l\ I ERRATA. Page 201, line 5, after "reach grasp" insert "step." „ 209, ,, 1, "bones, &o." sliould be omitted. „ 262, „ 18, for 37' read 98-6\ ,, 323, ,, 2 should be omitted. ,, 460, ,, 6 from bottom, for " mu.soulo-spinal " read " musculo-apiral.' THE ELEMENTS OF KELLGREN'S MANUAL TREATMENT EDGAR F. CYEIAX M.D.Edmburgh, 1001 ; Gymnastic Director, StocMiolm, 1899 NEW YORK WILLIAM WOOD AND COMPANY MDCCCCIV 6^ librae' LONDON .'S AND DANlRLSaON, L I'! PHFIELD STRKKT, W. DEDICATED TO HENBIK KELLGREN. 35SSS9 LlSr OF ILLUSTRATIONS. FIG. 1 Standing position . . Sitting position Lying position Kneeling position . . Hanging position . . Bend standing position Stretch stride standing position . . Yard standing position Hips firm knee bend standing position Walk standing position Sit lying position . . Crook lying position Crook half lying position . . Forwards lying position Side lying position . . Forearm flexion (forearm pronated), AR Reach grasp stoop fall standing double elbow flexion and extension PA Forearm flexion (forearm supinated), AR Heave sitting double forearm extension and flexion, AR Finger flexion, AR . . Lying leg flexion, PR, extension, AR Lying leg flexion, AR, extension, PR Forwards lying leg flexion, PP, raising, AR Half lying leg flexion, PP, extension, AR Sit lying knee extension and flexion, PP Half lying foot flexion and extension, AR Half lying double foot flexion and extension, AR Reach grasp standing head flexion, PR, extension, AR Arch forwards lying head flexion, PR, extension, AR . Head flexion laterally, AR Head extension, lateral flexion, and rotation, PR Ride sitting trunk flexion, PR, extension, AR . . Ride fall sitting breathing, PA Forwards lying back raising (arching) breathing, PA . Head loan arch standing toe raising, breathing, PA Stretch stride standing bending sideways, PA . . Hip lean walk standing lateral flexion, PP, extension, .VR Loin lean stride standing ringing, PP Ride sitting double arm abduction, AR, adduction, PR Swim sitting double elbow pressing downwards, PR, upwards, AR Halt lying double arm bending and stretching, AR Side lying leg lifting, AR, pressing down, PR . . Lying double leg flexion, PA, abduction, AR, adduction, PR Crook half lying double knee abduction, AR, adduction, PR . . PAGE 15 15 15 17 17 18 18 20 20 20 2.3 24 24 25 25 76 77 70 80 81 85 8() 87 90 92 92 94 95 96 LIST OF ILLUSTRATIONS FIG. 45 40 47 48 49 50 51 52 53 54 55 Head rotation Loin lean stride standing alternate rotation, AB Supination, AR, pronation, PR . . Sitting arm circling, PP Sitting hand rolling, PP Finger rolling, PP . . Ride sitting screw turning. PI' Arm traction sideways, PP Stretch half lying double hand and foot traction, PP . . ,, side lying hand and foot traction, PP . . High sitting double arm carrying outwards, AR, inwards, PR Stretch grasp standing drawing forwards, PP . . Side span standing drawing sideways, PP Loin lean stride standing drawing backwards, PR, forwards, AR Low sitting chest lifting (expansion!, PP Heave lean standing chest expansion, PA Stretch grasp toe standing hanging, breathing, PA Sitting head lifting, PP Graphic representation of shakings from wrist and finger- joints ,, ,, ,, ,, wrist and shoulder-joints Suction vibrations . . Graphic representation of vibrations from fingers ,, ,, „ ,, wrist and fingers Half lying vibration over the bladder, coronal suture \ibration, PP . Diagram of forwards lying rimning nerve frictions, PP ,, stretch side lying running nerve frictions, PP ,, stretch half lying running nerve frictions, PP Heave grasp standing side shaking, PP . . ,. ,, ,, heart shaking. PP ,, ,, ,, subcostal shaking, PP Back hacking, PP Chest clapping, PP Reach grasp step standing knee flexion and extension, PA, sacral beating, PP Standing vertebral coluinn stretching, AR at patient's head . . ,, stretching of the calf muscles, PA Stride sit kneeling raising, AR Biparietal movement Bitemporal movement Coronal suture \nbration and occipital suction movement Frontal vibration and double upper cervical nerve friction Nerve frictions round the side of the sl\ul'l Half lying stomach exercise, PP . . Temperature chart, case of typhoid fever „ scarlet fever. . 11)11 1(11 Id.-, KMi KIT HI 111 ir_' Hi 114 11(1 IKi 117 120 121 123 12.S 128 130 131 135 136 140 141 141 Kk) 176 176 178 189 191 193 197 198 1 99 214 215 216 218 218 221 222 222 227 25.-. 266 269 279 280 283 LIST OF ILLUSTRATIONS FIG. 99 100 101 102 103 104 l(t.5 10(i 107 108 109 110 111 ir2 113 114 11.", IKi 117 US llll 120 121 122 123 124 12.5 12(i 127 12S 129 130 131 132 133 134 135 136 137 138 Temperature chart, case of scarlet fever and mumps . . diphtheria erysipelas epidemic cerebro-spinal ineningitis rheumatic fever and erytliema erythema nodosum pneumonia . . Illustration of case of chronic pleurisy and spinal ciirvatiu'e Temperature chart of case of acute peritonitis . . Sphygmographic tracing, case of mitral incompetence mitral stenosis and incompetence Temperature chart, case of rheumatic (?) pericarditis, &c. Spliygmographic tracing, case of rheumatic (?) pericarditis, &c. Diagram to show extent of a case of lymphangitis Sphygmographic tracing, case of embolism into internal capsule PAQK 285 286 292 294 299 301 309 315 330 332 342 360 362 362 362 362 363 363 363 364 364 365 366 367 369 370 371 374 375 376 376 377 377 378 379 383 385 400 402 403 CONTENTS. PART I. PAGE Preface xiii. Chapter I. — Introductory ... ... ... ... ... .-. ... 1 Chapter II. — General Classification and Definitions... ... ... 10 Chapter III. — Gymn.\stic Positions ... ... ... ... ••■ 14 Chapter IV. — General Physiologic.a.l Effects of Active and Passive Movements ... ... ... ... ... ... ... ... 27 Chapter V. — Gymnastic Movements .. ... ... ... ... ... 41 Flexion and Extension (including Ringing and Falling) ... ... 45 .\bduction and Adduction... ... ... ... ... ... ... 89 Rotation (Turning) ... ... ... ... ... ... ... ... 97 Pronation and Supination... ... ... ... 101 Inversion and E version ... ... ... ... ... ... ... 102 Circumduction or Rolling ... ... ... ... ... ... ... 103 Traction 114 (Arm-) Carrying 117 Drawing ... ... ... ... ... ... ... ... ... 119 Expansion ... ... ... ... ... ... ... 124 Lifting 131 Shaking and Vibration ... ... ... ... ... ... ... 133 Friction ... ... ... ... ... ... ... ... ... 133 Hacking, Clapping and Beating... ... ... ... 197 Stroking '. 205 Kneading 207 Pressing ... ... ... ... ... ... ... ... ..- 213 Various other Movements which do not f.ill under any of the previous headings ... ... ... ... ... ... ... 214 Special Manipulations of Various Regions and Organs ... ... 220 Chapter VI. — CoxcLrniNG Rem.\rks to Part 1 240 PART II. Preface ... ... ... ... ... 246 Chapter I. — Diaunostic Exercises ... ... ... ... ... ... 247 Chapter II. — General Principles in the Application of the Manu.al Treatment 249 X. CONTEXTS PAGE Chapter III. — Specific Infectious Diseases ... ... 251 *Typhoid Fever 253 *Whooping Cough ... ... ... ... ... ... ... ... 259 *JIensles following on Whooping Cough ... ... ... ... ... 260 ♦Measles 263 ♦Scarlatina Anginosa ... ... ... ... ... ... ... ... 266 ♦.Scarlatina .\nginosa ... ... ... ... ... ... ... ... 269 ♦Scarlatina Anginosa ... ... ... ... ... ... ... ... 