at Maiison Square Gsrden before much opportunity had Ijeen given for work among the boys. 1% PHYSICAL EDUCATION IN SCHOOLS ,6p over IS,:;' •'°°™'"'"- ""^^ "^- '"^ '-«- has given Boys were classified by weight instead of age the scales bein . MityoLiscussln Vre^^r,^^^^^^^^^^^^^^ -i.ing, putting the ^^r^:^.^xzti^:^T '"''- and .n X907 there were ,c6 baseball teams competing agai^t'each '7° EXESCISE IN EDUCATION AND HEDICINE Other in the league. Valuable trophies and medals have been secured for competition, and many other devices are used for extending the exerc'se to as many hoys as possible. Prize buttons were given to all boys who achieved a certain standard of merit. To win the button he must chin the bar, run a certain distance, and jump a certain height, according to his age or weight. The standards have been set as follows: For elementary school boys under thirteen years, 6o-yard dash, 8f seconds; chinning the bar, 4 times; standing broad jump, 5 feet 9 inches. For all other elementary school boys: 60-yard dash indoors, 8 seconds; 100-yard dash outdoors, 14 seconds; chinning the bar, 6 times; standing broad jump, 6 feet, 6 inches. For high school boys: 230-yard run, 28 seconds; chinning the bar, g times; running high jump, 4 feet 4 inches. This has been extended to class competition, where all boys in the class compete to make an average. The league aids in the maintenance of discipline by requiring a certificate from the principal stating that the boy had reached the passing mark in his studies and deportment, before allowing him to compete either for a button or other prize. In the first contest for the button only three or four out of a school of 500 could pass the test, bi)( with practice 1162 boys qualified in 1904, and two years later this number had more than doubled. Teachers have been astonished, as well as pleased, with the improvement in discipline among these young and ambitious athletes, and this alone has insured their active cooperation, as well as the enthusiastic support of the boys. Systematic instruction in military rifle shooting has been made possible by the invention of the subtarget machine. It consists of a standard, with an ordinary Krag military rifle attached to a mechanism on top. This is so adjusted that when aim is taken with the rifle at a target across the room and the trigger pulled, the machine registers upon a miniature target the exact relative place that would have been hit if the gun were loaded. As there is no danger connected with it, the practice is rapid and economical, the mechanism being easily set up in any school-room. The PHYSICAL EDUCATION IN SCHOOLS 171 instructor standing at the lx>y's side is able to follow the man- ner in which he is aiming and to correct his defects. In- struction in the holding and sighting of the rifle is given, and annual interschool contests are held, ending in a final contest among the winning schools at Creedmoor, with the actual rifle, at distances of from loo to 400 yards. The boys thus have an Fig. i.7.-Subtt,w., Kun machine I„r rifle practice in high school, (Handbook of Public School Athletic League, N. V.). opportunity for acquiring the knowledge of wind, atmosphere, and light, necessary for good shooting in the field. This has been made part of the program for the School Athletic League, and has been a source of keen interest to the Ijoys, many of whom have acquired great skill. Upon attaining a certain degree of efficiency each competitor is given a badge. The national importance of having an army of boys graduated every year, each one knowing 172 EXERCISE IN EDUCATION AND UEDICINE the feel of a rifle in his hand, and having a knowledge of its use, — a knowledge that never leaves him,— need not be dwelt upon here. The Athletic League has extended its work by the formation of the girl's branch. Voluntary classes in gymnastics, games, and dancing have been introduced among the girls attending the public schools, from which teachers are by no means excluded, many of them attending and in turn leading classes of their own. Exercises most popular and generally practised by the girls are the peasant dances of Sweden, Scotland, Ireland, and Spain, involving much gymnastic work and developing strength, agility, and grace. Fig. 138.— Relay race, Girls' Branch ejblic Schools Athletic League. Games adapted for indoor and outdoor spaces are practised, and relay races between classes and schools have become a favorite feature. Owing I-' the difficulty in finding a spacious ground for their athletic competitions, the Public School .\thletic League has been the means of drawing attention to the need of good playgrounds in New York city. Largely through the influence of its officers, $400,000 were appropriated by the city for the purchasing and equipping of four athletic fields. Because of the enormous cost of land, it was impossible to procure sites on Manhattan Island, so that one was built in Astoria, one at Crotona Park, another at Stapleton, PHYSICAL EDUCATION IN SCHOOLS '73 Stolen Island, and the fourth in south Brooklyn. These fields are equipped with running-tracks, xrand-stands, and dresslni?- rooms; but if adequate provision had been made as the city was built, it would not have been necessary to jjo so far afield. Leagues similar in oliject and character have since then lieen formed in Newark, Chicago, and Cleveland. In Newark, where the work is particularly active, a medical examination of all contestants is required, aljout 80 boys being found physically unfit out of aooo competitors. Fig. ..9.-Field day tor school rhildrfn, Franklin Firld. Philaddphi.,, June ,o. „o8 (PlayKTOunds Association of Philadelphia). The Playgrounds Association of Philadelphia has an athletic committee to organize the athletic interests of the schools, both public and parochial, and the first field day was held in June, 1908, with 5000 children of both sexes taking part. It differs from the leagues of New York, Newark, and Cleveland by laying more stress on interschool competition in drills and games, where as many as 400 pupils from one school took part in a drill in com- petition with groups of 50 to 100 from smaller institutions. In addition to this there were group contests, relay races, and indi- vidual events. CHAPTER XI PHYSICAL EDUCATION IN THE COLLEGE AND UNIVERSITY The university is the culmination of the educational system, but there is a distinct break between it and the school. Most school children go into the business or trade they are to practice for the rest of their lives when they leave school, and many men enter college who have had but a meagre experience of school life, and the struggle for a college education is so intense that the exhausting work of preparation is frequently stamped on the physique of the matriculant. The long hours of school-work, the nervous exhaustion of teaching, the nights spent in study, and the days in office, factory, or shop — all leave their imprint so deeply that the knowledge of, and even the desire for, a larger and fuller physical life may be stamped out or atrophied in the very youths whose success in after-life depends on the conservation and development of their physical powers. Physical education for college students must then include per- sonal hygiene and the correction of remediable defects, the educa- tion of their physical powers to the highest point of efficiency, and the cultivation of those social qualities that can be taught through the agency of athletic activity better than by any other means. The necessity for physical training to go hand in hand with the other courses of the college curriculum has always been recognized by advanced thinkers in the realm of college education. Benjamin Franklin, in wTiting his pamphlet, in 1749, that led to the founding of an academy for the education of the youth, now the University of Pennsylvania, expressly states that "To keep them in health and to strengthen and render active their bodies, they be frequently exercised in running, leaping, wrestling, and swimming" ; and nearly forty years later Thomas Jefferson wrote FHVWCAl EDUCATION W THE COLIEOE AND IN.VCMITV .75 ™ '"* ■*" '" ""e conditions then existing, a Jt %!?' "' ;"'T.'" °""^ «y™"'"«^'' ««^hed America 'uh^ n ,h ? K?!' ''"'"■'^ '■" " P"^'""' chapter, and Z ^u ted „ the esubl«hment of gymnastics as part of the regular rS°,^ColJ:e^H°""' r -■^•-""-^-"■amp.on.MLTand o nr^hlf p"!; "■' "'"°8"^» "f •8.7-,8 containing the name insLo "' Ge^a? TC"--^- »' '-« 0~i-." a^d Bro^J^.--— ;::;-;^e.in. ^::=:z^t:rsi^:;r:;r;;:.^= subjects, ^d „.,^ of teaching boys to turn Lersau Then In i860 the first chair of Phy,ical Education and Hygiene in s^ni "u?„T'.r" T ""u"'"' '^ °^- ^"•"'l Hi,chcock,Tho stisfc a re th ^ "''"' ""' """^ ">easurements and vital i^e men. H,s conclusions, as embodied in charts and reports J^hn^nTT"' ™'"°"'"™' '" '"^ ^'"''-•'^ health fXh^ freshman to the senior year under his system of exercise as well as an increase in muscular development new' HeL'en'''' ^'""'^ •'• '"«™' ""^ «'^™ - -"section of the new Hemenway Gymnasium at Harvard, and he at once began he patient accumulation of vital statistics, now reduce^'o cC form and available for comparison. less^ol!?''? "'"'^'' ""'' ""■■^•^"'■"•^^ have established more or ll ,„r <^r"™™'^ "f Phy-cal education, in which a definite amount of exercise is required of from one to four classes. in ct. ", ^^^"'""^ '"""" ■""* ""■letics was founded m Chicago in ,89,, and in ,904 .he BarUet, Gymnasium It 176 EXERCME IN EDUCATION AND MEDICINE opened. This was a radical de|)arture for a large university because there was a definite undergraduate requirement, and provision was made for ade<)uatc supenision and control, financial and otherwise, of university athletics. This made [lossible the ideal relationship between physical training proper and com- petitive athletics, each having its place in the complete sy.tem of physical education. The Department of Physical Education as reorganized in igo4 at the University of Pennsylvania requires from the four under- graduate years, and from the primar)' years in the professional schools, except those holding a bachelor's degree, a minimum of two periods of exercise a week, and lectures on the application of exercise to disease are given lin the medical course. A wide option is allowed, and equivalent credit is given for attendance at the gymnastic classes or durmg active membership on the foot-ball squad, crew, baseball, track, or swimming teams, and in the fencing, wrestling, or boxing clubs. In the College of the City of New York the requirement is much more exacting, and in nineteen of the leading universities this department is now on an equal basis with the others, the theory of hygiene and physical training forming one of the college courses in many of them. A university course in physical education should begin with acare- ful examination, to find the exact physical condition of the student and so to give an intelligent foundation on which to base advice and instruction. He should be measured and his strength tested, to see how he compares with his fellows in proportions and power. His posture and development should be noted, and his heart and lungs examined for any latent weakness or disease. The acuteness of his sight and hearing should be carefully calculated, for he must know if there be any serious obstruction of the two most im- portant avenues by which his knowledge is to come to him. .\nd, finally, his ability to accomplish certain muscular feats that cover the main activities of the body should be ascertained. An analysis of the examination cards of looo freshmen showed that over 30 per cent, had lived a sedentary and confined life. FHV.ICAI. EDUCATION IN THE COLIEOE AND INIVMSITV ,77 While more than 60 ,«r cent, showed some mrkecl ,.hy,ical defect; the b roken-down .rch of the foot; the fl«, chL, and UNIVEB8ITV OP PENNSYLVANIA r-w_ ....*i« ••*••... I^^^^^""**"— --.j^" ... i.. ' *y * ,. f. * i ra -..v!' " ' ta «» te«i ....,..,** * «wM»>Mi....-..y.. ■'.-■Ml .0... 52_ ■ •-" g«*-... ....3««*<. ' •~— ■— ' ■■ynu'Tr. - — r^ Fig. ijo.-History blank filW by the iludenl. protrudmg abdomen of the anemic school-boy, with his round houHe"' T?'"^ ""■"• '""' "'"'''y -""-'-. or the drooping shoulder and the curved spine, or the dull hearing and faulty 178 EXERCISE IN EDUCATION AND HEOICINE sight that had been the unsuspected cause of headaches, nervous irritability, and exhaustion. It is tlie province of the department of physical education to bring this defective physique up to its normal level. m.J(a3 UNIvatUTV OP PENNIYLVANU MMOTMBfT «F PMVMCAL nUCATWI MMCMBUNMJnM ~. ...J.P..:./:..P.f.. OM ..^W!f AM '* toE ffrr. \ »-.».,y^Mr«W llHMaMatK Hh* .^f.%.W. >•«•.. ^PTPPFf^ ■ .^M.lT. tMgta. . .itf.t. m. ntim.^ff^f^,, .....ifA:. ^.^^.IJU. «,, r.!/r. —■% *M«i 3.0. wmmm-.J.^.'^...... I-M> 111*111 ... I^Ot.... .—«... ...r.... 1. ./:... ..f r *T«y^ .i - .w« ..y^^!?*.r<' . f . f . ^ . « . T MV ^..-^r:*' H!<.«TI*.Trf^^»«<..,...J*li»**;.»«U. _ Fig. 131. — Form for medical examination. The main work of the director must, however, be devoted to the average man, coming from the farm, the office, the factory, the shop, or the school, with no athletic ambitions, but wanting to make every moment of his time count. The college must provide him with enough exercise of the right sort to put and keep him at the highest level of physical efficiency to get the PHYSICAL EDDCAnON IN THE COLLEGE AND UNIVEKSITY 179 most good from his lectures and laboratory work, without in- volvmg too great an inroad upon his limited time. Fig. 133.— Measurement form. The athletes must also be provided for in the scheme, al- though they number less than lo per cent, of the total enrolment D«e ^^/t,. Itt_f_ N«...f-..c._.i:„.i.. ci-i. Enmiutioa of E^: K. | Eaenul Co.Jiiioa_ "'' 'eft and right a«l ' "r r . '?""'" "' '''=f'="'*- ""^ '^ads, increasing' on.Srwih,"'"':''' """" '" ™"">'"a.ions, of *"'"'*" of 'his metho< of flefins^ ru ,■ of wrestling should also be taught in ,h . " ''"''""'^■"s ■IK u.-fd is a • - ^y one man. Separate _. ace ^ ^.t;?:-:: - ^ ;"- i86 EXEKCI8E IN EDUCATION AND MEDICINE A year's course of extrtise will, of necessity, vary considerably with the special conditions to be found in the college or university, but the following plan, which is in use at the University of Penn- sylvania, will be found to contain the main essentials of progression. October: Physical examinations and examination of eyes, in- struction in swimming to first year men; prescription and demon- Fig. T3fi. — Gymnasium floor divided into three rourts by nets, thus permittinit bultet-ball in the central court and wrestUnR and gymnastics at the two jr.ds. This aUows of supervision of the whole flijor by one man (University of P.'niisylvania). stration of special exercises for round or uneven shoulders, con- stipation, flat-foot, weakness of abdominal walls, etc., given by the instructors on the gymnasium floor. Nmember 1-25: Class work in the gymnasium. Marching (or the indoor preliminary- practice of the crew (Fig. t4o), itockcy team, or base- ball team. Corrective exercises are also better done apart from the noise and confusion of the main exercise hall with its constant succession of classes. In the practical management of claases the advantage of having the ap- paratus in sets of six (Fig. i^g) is great. B^- this means the larj^est class may be so divided as to prevent the waste of time that orrurs when a long line of men must wait their turn to perform their enercise oo a single horse or pair of ban. reVSlCAL BDUCATION IN THE COllECE AND I'NIVEHSITY 187 tactics, quick time and double time; free setting-up exercises- gymnastic games. ' Nm>cmber i^-Dectmber i: Examination on first arrangement of apparatus; low horizontals, climbing ropes, flying rings, and yaultmg horse. Men are graded as a result of this examination mto first, second, third (or leaders), and fourth (gymnastic team) grades. ''W. ■W-Gynumium floor, shomng ,pp,«iu. in pUce tor cla» work Bnrin- p.n.lld b.r, .na^ i„ g.„g. ^ ,(., The p.r.11.1 bar, are placed m fl«,r^k"., and can b. „pl.ced by the buck or Ion, side ho™ (Univc„i>y of Pennsylvania,. December i-January 27: First arrangement of apparatus, about ten consecutive lessons on each piece, progressing in dif- ficulty. Drill with wooden dumb-bells. Reexamination. February i-March 4: Second arrangement of apparatus High horizontal bar, tumbling, buck, long horse, and parallel bars, class drill with wooden wands or Indian clubs, preceded and foUowed by examination and regrading. Indoor exhibition. March 4-April i : Third arrangement of apparatus. Pyramid 11 t88 EXERCISE IN EOCCAHON AND MEDICINE building, boxing, or wrestling; drill with iron dumb-bells or steel wands; dancing steps. University circus given by the leader's corps. FlK- 140. -Indoor practk'i; for c „„.. ,.,....,» actual rowing on thu river. iiidiilAtot iluring the vviiiu-r in pr(^i>arstion lor 1 9 ] — , ' _._ U 1 - - 1- •- A^ y - ■ / - / Fig. Mi.^The building of pyramids as a class Mercisr, U. of P. gymnasmm. April i-Afay 5: .\thletic sports indoors or on Franklin Field when possible., The start in sprinting; hurdling; broad and high jumping; putting the shot; running and dancing steps. Outdoor exhibition of the united classes. PHYSICAl EDI/CATION IN THE COLLEOK AND IMVERSITY .89 May i-June i : Physical examination of the graduating class It ■» found that, after two or three years of the regular educa- iloM drill in tree movrmcnla and dcmcniarj Itymnusium. tional classes, men take up specialties and devote themsches to advancer! Iwxing, wrestling, fencing, or s-vimming, or j.,in the crew football, or baseball squad. .\ certain standard of excellence il required to get credit for these siwcialties, however. an^ '"'-ound ^ ength test for a period of eight years. These four hundred «^ts of measurements of Hanard students, supplied by Dr Sargent, were used to determine the pro,K,rtions of the ''ideal rtT'h'd ;r' ^■'■"''' ^^■'^"--P-omed as placing in, right hand the spring dynamometer with which he is about to test his grasping muscles. girths of the physically ideal .American student of twenty-two With a height of 5 feet 9 inches, he carries a weight 'of 1 m pounds The girth of his neck, knee, and calf ^e thj / same, w the upper arm i} inches less. The girth of his high ,s J ,nch less than that of his head. His expanded che ' .. 40 inches and the girth of his waist is ro inches less. H K b eadth of h ■": "r '' '" ™-''P-ded chest, while the S stlh of 'I- ™' '"'' """'^ "'^' '-^"^"^ °f his foot, and the stretch of his arms measures . inches more than his height. '. ".1"^"^'" Sf.tan™ Monthly," Decemlier, 100; Scnbners," July and -N'.ivemlier, 1S87. ^ ^ m CHAPTER XII THE PHYSICAL EDUCATION OF THE BLIND AND THE DEAF-MUTE Havino described the physical education of the normal child from infancy to maturity, there remains only a description of the modifications required for the training of those unfortunates to whose minds the avenues of sight and hearing are closed; and of those others whose minds are flulled or who have already taken the first steps in the path that leads to the penitentiary or the mad- house. Since the world of the blind is limited by the horizon made by the reach of his arms, his suprcmacj' within this circle must be suoreme. Physical education does him a triple service by increasing the couidc; and confidence which he so sadly lacks by develop- ing hi:i muscular powers and by fortifying his body against those infirmities to which enforced idleness and a sedentary hal)it render him peculiarly prone. It is within comparatively recent years that the physical educa- tion of the blind has been studied with care, and that methods have been adapted to their possibilities and limitations. The m.ost striking characteristic of the blind child is a certain timidity or fear of appearing at a disadvantage before others, es- pecially in making an unaccustomed movement, so that the only exercise they undertake voluntarily is walking backward and for- ward in some confined i)lace with which they are familiar. They are liable to sit still for long periods of time, and usually develo]) certain rhythmic habi; movements of the head and hands, difficult to repress and correct. They must either /iW or limr a movement in order to learn it. P«VS.CAL K.,.CA„OX OK THE BU.vn .^„ THE nE.r-„CT. xgj for they have not the mirror of their companions from which to correct faults j.. their own posture or action. fn the measurement of boys at the Overbrook School for the Blind it was found that their height, weight, and lung development were under the average of normal Ijoys of the same age, as shown in the Sargent charts (Allen). The blind lK)y has thus even a greater need for physical training than the boy who can see. In many blind children ex- ercise must begin with the .simplest acts, such as dressing and undressing, which have been neglected in many homes where the blind child is waited on and not trained in move- ments that make for accuracy and tidiness. A course must pay special attention to the imjTOvement of posture in walking, stand- ing, and sitting, for the blinrl walk with the head inclined forward, the chest contracted, and usually come down hard upon their heels at each step, and it must embrace free mo\e- ments for the chest, arms, anon learninK hnr place and avoiding ,he collisions ,ha. woul.l ine,i,ably occur if their |)osition were a matter of conjecture Physical e.lucation for the blind shoul.l be cmnulsory at all ms itutions as it is at Overbrook, Pa., the classe bcTn« 1 and arranged ,n the order of their a«e, an,; „i,h some part^Hy bliml pupils mixed with the totalU blind to act as leaders The ZTZt "of" vtr '" "It''-^"'"''^'""' "-• ""' 'l»T- very much hn .. t. "" "■'"' '*'"• ""'■' "^'" '•" linins up they should keep in .ouch with one another by each pupil facing he 'I I '■P^- y-'^'-'-ftm Fig. M6.-M«hod of alignment in . d„, „( ,h. blind in Sweden (I.efebure). hand on the shoulder of the one in front, or, where a class is formed up in ranks, by placing the right hand on the cmpanL' sh^lder^and the left hand on the waist, as is done i7wen When a number are lined up in single file a regular class formation can be obtained without difficulty by giving the o'dl "ngh turn, and counting off, and this can easily be'reversed o the original line-up when the exercises are over Gymnastic apparatus work may be used with considerable advan^ge, but the leader should be able to see a little and mem bers of the class must learn the movement by passing theZd S 1_ '■■4 198 KXERCISK IX tlHCATtON AND UEnlCISK over the Itadtr while he is doitiK it. By this means a wide range of work can Ik: ilonc on the horse any a short flfxi .lu chain t., ihc lonx wire. As he runs the rin« shps alon^ an.l the feehnK an.l sound enable him to hol.l his lourse. At the end of the too yards a cord is stretched across, alx>ut sl•^en feet lii;;h, from which han^s a fringe of hammock twine lon^ enough to sir?kc the rimner in the face as he passes. This fringe covers the two lurallel lanes, so that competitors may run in pairs, an („ lb..). Owrbr^k record, j, ft. ,J ,„. ,Pe„„,y|va„ia Iralilulion for Iht- Inmruclion o( Ihe Mind, Overbroolc, Pa.). Even the running broad jump may lie practised, the measure- ment being made from the starting foot instead of from a fixed board. Other popular field sports are putting the shot, throwing the discus, and throwing the hammer-with a stiff wooden handle and thrown from a stand. A strange phenomenon for the psychologist is the [wpularity of a modified form of baseball, in which, at a signal, the pitcher throws the ball, the batter strikes, and the catcher catches. As a rule, no one accomplishes anything but the pitcher, and vet boys 20S EXKRCISE IN EDUCATION AND MEDICINE ^ ill Fig, 151.