270 ♦Scarlatina Suuplex ... ... ... ... ... ... ... ... 273 ♦Scarlatina Anginosa ... ... ... ... ... ... ... ... 274 ♦Scarlatina Gravior, with Middle Ear Disease ... ... 276 ♦Scarlatina .^.nginosa, followed by a Chill with Spinal Symptoms and Epidemic Parotitis {'?) ... ... ... ... ... ... ... 276 ♦Scarlatina ."Vnginosa ... ... ... ... ... ... ... ... 278 ♦Scarlatina Anginosa ... ... ... 280 ♦Scarlatina Anginosa, followed by Epidemic Parotitis ... ... ... 282 ♦Scarlatina Anginosa with Epidemic Parotitis ... ... ... ... 284 ♦Scarlatina Simplex, followed by Epidemic Parotitis ... ... ... 286 ♦Scarlatina Gravior ... ... ... ... ... ... ... ... 288 ♦Epidemic Parotitis 289 Diphtheria 291 Erysipelas Migrans BuUosum ... ... ... ... 293 Epidemic Cerebro-spinal Meningitis ... ... ... 298 ♦Rheumatic Fever and Erythema ... ... ... ... ... ... 300 ♦Erythema Nodosum... ... ... ... ... 309 Chapter IV. — Diseases of the Respie.\tory Organs ... ... ... 311 Acute Croupous Pneumonia ... .. ... ... ... ... 311 ♦Acute Bronchitis ... ... ... ... ... ... ... ... 316 Acute Pleurisy ... ... ... ... ... ... ... ... 318 Chronic Pleurisy 321 ♦Case 1 323 ♦Case 2 325 ♦Case 3 327 ♦Case 4 328 Chapter V.— Diseases of the Digestive Organs ... ... ... 334 Acute Membranous Tonsilitis ... ... ... ... ... ... 334 Acute Catarrhal Appendicitis ... ... 335 Case 1 336 ♦Case 2 339 ♦Acute rapidly extending Peritonitis ... ... ... ... ... 341 .•Vcute Gastrointestinal Catarrh ... ... ... ... 345 Acute Intestinal Catarrh 346 Chronic Appendicitis ... ... ... 347 * The cases marked witli an asterisk were not included in the original thesis of 1901. CONTENTS Constipation Case 1 Case 2 *Chronic Intestinal Catarrh *Diarrhcea Chapter VI. — Heart Diseases Mitral Incompetence Mitral Stenosis and Incompetence *Mitral Stenosis and Incompetence *Rheumatic (?) Pericaj-ditis, Cardiac Dilatation and Mitral Disea: Chapter VII. — Diseases of the Blood. Lymphatics and Dv Glands Chlorosis Lymphangitis Case 1 .' Case 2 Case 3 Case 4 ... ♦Case 5 ♦Exophthalmic Goitre Chapter VIII. — Diseases of the Nervous System Embolism into the Internal Capsnle ♦Infantile Spastic Diplegia ... ♦Diplegia fi'om Cerebral Hiemorrhage ♦Sequelie of Meningitis (Syphilitic! Bulbar Paralysis Disseminated Cerebro-spinal Sclerosis ♦Spinal Apoplexy during Secondary Syiihilis Infantile Paralysis ... Case 1 Case 2 Facial Paralysis of Peripheral Origin Post-diphtheritic Paralysis ... Neuralgia and Neuritis Supraorbital Neuralgia ♦Sciatica ... ♦Sciatica ... Mental Overwork Sequelie of Influenza Case 1 Case 2 Chronic Headache ... Epileptic Seizure while Bathing ... * The cases marked with an asterisk were not included in the original of 1901. page 349 350 351 3.-)l 3.53 35.5 359 364 368 370 380 380 382 382 384 885 386 386 387 391 397 403 407 414 420 423 433 437 438 441 444 445 447 447 448 450 451 454 454 455 456 457 CONTENTS Chai'TER IX. — Diseases of the Locomotor Clironic Elieumatisiu Case 1 ♦Case 2 Case 3, Lumbago Case 4, Lumbago ♦Case 5, Lumbago Sprain of the Gastrocnemius Muscle Chronic Synovitis, &c. Abscess in the Antrum of Highmore Dislocation of the right Humerus ♦Dislocation of the left Humerus ... Chapter X. — Diseases of the GENiio-URiN.iRY Organs ♦Sudden Incontinence of the Bladder ♦Menorrhagia ... ♦Threatening Mammary Abscess ... ♦Labour Appendix ... PAGE 461 461 461 462 463 465 466 466 467 469 470 472 474 474 474 476 476 478 * The eases marked with au asterisk were not included in the original thesis of 1901. PREFACE. This book has been written with the object of providing the medical profession with a scientific exposition of the methods comprised under what is widely known as " Kellgren's Manual Treatment." It is founded upon the thesis which, under the same title, was accepted with commendation by the University of Edinburgh in 1901, and gained for me the degree of M.D.; but the original thesis has undergone considerable expansion. Greater experience, more extended observation and a wider range of reading have led me to add so much to the first part that it has in effect been rewritten ; and in the second part I have in- cluded the. details of many cases treated in the course of my prac- tice after leaving Edinburgh. Some exceptional difficulties have attended the compilation of this treatise. For the first time has been attempted a systematic, detailed description of Kellgren's Manual Treatment ; and the task, onerous in itself, has been complicated by the fact that the physiological groundwork was insufficiently investigated, experi- menters having hitherto conducted but few researches into the phenomena resulting from gymnastic exercises. In addition, I have only been able to write during the occasional hours I could spare from my practice, the continuance of which being necessary not only for the double design of accumulating fresh evidence and verifying conclusions already drawn, but also for the purpose of widening as far as possible in every direction the range of that practical work which forms the basis of all sound theory. The present volume, although dealing with all the chief features of the subject under consideration, makes no pretence to exhaustiveness. I trust it will prove of such interest to the medical profession as to stimulate further enquiry, and I look forward to the time when many of the hitherto unsolved problems connected with the manual treatment will cease to baffle our understanding. Above all, it is my earnest hope that xiv. PREFACE this treatment will receive the acknowledgment and encourage- ment it so richly deserves, and that it will speedily be relegated to its proper place in the world of modern theurapeutics. My very best thanks are due : To Mr. Henrik Kellgren, under whom I have studied at intervals from 1893 until the time of writing, and to whom I lie under obligations of gratitude which it is impossible to repay. To Dr. Harry Kellgren, for most useful aid in many direc- tions, including the classification and description of shakings, vibrations, and frictions. To Professor Starling, for valuable advice on some of the points connected with the physiological effects of the various movements. To Mr. Allan Broman, for many kind suggestions and for generous assistance in the revision of the whole of' my work. To my wife, Annjuta Cyriax, medical student, my sister, Eva Cyriax, B.Sc, and Mr. Svahnberg, for help in numerous ways which it would take too long to specify minutely. Edgar F. Cyriax. London, 1903. PART I. GYMNASTIC MOVEMENTS. THE ELEMENTS OF KELLGREN'S MANUAL TREATMENT. CHAPTER I. INTRODUCTORY. Although medical gymnastics and also massage in some form or other have been in use for all time of which there exists any historical record, the first attempt to place a system of such movements on a scientific basis was made by the Swede, Pehr Henrik Ling. Ling was born in Ljunga, in the south of Sweden, in 1776. He matriculated in 1793, and applied himself to the study of divinity, intending to follow in the footsteps of his father ; in 1797 he took his degree. But his restless spirit rebelled against a sedentary life ; Ling wished to travel, and accordingly left his native country. First he went to Copenhagen, where he figured in various capacities, amongst