— The swimminR pool (Pennsylvania Institution for the Instruction of the Blind, Overbrook, Pa.). Fig. 15a. — TrolIeycoastinR on the athletic field {Pennsylvania Institution for the Instruc- tion of the Blind, Overbrook, Pa.). PHYSICAL EDUCAHON OF THE BLIND AND THE UEAF-ML'TE t 20J •i^rw^: m 1 I Hi FW- .SJ.-King B«mt. Kind.rgarlen building in Ihe background (Penn,vlvania insutution for the Inslruclion ot the Blind, Overbrook, Pa.). Fig. ,54._A game ot "blind mans buff" in the girls cloister (Pcnns.vlvania Institution for the Instruction of the Hlind, Overbrook, Pa. ). will play this for iiours at a time. Football is also played In- choos- ing sides and kicking the ball back and forth until the goal-line of :M(il 304 EXERCISE IN EDUCATION AND MEDICINE one side is crossed. This is also popular, and can best be done by choosing one, at least, on each side who has partial sight. Swimming is an excellent exercise for the arms and shoulders, and is practised with success among the blind. Fig. rsS- — Rocking-hoat (Pennsylvania Institution for the Instruction of the Blind, Overbrook, Pa.). .\thletic sports are quite as popular among the girls as they are among the boys. They enjoy jumping and running, and athletic and gymnastic apparatus, like the trolley-coaster, swings, and see- saws, should be provided for them in the gymnasium and out-of- PHYSICAL EDUCATION OF THE BLIND AND THE DEAF-MUTE 205 doors, while the rocking boat is safe and an endless source of pleasure to the younger children. The Deaf-mute. — A system of physical training designed for deaf-mutes must take into consideration the peculiarities in- cident to deafness that divide them from the rest of humanity into a class by themselves. And it must also bear in mind the fact that in almost every respect they resemble other children. A deaf child thinks in gesture and pictures, and so expresses his thoughts, but his verbal memory is undeveloped. His chest and all the ap- paratus of articulation are, in consequence, under the average, and ifl ";' Fig. 156. — Deaf-mutes playing basltel-ball. they are peculiarly liable to disorders of the respiratory tract accom- panying this underdevelopment. In girls of sixteen one series of observations by Miss Grace Green showed an average lung capacity of 118.3 cubic inches, as compared with 130 cubic inches of the normal girl of the same age. Their powers of coordination, particularly of equilibrium, are not up to the normal, and they have a peculiar characteristic slouch of the figure and a shuffling gait. Physical education would then include and emphasize the teaching of articulation, which is an art by itself; the develop- Mii ^1 306 EXERCISE IN EDUCATION AND MEDICINE I ment of the respiratory system; the cultivation of balance and the correction of postural defects. The education of the deaf is carried on better in an institution than at home, and as the great majority of such cases come from the poorer classes, and have to be made as efficient as possible as wage-earners, I shall write more particularly of institutional work. No formal drill should be given to the very youngest pupils, who have no "language," but ga ncs and free play seem to suit them best. To the class next youngest, whose language is limited, worlc should be given by word of command, followed by the execution of the movement, which the children imitate. In this way the movement of the lips is associated with the exercise, and the child ■s trained to read the lips In such wise as to learn the response to the command without further demonstration. Thi- teaching of lip-reading is part of the instruction in every institution for deaf-mutes. The last census of the United States shows that of 89,287 deaf, only 13,986 could r^ad the lips, and speech-reading was confmed almost entirely to thfe totally deaf, since the partially deaf or those who have acquired deafness in later life do not learn it, but depend on the use of some device like the ear-trumpet in preference. .-Vbout 39 per cent, of the totally deaf have been taught lip- reading at institutions like Mount .\iry. Pa., and elsewhere, and as every means is taken to practise the children in this art, physical training gives valuable opportunities. In the more advanced grades, as their language ,ecomes better, the significance of the command is apprehended and its full meaning realized. Exercise bv word of command is then of double value for deaf-mutes, since it teaches lip-reading and trains their verbal memory. There are two things to be remembered, however, in teaching a class of deaf children. The teacher must always be in front of the class, on a platform elevated at least one foot above the floor, so that each pupil may have a clear view of her mouth with- out having to lose the correct attitude in standing. Commands for marching and turning movements must always bring the class PHYSICAL EDUCATION OF niE BLIND AND THE DEAF-MUTE .07 back ,0 a position facing the platform, as the pupils have only the tha e 1 ; U r-""""^^ ^''''"''' •'^ «'™" ""h f"" force, so that the natural facial expression may be maintained. This while an advantage, is not essential, as I have repeatedly seen I djs respond promptly and accurately to a command given by the i, only without any sound. ^ ' oquil,bnum, in the foreground. "'"inu The shuffling gait and bad posture are corrected by setting-up exercises, taken in the standing and sitting positions, else attention should be given to the correct carriage of the head and shoulders; to the rhythm and length of the stride; to the position of the feet and the distribution of the body weight. Balance movements are most useful for encouraging a better «,uilibnum and improving the manner of walking, requiring, as they do, a high degree of coordination. Whether a lack of coor f'P ' - i 1 308 EXEECISE IN EDUCATION AND MEDICINE dination and equilibrium is or is not a direct result of deafness is not proved, although in many cases it would appear to be the case. In a series of experiments conducted by Miss Grace Green, at Mount Airy, 60 pupils were chosen from the intermediate depart- ment of the institution on account of their untrained sense of equi- librium. From this number 16 were excluded, classed as semideaf. Of those remaining, 37 were congenitally deaf and 17 were semi- mutes. Of the 27 congenitally deaf, 30 could sustain equilibrium with little difficulty and 7 could not, while of the 17 semimute, only a were able to keep in balance. It is also worthy of note that of the 44 cases, 32 were unable to maintain equilibrium on the balance beam or board. These experiments emphasize tHe importance of balance ex- ercises in the training of the deaf, for they rapidly respond to sys- tematic training. Deaf-mutes do not compare favorably with hearing people in the matter of longevity. ' They die in a larger proportion from dis- eases due to bad feeding, poor housing, and unsanitary conditions. Mouth-breathing is exceedingly common among them, and there is a high mortality, due to chronic affections of the respiratory tract. Great emphasis should thus be laid upon good food, warm clothing, the cultivation of speech, and the use of respiratory exer- cises, both free and by the aid of apparatus. It is to be remembered that one of the chief characteristics of the deaf is the lack of speech. The hearing child who is laughmg, singing, and shouting in his play all day is unconsciously giving to the lungs one of the most healthful exercises. The power of speech is a great incentive to the use of the lungs, and the ac- quirement of speech, one of the first things that should be taught the deaf child, can be greatly aided by exercises of deep breathing, together with movements of the arms, chest, abdomen, and lateral trunk, with special training in tone production and control of the respiration. The patient is thus given increased power to resist disease, and acquires better speech through this development of the entire respiratory tract. Miss Green has shown at Mount Airy a rapid and gratifying PHYSICAL EDUCATION OF THE BUKD AND THE DEAF-MUTE 309 increase in the chest capacity of the girls of that institution under the influence of physical training and Instruction In articulation. Her pupHs showed an average lung capacity of 118.3 cubic inches on entrance, In comparison with the average 130.3 for normal glrU of the same age. With training the average was raised to 139.6 cubic Inches from one season's work. Games and play are used freely, both to relieve the tedium of the more formal gymnastic work and to give that development which can be produced by free pUy alone. They differ little from the pUys of the normal child, and shouTd be designed so as to involve the actions of large muscle groups, training the children in alertness, decision, and accuracy. For boys and young men all the games and sports of the normal child are available, and it Is not uncommon to see the football or basket-ball team of such an institution taking Its place with that of a preparatory school or college of the same size, although the silence with which they pUy forms a striking contrast to • nrise of their opponents. CHAPTER XIII PHYSICAL EDUCATION OF MENTAL AND tlKXtAL DEFECTIVES It is during the early years of school life that the condition known as mental dulness, backwardness, arrested development, or feeble-mindedness develops sufficiently to be capable of definite diagnosis. It is there also that the first steps can be taken to correct mental sluggishness and to train 'the neuromuscular system of these atypical children. The backward child is always much older and bigger than the children of his class, hopelessly behind in his standing, usually remaining two or three years in the one grade, and sometimes promoted only when the desks and seats of the room have become too small for him. .\ny child that is not able to profit by the ordinary methods of instruction given to the other children of his age should be con- sidered backward or defective, and all such cases should be carefully observed, and a record of their habits and mental characteristics should be made in codperation with the medical inspector, or, if necessary, with an expert on mental conditions. A thorough ex- amination should be made of the special senses and throat; ade- noid growths where found should be removed, and defective vision or hearing corrected. The removal of these remediable obstruc- tions is frequently sufficient to permit the backward child rapidly to regain his normal grade standing. Mental dulness may be due also to physical weakness following severe illness, or to other curable conditions that may not have been recognized by the parent or family physician. Again, certain children in good physical health develop slowly at certain stages, afterward catching up with their fellows. This may be due to a PHYSICAL EDUCATION OF HENIAL AND MORAL DEFECTIVES 21, period Of rapid physical growth, and shouW t« carefully distin- yeat Wh'e^ ,h"" \ '™'"" *»"-"y backward for several years. When they wake up, as they eventually do, they frequently show unusual ab.lity. When these cases are accounted Tor, and ^mLl?r """T"" t"""^ " '""'°™'""y ""'"i. 'her; still remains a group of pup.ls who, while not actually idiotic, are so deficient mentally as to be entirely incapable of profiting by ordmary school methods. ^ ^ Fr»i"- w ™'"'"'"™ °f •<»'«» London school-children. Dr. Francis Warner, m .8go, showed over . per cent, of actual mental defectives, and similar investigations show that this ratio holds good in America. ' * The symptoms of mental deficiency are characteristic. Back- oulklv Th" "' '""■'""l''^ ""^ """•*' '^""' "■«' l™" '-"'"est qmcky. They are not observant, are not able to discriminate K;'; r"'"'"' '"'"'• '"""' "^ ^''^^- They may be unduly .dk and lis less or overexcitable. They are often disobedient; wdful, and liable to attacks of stubbornness and bad temper They are untidy in their personal habits (Femald), awkwarcHn heir gait movement, and attitude. In grasping, they are either feeJe or they may clutch the object and seem to be unable to let .t go. Incoordination is plainly shown in drawing and writing, in the lack of ,k,ll and dexterity in simple gymnastics, and in the lack of initiative and spontaneity. They do not show the strength vigor, alertness, and courage of normal childhood. When a diagnosis has been made, the i«rents should be frankly and tactfully taken into the teacher's confidence, the use of op- probrious terms to express mental defectiveness being carefully avoided. The parent should be impressed with the fact that the child IS not doing well at school and that for his own sake he should have special attention to prevent him from going backward, as well as to tram to the best advantage such jMwers as he has aight ca^ of backwardness may be taught in classes com- P^ of children who show about the same degree of retardation while pronounced and incurable cases are much better safe- til EXCKCUE IN EDl-CATION AND MEDICINE guarded in an institution where they can be more closely ob- ser\ed anf protected. The physical education would then vary with the degree of the defect and with the amount of control exercised by the teacher. In a school system special classes should be provided for them, and teachers should be specially prepared to Uke charge of these atypical pupils. Public schools for them have been in successful operation in Germany, Norway, Sweden, Denmark, France, Switzerland, and England. In London alone there are more than 5o classes, and such classes are also in successful ojieration in Philadelphia, Providence, Boston. Chicago, and elsewhere. Backward children are segregated for their own benefit, and also for the benefit of the other pupils of the school whom they would hold back. The classes should be small— not over 15 in number — and great attention should be paid to improving the child's surroundings in the home as well. His physical condition should be kept as favorable as possible by nourish- ing food, regular outdoor exercise, bathing, ample sleep, and careful attention to bodily functions and habits. The mental awakening resulting from an improved state of nutrition and bodily vigor alone is often striking. The education of the special senses and the training of the voluntary muscles to prompt and accurate response must precede and prepare the way for the more purely intellectual training. The unseeing eye, the unhearing ear, and the other obstructed avenues of approach to the central intelligence must be opened up by a series of carefully arranged "sensorial" gymnastics. The ultimate aim of these exercises is to train the child to acquire knowledge from his sen- sations. Next in importance comes the discipline c» the muscles, not only for muscular growth and practical coordination, but particularly with reference to the well-recognized relation of thought to muscular movement, motor training being one of the most potent factors to arouse the feeble powers of voluntary at- tention, observation, and comprehension. This motor eflucation should begin with the common games and occupations of normal childhood. The child should be taught to throw and catch a ball. PHV8IWI EDUCATION OF MENTAL AND IIO.AI DEfFXTIVES ,13 to kick . foot-b.ll, to jump and run. and, in fact, to p^form larger movement. cUinR for the natural u.« of the various mu«:le Rroum progressing with an eye to the normal evolution of the play in- stmct as .lescribe.1 in the chapter on Age and Occupation. -Vf ic and rhythmic marching are preferable to more fort, al gymnastics, involving close and continu-d attention, prom..i obedience, and accurate motor response. The« ,,ualities 1st ',e cultivated by the simplest movements at first or the goo.] effect wl be lost. Gymnastics by commands would at first be entirely beyond most of these children, whose attention would quickly lag and whose cofi,«ration and interest it would .e impossible to maintain. What has been said of general motor training applies with s,«cial force to the training of the f. ,er coordinations of hand and forearm rhis can best be done by kindergarten methods and by manual occupations, such as Sloyd, basketry, and weaving. Indeed here are no other means of influencing so profoundly the men- tal growth of the defective. Instruction must always tegin on a very low plane and progress at best will be slower than in he normal child. .\t an early age much of this neuromuscular training by gymnastics may be directe.1 to the various handicrafts and simple manual labor which will enable many of these children especially m institutions, to become self-.upporting in after-life' who would otherwise become a burden ou the community. Under this course of education some children develop up to the grade classes and retutr, to them, completing a fairly satisfactory school course. When, however, the degree is extreme an.l the condition is congenital or the result of disease or injury, these brain abnor- mahties remain permanent conditions, and no really feeble-minded person was or can be entirely cured (Fernald). It is always a question of how much improvement is possible m each individual case. Many of them may be trained to be at least self-supporting, if not self-controlling, but the greater number need oversight and supervision as long as they live. A large pro- portion become public charges, and it is important that they be kept m institutions as they approach adult life, that they may not i i »M EXEKCUE IN EDirCAnON AND MEDlrlNE have an opportunity to yield to the physical tcmputlons to which they are ao |)cculiarly susceptible, and so pro|>OKatc their own kinackwardncss, the relationship of the grades in mental defectives being somewhat like the successive ages in children so far as their helplessness is aonccrncd. The lower graclcs are like the youngest children, but their phv ical conformation does not corresimnd with their mental barkwanmess. The more ce directed, first, to the [XMturc and gait of the |)aticnts. Their most characteristic defect is the shambling walk, with dragging feet and slouching figure. This may be corrected by running to command up or down hill, by walking contests on tip-toe indoors or out-of-doors. Such exercises, briskly carried out, awaken the attention and make a good break in a long occupation period. The use of a springboard, supplementing walking drills, develops elasticity in the dragging step. Stooping may be Ci>r- rected by balancing a lxx5k or basket on the head, and the poise and ease of Ijcaring thus .improved. The placing of a ladder horizontally on tiie floor is a valuable way of correcting a slouching gait. The child steps between the round. , md must raise the foot well at every step. The stepping on bricks placed at regular dis- tances is another device for the same purpose. Military dri ' has a peculiar educational value for a defective (Barr). The 'oy learns a certain standard of precision, at- tention, and readiness of movement. The emulation brought about in these movements is important. The stimulation '^f his ambition to attain to the power of the others; to present arms in order that he may not disturb the general movement of the squad, is also one of the most important means of character building. rHVSICAI. EOICATION OF MENTAl AND IIO«AI. I.KPKCTIVKS 115 This diKiplinc i» alM> obtainwl by Kymnastic exercises in which prompt obedience to command is insisted u|)on. These drills should \x pnaiKi\ only for a few minutes at a time, and varie.1 in difficulty to suit the gru-le of the class. The training for skill and coordination of the arms and hands (FIk. 1,8) iiuiy l« accom- plished by the horizonul and parallel Urs and the use of ladders for climbing. One of the most defective coordinations in the atypical child IS found in the power of Krasping. The weak and ncr»ous finRcrs m of the untrained imbecile can retain nothing within its grasp, or tiie nm-ous clutch, unconscious of its violence, is • ually expressive of mental incapacity. It is necessary, then, to train this coordination by simple and strong exercses of hanging and climbing, catching and throwing, before giving to the child a hammer, a saw, or a chisel The throwing and catching of balls, from the baseball to the medicine ball, are useful, as are the simpler exercises on the bars and rings In high-grade defectives this power of regulating the grasp is better controlled, but it may be still further trained by weaving 'I 2l6 EXERCISE DJ EDUCATION AND MEDICINE club-swinging, or blackboard drawing with both hands, after the system of J. Liberty Tadd. Active sports are to be warmly encouraged, the exhilaration to the onlookers as well as to the participants being a good antidote to the lethargy and the timidity of the feeble-minded. The cir- culation is stimulated thereby, and the muscles, which are in- clined to be flabby and cold, are improved in nutrition. Dancing is an amusement in which most of these children delight, and many excel, and its good effect is evident at once. Running, racing, swimming, leaping, vaulting, quoits, tennis, Fig. 159. — Crippled nd defective cllildn-n R.irdcniiiK (PlayRrounds Association of PIliladtlNhia). croquet, are all most suitable, while football, baseball, and basket- ball are frequently well played and eagerly discussed by children even of a very low grade, but lack of initiative is the outstanding characteristic of the great mass of incapables. During a recent visit to an institution for the feeble-minded a group of boys were seen working in the field. Their attention being attracted, they all stopped, some with bent back about to lift a shovelful of earth, others in various stages of arrested movement. Thus they remained until called back to their work by the shout of the foreman. This mental apathy expressed by PHYSICAL EDUCATION OF MENIAL AND MORAL DEFECHVES 2l^ sluggish physical movement is present in nearly all low grades of mtelhgence, and can only be reached by such means as have been described. The other type of mental defectives shows an abnormal exci- tability, seen in restlessness, insubordinatim, and truancy, and it IS these children that so frequently find their way into the Juvenile Court, the reformatory, and the jail. Blunted intellect and moral failure, as a rule, go hand in hand, and It is a mistake to suppose that the criminal child or man is naturally bright. If apparently bright, it is usually in a narrow line and self-repeating-more allied to animal cunning than to intellectual power. He is vacillating, without fixed purjwse or aim, incapable of pursuing a consistent plan, and of a rudimentary or atypical mental development. Physical training, then, is specially indicated in the case of the youthful delinquent who so often enters the school for delin- quents ix)orly nourished, anemic, with muscles soft and flabby, frcm a life passed in the dark and unsanitary tenement house, homeless on the street, or uncared for in the village, .