others as a teacher of modern languages. Then he left Copenhagen, but of the ensuing few years of his life information is meagre and indefinite. It is certain that he visited Germany and France ; and also it is probable that during the course of his wanderings he spent some time in England ; but his career cannot be traced again with accuracy until 1804. In that year Ling was back in Sweden, and in the town of Lund was established as an instructor in the arts of fencing and gymnastics. While on the Continent he had been compelled in consequence of pecuniary difficulties to undergo many hardships and privations, resulting in serious damage to his health ; at the time already referred to his constitution was much impaired, and he was a constant martyr to rheumatism. Bodily 1 2 ELEMENTS OF KELLGREN'S MANUAL TREATMENT ailments did not, however, keep him from pursuing an active life, and his reputation as a master of fencing and gymnastics developed into considerahle fame. The movements and exercise necessitated by his daily work soon proved of great benefit to his physical condition, and shortly after his appointment in 1805 as fencing master to the University of Lund, Ling found that his rheumatism had disappeared, and that he had regained his former strength and vigour. These facts turned his thoughts in a new direction. What had been of benefit to himself might also be of benefit to others, and he came to the conclusion that it ought to be possible to devise various movements with different physiological effects for the treatment of various ailments. He likewise argued that a further series of movements could be contrived which would tend not only to keep healthy persons in that condition, but also to strengthen them by developing their bodies equally in all directions. The question now arose : how could these theories be turned to practical account ? Ling saw that it was impossible to work out a rational system of gymnastics without previous knowledge both of the structure of the human organism and of its complex functions ; he brought the matter to the notice of the Senatus of the University, and made formal application for permission to study anatomy and physiology. This was readily granted, and in 1806 he began to attend the dissecting-rooms and hear lectures. Not only did he make himself a thorough master of what at that time could be learnt in the departments of medical science above specified, but in the course of years he went through nearly the entire curriculum required of candidates for degrees in medicine and surgery, without, however, actually taking any qualification. In the light of the extensive knowledge thus obtained, Ling, by adopting, adapting, and modifying some of the movements he had learnt on the Continent, and by devising many other new ones, at last produced a practically new system of gymnastics which is called after him. This system is divided into four branches : — (1) Pedagogical (educational), in which the individual learns to place his body under his own control. (2) Medical, in which is learnt the alleviation or cure of diseased conditions. (3) Military (antagonistics), in which the individual learns to INTRODUCTORY 3 bring an external object {e.g., a weapon) under his own will and control. (4) iEsthetic, in which the individual learns by movements (gestures) to express his inner thoughts and feelings. The system very soon awoke the public interest, and Ling tried to induce the Swedish Government to assist him in founding an institution for the practice, study, and teaching of the new methods. His efforts, for some time in vain, were at length crowned with success, and in 1813 the Eoyal Gymnastic Central Institute,' subsidised by State, was opened in Stockholm, and lie was appointed its first Principal. The medical part of his system did not at first meet with the approval of members of the orthodox medical profession, who, in fact, did all they could to prevent its gaining ground. This is scarcely to be wondered at, as the fundamental principle on which it was founded {i.e., the beneficial effect of movement) was directly opposed to the doctrines which had ruled for so many years. Ling and his pupils, however, in the face of great discouragements, persisted in their efforts to get the value of their methods recognised ; they kept on demonstrating practically the results which could be obtained thereby, and at length, after many weary years of work and waiting, they achieved their purpose, as is evident from the fact that in 1831 Ling was elected by the Swedish General Medical Association to be a member of their body. Ling died in 1839, and according to his own words, uttered shortly before his death, left behind him only two men who really understood his system and were capable of furthering its progress.^ These were Lars Gabriel granting, the greatest of all bis pupils, and Karl Augustus Georgii. The former already installed at ' I shall iu the ensuing pages use the abbreviation G.C.I, to denote this Institute. - The following is a list of the chief biographical papers on Ling : — Frost, " Minnesord ufver ... P. Henrik Ling," &c., May 9, 1839, translated into German in 1861 by Rothstein, under the title of '• Gedenkrede auf Pehr Heurik Ling." Atterbom, " lutriidestal i Svenska Akadomien," 1840. Werlauff, " Bidrag till P. H. Ling's Biografi," in Freij, 1S48, pages 92-105. Nyblfeus, " Ling och Gymnastiken," 1853. Georgii, " A Biographical Sketch of the Swedish Poet and Gymnasiarch, Pehr Henrik Ling," 1854. Beskow, "Minnesteckning P. H. Ling," 1866. Nybljeus, " Minnestal (ifver Pehr Henrik Ling," 1870. J. L. (.letta Liedbeck), " Pehr Henrik Ling," in Tidskrift i Gymnastik (the biannual journal of the G.C.I.), vol. iii. part 10, 1893, pages 870-891. Torngren, "Minnestal ofver Pehr Henrik Ling den 15 Nov., 1896," in Tidskrift i Gymnastik, vol. iv., part 7, 1896, pages 413-432. 4 ELEMENTS OF KELLGREN'S MANUAL TREATMENT the G.C.I, as one of the head instructors, stepped into the chair rendered vacant by Ling's death ; Georgii became sub- director, which post he held until 1849.' About this time two new men came into prominence. Major Eothstein and Dr. Neumann, both Germans, who went to Stock- holm in order to study Ling's system. Later on Eothstein published the only systematic comprehensive work on Ling's system that exists (although the section on medical gymnastics is incomplete, and the one to which least space is devoted). It is entitled " Die Gymnastik nach dem System des Schwedischen Gymnasiarchen P. H. Ling." Neumann, a most careful observer, published various treatises — "iDie Heilgymnastik," " Lehrbuch der Leibesiibungen," &c., which, although excellent in many parts, are characterised by a decided tendency to exaggeration and hyperoptimistic views. To Eothstein and Neumann belongs the credit of having introduced Ling's system into Germany. When Brantiug resigned in 1862, Georgii was invited to succeed him, but declined, chiefly because he was attempting to introduce Ling's system into England, and did not wish to leave the field of his labours. Both Branting and Georgii were assisted in their work by Hjalmar Ling^ (son of P. H. Ling), who was as energetic as either of