\long with this common city type there will also be found in the Juvenile Court or special training school the apathetic dullard, stupid and shambling, whose every motion expresses mental lethargy and iihysical incapacity. .As a rule, these cases detest exercise or anything that disturbs their stupor, and for them discipline must be Spartan in character, for exercises need not be agreeable to be beneficial, as has been well insisted upon by Sargent and is daily proved in the reformatories. .A course of physical training for such children acts beneficially in three ways: By awakening the brain activity of those who are mentally defective; by bettering the badiv nourished and flabby muscular system by developing the heart and lung power; and by demanding alert and p ompt response to command, a most important lesson, to be taught so well in no other way. The course of training for the incorrigible youth or young criminal would begin with military drill, in which the boys are formed into companies with sub-officers selected from their own ^ PHYSICAL EDUCATION OF MENTAL AND MORAL DEFECTIVES 219 number. These companies are taught the usual evolutions of marchmg, countermarching, and the manual of arms The authonty of the officers selected from among the boys should cease w,th the end of each dr.ll, and promotions should be made with the greatest care. There is always a temptation to bullv if the giving of th,s temporary authority is not rigidly guarded. The perfection to which the military drill can be carried is shown by the attain- ment of the boys m the industrial school at Glen Mills, whose evolutions on the field would do credit to regular soldiers. The second means of training is by gymnastic exercises, and those in use at Glen Mills are semimilitary and founded on the German plan rather than the Swedish. The boys are lined up and marched to the gymnasium, which has a concrete floor Coats, hats shoes, and stockings are removed, and a brisk drill IS given either with wands or dumb-bells. This is followed by a five-mmute period of free play, in which the noise of the boy, is m marked contrast to the comparative silence of the class work. Following this IS apparatus work on the parallels, horse, and horizontal bar, class leaders being promoted from among the boys. After another .period of free play the lesson ends by gym- nastic games. The boys are then lined up, shoes and stockingfare put on, and they are marched back to their various occupations. The third means of training is by outdoor sports and games, in which great freedom of organization and conduct is allowed, although strict supervision is still kept and the boys are punished for misbehavior by being made to stand along the side line of the playground with the back to it for periods of five or ten minutes. If the offense is a severe one, the salutory exercise of continuous, slow deep knee-bending is added during their period of punish- ment. Competitive games with outside institutions are arranged and track and field sports are freely indulged in, giving good opportunities for moral and ethical training, w^hich are not ne- glected. The results have been so satisfactory that physical train- ing is now established on an equal footing with industrial training and school of letters work in the regular days' curriculum of these incorrigible boys. ^11! 220 EXERCISE IN EDUCATION AND MEDICINE Physical training has a marked effect on the physique, mentahty, and condu-t of criminals who have attained their full growth, as proved by the experiments of Hamilton D. Wey, at the Elmira State Penitentiary. His description of the criminal is illuminating : " The average youthful criminal, as encountered in the prisons of the Siate, is an abnormal production, physically, mentally, and morally. Generally under weight, with repulsive features in some one or more lines, and asymmetric head; he is coarse in fiber and heavy in his movements. His mind, while not diseased, is unde- veloped, or it may be abnormally developed in certain directions, the smartness resulting therefrom partaking of low cunning and centering about self. He is deficient in stability and will power, and incapable of prolonged mental effort and ; lication. His intellect travels in a rut and fails him in an emergency. His moral nature shares in the imperfections of his physical and mental state. Ho does not possess the power to discriminate betweer. right and wrong, or if so, it is in favor of himself and avails nothing to society. It is easier for him to incline to evil rather than to good, to the animal, rather than to the intellectual, and in this he is true to himself. His is a perverted moral nature— a blunted mind and a crude body." It is to physical training that we must look for the awakening of those powers that can be directed by firm discipline to the physi- cal, mental, and moral betterment of these derelicts. During a period of sixteen months a class of 43 dullards was given a course of physical training at Elmira. This comprised baths at frequent intervals, in conjunction with passive exercise, kneading the muscles, working the joints, and general friction by a professional trainer; and a manual drill in calisthenics to supple- ment the shop work, from which they were excused, although their school work was taken as usual. They were put on a specially nourishing diet. The physical exercise lasted for about two hours a day. They began with the ordinary marching, and in time were taught other evolutions, although the teaching of keeping step was a matter of weeks. When they could do this well, they were given setting-up movements and exercises with dumb-bells up to three PHYSICAL EDUCATION OF MENTAL AND MORAL DEFECTIVES 231 pounds in weight. The first experiment lasted from June until November, and showed a net average gain of i.2j jiounds a man. Various skin diseases disappeared, the muscular condition and the carriage improved, and the response to command became much more rapid and accurate. The whole expression of the face im- proved, the dull, stolid look assumed a more intelligent expression, and the eye gained in brightness and vivacity. .\ mental awakening accompanied this, and their progress in school rapidly showed the effects. During the five months they were under observation their average marking in school was 74.16 ner cent., as against 45.2 per cent, for five months immediately preceding their course of special training. This improvement was continued to a remarkable degree, and the stimulation of the physical powers in the case of three of the class impressed their mental organization to a degree that it enabled them to earn their release on parole, whereas if left to themselves their minds would never have been so quickened. To train these dullard's legs and arms to act with precision and in unison was more than the mere rehearsal of mechanical move- ments. It was menial as well as physical training, and Dr. Wey is of the opinion that in the prisons and reformatories of the country " there is a class of youthful felons who can thus be reached in their growth period and improved primarily through the training of the body, the cultivation of the head follo^ving in good time. If penal institutions in their educational work could more often look upon bodily training as a powerful agent for the physical, mental, and moral reformation of their charges, more men would be released at the expiration of their time competent to maintain themselves honestly." This result is only to be obtained by careful physical training with an educational purpose, for. as F. H. Nibecker, the super- intendent of Glen Mills School, so well puts it, " Hard work of any particular kind is not complete exercise, nor is it equiva- lent to physical training, by which the perception is quickened and mental training results, quite as pronounced in effect as from efforts that have mental training more directly in view." fl!i PART II ■ EXERCISE IN MEDICINE CHAPTER XIV THE APPUCATION OF EXERCISE TO PATHOLOGIC CONDITIONS The efficacy of both active and passive exercises in the treat- ment of pathologic conditions depends on their |)ower to change anatomic structure and to stimulate physiologic function. This anatomic and physiologic effect is very differently expressed in exploits of endurance, in feats of strength an " Monlreal Meci. Jour," } 3lH KXKiciiir. IN KmcATioN AM) UEniriNi: in^trumi'nl has l)ivn ri'inmminiU'il. Kut:n{nx and climl)inK arc of the urculusl value ((ir increasing the In. ihinx ca|>acit)' if kc|)t w ithin ihf limits of fatiKuv. All I'li-rcists nhoulil Iw prcscrilx'd In wriilnK, «ith the most minute dirc-ctions as to time. trei|uenc,v, anil wverity. an ' a record of the iwlicnt's »ei)(hl shoulil Ik' ke|>t, ami fre<|uent examinations ma>le to ilvlermine his proKrcss. a loss of weiKht iK'injf follo.veil li) a reduction of exercise. Daily su|>erv isi'il exercises arc necessary to increa.se rapidly the |K)HTr of chest expansion and ' italcaiwcity. Theyshouldbcdirectcd toa IraininK in the iH'st methertion to the need of the Ixxly. The oxygen in the blcxxl remains measurably constant, ami the only way to increase its absorption by the tissues is to do work that causes the breaking down of oxygen comfiounds. Deep breathing would result naturally from more demand, but it woul,iti„n or ins|>irati»n iFig. 161). Ri|x.at this movctntnt five tlmi-» slowly with the thoracic Fir. it>j. — Inhalalion — alidominal. Thr abdomen is protruded without ex- {uindinK the thorax. Vig. if>,t.— Rxhalation— ahdominaj. The aUlomen is indrawn and the breath expelletl without eonttacting the chest. wall nxeut ten to the minute. .\ valuable ^xercise is that given by Zander's machine, known as the "tower," in which pressure is placed on the back by a cushioned pad and the shoulders are drawn upward and backward rhythmically with the respiration. (See Fig. 38, p. 67.) Butler, of Brooklyn, has reported many cases of incipient phthisis in which deep breathirg lias been used as an accessory to overfeeding and rest, wilh marked improvement in weight and general health; but if the tubercular process is active in the lung, deep breathing will only irritate and aggravate what nature attempts to splint by limiting the movement over the affected area, and in some cases a hemorrhage may be brought on In the application of fixercise every attendant condition should be made as favorable as possible at all times, to get the best therapeutic results. Fresh air should be supplied in abundance, and treatment should be given in the open air or a well-ventilated room. Many of the disorders of the respiratory tract are due to the impurity, rather than to the temperature, of the air breathed. Regularity APPLICATION OF KXERCISE TO PATHOLOGIC CONDITIONS 235 and persistence on the part of the patient are absolutely necessary, and the benefit from half an hour's exercise rejjeatcd daily is incom- parably greater and surer than :in equivalent amount taken at long, irregular intervals. The necessity of constant individual su- ])ervision is also recognized by all who have had experience in the giving of treatment by exercise. Eiery movement should be pushed to its utmost limit of efficiency. Many reported failures can be traced to the lack of intelligent personal direction. It is not sufficient to give the patient a vague outline of a course and leave its carrying out entirely to an assistant, however well trained, for in no department of medicine does the personality of the surgeon count for more. His presence should Ije an inspiration to his patient, and he should himself insist upon accuracy and precision throughout each movement, however simple it may seem to the casual observer. lii CHAPTER XV FLAT-FOOT AND ITS TREATMENT Thk advantage of the upright ,«sition is somewhat oftset by the fre,,uenc7 of osterior arch Fr„. .;..-A„,er„,«„eri„r„ch: ,, Shor, „l.„,„ „„.™e„, ; =, 1„„, pl.„,»M,>™„, ; 3, plantar fascia. (Fig. 174) is formed by the os calcis, the scaphoid, the three cuneiform bones, and the metatarsals, with the astragalus as a keystone. It ,s supported by the ligaments extending between the adjacent bones like ties, but more especially by the short plantar hgament (Fig. ,74, ,) binding from the os calcis to the navicular. This powerful ligament completes the socket formed 3a6 FLAT-FOOT ANP ITS TRKATMF.NT 337 by the navicular and the os calcis, into which tits the head of the astragalus, or keystone of the arch. The other main ligament of support is the lonj; plantar (Fi^. 174. 2). which extemis from the bo duclor hallu™- , n.,„n I j ' '. Imiioii of flexor longus haiiutis; °,„ ,,- 3, fl«or brcvis dig.to- ,, fcndon ot peronem longus- , artej TRTchco "™ '°"«" ■■"""» "'"'"■■ '■ '"•■"'•' "< "" «-- io"«- di^r 'orum and lumbricalcs; 5. flexor brcvis minimi digiti (Richer). flexor brevis hallucis (Fig. ,„. 3)_assisted by the tendons of the flexor longus hallucis (Fig. 175. 4), the flexor longus ,ligi- torum (Fig. 176, 4), and of the tibialis ,x,sticus, passing around the ,nner malleolus, and binding together by its expanded ten.lon all the bones of the tarsus except the astragalus. The tibialis antfcus (Fig. 178, i) also helps by lifting the proximal end of the first metatarsal bone. These muscles, by their action all tend to hft the inner side of the foot and draw together the limbs of the anteroposterior arch, like the string of a bow If »38 EXERCISK IX KDICATION AND MEDICINE The lateral arch of the foot (Fig. 179) is imperfe<., in that its sup|x)rt IS at the outer side only, the weiBht being borne by the Fig. .;,.-D,.e,,l„>-,To/mu.,l<.,„f,ho I ig. .;S.-Th..tcndonMhat»upix,r, ihc 0..1: ■ Icr,„u.„,lo„„i,.;,, i„u.,(„«.i; ,. arch:,, Tibialis amicus p.„,i„„u„,l,r.„,. l.Mr l,rcv„ hallucs; 4, 5. adduc.or hal- nular li„anH-nt (,); 3, soU-us; 4, llcvor luc, CR,ctar). ,„„„„, .|i„il,„um- 5, til,iali, ,K„icu.; .. Ilcxor toiiyus hallucis; 7, tendo Achilles; S, alKluctor hallucis (Richer). OS calcis, the cuboid, and the fifth metatarsal. The arch rises upward and inward, and its free, unsupported edge is rcprescnteil by the astragalus, the navicular, the internal cuneiform, and the first metatarsal. The lateral arch is supported principally by the tendon of the peroneus longus (Figs. 177, i; 17ft, 2), crossinf; the fof)t diagonally from the cuboid to the internal cuneiform, and by the ligaments bintling together the adjacent bones; it also receives some sup|,ort from the tibialis amicus. Tliu body weight is transmitted through the tibia to the astraga- lus. This jiressure on the keystone tends to spread the members of the arch, and, in so doing, to stretch the long and short plantar ligaments. .■\s the structures yield the inrier side of the foot comes down, and the lateral arch shares in the flattening process. It is. Fig. r7g.— Lateral arch. Pull of pero- neus longus. FlAT-r(XJT AND ITS TREATMENT jjg however, the unsup,»rteyn()vitis, tht- pains frtim inrn-' and rall()siiif>, am! with n(.'urai^;iu (tf the nu'tatarsiis or thi' li-nil(> .Uhilks. Thf mn>\ frnnu-nt mistake in diagnosis is rhi'iimalism, which seldom alTirts the fo<)i alone, allhoui^h I have seen it in one case in which the dia;;nosis of rheumatism was lont'irmed Iiy its ^uhsequent apjiearanee in other joints. Ahhou;ih not a fatal disease, it is the anise of threat pain and discomfort, and sometimes the patient becomes chair or hedridden. 'I'reatment must lM)th supjHiri tlie arch and correct tlie de- formity. M) thai no treatment is complete which does not develop the structures in\olved in the iiornial preservation of the arch. 'I'he market is llcxKled with patent devices for the support of the hn»ken down arch, liut no meciianjcal tn^atmenl should lie eniplo.eri unless it accurately lits the particular case. More harm than j;(M)d has l-een done hy the use of ill fitting and imperfectly H'tj'portini^ f(H)l-plates. A fiH it plate or handa^^e of any kind must he l(M)ked u|»on in tin iij^ht of a s|ilint, l() he discontinued as MKm as ]K)sv.il)le, and lo he used only in conjunction with other means of treatment. In most cases treatment hy exercise shouhl he ))ejiun liy ma- nijiulation, stretching, and massa^jinj; the f(K)t; hut where the pain is t(K) se\ere. it may I>e necessary to j;i\e the foot a complete rest for two weeks or more hy incasing it in a plaster bandage. When tenderness is sulVicienlly lessened, the following manipula- tions and active exercises may he startet firmly, circum- duct the foot slowly in the folhiuin;; order: ir) Extension; 13) inversion; i,^t llexion; (4) eversion. '! his should be done with as much force as can be used without proi.— Walking I outiT sides of IlK- f i'5 :;il 'ili ii 346 KXFRCISE IN EDUCATION ANn MEDICINE The shoe should present a slrai^ht inner line, allowing perfect freedom to the toes, and hij,'h heels should be avoided. An I-'iK- 193. — M. April ,1. AfUT excellent shoe has heen devised by Small, of Boston, in which the ri^id shank from the heel to the sole of the shoe is replaced by one that is flcxil)le. allowing free movement to the whole ftxrt and vet FIAT-POOT AND ITS TKEATMKXT 247 giving adequate support. The inner side of the heel and sole may be thicliened, or a cork insole may be made to lift the inner side Fi«. "■■"'» "« head of the fibula rT.h. f' u™"' ""'""''"''; <^' 'h« lumbar soine- cl th t T" '^"^hanter; (4) ,he fourth iuraoar spine, (5) the seventh dorsal soine- m ti,» • , , vertebm prominens; and (7) the r^ddk of'th *??' °' ""^ These points having been Ck J hi , "'"°"' P'""'^- f. ' ' 11 35a EXERCISE IS EUtlCATION AND UEDICINE hcif;ht <>{ each of tht'sc |x>ints is thvn nntol, ami from this data the imsturu can be graphically shown. A com|)Ositc of 72 normal l)oys (Greenwood) between the a^es of fifteen and nineteen years shows the following tracing (Fig. 200). ♦?» FiH- iw -Lovctl'i aiipiiralun fi»r mea.yH (malf of ((oo(| larriagi' (I.uvett). By means of this stantlanl \vc are enabled to divide faulty attitudes into — (i) Round back, showing a general cun'c back- ward, with little lordosis. (2) Round hollow back, with the backward projection greatest in the middorsal region, and with pronounced lordosis, the forward projection of the head bringing TREATMENT OF R'JfXI) BACK AND STOOPEO SIIOI'LDERS 3^3 the upiwr three measurements almost in line. (;) Forward displaeement of the shoulders, the scapuU' and clavieles l>einK displaced mdeiwndently of the condition of the spine. This condition may e.\ist either with or without a rounded hack A graphic tracing of these curves may also l,e obtaine.1 by the pantograph mcthixl de- scribed in the following chapter. From the stand|>oint of treatment these deformities may be classihed into flexi- ble and resistant. FiR. jo,.-MakinB ,, trad.,B of Ihc a„,o„,- Fin. =o.,. -Anlcro|x„,crior trac- ^.^j , „„.» „I ,h,. .„i,„. ,,, ,h.. ,a„.„„,a„h i,«, of ,h.. ,„i„ c„r„, ■ ,x»,u°e; b, lirsl lyiic of muiiil lark ; f, cx- Innic misfanl round liaik in a vounR nirl- During the years of growth posture will usually take care of Itself if constant change be allowed, for change is instinctive and automatic in the chil.l, and his varied activities may be trustearts of the anatomy to reveal it. The causes of round sh,>ulders are, then, those general con- ditions that produce muscular or constitutional weakness, like rapid growth, overwork, Iw.l air in schr hyf-ienc at home, or general lack of exercise, and, si-condly, occupations that l furniture, long-continued writing anosition for more than a few minutes at a lime in a young child. His restlessness In school, is his only means of protest, and is the ol,ject of much misapplied correction by those school-teachers who believe that quietness ami gooezius. It is a very fretjuent de- formity among school-children, and it occurs in almost 20 per cent, of university students uncomplicated with other |k)s- tural defects. Where a greater deviation is present, such as lateral curvature, a note is usualiv mac outgrown, and patients usually Ijccome iwrmancntly and structurally set in the faulty ixisition, with flattcnctl chest-walls and distorted finure. By adc<|uate treatment all cases are capable of improvement, and almost all, except the most resistant, are ca|)ablc of complete cure. Before lK-ginnin(! treatment ii is {m|K)rtant to differentiate between the flexil>lc and the resisUint rases and lietween Ijoth ami arthritis, where pain is usually a prominent symptom. An irri- tated spine must also be excluded, as well as the early stage of Fig. aoj.— Comet support of dothing. The Wright romM on the root of the neclt insIr.-Ki of the shoulder lil>s (Goldthwait). Pott's disease, so that any case of sore spine before being treated by exercise should undergo a rigid examination, and \k kept for some time under careful observation. Treatment may be divided into— fi) Hygienic; (2) exercise; (3) stretching. (i) Hygienu.—The patient should have the best available surroundings as to light, air, and food, because, as a rule, they are underdeveloped muscularly and hive not the constitutional resistance nor the will-power of the average child. The muscle TMATHENT Or lOUNI) BACK ANll ST(K)PKr) Sllol LIIKKS 257 fatiuuc- Ihat comiHi on from ihc strainiil, lixwl iKwiiions amonR schcxj chililren must he au.icliil l)y e\iry a\ailal>li' means. Schcx)l fumiturt shoulil lit ailjusid to prevent undue llexion i>! the liark an-inK a rifle and pressure of a bandoUer for two years. m 368 EXERCISE IN EDICATION AND MEDICINE sideways lower; exhale. The left arm should Ik* shove*! downward while the right arm is raisetl. This exercise brinj^s into action the u)){)er part of the trajtezius, deltoid, rhomlxiids, and serratus magnus of the right side, and the latissimus dorsi and lower ])art of the pectoralis major on the left. Extnisc //.—Position, standing, arms down. Right arm sideways raise; inhale; forward bend (Fig. 222); upward stretch; arm sideways lower; exhale. J'in. a». This exercise has the same effect as the first, with the additional advantage of stretching the right side of the trunk more than the left, as the Ixxly is bent forward. Exercise III. — Position, prone, lying on i)linlh, right arm elevated, left arm forced downward, Kxtcnd the neck and back; relax (Fig. 224). Exercise IV. — Position, back to the chest weight, floor attach- ment; raise and lower the right arm iFig. 223). This brings into action the right deltoid; the upper part of the trapezius; the rhomboids, and the serratus magnus of the right side. T.KATMKNT ur KOUNU BACK AND STOOPED SHO.Ll.KRS ,tx, Fir. aaj. fiArwiV I-._ShruRsinK the riKht shoulder while hol.lins a tlumb-MI of 40 or 50 poun.ls (Figs. 225 and ..6) has the contrary effect from continually holding the weight .nd keeping the muscles m tension. The intermittent contraction and rduxation of the muscles tend to strengthen and develop them, an,l so make them [I • n 270 EXEICME IN EDl'CATtUN AND MCOICINC bhortcr when at rest, white continuous tension rapidly stretchci them and destroys their tonicity. The puttinK u|> of a light dumb-lx'll. five or ten pounds, from the floor to arms' length above the head, is another valuable exercise iFi); 237). The nautical wheel (Fi(?. 34, p. 6j) turneil counter-clockwise also will help to raise a lowered right shoulder. Fig. 315. Fig. aae. Fig. at^. Hanging exercises, in which the weight is borne by the right arm with counter-pressure on the left side, are of slight assistance in stretching the latissimus dorsi on the right side, but do not affect the upper part of the trapezius or the serratus magnus, both of which are relaxed in this position. The prognosis is good in all cases if these exercises be followed persistently and faithfully in the form of a daily prescription for three to six months. Most of the failures are caused by the carelessness of both surgeon and patient and by the readiness of the tailor to act as their accomplice. CHAPTER XVII SOOUf^lS-lTS CAUSES* VARffiTlES, DIAGNOSIS, AND PROGNOSIS . / ' ■ " '""' ''^l-''"- ' walk, the general direction of the infii'^ ,p.,u. ■. ,,.,r,-,-.