the others in developing his father's system. He was professor of anatomy at the G.C.I., from 18-51-1864, when he was appointed professor of pedagogical gymnastics, a position which he retained until 1882. Together with Thure Brandt,' who specialised in the gymnastic treatment of female diseases, the afore-mentioned Swedes must be regarded as the pioneers of the system, and as those who did most for it. No one of them I possessed the orthodox medical qualification ; but each had minutely studied anatomy, physiology, pathology and the nec- essary branches of science without knowledge of which they would, of course, have been helpless and unable to make any progress. ' Short biographical sketches of Brautiug and Georgii have been published by Hartelius in Tidskrift i Gymnastik, i.e., Hartelius's " Lefnadsteolsning ofver L. G. Branting," part 15, 1S81, page 931, &c., and " Lefnadsteckning ofver Carl August Georgii," part 16, 1881, page 989. ^ No biographical sketch o£ Hjalmar Ijing has been published in Tidskrift i Gymnastik. " A biographical sketch of Thure Brandt has been published by Wide in Tidskrift i Gymnastik for 1895, part ii. , p. 247. INTRODUCTORY S Although the results had been recognised by the members of the medical profession in Sweden, but few of the latter studied the system at all carefully or with a view to actually practising it. One of those who did so was T. J. Hartelius, M.D./ who was appointed professor of the medical department of the G.C.I, in 1864. He retained his post there until 1887, when he was suc- ceeded by Kobert Murray, M.D., who holds it to the present day. In order for a non-medically qualified man to graduate as a practitioner of Ling's medical gymnastics, the complete course at the G.C.I, must be taken; this lasts three years. Candidates have to acquire a theoretical and practical knowledge of peda- gogical, military and medical gymnastics, together with anatomy, physiology, pathology and symptomatology. In the case of qualified medical men a course of one year (such as I attended 1898-1899) is deemed sufficient. It consists of practical and theoretical instruction in pedagogical and medical gymnastics, the military portion not being considered essential. A knowledge of the pedagogical portion is regarded as of the greatest importance, as from it the medical branch is and has been to a great extent evolved ; some of the exercises are common to both, and there is no sharp line of demarcation between the two. Also pedagogical gymnastics are to be regarded as forming a hygienic and a prophylactic system ; by developing the entire body they promote health and strength, and thus tend to ward off disease ; or if the latter has set in they enable the body to recover from disease more quickly and thoroughly than could otherwise have been the case. At the end of the curriculum, after duly passing all examina- tions (which are conducted only in the Swedish language), the candidate receives the title of Gymnastic Director, which legally entitles him to practice as a medical gymnast, and places him under the jurisdiction of the General Medical Council. In spite of the fact that there is such a special course of short duration for medical men, very few avail themselves of it, and continual complaints have been raised that doctors and others coming from various parts of the world to Stockholm pay casual visits to the Institute, varying from a few minutes to a few weeks, and then return home posing as authorities on Ling's medical ' A biographical slcetch of Hartelius has been published by Levin in Tidskri/t Gymnastik, 1896, part ii. p. 449. 6 ELEMENTS OF KELLGREN'S MANUAL TREATMENT gymnastics. Hjalmar Liug, in his preface to Branting's post- humous works, issued under the title of " Efterlemnade Skrifter " in 3882, says (pp. xlvi. and xlvii., translated), "Frenchmen, Belgians, Englishmen, Italians and Russians, have in the course of years now and then sent here so-called authorities, who have stayed in Stockholm a few days, partaken of ceremonial dinners, looked on at the gymnastics without taking any practical part in them, and who understood nothing, neither the language nor the subject." Such complaints are still rife and Professor Torngren (now head of the Institute) and Professor Murray have frequently been heard to deplore the fact that such flying visits are the rule and not the exception. It is a matter of great regret that neither P. H. Ling, Branting, Georgii, nor Hj. Ling ever issued a comprehensive work on the subject of Ling's medical gymnastics.^ Being absorbed in obtaining practical results they had but little time to devote to writing, which they left to others. P. H. Lmg- says: "I have gone my own way and have not written," a statement which as far as medical gymnastics are concerned might with equal truth have come from his pupils mentioned above. In consequence, any one who wishes to enrich the literature of the subject is hampered at the outset by the absence of any standard comprehensive work by a real authority. And as a result of the casual hurried visits mentioned above, the vast majority of books and articles written on the subject by so-called " authorities " show a deplorable ignorance of even the very elements of Ling's system. And in the course of time new authors, unable to carry oat researches on their own account, have been compelled to fall back upon the productions of persons no better informed than themselves. In this way there has accumulated an extensive literature about Ling's system, but ' The following is a list of their works on medical gymnastics : — P. H. Ling, " Gymnastikens Allmanna Grunder," 1834 (18iO), reprinted with additions in 186G (a small portion only). This work was translated by IMassmann and istued under the title of " P. H. Ling's Sehriften iiber Leibesiibungen," in 1847. Branting, " Efterlemnade Skrifter," 1882 (a portion only). Georgii, " Kinesithorapie ou Traitement des Slaladies par le Mouvemeut," 1847 ; " A few words on Kinesipathy, or Swedish Medical Gymnastics," 1850 ; " The Movement Cure," 1853. Hj. Ling, "De Fbrsta Begreppen af Rorelselaran," 18C6 (portion only) ; " Forkortad ()fversigt af AUman Eorelseliira," 1880 (portion only); preface to Branting's "Efterjemnade Skrifter," 1882 (portion only). - " Gymnastikens Allmanna Grunder," 1884 (1840), p. 1. INTRODUCTORY 7 only very few works can be selected from it that have real value. It would appear that nowadays the mere production of a book labelled " Die Schwedische Heilgymnastik," or bearing some similar title, is regarded as proof positive of the author's practical and theoretical ability. Of late years much has been done to degrade the profession of medical gymnast, and the system has suffered in consequence. Nowadays all gymnasts in Sw-eden have to act under the super- vision of a medical man, which would certainly be an advantage for the former were his method of treatment understood by the latter. Unfortunatel}', however, the majority of medical men know next to nothing about it. Instances continually recur of patients who, while undergoing a gymnastic cure, are ordered to stop it every nd>w and then because they complain of not feeling quite as well as they might be ; often their medical man orders them rest in bed and some medicinal remedy until they feel better.' This certainly implies that the members of the medical profession in Sweden regard gymnastics as a somewhat dangerous method of cure. At any rate they nowadays trust only the simplest cases to the gymnast, and they are more and more disposed to limit the field of diseases in which gymnastic treat- ment might be used with benefit. All this has resulted in what may be described as " oppression of the gymnastic profession." Ling's system has during the last few years undergone con- siderable modification ; this is mainly due to the efforts of Anders Wide, M.D., of Stockholm. The latter has embodied his ideas in a book entitled " Handbok i Medicinsk Gymnastik," published in 1895-1896, translated into German in 1897, into French in 1898. and into English, under the name of " Handbook of Medical Gymnastics," in 1899 ; the Swedish edition was re-issued in 1902 as "Handbok i Medicinsk och Ortopedisk Gymnastik," and translated in the next year into English as "Handbook of Medical and Orthopsedic Gymnastics." Until the publication of his works the only systematic treatise that had been issued in Swedish was Hartelius' "Larobok i Sjukgymnastik," 1870, reprinted 1883 and 1892. In consequence, Wide's publications have been accepted as standard works, especially by Swedish ' This, as can readily be understood, is a great grievance for the gymnast. Cf. Hartelius, " Den Pedagogiska och Medicinska Gymnastiken," in Tidskrift i Gymnastik, vol. 1., part 7, 1887, p. 313, &c. 8 ELEMENTS OF KELLGREN'S MANUAL TREATMENT medical men, who, as I have said before, in the main know hardly anything about tliis branch of therapeutics ; they have also been thus accepted by many medical men on the Continent ' who have taken up massage and gymnastics as a speciality. It shows, however, how little his supporters know about Ling's gymnastics when I assert as beyond doubt that the first part of his handbook (consisting of about 150 pages), containing the descriptions of the various movements, teems with misstatements and technical errors. Besides this it is obvious to a careful student that the modus operandi of many of the exercises is described so faultily that it is impossible to gather the precise mode of execution, and the effects that these exercises are meant to produce, both from a ph3'siological and anatomical point of view, are in the majority of cases entirely omitted. Most emphatically a hand- book based on such a lack of sound fundamental principles should never have been written. The results of the cases treated by Wide are seldom in any way remarkable, and in some cases they show a distinct retrogression compared with the results obtained from Ling's system in past years. In fact, gymnastics given formerly according to the latter's methods are becoming modified to suit those of Wide, and this is a change for the worse, one which I sincerely hope may soon be effectively checked. Henrik Kellgren, born in 1837, entered the G.C.I, in 18(53, and v/orked there under Hartelius and Hj. Ling until 1865, when he graduated as gymnastic director. Soon after he had begun to practice as medical gymnast he improved many of the manipulations already existing in Ling's system, and added some that were new (without, however, attempting to publish anything concerning the same). As an example of the new manipulations may be quoted nerve frictions and vibrations, by means of which he was able to treat vcith remarkable success diseases of the central nervous system, kc, and which, in his hands, formed a powerful weapon to combat acute specific infectious diseases. It would appear, therefore, that at the present time there are two distinct branches of Ling's system. The one, as expounded ' Jlany criticisms on Wide's German translation have been reprinted, under the title of " Referate iiber Handbuch der Medicinisehen Gymnastik von Dr. Med. A. Wide," by 0. Wide, in Tidxkrift i Chjmnastik, 1898, part 2, pp. 712-734. INTRODUCTORY g in Wide's handbook, is a distinct retrogression and does not compare favourably, either in method or results, with Ling's system as practised by Branting, Georgii and Hartelius. The other, as practised by Henrik Kellgren, marks an equally distinct progress, both in the variety and the technique of execution of the movements, and also in the application of the treatment to many fresh cases, hitherto untouched by the hand of the gymnast. It is the latter branch, to which the name of Kellgren's Manual Treatment has been given, that I intend to interpret in this work. Some of the changes made by Kellgren are often apparently slight, and an inexperienced person might either fail to detect them, or consider them too trivial to be worth regarding. With respect to this treatment, however, more so than in the case of any other, such apparently slight improvements often make a very great difference in actual practice, and heighten enor- mously the beneficial effect aimed at. The medical profession all over the world has until now almost completely ignored Kellgren's treatment, and thus there are hardly any essays from medical men on the subject. The only attempt to describe any of Henrik Kellgren's exercises and manipulations are to be found in the writings of his brother, Arvid Kellgren,^ for many years a pupil under him, a graduate of the G.C.I, and M.D. of Edinburgh. Apart from these a few casual notes by other authors have appeared from time to time in stray medical periodicals, but that is all ; in short, the literature on Kellgren's treatment is practically iiil. ' These are " Vortriige iiber Massage," consisting of a course of sixteen demon- strations given at Pola at the request of the surgeons of the Imperial and Royal Hungarian Navy in 1888-1889, reproduced in " Statischer Sanitiitsbericht iiber die Ivaiserliche uud Konigliche Kriegsmarine fUr das Jahr 1888," and " Technic of Ling's System of Manual Treatment," the first half of which is practically the same as the foregoing, which was accepted as the author's thesis for the degree of M.D. at Edinburgh in 1890. His latter work has been translated into French, Italian, and with some few alterations and additions, into German. CHAPTER IT. GENERAL CLASSIFICATION AND DEFINITIONS. As Kellgren's methods are based upon Ling's, I shall, whenever possible, follow the example of the best textbooks ^ on Ling's system regarding classification, arrangement, Ac, of the various positions, exercises and manipulations. The Swedish term " Sjukgymnastik," which may be trans- lated as " medical gymnastics," has at various times been replaced by synonyms, such as " Rorelsekuren " (i.e., movement cure), Heilorganik (Neumann-) " Kinesitherapie," " Kinesipathy " (Georgii ') and others too numerous to mention. By a gymnastic position is meant the posture which must be correctly assumed before a gymnastic movement either of the active or passive kind can be executed, and which must be strictly maintained throughout the performance of such movement (with the exception, of course, of that part of the body which is actively brought into play thereby). This rule is only relaxed in certain cases of passive movements (see