-, . (lescriW in the previous chapter, ^■1 the „.,ee ror, -,u . ., ,. ,1 and backward curves soon develop .V;t only n.. ■ Ihere 'k mduc eraggeration or suppression of ne«- .L.r ., ,. ;„rt.„|y sh>,,vn, but during growth lateral de^•ia- tions may ,.ls,. ,c, ,, overstretch the supporting muscles an.l ligament., n , ,,,„ ,„ .y,^^^^^ ^^^^ vertebra; themselves while in their plastic slate. The integrity of the spine is protecteh. ,h„™boideu, major and minor ■nd the levator anguli scapulc. region is locked, and the movement is in the dorsal region more than lower down. It is accompanied by rotation of the bodies of the dorsal vertebra; to the convex side of the lateral curve. Side bending from the position of extreme extension takes place in the lumbar region almost entirely, the dorsal vertebra being locked 274 EXERCISE IN EDUCATION AND MEDICINE Rotation of the bond inferior. On the left the ainchments are shown diagrammalically it is diminished by fle.sion or extension and is slight, even in the erect position. The most freely movable regions are most abundantly pro- viied with muscles, and it is to the analysis and application of their action that treatment of deviations by exercise must be directed. SCOLIOSIS— ITS CAUSES, VARIETIES, DIAGNOSIS, PROGNOSIS 275 The frequency of scoliosis among children and youths may be gathered from the fact that in an examination of 122 high-school boys enterefl for an athletic meet I found it in 32 cases, or 19 per cent. In an examination of 446 athletic college students it was found in ig per cent. In another series of 200 college students it was well marked in over 8 per cent., and slight in an additional 16 per cent. In a girls' high-school, out of 160 examinations, it was found in 31 cases, or 19 per cent., accompanied by severe backache in 1 7 cases. The figures of other observers, like Guillam, Krug, Hagraan, Kalback, .Schotter, Eulenberg, Roth, and Whit- man, give an average of alwut 27 per cent, among schl-children Fig. 331.— In ovcTvxtension of ihe spine the bending takes place principally at the neck and loins (Dwight). and place the periotl of greatest frequency between the ages of seven and fourteen. The causes of scoliosis are both congenital and acquired. Among them may be mentioned wry-neck, defective hearing and vision, asymmetry (Figs. 232 and 233) or faulty development of the bones, like rickets, dislocation of the hip, arthritis, and uneven development of the lower extremities from joint disease or other causes. Astigmatism has been given a large jilace in the caus- ation of scoliosis l)y Gould, who has well described the tilting of the head in such cases, particularly when reading or writ- 276 EXERCISE IN EDICATION AND MEDICINE ins;. His experience has been confirniecl in case rc|K>rts (luoied by Rogers.' •'Case /.—October 7, 1901, H. H., aRcd seventeen, .\meri- Fig. 333. — Lateral rurvaturc frtini un- even extremities and deformefi iielvis. The black spots mark the iiosterior suiierior spine of the ilium. can school-girl, complainetl i)f jjain through eyes anil head, extending down the back, and aggravated by study. Some months previously her phys- ician noticeil a lateral curva- ture of the spine, anil an attempt had been made to correct this deformity I'V the daily use of calisthenics. She was wearing glasses given her \,y an optician. (). D. 0.50 C. 90 - O. S. 0.75 C. ijo". and with tlwm got 0.7 vision, 1 ■■ Ji.urnal of the .\mfriian Meili.al Ass .rialion," July it,. i.;o7. t'iR. 3Zi- — The result of raisinK the fixtt three inrhes to brinst the spines of the ilium 10 the same level SCOLIOSIS— ITS CAUSES, VARIETIES, DIAGNOSIS, PROGNOSIS 277 l>ut there was noted at once a tendency to tilt the head to one side when using them. After examination under a mydriatic she was ordered O. D. -I- i.o ( • ) 0.50 C. 75°; O. S. + 0.50 ( + ) 1.0 C. 100° for constant wear. •■April 19, 1902: The patient had improved preatly, the asthenopia was gone, and the spinal defect was not noticeable. s|,initi ilcformily The gymnastic exercise had, however, Ijeen continued, and the beneficial result wa-; attributed to this alonu." It is to l>ad jjoslure. long continued, in standing, sitting, and 378 EXERCISE IN EDUCATION AND MEDICINE I lying, joineil with the carrying of weights in the hands or sus- pcndetl from the shoulder, that we must look for the origin of the vast majority of cases, which may be classed under the general heading of the Sfo/ww's of fatigue. A frequent fault in the standing posture is th»- habit- ual employment of one leg, usually the right one. as a base, the other foot being used as a prop (Fig. 235). This pro- Fig. 335. — Lowerirx of the riRht shoul- der from resting the weight on the right leg. One way in which a C curve begins. Fig. 336. — Pose from ^n .intitjuc statue of a Ijoy illustrating thi- attitude of r(.st with the weight on the right foot. The right hip projetted and right shoulder lowered, forming a C curve. duces a C-shaped cur\e with marked lowering of the right shoulder and prominence of the right hip. Many children assume this position, in which the strain is Ijorne Ijy the ligaments of the hip and spine .for long perioris, and feel imcomfortable when the weight is transferred to the other foot. SCOUOSIS-ITS CAUSES, VARIETIES, DIAGNOSIS, PBOGNOSIS 279 Such cases are nearly always accorapanici by rounding of the shoulders, flattening of the chest, protrusion of the abdomen, and rotation of the Nertebr=e, all sign., of muscular fatigue and ligamentous strain. The sitting posture is beset with possibilities for deformity The comnion habit of sitting with one foot tucked up on the seat IS respons^le for some cases, but, ateve all. the compulsory holding «f«iy »«ed position for long ,.eriods of time. We know that if we hold the arm out at right angles the pair ami fatigue soon become intolerable, and few can stand the strain so long as five minutes. The greatest stram falls u,»n the dehoid, which has no relief from continuous action. The same cm,dition c^rurs in the back and shoulders of the school-child forced to remain sitting for any unusual length of time. ' The complicated system of spinad muscles, bv working in relays postpones fatigue very considerably, the slighter change of move- ment bringing into action a new set and relieving the tired ones and this consunt desire for rest by movement i- the most striking quality of all young animal life. With the K'inning of school-life the child is made .0 sit from hree to six hours with but momentary rests at long inten-als, ami the resultant restlessness must be suppresse,! bv the teacher for tl.e sake of discipline. The rapid fatigue of 'the umleveloped muscles and the irregular compression of the growing bones go far to hx the faulty posture, especially in those who are weak and delicate. The process of collapse and tiring of the spinal mu.scles during writing is well described bv Fahrner- "Before writing begins children sit perfectly upright with both scapula, thrown back equally. .Vs soon as wxiting begins all children move their heads slighdy forward and to the left Soon head after head drops from the rapid fatigue of the neck muscles In a short time the back also collapses, so as to hang from the shoulder-blades supported by the up,H.r arm. Then two distinct types of posture are seen. Those writing on the upper par. of the page support themselves upon the riesk. and the rounded back curves forward. The eyes are three or four inches distam from aSo £XEXC»E IN EDUCATION AMD MEDICINE the desk, and the support is from three points— the left elbow, the chest, and the right forearm slightly. When at the bottom of the paper, they lose their third support and have the left elbow alone. .\dd to this a twisting or skewing of the back towartl the right. The head is Ijent toward the left shoulder, and the eyes brought within six inches of the japer. The onset of this deformity is hastened tiy mental fatigue, which is faithfully re- flectens, and (5) a standard series ot ,x,ses in faulty, habitual, and correcte.1 |«sture. Plumb-lines are sometimes used, and deviations from them are noted at different levels. The shoulder-levels have been measured from the ground, and various other isolated facts have bc^n taken, but these methods are all im- perfect, cumbersome, and lack the uniformity necessary for com- parison one with the other. Bernard Roth's plan of recordin;; rotation by molding a flexible strip of pure tin across the back at the desire.1 level, and making a tracing from this upon paper, is easv and accurate Fitz describes a method of photographing the patient behind a screen, consisting of a rectangular frame with threads strung vertically and horizontally, cutting the entire surface into s,,uares of one mch. A rapid method of recording the deviation is by attaching a strip of a.lhesiw plaster to the spine and marking the position of the spinous processes on it. The most accurate and convenient instruments are those emploving the pantograph method, of which the most elaborate IS that of Schulthess, which gives a life-sized tracing of all the contours. Its size and ex,,ense, however, make its general introduction impossible (Fig. 240). An attempt has been made to fulfil these conditions in an MKiocon nsoimioN rtsi ouir (*NSI ond ISO IIST CHART Nn. J) I.I b£ I 2.0 ^ is /APPLIED IfVMGE Ini B^— '• leSi Eail Wain Street Roch«il«f, r4*w York 14609 USA .^— .^— (716) *e3 - 0300 - Phofi. 384 tXERCISE IN EDUCATION AND MEDICINE instrument which I have employed for some years. It consists of a horizontal iron stand into which a rigid upright rod is firmly screwed. To this rod two jointed arms are attached by movable collars clamped by thumb-screws. The lower arm passes behind the patient and fixes the hips by means of clamps, preventing any sideways movement. The upper arm passes in front of the Fig. 340.— Schulthesa apparmttu for recording lateral curvature (LUning and Schul- theaa). patient and fixes the shoulders. To the collar of the upper arm a plate is hinged for the attachment of the pantograph, set to make the tracing in the proportion of i to 4. Ruled paper is stretched over the plate and held by clips behind. The pointer should be adjustable in length, short for the tracing of the spine and scapulcc; and capable of being lengthened for tracing the outline of the shoulders and hips. SCOUOSK-,TS CAUSES, VARIETIES, DIAGNOSIS, PROGNOSIS 285 To take a tracing the spinous processes are first marked with a flesh-penci The patient is placed on the stand with the heels ogether, the hip. are clamped at the level at the trochanters, and M mto the habuual position. The line of the spine is followed by the short pomter (Fig. .4, ), the gluteal cleft and the points of -Z i h scapute mark.^; then an outline of the shoulders and hips is rapidly traced by lengthenmg the pointer to touch the most pmminent ^rts Cross-secfons may be taken to show rotation bypassing the end of the pantograph across the back, at the desired level, the patient bend- of the back, showmg the difference in levels, deviation, and rotation (lb ii ( i 386 EXERCISC I.N EDLCATION AND MEDICINE their txtent being to scale, anti estimated by counting the squares on the ruled ])aper. These tracings should be repeateil from month to month throughout a course of treatment. Diagnosis.— Scoliosis must be carefully distinguished from Pott's disease or tuberculosis, symptoms of which are spasm of Fig. 24a. — Making a tracing of the rotation at the luml>ar region. the muscles and loss of mobility in the spine, with pain on motion or jar, pains in the chest and abdomen, fever, and impairment of the general health. Lateral deviations occur in the course of this disease, but it is usually a leaning of the body to one side rather sharply, instead of a true gradual curve. In later stages a knuckle of bone develops at the seat of the disease, but the danger of mistaking it lies before this has developed. SCOUOS,S-ITS CAfSKS, V.«,.T.ES, DUGNOSIS, PR<«X„S,S .8; In Ticket, the malformations of the ^■ari„us bones may usually ^JZir ' "'""'■"'"'■°" """ ■"—-«-•"'. and the othi consftutiona symptoms are characteristic, the cun-es of the spine Joii«). '^ ^"^ """"^ >"=«nient l,y immobili^.ion (Ridlon and In infantile paralysis there is a manifest loss of power in the affected muscles, which renders its diagnosis comparatively easy pecially by the aid of electricity. In these cases the deform f; u ually becomes great, and the condition is resistant of treatm^m Curvatures resulting from pleurisy and empyema are alTays toward he convex healthy side of the chest (Fig. .44; and are easily distmguished by the history and appearance Hi I !£! III): 388 EXEKCISE IN EDUCATION AND MEDICINE The most frequent form of scoliosis is the total C-shaped curve involving the entire back (Fig. 245). In his series of looo consecutive cases, taken from a large private practice, Bernard Roth found 523 presenting this type; 329 presented a right dorsal and left lumbar (Fig. 246); 72 of his cases showed a total right curvature, while 33 might be classed as irregular. This is substantially the same proportion as in ^ ■^ Fig. 344.— Tracing of scoliosis due to collapae of right side after empy- ema and resection of ribs. ; Fig. 345. — C t irve in i young woman. ot curve. Fig. 346.— Tracing typical a-shajied Scholder's examinations of school-chiliren a I,au.isane. His entire table is as follows; Among 5;i school-children with lateral curvature, out of 2134 children examined, 60.3 per cent, showed curves convex to the left, 2 1. 1 per cent, showed a right convex curvature, and 8.5 per cent, showed compound convex curves. His totals are: Leit Convex. Total scoliosis 48.1 per cent. Dorsal scoliosis 8.4 " Lumbar scoliosis 11.8 " Combined scoliosis 8.5 " Right Citttfex. 7-8 |>er cent. 4-3 8.3 " Tolal. 56.0 I»er cent. 13.7 30.3 8.5 " The total curve is most commonly found in school-children, and is followed by the right dorsal and left lumbar. Transitional cases are nearly always preceded or accompanied by round shoul- ders, flat chest, and protruding abdomen, and by general care- lessness in carrying the body weight when standing at rest, as m Fig. 235. This alone would tend to produce a well-marked total curve with the convexity to the left. As this posture becomes ')UOS,S-m CAISES, VARIETIES, OUONOSIS, PROGNOSIS ,89 fix he balies of ,he luml,„ vertebra- rotate to the left „! .hi m facing a strong wind. This ca"use's a rotation of the bodies of the cervical verte- T 1° ""^ "^^^' '^"y'"S »"h i' the Ixxlie. of the dorsal vertebrae, producing the characteristic ri^ht dorsal curvature with rotation to the right, and followed by a left convex lumbar, the level of the great est deviation in these cases being usuallv from the sixth to the eighth dorsal. In total curvatures the deviation is greatest lower down-about the ninth or tenth dorsal, or even at the twelfth In "• -'""" "■"">■"«.. la"r"v 'n '''"'"'■'"' '™'" """-= "''^'o"'""" "f "«= P^'v- or i.regu- inr^r ;erir;~ " -^-"'^ ^""^''" -• "--" nottr::;T^™Ltrs5:rcar ^d"^ r™'^- - ^^-"j'ui.i-. in severe cases there may be oressiirp ii,,r,„ .i, roots, causins oain Th„ „ i , pressure upon the nerve- breath is coiCn'o ^^ """^ °^ ''"'■«"^' «■'■"' ^h°«"ess of ath,^is common on account of the diminished capacity of the .. .,- IraiitiK illus- trating a C curve as a result of uneven Mtremjties. 39° EXERCISE IN EL'UCATION AND MEDICINE lungs and interfirence with the heart action, but these symptoms are [leculiar to the more aggravated cases. As the deformity tends to increase during the growing jjeriod, these symptoms may not become insistent until the approach to adult life, when the patient is prone to develoj) phthisis or to have disturbance of the digestion, impairment of the general vigor, and slow increase of asymmetry, with increasing pain in the back, as senile atrophy of the inter- vertebral discs progresses. Prognoiis. — Total functional curves may continue as such throughout life, increasing slightly, although, as a rule, they change to structural curves and become comi)Ound in form as they pro- gress. Some permanent deformity is certain in all cases where V ;.).\Ma;./. \ ; Fig. 34K. — Courae of the S curve under treatment. the vertebra have become distorted and a functional cur\e has become structural. By treatment all but structural casts should be capable of permanent cure, and even they should be in every case greatly improved, the deformity masked, and the general health and efficiency retained. This applies more especially to children who have not yet acquired their full growth. When full growth has been attained, before the case comes under observation, com- plete cure is not to be hoped for, and the only thing to be expected is some improvement in the general condition and a variable diminution of the deformity. Cases due to infantile paralysis or to the collapse of one side of the chest, from empyema, are peculiarly resistant and must be treated w'th great caution. Cases due to rickets are also resistant, although most of them are capable of considerable improvement. CHAPTER XVni THE TREATMENT OF SCOUOSIS The treatment of scoliosis falls naturally into two divisions- . The reormauon of the physical habits and improvement of the general condition; (,) the correction of the deformity by ejtercise, stretching, and support. '' ^ Correct standing posture must be taught by the aid of a mirror as descr,bc.l ,n the chapter on Round Shoulders. This must ^ x« ;aC '''^" ^"" ""' "' ^'^^"" ™"' " ''" "- "-■■"•^'"^ I, r a 391 EXERCISE m EDUCATION AND MEDICINE Astigmatism should be at once corrected where it is the cause of tilting of the head, and the habiU of school life should be care- fully regulated. The writing posture has been much maligned, and even with well-fitting seats and desks the present writing position is such as to favor the formation of fatigue scoliosis to a marked extent. Slanting script has been blamed as an encourager of postural F%. JSo-^-Ouuve of pottufc d body atid heul, the pAper thown. uul the pen-holder u^kkl in ottleT to bring the writing field into view (Gould). defects, but the directions given for the correct writing position are impossible from a practical standpoint, as has been demonstrated by Gould, who shows that the hand in the writing posture, as usually ordered, lies between the eye and the writing field, which is hidden by the thumb and finger and the pen-holder (Fig. 249). As a consequence, the pupil turns the paper to the left, and the pen to the right, accompanying this by twisting of the head further to the left, with the chin tilted to the right (Fig. 250). If the paper, instead of being phiced in front of the pupil, be THB WKATHENT Of bCOUOglS »9J ^^'i 'u m"1 °' "• '"■'>' ""'• "■"« '"«^""i« "« overcome, and the child obtaim . clear view of the writing field, the only po«.bk defom,.ty then being . forward bending of the head. Th«, he thm..s, can 1« avoiderl by tilting the desk top to an angle of 45 degrees, a suggestion prol«bly impossible in most schools under present conditions, but the shifting of the writing p.,«r i, easy of adoption, and covers the most serious objection to the present writing position. •K Jl'u '"'* '"' "" '^°""™«^"'"' °f » well-fitting desk is so Mmple that there seems no excu.se for neglecting it. The height of the seat from the floor should be such that in sitting the feet rest easily on the floor or on a foot-rest. The slope o the seat should be bacicward and downward, in the promrtion of one m twelve, the depth L-eing a'-out two-thirds the length of the thighs and the width that of the buttocks. Making it concave adds to the comfort. The back of the seat should have a slope backward of about one in twelve from a vertical line, and the back support should cc:ae to the mid- dle of the shoulders and touch the small of the back. The height of the desk should be such that the back edge allows fair room to rest the fortarm naturally with the elbow at the side, and the slope should be about one to six forward and upward, the edge overlapping the front edge o the seat by about one inch. The desk may well be made adjustable for distance (Fig. 251, a~b), so as to allow freedom in getting in and out, by pushing the desk-lid forward. These points are covered m the Garber adjustable desk, described in the chapter on Schools, but no matter how well fitting the school fumitim may be, unless there is constant change allowed, scoliosis is sure to develop in some growing children. ^f±^_ Fig. ari._To Khow the mcuurements requiird n determining dcik propcmions, a-h is thi dUtance which is here miniu, becaiue t le edge of the d«k overLp. the front of the wat. fi >■ if M 11 to »9* i.xtMcmt: IX t.iiicATioN AM) ukdicim: ii INxir liKhtin^ of tlu- >ihiMit nN>m i> u thinl Hourcu from which scoliosis Iw^ins. If the |>u|iil lunnot sec dearly, he Ininils forward or strews his l)ack, and the same elTect is prtxIu'X-d if he sits in his own liuht. A well-rlesi^ned sch«)ol-rcK>m should have windows placed hi^h enough to let the li^ht fall <>\er the left shoulder, and never directly from in front or behind. The raisinji of om side of the seat will reverse a lie^inning curviture (Fi^s. atSand .--.v^). and this may lie used as an auxiliary mean.i of treatment by plarint^ the patient uiKm such a seat from a half lo one hour daily. \\ i?ere one lej^ is short, the f(xtt should he raisol l)y wearing an insole of cork in the Ixwt; antl a child who h'lbitually rests with the weight on the rij^ht le^. as in Fig. 235, should be trained to reverse the resting |>osturc l>y using his left leg as the habitual base of sup]K)rt. The main corrective treatment of scoliosis must, however, be by active exercise and stretching, and the muscles must be de- veloped ami trained to maintain the correct jKislure with ease. Treatment must be thorough and regular, extending from half tn one hour daily for six months at least; and even after an apparent cure has been obtained, the patient should be kept under close observation for at least two years, to check the first signs of rela])se. As most children su*Tcring from scoliosis are below the normal in strength and resistance, it is essential that exercise should not be pushed beyond the |K>int of general fatigue, ami the greatest care shoulh,H. picurol in '.nn« use,!, an. ,h. ,urKc,.n «ra,„in« .he K-f. or ri«l„ h.n.l an,l s" |.r.Kluc,n« a ., agonal ..n.i..n on the spin.. All free movement, S ,7 T- '" l'" ''■■"'"■ '""'"■""■ "••"■'' '^ '"""■' "I-- - lallj l)y holilinj; the arm- «> us to ^.ive the j;reale>l corrwiion of the cur\aHire. This may Ijc with the ri((hl arm up ami the left arm out, or with the ri^ht arm up ami the left arm ilown, FiB. JS>.— A (irl aunt 7 yran with KVrre uaacous lateral rurva- tun- of the spinp, in the "hahit- ual" inalure (Bernard Roth). ■ J53.— <;irl aged ; years, viith severe u- X-..U. lateral curvature of the .pine, when |,la,i-J "■ 'I- "keynole" [rature (Bernard Roth,. in the * or With both arm., above the hea.l, or the ri«ht arm ex.en.letl each individual case. In applying asymmetric exercises it is to be remembercl that the most freely movable regions of the spine are the most abun- dant y provitied with muscles, an,l a brief analysis of their action and the means of isolating their play under normal conditions will 296 EXESaSE IN EDUCAnON AND MEDICINE be of assistance before Uescribing the sjwcial exercises employed when their action is disturbed by scoliosis. In the lumbar region the psoas takes its origin from the bodies of all the lumbar and the twelfth dorsal vertebrie, passing down- ward and out of the pelvis to be inserted into the small tro- chanter of the femur (Fig. 254). The femur can be used as a lever to pull on the bodies of the vertebra by means of the psoas. As rot. tion of the lumbar spine takes place about the articular facets, acting as a pivot, and behind the origin of the psoas, the right psoas could thus be made to pull the bodies of the lumbar vertebra; over to the right, and would tend to un- wind a rotation to the left. The problem is to put into action <^^ IIjA ^"'^ Fig. 354.