Chapter VI.). To define a " gymnastic movement" is not easy, because the term is applied to everything from the most powerful active exercise to the most gently and lightly-applied pj^ssive manipula- tions. Its various significations will best be gathered from the following classification and descriptions. Gymnastic movements are divided into : — I. — Active. II. — Passive. I. — Active Movements are such as are performed by an ' The only two textbooks of any real value are as follows: Neumann, "Die Heilgymuastik," 1852; Hartelius, " Liirobok i Sjukgymnastik," first edition 1870, second edition 1883, third edition 1892. - "Das Jluskelleben des Menschen in Beziehung auf Heilgymnastik und Turnen," 1855, j). iii. '■' " Kinesitherapie ou Traitemeut des Maladies par le Mouvement," 1847. "A Pew Words on Kinesipathy, or Swedish Medical Gymnastics," 1850. GENERAL CLASSIFICATION AND DEFINITIONS ii individual through his own volition, and by means of his own effort. In order to accomplish any active movement definitely and exactly it is necessary to determine clearly the following con- ditions : (1) a point of departure, i.e., a commencing position; (2) a certain number of intermediate positions, which could theoretically be extended to infinity ; (3) a point of termination, i.e., a final position ; (4) the velocity and rhythm of the movement. Active movements are of two kinds : — (1) Without resistance, called purely active or unduplicated. These are further divided into (a) free ; (b) bound. (2) With resistance, called duplicate. These are further divided into (a) concentric ; (b) excentric. Purely active movements are those in the course of which no external resistance is offered to the patient's efforts. With the " bound " variety, steadiness and isolation are secured by means of fixation or support either from apparatus or from external assistance applied by another person; with the "free" variety no such means are employed. Duplicate movements are those in the course of which another individual, henceforth to be called the assistant, resists the efforts of the patient, or vice versa. The resistance or force used by the assistant is modified according to each patient, his daily variation, and the nature of the malady under treatment, so that the maximum effect desirable be obtained. In a duplicate concentric movement the assistant resists while the patient causes his own contracting muscles to shorten. In a duplicate excentric movement the patient resists, while the assistant causes the former's "contracting"' muscles to become longer. The terms " duplicate concentric " and " duplicate excentric " were first introduced into German by Neumann," and have since been adopted by the Ling school, who speak of either " dupli- cerade " or " dubbel " exercises. The older terms were " half- ' It seems a contradiction to speak about contracting muscles becoming longer, but the terms are those used in physiology. - See " Zav (Schwedisohen) Heilgymnastik " in Gasper's Wochenschrift, 1849; " Heilgymnastisohe Pragmente," ibid., 1850 ; " Die Heilgymnastik," 1852, pp.15, &c. 12 ELEMENTS OF KELLGREK'S MANUAL TREATMENT aktiv " and " half-passiv " (c/. Kothstein/ Eulenburg,- r legs, as thereby the lower part of the quadriceps cruris is thrown out of action. (2) Flexion and Extension of the Trunk on Itself. Forwards Lying Back Raising (Arching) Breathing, PA. The patient assumes the forwards lying position. The assistant fixes the patient's feet and exercises traction on them away from the trunk. Placing his arm into hips firm position, the patient then brings himself into arch forwards lying position, and remaining thus, breathes deeply three times (fig. 34). The effect of this exercise may be increased by putting the arms into neck firm, or even in stretch position (see p. 79). The extensors of the spinal column and thighs are in action. This movement is also a respiratoi'y exercise. Head Lean Arch Standing Toe Raising, Breathing, PA. The patient assumes the head lean arch standing position with hips firm. He then rises on his toes, but keeps his head at GYMNASTIC MOVEMENTS 8i the same level as at first, after which he sinks down on his heels, on this occasion letting body and head move together ; the net result is to leave the spinal column more arched than before. The process is repeated three times ; each time the patient's head descends, and each time his spinal column becomes more and more arched in the dorsal region, while his chest is brought out more prominently (fig. 35). Deep inspiration should take place during the rising on the toes, deep expiration during the reverse. After the third repetition the patient straightens him- self up to hips firm standing position. When patients are unable to perform this exercise without the spine becoming lordosed during its execution, the position of the head may be left constant instead of being allowed to change with each sinking on the heels. The muscles affected are brought into use in the following manner : — During the first part of the exercise, in order to bring the patient into arch position, there takes place : — a slight con- centric contraction of the erector spinas muscles with elongation G 82 ELEMENTS OF KELLGREN'S MANUAL TREATMENT of the anterior abdoiuiiial muscles. This is ahnost immediately replaced by aa excentric contraction of the anterior abdominal muscles, to counteract the pull of gravity, with passive shortening of the erector spinae. Elongation of the anterior abdominal muscles in consequence of recommencing concentric contraction of the erector spina; then takes place. During the second part of the movement {i.e., during the toe raising), the erector muscles of the spine and extensors of the ankle-joint are in action. The return to the original position is effected through concentric contraction of the anterior abdominal muscles {cf. Hj. Ling'). This movement is very useful in disorders of coordination, (see p. 68); it is also a chest expanding exercise (see p. 124 . (3) Flexion and Extension of the Trunk on the Hip-joints, combined with Flexion and Extension of the Trunk on Itself. Stretch Stride Standing Bending Forwards, PA. Tlie patient assumes the stretch stride standing position, (fig. 7, p. 18), stretched to his utmost with the abdomen well drawn in (this latter is very important in the case of a patient suffering from pelvic disease or hernia through the anterior abdominal wall). He then proceeds as follows : — (1) He flexes his trunk on his hips as in ride sitting trunk flexion (p. 77). In order to preserve the balance the pelvis must meanwhile be carried somewhat backwards. (2) Having executed this movement as far as possible without bending the knees, he flexes the spinal column on itself, the flexion commencing in the upper dorsal region and gradually passing downwards. The arms, however, are throughout to be kept as far back as possible. (3) When this has been carried out to the utmost limit, he executes the reverse of (2), still keeping the knees quite straight. (4) Fmally he executes the reverse of (1), so as once more to reach the initial position. This division into parts is merely for the sake of clearness of description ; in practice the exercise should be performed evenly ' "De Pcji-sta Begreppen af Riirelseliiran," J866, pp. 21G, 217. GYMNASTIC MOVEMENTS 83 and continuously, the parts merginf; into one another without a break. The actual movement is initiated by a concentric contraction of the anterior abdominal muscles and flexors of the hip-joint, with elongation of the extensors of the hip-joint. This is almost immediately replaced by excentric contraction of the latter, to counteract the pull of gravity. When that stage of the movement is reached where the spinal column is flexed on itself, there takes place excentric contraction of the erector spinse, aided at the very termination of this stage by recommencing concentric contraction of the anterior abdominal muscles and flexors of the hip-joint. The reverse movement is then efl'ected by concentric contraction in the erector spinse and extensors of the hip-joint. The flexors of the ankles are first excentrically and then con- centrically contracted. The extensors of the knees have to work hard in order to maintain the straightness of the knees against the pull of the hamstrings. Many of the other muscles of the leg are active in order to maintain equilibrium. Effect on the abdominal contents. — In consequence of the alternate application and removal of pressure and of the alternate elongation and shortening of many of the abdominal blood and lymph vessels, the whole of the abdominal contents are stimu- lated, and the venous and lymphatic return from them promoted. For the same reasons the flow in the thoracic duct and inferior vena cava will be hastened, as these structures lie against the vertebral column and closely follow all its movements. Thus the venous return from the legs will be influenced as well as that from the splanchnic area (cf. P. H. Ling,' Georgii,^ Hj. Ling,^ Loven,'' Braune'). Effect on the thorax. — The blood-vessels and lymphatics of the intercostal spaces will be alternately subjected to and relieved from pressure, and thus their venous and lymphatic circulation will be promoted. The latter is aided by the fact that the lym- phatics of these spaces are arranged in two sets just as in all the ' " Gymnastikens AUmiinna Grunder" (1834), 1840, p. 143. - " Kinetic Jottiugs," 1880, pp. 112, 113. 5 " Porkortad Ofversigt af AUman Rorelseliira," 1880, p. 54. ' " Om Blodet," 1876, pp. 59, 60. ' "Beitrag zur Kenntniss der Venenelastioitiit," pp. ii. aud v., in " Beitrage zur Anatomie und Physiologie, Festgabe fiir G. Ludwig," 1874. 84 ELEMENTS OF KELLGREN'S MANUAL TREATMENT tendons and aponeuroses of the body ' (see p. 27). The lungs are alternately diminished and increased in volume. Effect on the spinal cord and size of the spinal canal. — First elongation and then shortening of the spinal cord^ and its longi- tudinal veins take place ; the spinal cord will be stimulated, and the flow in the veins hastened. The capacity of the spinal canal is probably first slightlj' diminished and then increased.' (4) Lateral Flexion and Extension of the Trunk on Itself. Stretch Stride Standing Bending Sideways, PA. The patient assumes the stretch stride standing position, stretched to his utmost. He then flexes his trunk laterally to side bend position, stretching especially the arm of the elongated side, keeping his lower limbs and pelvis as still as possible. No rotation of the vertebrae should take place, i.e., there should be no protrusion of either shoulder or hip. The reverse move- ment is then executed, thus bringing the patient back into the initial position, after which the whole process is repeated towards the other side (fig. 36). Respecting the muscles that are in action in this movement : — Suppose the patient to perform the exercise towards the left side. At first the left lateral flexors of the trunk contract concentrically to a very small amount ; immediately after this they undergo a passive shortening, this being due to excentric contraction of the right lateral flexors, to counteract the pull of gravity. When the latter are incapable of further excentric contraction they become elongated, in consequence of recom- ' Dybkowski, " Uber Aufsaugung und Ab-sonderung der Pleurawand," in Arbeiten an der Phys. Anat. zu Leipzig, 1866, pp. 40-67. - See Hegar, "Die Ruckenmarksdeiinuug," in Sammlung Klinischer Tortragc, 1884, No. 239 ; Gyncikologie, No. 65, pp. 1699-1714. Tourette and Chipault, " Le traitement de I'ataxie par I'eloDgation vraie de la moelle ^pini&re," in Nouvelle Iconographie de la Salpetiire, 1897, vol. x., pp. 145-154. Tourette and Gasne, "Le traitement de I'ataxie locomotrice par I'^longation vraie de la moelle epini^re," ibid., 1898, vol. xi., pp. 18, 19. P. H. Ling refers to exercises on the spinal cord in " Gymnastikens AUmiinna Grander" (1834), 1840, p. 158. C/. Neu- mann, " Lebrbucii der Leibesiibungen des Menschen," 1856, part ii., pp. 136, &c. Hj. Ling, " Forkortad Ofversigt a£ Allmiin Rorelselara," 1880, p. 54. ' Reid and Sherrington, " The Effect of Movements of the Human Body on the size of the Spinal Canal," Brain, vol. xiii., 1890, pp. 449-455. GYMNASTIC MOVEMENTS 85 mencing concentric contraction of the left lateral flexors, which continue to contract until the right side of the trunk cannot be elongated any more. The right lateral flexors then perform the reverse movement. The effect on the abdomen is the same as in the case of the last exercise. The circulation in the inferior vena cava and the lower two azygos veins is hastened, as is also the venous and lymph flow from the intercostal spaces and the pleura. There will be alternately an increase in the size of one lung, coupled with a decrease in the size of the other, and then the reverse. Effect on the spinal cord. — All lateral trunk movements produce elongation of one side of the cord and shortening of the other, though whether this is sufficient to cause an appreciable stimulation has as yet not been experimentally demonstrated. 86 ELEMEXTS OF KELLGREN'S MANUAL TREATMENT Hip Lean Walk Standing Lateral Flexion, PP, Extension,^R. The patient assumes the hip lean walk standing position with neck firm. The assistant grasps the patient round the elbows, and, while keeping up traction away from the pelvis, flexes his trunk laterally over the bar into side bend position. The reverse movement is then executed with AE applied at the elbow of the extended side, the assistant's other hand being only used to steady the patient (fig. 37). The muscles placed in action are the lateral flexors of the trunk on the side remote from the support, which are first passively elongated and then concentrically contracted. The effect of this movement on the abdomen and thorax is the same as in the case of the last exercise. GYMNASTIC MOVEMENTS 87 Ringing.' This is a passive form of movement, consisting in a rapid alternating flexion and extension. The use of the v?ord, how- ever, is very restricted. Loin Lean Stride Standing Ringing, PP. The patient assumes the loin lean stride standing position, with the arms in neck firm position. The assistant applies his grasp under the patient's elbows, and keeping up traction away from the pelvis, flexes the patient's trunk to one side (say the left) into left side bend position, then right over through the ' This is a literal translation of the Swedish word " ringning," and though not bearing quite the same meaning, is yet the nearest English equivalent possible. 