— Direction of the pull of the jwoas on the lumbar spine. the right psoas muscle without involving too many additional muscle groups. If we flex one or both thighs, the abdominal muscles do most of the work. If, however, the right thigh only be flexed, and the left heel pressed backward against the table, the patient being recumbent, the abdominal muscles may be relaxed, and a comparative isolation of the right psoas obtained with a little practice (Fig. 255). The intrinsic muscles of the back, known collectively as the erector spinae mass, including the multifidus and other short deep slips, are most complicated in their distribution, this very com- plexity being useful in that its strands may be employed in relays, the tired fibers being replaced by fresh parts, and the onset of fatigue accordingly postponed. THE TREATMENT OF SCOLIOSIS 297 As a mass it takes its origin from the fjosterior asi)ect of the sacrum, from the iliac crest, the lumbar spines, and the transverse processes. It is very thick and fleshy in the lumbar region, where Us two mam divisions are defined, the outer tendons going to the SIX lower nbs, just outside their angles, and prolonged upward by the accessorius and the cervicalis ascendens, the inner division more thick and fleshy, going to rib and transverse process through-' out the entire dorsal region, with an additional bundle going from the second lumbar spine to the first dorsal (Fig. 230) The deeper layers of this inner division fill the hollow between the transverse and spinous processes, the general direction being for- ward and inward, while in the lumbar region muscular slips go Fig. i55._Raisi„g right fTOt »rtth weight attached. between adjacent transverse processes, as well as between the spmes. The general action of this muscular mass is to bend the spine like a bow-string and to pull down the ribs on the active side at the same time increasing lordosis. The quadratus lumborum is a depressor of the last rib, and acts with the erector spina, of the same side. The lumbar and lower dorsal portions of the erector spina; are isolated in action alternately in the act of walking, as can be readily demonstrated by placing the hands over the loins and feel- ing them spring into action at each step (Fig. 259). Support of the weight on the right leg involves a contraction of the left lumbar erector spinas. Support of the weight on the right arm and the II! ■ i! 2gS EXrSCISE IN EDUCATION AND MEDICINE feet, as in the diagram (Fig. 257); brings into action the right erector spins, but if the support be at the hips, the action is re- versed except in the cervical region (Fig. 256). In the dorsal region the muscles are much thinner, more tendonous, and the intertransversales and interspinales degen- erate into ligamentous bands, and the dorsal spine is much less directly affected by muscular action than either the lumbar or Fig. 356. — Left rrector spins in action . Exercise //.—Position standing, fingers interlocked behind the back. Movement: Roll the shoulders backward, supinating the arms (Figs, sio and 211), and then bend the body to the left. This exercise stretches all the anterior muscles and ligaments of the shoulder-girdle, improves its flexibility, and reverses the curve. Exercise ///.—Position standing, left foot forward in lunging position, hands on hips. THE TREATMENT OF SCOLIOSIS 301 Movements: Raise the right arm sideways; inhale; upward stretch; forward bend until the right hand touches the noor in front of the left foot; upward stretch; exhale. This may be varied by bending from the standing position and raising the left arm (Fig. 262). Fig. 261. Fig. 363. This movement, besides developing the upper right shoulder muscles, improves the lung power by filling the lungs in their most favorable position and compressing the air in the downward bending movement. The right side of the thorax is stretched during the forward bending movement, and the left latissimus dorsi is contracted by i)ressing downward on the left hip with the left hand. Kxerdse /I'.— Patient supine on the plinth, with the right knee over the end, the left arm behind the back, and the right ha'nd grasped by the surgeon. Movement: Starting with the elbow at the side, the surgeon pulls the arm up slowly sideways, the patient resisting. When 303 EXERCISE IN EDU(\TIO.N AND MEDICINE fully extended above the head, the surgeon exerts as much tension as possible, counting five. The patient then draws the arm down to the startmg position, the surgeon resisting. FiS- 363.— Stretching of rfgtit side In this stretching movement the two points at which the stretching power is applied are the right hip and the right shoulder so that this tension will reverse the curve and stretch the right Side of the trunk. * Fig. 364 Each of these exercises should be repeated at least twenty times, and should be followed by a short rest, after which the following should be given: ii!! THE TREATMENT OF SCOLIOSIS 303 Exercise V.-Patient lying on the right side with the leu, .rh-r/ra?' '^^ '^'^ ^-^ -— "-^ ^- -' ^ Movement: Side flexion of the trunk (Pig. 364) In this exercise it will be necessary for the surgeon to assist most pafents at first and to urge them .0 bring the b^y as hig poss,ble. The entire erector spin.- mass on the left side is — ully employed, and the effect may he still further increaCby placmg both hands behind the head ncreaseendin« is accompanie.1 thi» exerci^ ui), have I , effcxTon th ^f """' """'^•. » "-at vertebr.beinK locked inllZ^::':,^;^: '""'^ ""^ '"-"" Fig. .r Exercise ///.-Pati. ,t standing, hands at the sides on :i:eT"K J::r,el:" '^^ "" '-"-^^ "•«"• nana touching . I flo^rriLeltak^TT' '"'""^' f"™"" '^"d, (Fig. .70. ' "''■ """*= '"'^'' '" 'he standing position left heel, hand, on the hips '^"''""^ ^^ *''"' "" if *■? Jo8 eXElnSE IN KIX-CATKIN AND MKniCINE The tension on the right foot should Iw incrca.schot -bags across the ankle, starting with a weight of five |iounils, aiul increasing it to ten or fifteen as the strength allows (Fig. 155, p. 397). The iMtient should Ijc carefully instructed to relax the alxlominal muscles so that the strain may fall u|H)n the right psoas, which will pull the limlies of the lumlwr vcrtebrii- over to the right and so unwind a lumbar mtulion In the left. Exercise V.— Patient jrone, the right foot fixed, the left arm up, and the right arm down. Movement ; Trunk extension, with the stretching of the right arm backward and the left arm forwdrd (Fig. 373). i!. 1 fit- til- Exercise VI. — Patient supine, right knee over the end, as in Fig. 363, but right arm behind the back, left arm ."^rasped by the surginm. Movement; The left arm is pulled upward and strong tension is put upon it by the surgeon. The patient then pulls the arm forward and downward, the surgeon resisting. In this way the rotation is unwound by the diagonal tension running from the right hip to the left shoulder, reversing th<' curves. Exercise 17/.— Patient lying on the n^ht side, as in Fig. 264, but the right hand on (he hip, the left hand behind the head. Movement : Side flexion to the left. This exercise is aimed at the lumbar curve, which will be reversed by the side-bending to the left in the extended position of the spine, essentially a motion of the lumbar region, the bodies of the venebne tummg toward the concavity of the curve. V \i I THE TIEATHENT OF KOUOUI ^g^ £»-r,f», I7//,-Patif„t fccuml^nt, ,upine. R..,c the Icf, arm ami ,he rl^h, !.«; inhal,.; lower; slowly „hal. Thisshoul.ll«..f„||„we.ll,ytt.,hortrcsi. Xi»naK. Exffciu /.V.-.Su«|*n.sion hy the Sayrc sling. Movement: Si,le .rac.lon, prepare M„^ ,Le,l on ,hc left lumbar region. Re,,ca. from ten to twenty limes (FiK !.'))"' ■^'■~ ^'"" '"'"'"' ""' •"■""■ »'■''•= «'*'™ "' 'he rlKh, In a left dorsal an,l rixh. lumbar curve (Fi^. ,75) practicallv .he »me exerc sc-s may l« u«,l. except tha. ,n e -r^ cat ,h opiK>s,te IcK an.l arm are employe,!. f'W- ifj-l-'our Itadnuj iilu.Craling the V S C. C, aged thirteen. Consulted mc January 27, ,806 nght lumbar curvets with rotation, round shoulder, flat 'h " pro.rud,„g aUlomen and chin, and general re.rSofll^ General health has not been very L-mxi T^.„ • . ... already been treated for spinal cur^Turt "''"' '"' The indjcations here would be to dcvpUr, .i,„ 1* ml 3IO EXERCISE IN EDUCATION AND UEDICINE After daily treatment, lasting over two months, the second tracing was obtained, the lumbar cur\ature being practically Fig. 374. — Movement for left dorsal and right luml>ar curve. corrected, although there was still a dorsal curvature with the right scapula low. She reported twice a week for two months, taking a modified daily prescription at home. She then left the city for the summer, ~l \V \^ Fiy. 375.— Couree of triple curve under treatment: Lefl lumbar, right dorsal, and left cervical. and the following October a third tracing was taken, showing that the improvement was retained. During that winter she reported once a week and continued her exercise at home. THE TREATMENT OF SCOLIOSIS 3" ^0 a^ ■( ) '•|»4f. *^ -^^^-'M*. Three years later a fourth tracing was taken, showing that the correct position had been maintained. It will be noticed from the tracing that the jjatient has developed from a child of thirteen to a young woman of sixteen (Fig. 275). Cunes due to infantile paralysis will require long-continued treatment, esiwcially where they are severe and structural localized and fixed. In some of these ca.ses the best that can be hoped for from gymnastics is to develop the general mus- cular system, and to form com- pensating curves above and below the primary curve, thus giving a general appearance of symmetry to the outline of the back. S. M., aged nine years. Consulted me in September. Six years ago he had left hemiplegia lasting six months, which, to all appearances, graduahy passed away. .About two years ago he noticed while walking that the left shoulder protruded (Fig. 276, i).. Examination showed a left lateral curvature high in the dorsal region. Marked rotation, some pain over the convexity, and diminished flexibility. Slight compensating curves in the lower dorsal and lumbar region were present. After two months of daily exercise and stretching, a second tracing was taken, showing the development of the compensating curve and the lowering and partial replacing of the left scapula. The improvement continued from September until March, when a third tracing was taken, .showing a lowering of the scapula at the expense of an increase of the lumbar curve (Fig. 276, 2). This was the extent of the improvement obtained, but t'le general api)earance of the back, especially when dressed, was very much better, and the muscular development and general efficiency greatly improved. Where the curvature is due to inequality of the extremities, as in the tracing, this must be corrected by raising the heel of the 3" EXERCISE IN EDUCAnO;'. AND MEDICINE /., Fig. shortened side, which is sometimes all that is necessary (Figs. 232 and 233, p. 276, and Fig. 247, p. 289). One of the most important points in the treatment of all these cases is the development of the thorax, and it is remarkable how- much improve.nent can be obtained in this direction by respiratory and stretching exercises. I 'ne case, S. R., aged -^^ighteen years, came with persistent wearing pain in the back, round shoulders, and lateral curvature. There was a strong family history of tuberculosis. On October 7th her lung capadity, tested by the spiro- meter, showed 80 cubic inches. November 28th, after a little over one month of steady work, it was no, and on Janu- ary 3d, 125. The pains in the back had disappeared, the cur- vature was corrected, and her general health excellent (Fig. 277). Here was an increase in lung capacity of 45 cubic inches in three months. While such a result is unusual, still, after going over thirty consecutive cases, I find an average gain of 21 cubic inches, and among these were several that have increased from 30 to 35 cubic inches in less than three months by daily work. In structural cases, where the treatment by gymnastics and posture is insufficient, stretching and retaining apparatus are necessary. .Among the simplest is the following (Figs. 278 and 279) : " The patient lies face downward, with the knees flexed, on a board three feet wide and four feet long. .Assuming the case to be a right dorsal curve, a broad canvas strap is passed around the left upper thorax, over and under the patient, and fastened to a cleat on the right side of the board. This furnishes a point of resistance against the left side of the upper thorax at the level of the axilla. A broad canvas strap is then passed aroimd the left —Tracings at the beginning and alter three months of daily treatment for chest expansion and curvature. THE TREATMENT OF SCOLIOSIS 313 Side Of the pelvis, above and below, and is fastened to a cleat on the r,ght s.de of .he board. This furnishes a point of pr^ure agamst the left side a, the level of the pelvis. 1 broad'ZI Fig. .,8.-Slr«<:hi„g b<»rd with loop., „ady for appli lotion toafc/zdoraal curve (Lovett). Strap is then placed around the thorax on the right side at the level of the greatest po.nt of the curve. Its upper end is fastened to a n...„.-s.„tcKi„g bo.^ ,i,t loops, ^,^,^,„ , ^,, „,;.. ^ ^^ (Lovett). cleat at the left side of the board; its lower end, passing beneath at the left side of the board. By means of this pulley any reason- i.'! ir i II ^^1! I ' I 314 EXERCISE IN EDUCATION AND UEDICINE able degi'ee of force may be exerted against the right side of the thorax, pulling it to the left and at the same time reducing the rotation, because its upper end is fastened, its lower end moving toward the pulley. The efficiency of this apparatus is greater than the same movement done during suspension, because stretch- ing is done more easily when the spinal muscles are relaxed. Patients should be stretched up to the point of mild discomfort daily, and kept in the corrected position for fifteen or twenty minutes. The application of apparatus in severe cases for retaining the improvement obtained by gymnastics and stretching need not be ^ Fig. aSo. — Course of triple curve under treatment by exercise and stretching only. taken up here in detail. The steel brace and the plaster jacket both have their advocates, but they should be applied only to retain the child in the best possible position during the growing period, and dll apparatus should be easily removable, so as to permit of daily exercises, which should be persisted in for months or even years if one is to expect a permanent result. Improvement or qure should not be considered permanent until the correct T>osition is maintained without apparatus from month to month, as shown by repeated records. CHAPTER XIX °^*^^ ATHIETICS AS A FACTOR IN DISEASES OF THE CIRCULATION _ To exercise has been assigned the rflle of cause, as well as cure m most of the disorders peculiar to the circulatory system. The heart is a muscle capable of development and liable to overwork, and the arterial system shares intimately in changes takmg place in the centra! organ of the circulation. The heart may suffer from— 1. Acute or chronic overstrain, characterized bv dilatation hypertrophy, and leakage at the valves. 2. The accumulation of fat in the walls or in the pericardium. 3. A slow hardening and degeneration of the heart wall and a les.sening resiliency of the arteries, « Ith increased blood-pressure known as arterial sclerosis, in the production of which prolonged muscular overstrain has been given an im,»rtant place by some authors. 4- Anginal attacks, accompanying dilatation and caused by bodily or mental overexertion, frequently associated with arterio- sclerosis. 5- Actual distortion of the vahes, due to inflammatory action accompanying acute rheumatism, chorea, and certain other acute diseases. In the fifth class the valves may become crumptel and the orifice reduced in size, iusing stenosis, or the flaps may fail to meet, the blood-stream leaking back when the contraction is over- sometimes both conditions may exist in the one valve. In the order of their seriousness valvular defects may be classified as: First and least dangerous, stenosis of the aortic valve (Fig. 281), overcome by a compensating thickening of the 3>5 I (.'' 3l6 EXERCISE IN EDUCATION AND HEOICIKK left ventricular wall; second, mitral insufficiency (Fig. 383), the s D s D s D s FJR. 3X1. —Endocardial heart-tnurniur. Stenosis of the aorta. A ayitolic murmur ia the ri^ht second intercMtal apace (Vierordt and Stuart). bltxxl regurgitating into tiie right ventricle through an imperfect closure of the valve between it and the lesser circulation in the s D s D s D S Fig. 382.— j:ndocardial heart-murmur. Mitral insufficiency. A systolic murmui at the apex of the heart (Vierordt and Stuart). lungs; third, stenosis, or narrowing of the mitral vaKe (Fig. 283), followed by an increase in wall thickness and dangerous dilata- s D s D s D s Fig. 383. — Endocardial heart-murmur. Mitral stenosis. A diastolic r the apex, the first sound valvular or appro.ximately so, if the second sound is heard at all {Vierordt and Stuart). tion of the right ventricle; and last, insufficiency of the aortic valves (Fig. 284). which throws such an increased burden on s D s D s D s Fig. 384.— Endocardial heart-murmur, .\ortic insufficiency. A diastolic murmur at right seccnd intercortal space or, lietter, lower down to the left of this over the sternum (Vierordt and Stuart). the left ventricle that any overstrain is liable to be suddenly fatal. This last condition is the usual consequence of the Arst, ATHIETICS AS FACTOR IN DISEASES OF THE CIRCILATION yj since the hyiwrtrophy resulting from aortic stenosis soon sivt-s place to dilatation of the aortic orifice and consequent regurgita- tion of blood into the left ventricle. In the iihysiology of exercise it was explaineil that bv exercises of effort the blood-|)re5surc was suddenly raiseil to nearly double the normal, falling quickly to its normal level with the cessation of the action (McCurdy). In the ex|>eriments of Bowen,' on exercises of speed and endurance, the rise of the blood-pressure followed the rise of pulse-rate, gradually declining until the end of the test, when it fell to subnormal and slowly recovered. .\ccomi)anving tests of either effort or endurance, there is always a temimrary dilatation of the heart, which must not be looked u]x,n as an evil. The heart tends to dilate, a.s pointed out by Roy and .\dami, as a matter of economy, vhenever its work is incrt-ased. This economy results, first, from the fact that any muscle works at an advantage when somewhat elongated, and, second, because the volume of the spherical mass changes faster than its surface. From this It is clear that, as the heart dilates, the volume of blood pum|«d out by each contraction of the heart muscle increases faster than the stretching of its walls, whose inherent elasticity also tends to preserve their integrity. It is only when the dilatation becomes excessive and is accompanied by greatly increased blood-pressure that harm results. This dilatation of the heart, due to the neces- sity of increased muscular action, is physiologic, and it is only when other symptoms are present that the heart is really over- strained. The difference between one acute overstrain and the continuous overtaxing of the circulatory apparatus must also be borne in mini], as the second condition can only l>e the result of the accumulation of repeated single overstrainings. The investigations of Theodore Schott arc jwrtinent to this question. He selected wrestling as his exerci.se-an exercise of effort in which the entire muscular system takes part, but which combines endurance if carried on for any length of time. The results on the heart action are shown in the six pulse-tracings. *".\mer. Jour. Phvs.," vol. xi, Xo. r. ii- illi 3i8 EXEKCISE IN EDUCATION AND MEDICINE The dilatation of the heart, both to right and to left, was from one to two centimeters or more. With the advent of cyanosis he also discovered a great lowering of the blood-pressure. He affirms that all symptoms gradually disappear in a healthy man, and that the severest exercise, even if accompanied by compression of the abdomen by means of a belt, has but a temporary J^J^AKJ^J^^N^ytKSsM^ l^sh^ / I Fig. j8s.-a, 4 :3j p. u. Before wrralHng. J, 4 145 p. «. Atlcr ihrtc round, of wverc wrestling. ., 4 :5s P. m. Conlinued wrestling. J, 4 :56 P. u. Renewed wtest- Img. e. s :" P- «• After severe wrestling with tightened bell. /, ,-.4, p. u. Alter twenty minutes' rest, showing approach lo normal action (^chott). effect, and he concludes that all symptoms of heart insufficiency disappear in a few minutes, and that acute overstraining of the heart, when it does occur in healthy individuals, tends to disappear readily and naturally, the time required depending on the elas- ticity of the tissues. With older persons, when the heart-walls have lost a considerable part of their elasticity and the arterial fi; ATHLETICS AS rACTO, « DMEASES O, THE CUCULATION 3,9 wf-houriXr""' "" '■' f""""" "'™"«'' "^ ™-« "f 'raining «.Ihout further symptom., or bad results. Darling remri, » s.m,lar case in an oarsman on the Har^■ar,l crew T,™ hiT, tl neay strain may cause an acute dilatation, especially if accom panied by great mental exci.-ment One case reported by Stengel was that of a young man sound day or t«o of the mjury. In the course of a very tryinir foot ball ^me physically and mentally, he collapsed 7ud7enTy. VVh 1 seen, he was bleedmg at the nose, cyanosed, with weak flutteHn^ Lt'wt;" t: "' "^ "^f ^"^'«^-Hr..folrt ts conLr f/ K rf """P"''"'^ P^'^'™'"'' *"d '"'• not gain ^tter and 7 ^™''" ''°'"'- "^ "'- ''«'""« rapid y better, and m a few days seemed quite well. .After ten days' res^ consequences. He has engaged in athletics more or less activelv This s the most severe case of dilatation of which I have any personal knowledge, although frequently I have found a dilution "The dilatation is, I think, concerned in second wind. The i \ n ■til! 3«» EXERCmt: IN KtlUCATION AND MEDICINE f healthy heart increase!) its output, the luni{s expand, rcsisUnce falls, the riKht icntriclc pulls itself tof{ethcr, and second wind is established. This process, trying enough to an unsound or defec- tive heart or to elderly men, is perhajw never injurious to the healthy heart in young adults. I have many times seen under- graduates and others look ghasdy at the end of a long spurt of exercises, but never saw a sounri young man the worse for tem- porary distress of this kind. If, as in a few cases that I have seen again and again in growing youths, dilatation of the heart occurs leadmg to cyanosis, the attending confusion or vertigo is generally sufficient of itself to stop the exercise ii) time." With the statement I can most cordially agree, and if |)tr- mancnt or rapidly fatal injury ever occurs, it must lie in the notoriously unfit or in those whose age should have led them to choose more sober pursuits. The presence of a murmur without other symptoms is so common as to be almost habitual in the young. It is most fre- quently found over the pulmonary valves, but when at the apex, is not necessarily due to mitral regurgitation. The marked acceleration of the onset of fatigue and the slow recovery in the untrained or the overtrained man is familiar to all who have seen »uch cases after violent and prolonged exertion, but the ultimate recovery of the sound heart from such exertion may be said to be universal. Blake and Larabee. in their observations on long-distance runners, averaging about twenty years of age and covering three Marathon races of 24 miles each, write : "So far as observed, no ])ermanent injury of any kind has resulted from any participation in these races." Simple or single overstrain and acute dilatation of the heart may ther e said to have no immediate after-effects on the healthy young adult; The remote after-effects of strenuous exercise has also been studied by Morgan and Meylan, the material for their observations being university oarsmen, members of the university crews of Oxford, Cambridge, and Har\ard. A crew man is required to row repeatedly a distance of four miles at top speed, the posture ;i ATHLKTXS AS FACTOR ,s ...SKASKS „r THK CIRCLATION J„ Of ro«.i„« lH,.ing such a, ,o im|,c,le Ihf full frcclom of the lun«, an.l h ; hear, s aeon, whil. ,he movement i, „, such intensity JZ, ::;;:, "'^f^'' "^ - '-<-' — ^ '-m the resulting. J.: In his l..,k, calk-l ■l-niversity r)ars." K. H. M„r«an look ami C aml>r„lKe, from .8,c^6,;, as his lUI.I, ami in his investigation Of t esc, ; ether s,..ak of themsc-lves as probably injurctl. „r ve L:sr '■'■ '''"^ ^^•'''''•'■'^"' --'™- "■■•''■ -^^^^^^^^^^^ On tabulating the crews with reference to ex,«ctation of life hn e„m,«re,l with Dr. Farr's Knglish Life Tables, which Ja es the exix-ctation of a man of t^.enty at forty years, he found o th r'a^'TT "' "" "^"" """"■'"« '"^ "™-' «-'ati Of th7, 'h It ■'i'"'™"' ""^ '""^■'«" >■-- '•"»'«" "f forty. O the 39 deaths, he found that , , dinl of fever, ; of consumption from other forms of chest .li.sease, 6 from accident, 3 from hean hfs disease, and S fron. various caul „o connected with athletics. Of the 7 dvinL- fmn, .r,n The, show about the average mortality from diseases of the rt 7 T'T ", """ " """" »-""P"-on, asdi.,close.l that Lr r r"\"'"^'' ""' " '""^' •^-^ -"><=""--' that they rowe,! without preliminary meji,al examination. There were no sudden deaths nor rapi.lly fatal heart cases In America a similar but much more complete set of observa- tions were taken on Harvard oarsmen by Dr. G»rge L. Meylan, of Co umb,a who interviewed every survi>or ..ersonally whe^: P-..ble, or had the re,x,rts made out by their mllical attendant^ He foun.' that 15. men had rowed from ,85.-9. "f whom i sfll su.,ved (November r. rpo.), thus allowi,;^ eleve y^r tZf"n T ^^^-^f -"^ '" Sfve time for any evifeffec.s to show. He mtemewcd 76 men personally, and sent to all a 91 3*» KXEICIHE IN EOUCAnON AND UtDIClNt questionnaire tlwt was m«t aclmirablc in its compleleneii. In lonfievity, the first crew (iSti) showed an incr^se of 1.6 years |jer man com|>arc . luld Iw increased to 5. jq years \xr man. ( )f the 3 j deceased oarsmen, only 2 ilieil of heart disease, 1 of consumption, 2 of Bright's disease, 8 were kilkil in the Civil War and by accident, 3 died of pneumonia, 2 of ajjoiJexy, i of dissipation, i of imresis, 1 of cancer, and ic of unknown cause*. Tn neither of the 2 cases of heart disease was rowing given as the cause. The after-health was most satisfactory in 68, gixxl in 36, and (KX>r in 1. Only 2 believed that rowing had injured them, one claiming to have dysiwiisia, and the Dther an enlargetl heart, which, however, had caused him no inconvenience since he left colic;-'-- T'^cse resi'Us would seem to prove conclusively that rowing is not a serious factor in the production of early death from arteriosclerosis or other circulatory disorders; but it must be remembered that these were lives doubly selected— first, for constitutional vigor, and, secondly, for muscular strength. The rfite of muscular overwork in the proiluction of arteriosclerosis must, then, be looked for rather among those in whom it is carried on for long hours under unsanitary conditions, like the miners observeTlcrs pulse tracing before beginning trealment (Lagrange). This excursion lasted six hours, and he lost much weight from perspiration, but that night he had neither irregularity nor palpita- tion. In the second week he could climb a hilj 527 meters high, but It took him four hours-twice the time for an ordinary person He had to stop and rest 150 times. He had no evil effects that night. Owing to the profuse perspiration, he had great thirst which he relieved by gargling cold water, but he did not drink any more than usual. Fig. i88.-Oerlels pulse tracing after six weeks' treatment (Lagrange). After four weeks he began to take longer excursions, and found that he could endure them with comparative ease, aiiu, although breathlessness came on more quickly than it should, the normal action of the heart was rapidly reestablished by resting. In six weeks' time he returned to Munich and again took up practice, having reduced his weight eight kilos. His pulse remained normal in ordinary walking (Fig. 288), and he could go up two '1 3»8 EXERCISE I.V EDUCATION AND MEDICINE flights of stairs without breathlessness. This improvement was Itept up by periods of training and rest for eighteen years, when Lagrange saw him and reported him in excellent health. Shortly after his return to Munich he began to establish his cure. The one at Reichenhali is typical, and a map shows the details (Plate i). The course was regulated with care and minuteness. The paths were marked with stations, benches were placed for resting, and the trees beside the road had bands or flags of red, purple, green, or yellow, the colors representing the degree of its slant. The exercise was thus prescribed in degrees of increasing distance and steepness. The range of the Oertel cure is strictly limited. It is, first of all, a preventive measure, and can be employed with advantage to improve the general nutrition and to prevent fatty infiltra- tion from becom.ing localized in the heart. Even in cases where this has already occurred it is still of great value, as it also is where the compensation has been already established by milder means. Where compensation is broken dov.-n, and where the patient is compelIewers and limitations have been gauged. Most of them may be done in bed if necessary. Some form of artificial respiration has been used by others, and may be profitably added to any treatment of these conditions, either in the forms already described or in the chest-raising or shoulder-raising (Fig. 315) described by Satterthwaite,' in which the patient inhales as the operator lifts, and exhales as the operator relaxes. This is repeated eight to sixteen times, with one or two natural respirations between each movement. Satterthwaite has further modified the technic of the Schott treatment by arranging the exercises in series of progressing diflSculty, which he names schemes I, II, and III, includiig massage of the thigh and back. The following is a brief outline of the course of exercise carried on for the first two weeks: Scheme N'c». I r. Chest lifting, lying or siuinx 2 minutes. Intermission i minute. 2. Foot and leg massage 2 minutes. Intermission i minute. 3. Forearm flexion and extension i " Intermission i " 4. Hand and forearm massage 2 minutes. Intermission 1 minute. 5. Leg and thigh flexion and extension 2 minutes. Intermission i minute. 6. Arm and shoulder massage 3 minutes. Intermission i minute. 7. Thigh flexion and extension 2 minutes. Intermission i minute. 8. Chest percussion a minutes. Intermission i minute. 9. Trunk flexion and extension 2 minutes. Intermission i minute. 10. Thigh and back, massage 2 minutes. Total length of seanre jg minutes, * "Intern. Clinics," vol. i., thirteenth series. 344 EXEKCISE IN EDUCATION AND HEOICINE This is increased in severity and the order slightly changed in Scheme No. II, which is carried on (or the third and fourth weeks: [: SCHEMF. No. II t. Chnt lifting, lyinK or sittinf; 3 minutes. Intermiiaion i minutr. 3. Foot and leg massage a minutes. Intermission ... i minuie. 3. Forearm N'xion and extension 3 minutes. Intermissum i minute. 4. Hand and forearm massage 3 minutes. Intermission r minute. 5. Leg abduction and adduction 3 minutes. Intermission i minute. 6. Arm and shoulder massage 1 minutes. Intermission i minute. 7. Trunk rotation , 3 minutes. Intermission i minute. 8. Chest percussion 3 minutes. Intermission i minute. 9. Arm separation 3 minutes. Intermission i minute. 10. Thigh and back massage 3 minutes. Total duration of stance 33^mutesr Scheme No. Ill 1. Chcrr lifting a minutes. Intermission i minute. a. Foot and leg massage 3 minutes. Intermission i minute. 3. Quarter ci. iing (forward and backward) 4 minutes. Intermission i minute. 4. Hand and forearm massage 2 minutes. Intermission t minute. 5. Head rotation or flexion 3 minutes. Intermission i minute. 6. Arm and shoulder massage a minutes. Intermission i minute, 7. Trunk twisting 4 minutes. Intermission i minute. 8. Chest i)crcussion a minutes. IntermisHon i minute. 9. Trunk flexion (laterally) 4 minutes. Intermission. . . . .' i minute. 10, Thigh and liack massage 3 minutes. Total duration of stance 37 minutesT «:XE«CISE T«EATIIENT OF DISEASES OF IHE CUCLLATION 345 For the fifth and s.«th weeks a further change in the series U made, and some new e«rcises are introduced that might not be wel borne at the beginning of the course, particularly ,,uarter circhng and head rotation. ' ' It will be noticed that in this final series the exercises involve newer and larger groups of muscles, and that all the great muscles o the body have been exercise.!. The duration of the stance is also onger, and more force should te applied. The movements should be very slow, and the intermission should be carefully observe"'■'"* "' "•■^ ^^'' '■" "•■''■"K the column of blood to this unaccustomed height. With this opinion Sat- terthwaite agrees. Good results may be expected from exercise in almost all disorders of the circulatory system except arteriosclerosis. . he exercise treatment is unusually successful in condition, of heart weakness complicated by obesity, where improvement should be noted from the first. It is of undoubted value in most valvular aisease, with signs of failing compensation, the dilatation of the peripheral vessels resulting from the exercises being followed by an improvement in the strength of the pulse and a lowering of the rate, an improvement that may be maintained for years In most cases the patients may return to their ordinarv occupations and duties, and if signs of relapse begin to appear, 'the taking of a course is sufficient to reestablish the equilibrium until the heart shares in the inevitable degeneration of advanced old age CHAPTER XXI OBESITY I ITS CAUSES AND TREATMENT The excessive accumulation of fat must lie considered as a symptom rather than as a disease. It is due to ovemutrition, to underoxidation, or to a combination of both acting together. When the allurements of the table are too great for the body's needs, the surplus is stored up as fat in the tissues least disturtel by muscular action, and local deposits are made in the region of the abdomen and hijB or in a general layer throughout the sub- cutaneous tissue of the entire body. Heredity has a marked influence in this fat-making tendency, about 60 per cent, of cases reported by Anders having this history, while its association with gout, that other disorder of overfeeding and underexercising, was found in 43 per cent, of his cases.' The normal oxidation of the ingested food may be hindered by a sedentary life involving little tissue waste from muscular exercise, or by the mental and physical torpor and habitual inactivity of the too ardc-nt pupils of Silenus, whose fat is also protected from combustion by the rapidly oxidizing alcohol, which retards all tissue waste, and so favors increase in bulk. It may also be hindered by lack of the proper functioning of the thyroid gland. Fat is a cheaper form of tissue than muscle, requiring as it does a less abundant blood-supply, and its presence should be considered as an evidence of lowered nutrition. As the amount of fat increases the desire for exercise diminishes, and the capa v for activity is lessened, because of the speedy exhaustion that follows any unusual muscular work. Local obesity is frequently found about the waist-line, the deposits occurring in the abdominal walls and in the mesentery and omentum. This, when excessive, gives rise to a pronounced ' S« "System ot Medicine," Osier and McCrae, vol. i, 846. 346 OBESITV: ITS CAUSES AND WEATIIENT 347 deformity, simulating tumors, pregnancy, or ilro|«y. In tlimt who aIpitation, irregularity, and thready pulse is rapid or extreme, the "outlook is gloomy" (Anders). If, on the other hand, the perspiration is profuse, the general condition and color remain good, and the pulse strong and regular after exertion, much may be expectetl from a reduction course. Most of the causes of death in obese cases are due directly or indirectly to affections of the circulatory system, and its condition must be the keynote for treatment, as was recognized by Oertel in his " terrain cure, " described in the previous chapter. The fact that obesity is frequently but a symptom emphasizes the necessity for a prelimiiytry examination to determine the pres- ence of any of the many complications that are \isually associated with it. In this examination habits of life, particularly with reference to diet and exercise, should be notertance. Most gouty middle-aged men present a history of violent in.lulgence m physical exercise during youth, followe.1 bv a luxurious and inactive later life, with overfeeding ami excessive indulgence in alcoholic liquors. In diabetes a reduction cure shouW never be undertaken, especiaUy if the obesity be only slight or mo,lerate, although in cases where it is excessive, accompanied by heart symptoms, the patient should, where possible, be relieved of any excessive fat. Only in this way can the heart l«; protected from excessive strain but It should be used with the greatest caution. In selecting cases for the reduction cure three considerations should be held in mind: first, the amount of inconvenience the obesity causes; second, the presence and extent of the complica- tions referred to above; and third, the age an.l general nutrition of the patient. When obesity is moderate or extreme, the physician may be con- sulted from vanity, which may thus become one of the most powerful 350 EXERCISE IN EDUCATION AND BfEDICINE levers in his hands to insure the thorough and complete carrying out of the irksome rules that the patient must follow if the desired result is to be obtained. This seemingly trivial consideration is one on which the success of the treatment often hinges in the ease-loving, luxurious class from which so many of these patients come. In young and sound adults active courses of five weeks or more may be repeatctlly undertaken with safety, allowing intervals during which the loss of weight is merely maintained. In those of advancing age, where the obesity is extreme and the vital energies are beginning to fail, a reduction cure would only ac- celerate decay and lead to rapid loss in strength and functional I>ower, with the continual added risk of heart failure. Reduction cures may be divided in^o three classes or degrees of rapidity: 1. The first degree, in which the loss is very slow, the patient losing two or three pounds a month. It applies to those with an enviable amount of fat which shows a tendency to increase. It does not require great sacrifice from the patient, who must alter her diet by the reduction of fat, starchy, and sweet foods, restrict or abandon alcoholic beverages, take only foods of small caloric value, and engage in regular active physical exercise. 2. The second degree, in which loss should be from five to ten pounds a month, applies to strong, plethoric subjects, who can safely indulge in active exercise. The diet is more strict, and the exercises more varied. It is especially valuable for individuals in whom complicating disorders of the heart, arteries, bronchi, or digestive apparatus render it impossible to take from the start the more rapid or — 3. The third degree of the reduction cure, which should be carefully supervised and may be carried out at an institution with aper regulation of the diet, should steadily and consistendy In one of my patients, a young lady aged twenty, it was reduced mol TT 7;°" •"""'^ '" ''' P"™''" '■" '^ I-o" of fo^ months, which mcluded several weeks lost by inter;up,ions. By a very much modified home prescription this improvement wal mamtamed at the last examination, taken six months afteTar.! George Cheyne, bom m Scotland in i6;.. By the time he was thirty his excesses in eating and drinking had brought his weight In^ ^hot breathed, lethargic, and listless. He dieted on milk one-.hird (.50 pounds). He recovered his strength, and lived to the age of seventy-two, writing an essay on health and long life fro™ ^""1" '"'"'"'™ """' '^' ''""' *'^°"''' ^ ^""'""y ^^amined or edema of the extremities are found. Sometimes, when loss of weight IS rapid and obtained by means of drugs and diet alone without care to improve the muscle tone and so to support the viscera, certain complications arise (constipation, hernia, and gastroptosis), particularly in middle-aged and flabby women Dis- placement of the kidneys and uterus may also be traced to the rapKl absorption of the surrounding fat, and symptoms caused by Zt T^"". '"!r "''''' '^" ^''""'' "> ^' '"°'- troublesome than the obesity itself. CHAPTER XXII OTHER DISORDERS OF NUTRITION GOOT, DIABETES, RHEUHATISSI. GASTRITIS, CONSTIPATION, AND HERNIA The rflle of exercise in the prevention and treatment of gout occupies an important place in every discussion of this disease. Like obesity, with which it is so often associated, gout is usually a disease of ovemutrition and underelimination, and the indica- tions would be to decrease the intake and increase the excretion of waste by all the avenues. The rules for diet are still the subject of dispute, but all writers agree that exercise is of great value in reducing the weight of the gouty patient when obese, and of increasing the activity of the skin and lungs. The nature and dosage of the exercise must be regulated according to the condition of the patient. In young and vigorous subjects, almost any of the active athletic sports appropriate to their age may be engaged in (These are enumerated in the Table of Sports, in Chapter VIII.) The great majority of patients will require exercises of endur- ance, like walking, which should be regulated in distance and speed. Golf has a peculiar value, from the fascination it possesses for individuals of all ages, a point not to be lost sight of in the management of self-indulgent cases. Horseback-riding has the added advantage of vigorous massage, especially if the horse be trotted, and if the ravenous appetite resulting from the open-air exercise be kept within the limits of discretion. For those who are unable to take more active exercise a course of gynmastics, including duplicate passive manipulation and 3S« OTHEK DISORDERS OF NUTRinON 357 It must not be forgotten that a debauch of exercise in a vaktu- dinanan may precipitate an acute attack by throwing into the crculauon suddenly the fatigue products and causing an acute po,sonmg, so that great care should be observed to begin gradually and mcrease the amount as the system accommodates itself to the necessity for more active excretion. an/?'°^ !!" '"^"'' '■''°''' '" *'"■''' ''"""y l™*'^'"' fl<«k acquire and retam their reputation because of the healthy and mod.-rate regimen, purgative waters, and regular habits that are required of patients taking the cure. DIABETES In the hygienic treatment of diabetes exercise has an important place, since muscular action favors the combustion of sugar, from whatever source it may be derived, and among diabetics the ^"H^ ^on«ipation favors the onset of coma When present, constipation should be corrected by local and general massage daily, and by the simpler forms of free or dupli^te movements. "upuuiie four!LtTJ'"'''';'.,°' ^°""' '""^ «™"^' ""^'^ ""fading in fourteen diabetics daily, a twenty-minute treatment being gfven a m«ed diet. There was a constant diminution in urine, decrease Wh Z"^'" '"' "^^ ""«"'' ""'1 "^'"™ °' perspiration. When the patient ,s sufficiently strong, he should be made to live as much as possible out-of-doors in a dry, warm climate and a dai^y .ask should be set for him. The exercise shouldt genUe in character and carried out systematically. Gardening and itn^'n'^M r ''""'■'' ^''°"'" "^ '"^ f"™^ -'«'«d. but the patient should be warned to stop within the limits of fatigue toriuni^T """.^ ""'"^ °" '" ""' ^'' '"'™'»K* '" a »na. nlT' !, "^ ' conveniences for bathing and massage are found, and where the habits of life can be regulated with Lter hope of success. 358 EXERCISE IN EDUCATION AND MEDICINE ■HEUMATISM The manifestations of rheumatism, whether they appear in the muscles or in the joints, may often be treated by vibration and massage, with very considerable success. In muscular rheumatism the stemomastoid, the erector spins muscles, and the lumbar fascia are favorite sites for the attack. There is probably a coagulation of the semifluid muscular sub- stance, with adhesions and retention of waste-products, of which uric acid is the worst, causing pressure upon and irritation of the nerve-filaments, and spasm of the muscles. The pain of this condition is exceedingly acute, and requires rest and counterirritation. Vibration may be applied to inhibit the pain, by using the ball attachment, a medium stroke, and deep pressure several times a day over the spinal centers governing these parts, and the soft brush and rapid stroke over the affected parts themselves several times a da If the pain Is acute. Massage is also useful, after the acuteness has abated, in soothing the irritation by gentle stroking and friction, increasing in force with the improved toleration of the subject. The evils resulting from forced Inaction In patients who are suffering from muscular rheumatism, either In the lumbar region or elsewhere, is counterbalanced better by gem-ral massage than In any other way. The movements used vary from gentle stroking to deep kneading of the muscle masses, with manipulation to extend the stiffened joints gradually, but without causing severe persistent pain. Arthritis deformans Is an incurable disease, but the inevitable progress of deformity can be held back and great comfort can be given to the patient by vibration, massage, and manipulation. Ankylosis t-My be prevented by checking the formation of adhesions, and the stretching and breaking down of those already formed, while atrophy of the muscles, always a pronounced symptom, may be delayed. Douglas Graham reports most encouraging results in a number of cases treated by himself, five out of six showing marked improve- ment. His mode of procedure was deep manipulation without OTHEK DISORDERS OF NUTRITION 359 friction, passive motion as far as the pain would allow, and some- times fartiier, and resistive movements as soon as tliey could be done. He disregards pain if it rapidly disappears after the treat- ment; if it persists, treatment must be suspended. He recommends kneading, with one hand, to break up indura- tions or disperse effusions, while the other pushes along the circu- lation in the veins and lymphatics alxjve the joint. Massage would not be used, of course, when the disease is very active.' Graham quotes the case of .Wmiral Henry, who was a sufferer from this affliction for twenty-eight years. In 1810, at the age of seventy-nine, he was quite crippled, but by means of various mstruments, made of bone, polished smooth, and hammers covered with cork, he persevered in the use of deep friction and percussion night and morning for three years. .At the end of this time, it is said, he had completely succeeded in removing the sweUings and restoring the use of his limbs. At the age of ninety-one he wrote to a friend: "I never was better, and at present am likely to contmue so. I step up and down stairs with an ease that surprises myself. My digestion is exceUent, and every food agrees with me. 1 can walk three miles without stopping." Unfortunately, such a case is so exceptional as to have been passed down as ove the unbilicus, and ation, accord- ing to Bolin, ami certain active movements are necessary to supplement the more |»issivc forms. Among the exercises that have proved of value may Iw cited the turning of the nautical wheel (Fig. 34) and the trunk rota- tion described in Exercises I and II for abdominal weakness (Figs. 326, 327, 338). Two exercises may be described that act directly by pressure on the abdominal contents: Exercise I. — Patient lying supine on a couch, arms at the sides. Raise the right leg with knee bent. Clasp the hands over it and press it in against the abdominal wall. Repeat with the left (Plate II, Fig. i). Repeat twenty times. Exercise //.—Patient sitting astride a plinth, arms behind the back. Trunk circumduction bending well forward to the right, then forward and to the left (Plate TI, Fig. a). Repeat twenty times. Circumduction of the pelvis is given most effectively by Zander's "camel," the patient sitting on an eccentrically moving saddle, or on the " horse, " which is a substitute in movement fop the trot, and riding on horseback itself is to be strongly recommended when available. The effects of treatment should be noticed from the first, and relief is usually immediate and made permanent by continuing the improved physical habits. Weakness of the abdominal muscles and fascia is responsible not only for many of the more chronic affections of the gastro- intestinal tract, due to insufficient support or to lack of the normal massage, which the diaphragm and the abdominal walls should PI AfK II OIHEK DISORDERS OF NUTRITION 363 give to them, as already described, but the relaxation of the openings through which the blood-vessels and other structures pass out of the cavity, leads to actual hernia of the viscera. When hernia takes place at the umbilicus, there is a stretching of ihe fibrous tissue alone. When it takes place at the femoral ring. It IS merely a dilatation of the innermost compartment of the femoral sheath. Inguinal hernia, which is very much the most common form, is, however, in part due to a stretching and spreading apart of muscle and tendon, and exercise may be of marked as- sistance in strengthening and closing the internal and external t-ower part of internal oblique thrown for- Fascia tranaversalis Spermatic cord Poupart's ligament Fig. 3jg. -Deep layer, showing internal ring and transversalis muscle. The dotted line shows the attachment of internal oblique. abdominal rings, and ;« helping to guard against its advent or prevent its return. A careful diagnosis is essential to exclude femoral hernia, and certain cases in which the bowel does not enter the internal ring, but breaks through the conjoined tendon directly beneath the external ring. The internal abdominal ring is found just beneath the cres- centic arch of the inferior border of the transversalis muscle. It is at this point that the vas deferens in the male and the round ligament in the female enters the abdominal wall. The trans- versalis Ukes its origin from the outer third of Poupart's ligament. The internal oblique has its origin from the outer half, :» that its lower fibers cover the internal abdominal ring as by a lid, and the 364 EXERCISE IN EDUCATION AND MEDICINE development of this muscle has a distinct influence on the ring's integrity- The external abdominal ring is a slit between the tendinous pillars of the external oblique, and every contraction of Fasda transvenalis Spermatic cord Poupart's ligament Fig. 323. — Attachment of internal oblique, showing the covering of the cord. this muscle pulls these pillars together, closing it. This action of the muscle serves as an automatic protector of the opening during active exercise. Poupart's ligament Gimbemat's liga- ment Intercolumnar fibers External abdominal ring Outer or lower pillar of external aboomi- nal ring Fascia tnangularis Fig. 324. — Superficial layer and external abdominal ring. The inguinal canal, which is normally collapsed, is bounded, then, superficially from without inward, first, by the external and internal oblique; second, by the external oblique alone. Hernia may enter the canal at the internal ring, or break in through OTBER DISOKDEKS OF NUTRITION 365 the fascia that guards its center or inner end, tearing ahead of it or pushing aside the weakened conjoined tendon of the trans- vcrsalis and internal oblique; Ijut in all cases it makes its exit by spreading apart the columns of the external abdominal ring. In threatened or actual inguinal hernia much can be done by strengthening the external and internal oblique and the transversalis muscles by active movements. The most suitable cases for this treatment are in children and adolescents, where the condition is not congenital and where natural growth assists in the process of repair, although good results have been obtained up to fifty years of age, either where hernia is actually present or where . there seem to be the premonitory symptoms. One is frequently consulted for a dull, aching pain either in one or t)oth inguinal regions, particularly after some unusual muscular strain or fatigue, by patients who, on examination, show unusually dilated external I^'B- 325— Seaver's fiat truss iMWi, rings. There is tenderness and a distinct impulse on coughing, but no actual hernia. Others, again, in whom hernia is present complain of no inconvenience from it. One man played foot-ball for years with an enormous scrotal hernia, which he did not even support. He then went to Cuba, did a great deal of horseback-riding and other violent exercise, during which it disappeared, is now quite sound, with no return for five years and no necessity for wearing a truss. This is, however, far from being a typical case, for strangulation may occur at any time, and forms a constant menace. Ml hernias should, of ci.urse. be reduced and retained, prefer- ably, by a truss that docs not present a convexity of surface great enough to enter and spread the abdominal ring. The flat pad described by Jay \V. Scaver (Fig. ;,25) is comfortable to the patient, ran be kept dean at all times, andean Ijc worn in the water with- out damage. It is especially suitable for young men. It con- 366 EXERCISE IN EDUCATION AND MEDICINE sists of a small steel band, covere without holding the breath. In a double hernia both hands should co\er the abdominal ring and the twisting should be to alternate sides. OTHER DISORDERS OF NUTRITION 367 Fig 336. Exercise //.—Patient stanilinn, hands clasped behind the head. Trunk circumduction to the right (Fig. 327), bacliward (Fig. 328), Fig. 317. to the left and forward (Fig. 329). Repeat fue times and reverse up to twenty times. The breath should not be held 3« KXeCCIgE IN EDUCATION AND MEDICINE during this exercise anrl the hernia should be kept up by the truss. This movement brings into action all the abdominal muscles, and keeps the chest in the best possible position. Fig. 399. Exercise III. — Patient seated, facing stall bars, feet fixed, hands on the hips, with fingers over the ring. Backward bending and twisting to the right and to the left alternately, without holding the breath. Repeat twenty times. This brings in all the abdominal muscles, the lateral twisting especially causing a powerful action of the obliques. It may be modified by placing the hands behind the head (Fig. ^30) after the muscles have been developed enough to stand ii, the truss being in place. The nautical wheel is a valuable piece of apparatus in the treatment of this condition (Fig. 34). as are all the lateral trunk movements of the Swedish gymnastics. Massage with the finger-tips, consisting of kneading and petrissage, should be used over the abdominal rings at the end of each treatment, to stimulate the local circulation and promote their contraction. OTHER OlSOKDERS OF NlTRinON 369 Under this (Itvelopmenial treatment, Seaver rc|)orts that over 70 per cent, of his cases have been relieved of the necessity of wearing a truss of any kind, and my cxiierience would confirm his observations. I have also seen the greater! Ijcnefil resulting from it in men up to fifty-five fears of age, the general improiemcnt in tone of the »Wo«inal muscles awl reiki Inam the consunt pain and dragging ^iK- .1,10. sensation being complete, while the muscles acquire an alertness in contraction that prevents their being taken by suqjrise by an unexpected movement or strain. it is frequently due to the sluggish and ineflfective action of these neglected muscles that hernia is alIowes in which the thigh is flexed, the knee-joint being kept " in extension, stretch the nerve and frequently give relief- and hnally, toward the end of the treatment, active movements are of value m counteracting the atrophy that results from inaction and the disease itself. Graham deprecates the use of massage over the sciatic nerve, and confines his manipulations to the muscle masses of the front and sides of the thigh, with gende stroking only on the posterior aspect of the limb. Where hacking and percussion are used the movements should be genUe, and any increase in the pain after massage should be a sign to desist. Massage is not well borne in brachial neuritis, especially during the aciien.5ss of the attack, and absolute rest isAen essential. 37» IXEICISE IN EDUCATION AND MEDICINE Only in the later stages may it be employed, and then with pre- cautions to avoid a reawakening of the inflammatory process. Balfour, of Edinburgh, employed [lercussion and compression for neuralgia in 1819. Kccles reports relief by local massage of intercostal neuralgia and neuralgia of the cervicobrachial nerves. In the trifacial and occipital forms relief is sometimes afforded by gentle [lercussion and kneading of the scalp and face over the seat of pain. The improvement in the circulation and the elevation of the subnormal local temperature by the warmth of the hand during massage are doubtless contributory causes to the relief of theie symptoms. , Nerve excitation and vibration for the relief of pain by means of percussion became of great interest and importance as a result of Dr. J. Mortimer Granville's experiments in London. Acute pain he likened to a high note in music, produced by rapid vibrations. Dull aching pain he likened to low notes, caused by slow vibrations. He attempted to bring discord into the rhythm of morbid vibrations, and so relieve or cure the neuralgia by his instrument, the "percutor," in which the rate of blows could be changed at will, and the modem vibrator is but a modifi- cation of his instrument. OCCUPATION NEUROSES Scrivener's palsy has become comparatively rare with the increased use of the typewriter, but exhaustion neuroses are frequent amonp piano-players and violinists, baseball-pitchers, and telegraph operato.s. While no aiorbid anatomic change can be made out, this trouble appears to be the result of an exhaustion or overexcitability of the centers controlling the muscular movements most involved. The symptoms are cramps and spasms of the muscles, weakness and debility, extending even to paralysis, tremors, a feeling of great tiredness, with acute shooting pains, and sometimes a subacute neuritis, with pain, numbness, or tingling in the fingers. These conditions run at best a chronic course, which can be greatly IXnau IN IHI TKEATKENT Of NUVOUl OtSEASU 373 •hortened if perfect rest from the habitual mmement and daily manage and manipulation, with simple gymnastics, be applied. In one of my cases, a violinist, a nen'ous girl of fourteen, with fatigue pains coming on rapiilly and numbness of the third and fourth lingers of the left hand, a daily course of massage, con- sisting of friction and kneading of the fingers and small muscles of the hand, forearm, arm, and shoulder, accompanied by manipu- lation of the joints separately and a few simple gymnastic exercises for the fingers separately and together, brought about a complete recovery in about two months, enabling her to resume her study. This is an unusually favorable result, and under the best of conditions the tendency to rela|)sc must be kept in mind. INFANTILE PARALYSIS The onset of this disease is usually without warning, beginning with vomiting and fever, and the paralysis may often be found the next morning, but usually comes on from two to four days after- ward. Sometimes it is not noted for a week or ten days. It is accompanied by rapid wasting of the muscles, which, however, may be obscured by the presence of fat. Sooner or later contrac- tures develop, causing eversion or inversion of the foot, o\ erexten- sion or flexion at the ankle, while dangle foot is present after complete paralysis of all the muscles. There may be overextension of the knees or relaxation of the abdominal walls, simulating hernia; the scapute may be winged as a result of paralysis of the serratus, and the unbalanced actions of the arm and hand muscles may produce marked deformities. The paralysis is characteristically random in its distribution (Gowers), but the following table shows the most frequent combi- nations of regions involved. "lOOCOn WSOWTION IBT CH*n (ANSI ond ISO reSI CHAUT No. 2) III— la 12.8 12J 5 laia |M :?itt ■— llli IIS I^U& jS A APPLIED IN/MGE Ine 374 EXERCISE IN EDUCATION /*ND MEDICINE TABLE SHOWIXd DISTRIBITIOX OF PAKALVSIS Dudieiine. Sceli|,'mullcr. SinkU-r. Slarr. Macl'hail. Total B<»th legs Q ,4 ,0; 40 45 -'15 R'Sht leg .5 15 03 20 y i,v Left leg 7 27 6.' 27 20 143 Right arm 5 9 5 7 ^ ^q Left arm 5 4 s 4 2 23 Both arms j i 1 2 2 S All extremities 5 2 t^- 5 4 ^1 Arm and k-g, same side . , [ 2 21 411 44 Arm and leg, oiiposiie sidi- 1 2 1408 Trunk i o 22 3 o 26 Three cxlremilies o o 10 2 2 14 Total 02 75 340 liS 99 694 The groups in\olved may be discovered by the wasting, by electric stimulation, and by careful examination of the actions that are imperfect or absent. The voluntary movement present must be estimated with great accuracy, and the difficulty of this has been iiisisted upon by Becvor, in his Croonian Lectures on Muscular Movements (1903). Fig- 33 ' —Incorrect position for test- ing thp action of the triceiJs. Fig. 33J. — Correct position for te.iting the action of the triceps. Among the fallacies that may occur are the confusing of the action of gravity for muscular action. A slow relaxation of the active biceps may be vonfounded with contraction of the triceps EXEKCISE IN THE TREATMENT OF NERVOUS DISEASES 375 When the bent arm is slowly straightened when hansing at the sKle whereas ,f the arm be first Hexed and the elbow be held at the leve of the shoulder and the patient told to extend it, he will be unable to do so (Figs. 331 and 332\ Another error that must be guarded against is the cre.liting of a muscle with contractile power when the movement is the Fig. J33— Correct posilion for testing the anion of the fl„ors of ,hc dl«,„ The swinging of the arm is thus prcventcer cent, among the children of Boston. Stammering is exceedingly contagious in a class, and rapidly spreads among school-children, making schools, according to Melville Bell, veritable nurseries of stuttering. It has been attributed to the forcing of their education before the brain is sufficiently developed to govern the power of vocal utterance, so that a course of treatment would begin with gymnas- tic exercises, such as described in Chapter XIV, for the breathing muscles, the first to function in the development of the child, while, later on, the muscles of phonation, and, lastly, those of Fig. 3,14- — The points of contact between the tongue and palate in the formation of the nounds I., R, and K (G, Hudson Makuen). articulation, are trained. Treatment wr ild tbr.s be based on the preliminary developmert of the fundamental and intermediate mechanisms, ending with the finest and most specialized coordina- tions. Audible speech is caused by the blast of air driven from the lungs by the muscles of expiration through the slit of the glottis, bounded by the vocal cords, whose approximation is varied by the laryngeal muscles, into the mouth, where it is formed and modified by the muscles of the palate, tongue, and lips. The complete production of speech, then, is eflfected by a coordination of muscles in the chest, throat, and mouth respectively. Hudson Makuen lays special emphasis on the difference between ordinary passive breathing and the breathing of voice production, or "artistic breathing," the function of passive breath- EXEKCISE IN THE TKEATMEST OF NFRVOIS DISEASES J79 ing being simply to aerate the blood and eliminate waste-matter, while breathing for voice production is to set the machinery of the voice in motion and to control this motion as a definite voluntary muscular process. The first muscular act in breathing for voice ■'roairc(l.' The ataxic symptoms may In: classilicil as— in) Abnormally rapid movcmi-nts; [h) exaxncratiil muscular fxcrti(m in |x;rformin^ simple acli(ms; d ) prolonKtil contraction, continuinn after the movement has la'en c<>mpletcssil)ility of educating the impaired cen:ral nervous system, and rcestablishint; the lost or enfeebled coordination anil sensibility. The symptoms against which it is ilirccted is a motor disturbance, which has its origin not in a diminution of the muscle's motor |iower, but in a loss of sensibility in them, and it is based on the capacity of the neuro- muscular system for education so Ion;,' as the motor apparatus itself is intact. It consists in relearninj; the ordinary movements, lost in consei|uence of a partial or total loss of sensibility, a task which in principle is identical with the acijuisition by a healthy person of a complicated feat invob in); a nice adjustment of mus- cular action, such as ju););lin); or balancinK. Reliance must then be placed mainly on exercises of skill, alternatinK with passive movements and mas.saj5e, as a relief to improve the nourishment of the muscles without continuing the demand on the rapidly tiring will-|x>wer. The exercise jeatment of ataxia has been pojjular for many years in Sweden, and was used forty years ago in America by Dr. Weir Mitchell, but many of the devices employeil have been invented by Frenkel, of Heiden, and are for the first time described in his work on tabetic ataxia, from which some of the accompanying illustrations are taken. In attempting the simple movement of rising from a chair the tabetic patient usually forgets to draw the feet backward, and so finds himself unable to rise without assistance. He has thus to learn this simple coordination over again. ' Frenkel, p. 4f>. THE TSEATULNT OF LIKOMIITOK ATAXIA IIV I^AKRCrSK J85 Muvvmcnts of walking (orwaril, barkward, anil to the siilc, with steps of measurt'il distanci', should nuxt h: i>ractisfd. For this purixwc the ll<«)r may lie |)aint<.il with l)laiK lines or with fixit-prints at mcasuwl distances (Fi){. 337). If lines \>c drawn ziRzaK on the floor, their continual change of direction makes this walking exercise much more exacting to the latient, and an irregular |>attcrn on a cariict has l)een uscil lor this |)ur|xMe. FiK- ,1.17. When these simple movements ha\e Ijeen mastered, walking up and down stai/s with the use of a bannister should lie practised. A sjjecial stairway designed Ijy von Leyflen has two bannisters, and the stei)s are cut so that the foot must be placed down accu- rately at each step (Fig. 338). The greatest precautions must be taken to prevent the patient from falling in this exercise and so becoming timid or discouraged. A belt with a handle or strap attachment should be placed about 386 EXEKCISE IN EDUCAnON AND MEDICINE 1% Fig, 338.— Dr. von Leyden's stainvay used for exercises to reeducate the lost co- ordination in locomotor ataxia cases (Pennsylvania Orthopedic Institute and School of Mechano-Therapy (Inc.), Phila.). (Courtesy of Mr. Max J, Walter.) Pig. 339- the waist, and an attendant should always be ready to catch him if he shows signs of losing his balance. Exercise of the lower THE TREATMENT OF LOCOMOTOR ATAXIA BV EXERCISE 387 e^tremitfes can be carried on in bed, where the disease is too far advanced to permit of walking or standing. He is told to touch the great toe of one foot with the heel of the other (Fig. 339) then f'lR- 340 to run the heel upward along the front of the shin to the knee (Fig. 340), and back again. .Another exercise is the placing of Fig. 341.— Notchfd board (Franktl). the heel of either foot in notches cut in a board, as shown in the illustration (Fig. 341). If ,he patient be seated in front of a set 388 EXEKCISE IN EDUCATION AND MEDICINE ]'(' of movable pins, he can exercise by kicking them in turn, the attendant naming the one that he must touch with his foot (Fig. 342). Simple movements such as these will cause rapid exhaustion, and the pulse-rate must be carefully watched, and the exercise stopped short of fatigue. Fig. 343. — Dr. von Leyden's ten-piti amngement used lor ttle re-educstion of lost co-ordination in locomotor ataxia cases (Pennsylvania Orthopedic Institute and Sctlool of Mcchano-Ttierapy (Inc.), Phila.). (Courtesy of Mr. Max J. Walter.) The upper extremity may be trained by taking a wooden block about eighteen inches long and triangular in section, so prepared that one edge remains sharp, a second beveled off, while the third has a curved groove. The block is placed on a table in front of the patient, in a position indicated by the drawing (Fig. 343), with the grooved edge up. He is requested to draw the point of a stout pencil or pointer along the groove from the farther end of the block toward him, at the same time holding THE TREATMENT OF LOCOMOTOR ATAXIA BY EXERCISE 389 his fingers and wrist-joint perfectly stiff. The object of the exercise is to teach him to keep his arm raised in a definite position, and to malte simple excursions in the horizontal plane. This exercise is by no means easy, especially when the pencil has to be held with the slightest force. .\t first it will often leave the groove, but with practice its progress becomes more steady, although scarcely ever free from wabbling. It is usually a great surprise to a patient on his first exam- ination to find that he is unable to place his finger to his nose a= Fig- ,143-— Triangle block for the hand coonUnation (Frenkcl). with the eyes closed. This simple exercise may be practised and varied in numerous ways. Frenkel uses a perforated board (Fig. 344), the tip of the forefinger being placed in the numbered hole called out by the attendant. It can be made more difficult by having him insert pegs into the holes. When this coordination is suflSciently improved, he may advance to the catching of colored balls swung from a horizontal bar and caught on the swing (Fig. 345); and he may be set to copying diagrams with a pencil. .As soon as he shows signs of 390 EXERCISE IN EDUCATION AND MEDICINE flagging interest, his task should be replaced by another set of exercises. Fig. 344. — Perforated board (Frenkel). Along with these set exercises he should be trained in the useful operations of dressing and undressing himself, helping Fig. 345. — Colored balls swinging (Frenkel). himself at the tabk, using pen and ink, and other procediures that come up in the course of the day. THE TKEATMENT OF LOCOMOTOR ATAXIA BV EXERCISE 391 The exercises are useful only when the attention is fully con- centrated on them. This necessity for concentration and the excessive muscular exertion required to perform simple acts, the fear of accidents, and the annoyance which he feels, especially at the beginning of the treatment because his limbs will not obey orders, all combine to produce rapid and profound fatigue, and the practice of any movement should not be continued for longer than three or four minutes. In severe cases, where nutrition is impaired, one-half to one minute will be quite sufficient until he has become strong enough to bear the strain of longer-continued practice and no new exercises should be begun until there is com- plete recovery from the excitement and fatigue of the previous one. Tabetic patients have more or less completely lost the sense of fatigue, consequently in determining whether he is tired or not signs of inattention and the rapid action of the heart will be the most relir-ble guides. The pulse usually rises to 120, or even to 160, beats a minute, in direct proportion to the difficulty of the movement. It should be the routine practice, therefore, to examine the pulse at the beginning of the treatment and frequ.-nUy throughout it, and to interrupt the work by a period of rest as soon as the pulse-beats exceed 150. The interval of rest should last until the heart-rate approaches normal again, although in most cases the pulse will remain a trifle above its usual rate. If it becomes unduly frequent after slight exertion, it is a sure sign of tabetic cachexia, and such patients must be treated with the greatest caution. The exercises are for coordination and not to increase the muscular power, therefore no exercise requiring much expenditure of strength is of projjortional value as a training in coordination, and so must be considered harmful. Two periods of exercise a day arc the average rule of practice. To go beyond that is to go into the danger zone, unless each stance be made short, and the patient is robust and determined to make rapid progress, in which case three periods may be given. In the morning he takes the movements designed for the recumbent position, which are the easiest. In the afternoon he may have fif- 39a EXEKCISE IN EDUCATION AND MEDICINE teen minutes of walking exercise, with frequent rests. If tlic amount be properly regulated, eaqh successive exercise should be followed by an increase in control, so that at the end of a period he should feel more fresh and vigorous than before starting. It is wise in some cases to substitute for one period c general massage or electric treatment, which has the great advantage of resting the patient's will and attention and improving the nutrition. The unfailing certainty of the improvement and the fact that it is the improvement of a symptom caused by an organic lesion attaches unusual interest to this treatment. The hypotonia and sensory symptoms remain practically unaffected, although very frequently they seem to improve, probably because the patient's mind is diverted from them and directed to the acquirement of muscular skill; the improvement in muscular control, however, may remain for years. The ideal result would be the restoration of the normal accuracy, control, and velocity of the movements, a result which Frenkel claims to have achieved in many cases. The restoration in locomo- tion is, however, generally sufficient to enable the patient to resume his usual business or profession, and this is all that may be expected. In one case coming under my own observation, treated by John K. Mitchell at the Orthopadic Hospital in Philadelphia, and not by any means an unusual one, a miner from California who came bedridden and accompanied by an attendant improved to such an ex.<.nt that he was enabled to travel across the continent by himself and resume the active management of his mines. Such a result is so frequent as to be almost the rule. The improvement is more or less lasting as the patient's occupa- tion does or docs not entail constant overstrain. If the ataxia does increase again, a course of exercise will once more bring it under control. In giving a forecast of the progress to be expected in any case the natural disposition, the alertness, and the ability for muscular exercise n ist be found out and given full weight by the surgeon. The more skilful patients will make more rapid progress, and the best results are obtained among those who have THE TKEATUENT OF LOCOMOTOR ATAXIA BY EXERCISE 393 been accustomed to work demanding dexterity, or who have been successful devotees of athletic sports, men who have lived a good deal in their muscles, and who have at one time had the muscular sense well developed. Another important factor is the patient's personal courage. Apprehensive or cowardly patients will not risk the slightest move- ment without support or attention, and will have to practise for a long time before much definite improvement can be noticed. The longer and more thoroughly a course is continued, the more certain and lasting will be the improvement, and the closer will the patient approach to the normal in motor capacity and accuracy of movements. INDEX Abdohinal ctHitrol, cxcrcUea (or, 339 Acridents in athletics, tgo Activity of child, 158 Adami on dilatation of heart, J17 Adam's position, 383 Age limit in games, 135 Amherst, Dr. E. Hitchiotk at. i/j German gjm.iastics at, 83 physical education at, 175 Anatomy in jiu jitsu, 109-113 of hernia, 363 Anders on obesity, 346 Anemia, exercise in, 336 Apparatus employing friction, 64 Goldthwait's, for round shoulders, 363 gj-mnastic, origin of, 138 physioUigical classification, 139 Lovett's, for stretching round shoul- ders, 264, 365 school furniture as, 166 Swedish, loi Argyll-Robertson pupil in ataxia, 383 Arnold, E. H., on games, 164 Arterial tension, measurement of, 34 Arteriosclerosis, causes of, 323 definition of, 323 diagnosis of, 324 in Cornwall miners, 333 Peacock on, 332 Articulation, teaching of, 305 Artificial respiration, 33a Sylvester on, 361 Astigmatism in scoliosis. Rogers on, 276 Ataxia, Arg>-H -Robertson's pupil in, 383 exercises for, 385 treatment of, 384 Frenkel on, 384 John K. Mitchell on, 392 Ataxia, prognosis of, 393 rapid fatigue in, 3gi Romberg's symptom of, 383 Stewart on, 383 symptoms of, 383 Athletes, examination of, 190 scholarships of, 190 Stengel on heart-murmurs in, 319 Athletic League in N. V, Public School, 16S in public school, efficiency tests in, 170 sports, conduct of, 190 training, aims of, 42 dangers of, 42 ; Athletics, accidents in, 190 class, 184 for blind, 19^ ' specialization in, i8g j Automatism in exercise, 41 Back, examination of, 354 Balck. Colonel Victor Oustave, 91, 102 Balfour on neuralgia, 373 Barr, Maurice E., on mental defectives, 314 Bartlett gymnasium, Chicago, 175 Basedow, 74 Bed-posture, Brackett on, 380 Fitz on, 380 Beevor on tests for paralysis, ^74 Bell, Sir Charles, 30 Benke on heart growth, ^8 Bernadotte, sympathy with IJng, 88 Bernard, Claude, lectures of, 90 Beveridge's rubbers, 96 Bezly Thome on exercise for heart, 325-339 395 396 Birycling, effect on blood, ,^3 Hithup, Emily, on I>rlMnr, 115-117 Blake on nmnithon races. J20 Blind, athlciiiB for, joi compuliory exeiriie fur, 197 exeniir fn, 56, S7 Chicago University, physical education at, 176 Child, normal activity of, 158 Chorea, 380 treatment of, 381 Circulation, influence of games on, 136, 137 City homes, condition of, 140 CUrk, E. E., on falietlu voice, 380 Class work, exhilaration from, 130 progression in, 189 Clifford- Al butt on heart-strain, 3 to College gymnasium, et|uipment of, 185 life, physical effects of, 181 of City of New York, physical educa- tion at, 176 yearl\ course in exercise, t86 Columbia University, summer 9rho(d at, 191 Concentration of attention, 31 Conditioning, effects on fatigue, 33 Constipation, Bolin on, 363 exercise for, 361 frecjuency of, 360 massage in, 336 Zander on, 363 Copenhi^n, 75 Cornwall miners, arteriosclerosis in, 333 Correspondence schools of exercise, 119 advantages of, i30 dangers of, 131 Crime, juvenile, 138 Criminals, characteristics of, 217-330 Wey on, 330 Curtain hall, Sargent's, 128 Curves of normal spine, 350 Daily exercise, Gulick on, 134 set of free exercises, 134 Darmstadt normal school, 80 INDEX m Dwwta, *Q Day'i order, I (n^'t, 93 origin of, 9 1 Dcaf-muiM, iMiUnce movemenU (or, toy exeniM (or, aott gamet for, 30Q longevity of, 20ft mcuurementi of, ios-mq phyilral [in-ulkritin of, 305 Deep l»reathing, Butler on, 334 exrniiei for, aaS Defitrmed icapuia, (^otdlhwail on, a66 Deformities of foot, 356 Delin(|uents, military drill for, 317 phyiiral education tut, 317 Deliarte, Anna Pavson Call on, 1 1 5, 1 1 7, 118 Bishop on, 115-117 Geraldy on, 115 Giraudet nn, 115 life of, 114, 115 Stchbins on, 115-117 aayings of, 1 15 Steele Mack.iv-e on, 115 system of, 115 Deaaau, 74 Developing apparatus, Goldie's, 63 Sargent's, 60, 61 Diabetes, exercise for, 357 Finkler on, 357 Diagnosis of arteriosderiosis, 334 of flat-foot, 342 Dilatation of heart, 317 Roy and Adami on, 317 Du Bois- Raymond, 81 Dullards, improvement of, 231 physical training for, 220 Dumb-bell, Sandow's spring, 118, iig Dumb-bells used by Greeks, 57 Dyspepsia, exercise in, 360 nervous Weir I Mitchell on, 360 Ebebhart on vibrators, 71 Eccleson massage in sciatica, 371 on neuralgia, 372 Edinger's theory of locomotor ataxia, 382 Education of immifimnit by |>Uysroundik 140 EIRcuragc, tirsi n|>tim, 30 on blixid-pressure, 35 i|ualitles rullivateil by. at Elmira State Penitirntiary, 330 Emerson. C. W., exercises trf, ti8 Endurance, excrtlirs of, 18 Enehuske, Ctaes, 03 Equipment of college gymnasium, 185 of lai^ playground, 150 of school gymnasiums, if>7 of small playground, 143 Erector spinir, actio" of, 297 Evolution in play. 124 Examination for acotiosis, 38} Bolin on, 282 of athletes, iqo of hack, 254 of itat-ft, 241 of t)ljesitj-. 34ft pliysical, of students, 176 Exercisff, active. 17 automatism in. 41 class credit for. i8i corresjtondc ivt- schools of, 1 19 daily, Gulick on. 134 detinition of, 17 for ataxia, 385. 389 for Wind, 195, 197 for constipation, 361 for deaf-mutes, 206 for diabetes, 357 for gout. 356 for heart, Bezly Thome on, 325-329 Heineman on, 325-345 weakness, 325 for hernia, 366 for ttcoliosis, 2Q4 for sedentary o^cu|)ations, 134 for tuberculosis, 227 free, daily set of. 134 398 ,N EwrclM In •nemU. aa6 in cuUeir, Benjsmln Franklia on, 174 Jefleraim ftn, 174 in ilyaiiriMia, \tto in Kaurilli, 359 In morning, 154 in old ttgr, 130 in luitKilngitiil cimdiiiont, 333 In^truitiiin In theory nf, iiji tit endurume for goul, 236 pBMi\T, 17, J 7 elTct tt »f, 3i in fatigue, 27 on Atrophy, ji periods in xhoitl, 164 prrxription for m»lio»Iii, joo lonlf effen nf, jj6 yearly course, in (ollege, 1H6 Exercises for abdiiminal ronirol, jjq for chett ex|>ansion, 33S for flai-fout, 3i}3 for heart, Satterthwaite on, ^^^ fur nervous d-pre»iure, 37 on heart, ,i8 (|ualilies rullivaled by, 23 of skill, 18 schtK)!, 81 Exhaustion, 16 from alertness, 40 Exiiei lalion of life. Farr's tables on, 321 Ej-e examinations of students, i7g Facial expression as ind^x, 21 of breathlessness, 23 of effort, 19 Fkcttl expreiiion of fatigue* 24 of rage, 30 tit strain, ao Fahrner rtn fatigue at h huol, 379 Farr't la)>les of ex|iet tation of life, jai Fatal iDUc!:, JafMneie 107 Fatigue, acute, 33, a chnmic, 36 ladal expresaion of, 94 fever, 44 general, 34 efTe« Is of, 3j in ataxia, .)qi maiKige in, 49, 333 pasiive exenises fnr, 37 poise of head in, 35 products, intoxication by, 41 Lee on. 43 relative, .w scoliosis of, 378 stiUicute, 36 temjierature in, jfi Faulty attitude, varieties of, 353 Feeble miniledness, physical iignt of, 310 Fellcnberg, 74 Femald, 311-313 Kinkier on dialietes, 357 Finsen, 75, 76 Fitz, Cettrgr W., on mund shoulders, 155 on Ited-jMJsturc in scoliosis, 380 on round shoulilers, 363 tiiethod of measurement in scoliosis. 3S3 Flat-f«>ot, cause of, 238 diagnosis :)f, 343 examination of, 341 exercises for, 342 freijuency of, 240 Ochsncr's Imndage for, 348 record of, 241 Rol on, 246 shf-- for, 246 syiii|.toma of, 339, 240 tn-iiiment cif, 243 Whitman's foot-plate for. 347 Folk-dancng in playgrounds, 152 Follen at Harvard, 82, 175 INOIX Food and mutruUr wtUt, 41 Foo«, deformiiict of, jj6 laiml «rch o|, sjg HrtKlure at, 336 Fom-UII playtra, weight irf, iflo Frankfurt, lurnfrtt at, ;q Franklin, Benjamin, cm exrrriie In tol- •*lie. 174 Field, 184 Frrnkel un auxia, 384 Fridion, dett ription ul, 51 Fn«)«l, 80, 134 CjAlen on maHage, ^o GamrH, u^r limit in, uj (lauirKntlun r hliml, i(>« for tleaf-tnulffl, 209 g.vmna8li<, ij8 in rrtrsB, 16^ ir.fluemcon drrulation, 116, 127 musilca used in, 13ft, 1^7 nerwionirol rei(uimJ in, uA, ij; p«»|»ularityof 4, jjt, 1, tieginnings of, 88 Swedish medicaJ, 103 Hartemis, 90 HartWTlI, 93 Harvard, Follen at, 17s Hawk on blocxi-iount, 31 Heart, Bczly Thornc oncxerciae for, 335- 3 '9 dilatation of, 317 diseases of, 315 action of exerc ise in, 33^ Wide on massage for, 335 exercises of enduram e on, 38 Saltcrthwaite on, 341 growth, Benke on, 38 Heineman on exercise for, 335-345 murmurs in athletes, Stengel on, 319 of oarsmen, 330 overstrain of. 317 400 Heart, prognosis of exercise treatment for, 345 strain, Clifford- Albutt on, 319 Schott on, 317 valvular defects of, 315 weakness, exercise for, 225 Heat, regulation of, ig, 30 Heineman on heart exercise, 325-345 Hemenway Gymnasium, 175 Mrs. Mary, 92 Henry, Admiral, case-report of, 359 Hermann, rout of, 76 Hernia, 362 anatomj' of, 363 diagnosis of, 363 ejcercise for, 366 Seaver's truss for, 365 supiKirt for, 365 High tension, Brunton on, 323 Hippocrates on conditioning, 44 Hitchcock at Amherst, 175 on measurements, 191 Hokusai, sketches of, 105 Homans, Miss Amy M., 93 Hooker at Amherst, 175 Horizontal bar controversy, 81 Ideal college athlete, 193 Indianapolis, college at, 82 Inomotor, Sargent's, 64 Intoxication of fatigue-products, 41 Jahn, 74-77, 80 Janeway on blood-pressure, 35 Jefferson on exercise in college, 174 Jiu jitsu, dangers of, 113 introduction in America, 108 knowledge of anatomy in, 109-112 modifications of, 108 O'Brien on, 108, 111, 113 origin of, 104 secrets of, 106 Jiudo, 104 Juggling, physiology of, 21 Kano school in Tokyo, 108 Keynote position. Roth's, 382, 295 Kidneys, action of, in elimination«44 Kindergarten, games of, i6t Kinghorn on phthisis, 227 Kitson, H. H., 193 Kuatsu, art of, 104, 106, 107 Lagrange, 328 Larabee on Marathon runners, 320 Latent period, 30 Lee, F. S., on fatigue-products, 43 J- E., .37 Lefebure on day's order, 101 Lever, principle of, 6g Lieber, 77-82 Liedbeck, 88 Ling, Hjalmar Frederick, 90 honors awarded to, 88 literary activity of, 87, 88 on massage, 46 Peter Henry, 74, 81,86 life of, 86 physiology of, 89 Lip reading, teaching of, 206 Locomotor ataxia, definition of, 382 Edinger's theory of, 382 Lombard on weight loss, 42, 43 Longevity of oarsmen, Meylan on, 321 Lovett's apparatus in round shoulders, 261, 265 measurement of round shoulders, 251 Lund, University of, 86, 87 Lung capacity, rapid increase of, 313 Macdonald Smith on full contraction, 117, 118 Machine, McKenzie's, for scoliosis measurement, 384, 285 Maggiora, experiment of, on massage, 47-49 Makuen on artistic breathing, 378 Marathon race, 44 Blake and Laraliee on, 320 Mason, J. L.. 154-156 Massage, action on muscles, 47 as stimulant, 333 automatic, 39 classification of, 5' 401 Massage, detinitinn of, 45 derivalion iif, 45 duration of, 55 effects of, ^A for fatigue, 4q f(ir heart disease, Wide, 325 for muscle wasting, 31 for obesity, 335 for rheumatism, 358 general, 54 hisliiry (if, 45 fur ronsiipation, 226 for fatigue, 222 (or gastritis, 226 in Oreeie, 45 in Japan, 45 on nervous system, 41 for neuritis, 371 for ol)esity, 352 for rheumatism, 22A, 358 for sciatica, 371 for sprains, 223 Ling on, 46 Maggiora's experiments on, 47-49 mechanical effects of, 49 Mezgar on, 46 precautions in, 55 rc([uirements of, 46 McCurdy on l)l(K>d -pressure, 36 McKenzie's machine for measurement of scoliosis, 2S4, 285 Mvtisurement, Filz's methixl, in scoliosis, McKenzie's method in scoliosis, 2S4, 285 of blind, 195 of deaf-mutes, 305-209 Roth's method, in sc<)li(«is, 283 Schulthess' machine for, 283, 284 Spellissy's method, in scoliosis, 283 Mechanotherapy in America, 71 Medical gymnastics, sujwrvision in, 235 Swedish, 103 Melville Bell on stammering, 378 Mental defectives, Barr on, 214 diagn(«is for, 212 gymnastics for, 21a Mental defecti\-es, habits of, ju management of, 31 1 military drill for, 214 ]iniiKirtions ^>i, 210 sch(M)ls for, 212 Tadd on, 216 Warner on, 21 1 Meylan, Geo. L., 157 on longevity of oarsmen, 321 Me/gur on massage, 46 Military drill for dclinijuents, 217 for mental dcfeciivcs, 214 gymnastii s, Swedish, 94 Mind and Ixxly, H3 Mitchell on ataxia, 392 on bloiKl changes fn»ni massage, 32 on blood-count, 227 Montrichard, 86 Morgan on survival of oarsmen, 321 Mosher on standing ]R)Sture, 165 Mosso's plethysmograph, 31, 32 Mount Airy, 208 institution for deaf-mutes, 206 Movements, automatic, 39 l»rain, control of, 39 necessity for natural, 40 s|)ontaneouB. in infants, 122 Muller on tifteen minutes daily exercise, Murray, qi Muscles, action of massage on, 47 of spine, 271 overdevelopment of. 22 ruptured, cause of, 30 from effort, 30 soreness, cause of, 29 tonus, 29 used in games, 126, 127 Muscle-wasting, massage for, 31 Muscular action, isolation in treatment of scoliosis, 296 contraction, lirunton on, 31 desl, 160 normal, Greenwood on, 253 standing, change of spine in, 250 Mosher on, 165 Roberts on, 259 spinal curve in, 250 Presence of mind, 40 Prognosis in ataxia, 392 in exercise treatment for heart, 345 in obesity, 348, 355 in paralysis, 376 in round shoulders, 356 Prolongation of life, Weber on, 131 Psoas, isolation of, 3t}6 Public School Athletic League, girl's branch, 172 grounds of, 172 Pulley-weights, dangers of, 63 description of, 5S-6a limitations of, 63 j Pulley-weights, principle of, 57, 58 Pulse-rate in exercise, Bowen on, 37 Zander on reducing, 325 Quarter CIRCLE, 59, 60 Race, facial expression of, 30 Record of fiat-fcxjt, 341 Reichcnhall, Oertell's cure at, 328 Research in physical ccimaiion, iqi Respiration, artificial, 233 Japanese, 107 chemistry of, 33 Rheumatism, Douglas Graham on, 358 massage in, 226, 358 vil)ration for, 358 Rifle sh(x)ting in schools, 170 Riva-Rocci sphygmomanometer, ^5 Roljerts on standing iK)8ture, 259 Rogers on astigmatism in scoliosis, 276 Romberg's symptom of ataxia, 383 Roth, Bernard, 90 on flat-foot, 240 on method of measurement in scoliosis, 383 Matthias, 90 Roth's keynote [K>sition, 383-295 Rothstein, 81, 89 ' Round 'ii-k, tracings of, 353 shoulders, causes of, 254 definition of, 251 diagnosis of, 256 exercises for, 257 Fitz on, 255, 26-* frequent y of, 255 Goldthwait on, 255, 256 Gt>ldthwait's apparatus for, 263 Lovett's apparatus for. 364, 365 measurement of, 251 prognosis of, 256 treatment of, 256 Zander's lower for, 262 Rousseau, 74 Roy and Adami on dilatation of heart. Running, change of pace in, 27 long-distance, 36 n ! 404 INDEX Il* ^ Salzm/ , 74 Scoliosis, examination for, 282 Samauri, order of, 104, 105 exercise for, 294 ^■'' Sandnw's s|iring (lumlHlieU, 118, iiq c\[>erimcntal, 381 Sandpi'e, care of, 144 Filz's method of measurement, 283 Sargent, Dudley A., at Har%'ard, 175 frci|uency of, 274 on curtain ball, 128 (iould on causation of, 275-277 ^^^^^H , on devflopiig apparatus, 60, 61 isoUtion of muscular action in ireat- ^^^^^B . on inomotor, f)4 nient of, 296 on measurements, iqi, ig,^ measurement of, 283 ^ ^^^^^^1 ' on pulley weights, 5?-<>i of fatigue, 278 S tterthwaile's exercises fur heart, ,^4.1 prescription .>f exercise for, 300 SavTe's aling, 304 [)rognosis of, 290 SrhnepfcPthal, school of, 74 Roth's method for measurement of. ^^H' Schl, rules for construition of desk, Reed -skaters, measurements of, 193 ^^^1 development of thorax in, 312 Spellissv's photographic meih.wi for diagnosis of, 286 measurement in scoliosis, 383 ■i Sphygmomanometer, Stanton's, 34 Spiess, 74-80 S]»inal asfisiant, Ta>lur's, itn, 264 curve change in siandinK I»<»slure, 250 Spine, infantile, shajie of, 350 movements of, 272 muscles of, 271 normal, (urves of, 250 Sporting Times, founding of, 01 SiKtrts, analysis for class use, 1S5 Sprains, massage in, 222 Sprinters, Phillips on. i(j2 Stagg on weight reduction, 352 Stairway, Von Leyden's, 385, 386 Stalencss, 22, 41 Stammering, 377 Bell on, 37S frequency of, 37S treatment of, 379 Stand-i)ressure, 35 Stewart on ataxia, 383 Stokes, 325, 326 Strain, facial expression of, 20 Striking, 52 Stroking, descripti<'n of, 50 Students, eye examinations of, 179 physical defects in, 177 excess of, 176 Subtarget machine, 170 Summer camps for ritv children. 157 V. M. C. A., 157' schools. 191 at Chatauqua. :.vi at follegL- of City of New York, itji Supervision in medical gymnastics, 235 Syl/ester on artificial respiration, 261 Symptoms of flat-fi>ot, 239, 240 Swedish apparatus. 101 gymnastics introduced in United States, 91 JtX 405 I Sweedish gymnastics, limitations of, lOI military, 94 ' medical gymnastics, 103 system, characteristitsof, 94 Swimming In playgrountls, 152 Tadd on drawing for defectives. 216 Ta|>otement, description <»f, 52 Taylor <»n developing ap[Hiratus, 70 Taylor's " spinal assistant," 262, 264 Techow, 89 Temi»erature during exercise, Bowen on, rise <)f, in mustular action, 29 Tendon, strain i>f. 30 Therajwutic effects of games, 1 28 Thorax, torsion of, 299 Thyroid extract in olicsity. 354 " Tidschrift i Gymnastics," 90 Torngren, 91 '■ Tournaments, dutes of, 76 Treatment of round shoulders, 256 of scoliosis, 291 of uneven shoulders, 270 Trenihle-pressing, dcscripiiim of, 54 TulK-nuti)ftis, exercise for, 227 Turnfest at Frankfort, 79 Turngcnieinden in America, 82 Turning in German Universities, 76 Turnkunst, liadgc of, 76 Turnplatz, first, 75 Turnvereine, descriptions of, 79 University oars. Morgan on, 321 of Pennsylvania, 31, 42 physical education at, 176 I'rbinization of jxjjmlation, 132 Valvular defects of heart, 315 \'an de Walker on the blind, 199 Vibration. 53 application of, 71 for rheumalUm. 358 for sciatica, 371 Pilgrim on, 71-73 theory of, 73 406 VibraUvt, Eberhart on, 71 mcxlifications of, 70 Zander's, 70 Virchow, 81 Vun Lryden's ttainvay, 385, j86 Von Noorden, 325 on massage in obesity, 353 Von Schenkendorff, 83 Wadino pool, 153 Wallting, rate of, 134, 135 Warnrr on mental defectives, 211 Washington Gardens, gymnasium at, 82 Water-polo, effect on blood, 33 Weber on prolongation of life, 131 Weight, loss of, 42 Lombard on, 43, 43 of foot-liall players, 180 of oarsmen, 180 reduction, dangers of, 355 Stagg on, 352 Weir Mitchell, 31, 55 on nervous dsypepsia, 360 on neurasthenia, 376 Welledey and Boston Normal School, 93 Wey on criminals, 330 Wide on massage for heart diseaae, 335 Williams College, 143 German gymnastics at, 83 Whitman's foot-plate for flat-foot, 347 Witmer on pain organ, 73, 370 Writing position, 160 Gould's, 293 Vale University, Gernum gymnastics at, 83 Voshin-Riu, 104 Zavdek, 17, 54 history of, 66 institutes, 66 machines, 66-70 advantages of, 70 on constipation, 363 on reducing pulse-rate, 335 Zander's tower, 234 for round shoulders, 363 vibrator, 70