88 ELEMENTS OF KELLGREN'S MANUAL TREATMENT original to right side bend position, and back again. Altogether the process is repeated six or eight times fairly quickly, the patient returning at the close into the initial position (fig. 38). This movement may l^e performed from other initial positions, such as ride sitting or loin lean stride kneeling. The effects on the abdomen and thorax are similar to those in the case of the last exercise. The lateral flexors of the trunk are alternately passively elongated and shortened. Exercises which, like the above, consist in a passive alter- nating flexion and extension of the trunk, have always been regarded by the Ling school as having a sedative effect on the brain, and thus tending to remove insomnia.' [The term ringing has also been applied to sit lymg knee extension and flexion, PP (see p. 68).] ' Cf. Hartelius, " Larobok i Sjuligjmnastik," ISVO, p. 106 ; 1S83, p. 1892, p. 109. 109 GYMNASTIC MOVEMENTS ABDUCTION AND ADDUCTION. (1) Of the Shoulder-joint. Modern anatomists are still somewhat at variance regarding the mechanism of these movements. It used to be laid down that the first half of the movement up to the horizontal was accomplished by movement at the gleno-humeral joint, the scapula being fixed, and that the second half depended solely on rotation of the scapula. This explanation, however, is manifestly incorrect ; it implies that the scapula would rotate through an angle of 90", so that at the conclusion of the movement its vertebral border would be horizontal, which is contrary to what actually obtains. At a later period certain observers stated that the scapula rotated most during the first half of the movement and least during the last quarter.^ As a matter of fact there are two methods of performing the movements of abduction and adduction of the shoulder, just as in the case of flexion and extension of that joint : — (i) As during every-day life, the scapula not being fixed. (ii) As during gymnastic exercises, the scapula being kept drawn inwards and backwards. In the former of these two cases the facts are as stated by the authors just referred to ; in the latter the details are as follows : — (a) During the first part of the abduction up to yard position. The scapula remains immovable, and the movement takes place only at the gleno-humeral joint. (b) During the second part of the abduction up to stretch position. At first the movement is effected almost exclusively by ' See, for example, Cathcart, " Movements of the Shoulder-girdle involved in those o£ the Arm on the Trunk," in Journ. of Anat. and Phys., 1884, vol. xviii., pp. 211, &e. Cleland, "Notes on Raising the Arm," ibid., p. 275. Cleland and Mackay, " Human Anatomy,'' 1896, pp. 155 and 267. Dalla Kosa, " Physiologische Anatomie des Menscheu," 1898, vol. i., p. 283. Mollier, " Uber die Statik uud Mekauik des meusohliehen Schultergiirtels unter uormalen und pathologischen Verbaltnissen," 1899. Steinhausen, " Beitrage zur Lehre von dem Mechanismus der Bewegungen des Schultergiirtels," in Archiv. f. Anat. u. Phys., Physiol. Abth., Suppl. End., 1899, pp. 403, &c. Gray, " .\natomy. Descriptive and Surgical," 1901, p. 235. 90 ELEMENTS OF KELLGREN'S MANUAL TREATMENT rotation of the scapula, the gleno-humeral joint participating very shghtly indeed. Then the scapula rotates less and less in pro- portion to the movement at the gleno-humeral joint, the final stage being effected almost exclusively by movement at the latter. During the reverse movements the reverse takes place.' The reasons for keeping the scapula draw^n inwards and back- wards are the same as those given on pp. 45, 46. The amount of internal rotation of the humerus that is present in the original position {i.e., where the arm is hanging vertically downward) will, if kept constant, render it impossible for the arm to be fully abducted. A certain amount of external rotation of the humerus must take place in order to enable the arm to be brought into stretch position. From the standpoint of medical gymnastics the movements of ' Cf. Hj. Ling, " De Piirsta Begreppen af R5relselaran," 1866, pp. 206, 229, 230. GYMNASTIC MOVEMEXTS 91 abduction aud adduction of the shoulder-joint may be divided into two classes : (a) without co-movement of the elbow-joint ; (6) with co-movement of the elbow-joint. Two examples of each will be described. Ride Sitting Double Arm Abduction, AR, Adduction, PR. The patient assumes the ride sitting position ; the assistant grasping the patient's wrists, performs traction away from the shoulder and resists while the patient abducts his arms through yard position (with the palms of his hands looking directly for- wards) up to stretch position (where the palms should look directly towards each other). The reverse movement is then executed, generally with PE, although it may be given with AR (fig. 39). Alternate abduction and adduction of the shoulder-jouit takes place with a certain amount, respectively, of external and internal rotation of that joint and supination and pronation of the radio- ulnar joints. If the movement be executed as above, the abductors are exercised, but if executed as abduction AR, adduction AR, then first the abductors and then the adductors are brought into play. The chest alternately increases and decreases in size. The effect on the venous and lymph flow is practically the same as in the case of arm raising (pp. 48, 49). Swim Sitting Double Elbow Pressing Downwards, PR, Upwards, AR. The patient assumes the swim sitting position ; the assistant keeping up traction away from the shoulders, presses over the upper aspect of the elbow-joints, so as to cause adduction of the upper arms through a right angle, i.e. until they lie against the sides, the patient continually resisting and keeping his elbows well back. The reverse movement is then executed with AR (fig. 40). Adduction and abduction (but not rotation) of the shoulder-joint takes place, the muscles called into action being its abductors. Half Lying Double Arm Bending and Stretching, AR. The patient assumes the stretch half lying position with the palms of the hands looking either directly away from one another or directly forwards (more rarely directly towards one another). 92 ELEMENTS OF KELLGREN'S MANUAL TREATMENT The assistant ^'rasps the patient's hands in his own and resists, while the patient, keeping his upper arms and forearms in the coronal plane, adducts the former and flexes the latter, nntil the maximum of these movements is ohtained. The amount of pro- nation adopted in the initial position should be kept constant. The reverse movement is then executed with AE (fig. 41). During the bending the adductors of the shoulders and the flexors of the elbows are placed in action ; during the stretching their antagonists are called into play. With persons not accus- GYMNASTIC MOVEMENTS 93 toiued to the exercise, there is a tendency for the pectoral muscles to draw the elbows forwards, and this tendency is greater when the forearms are supinated than when they are pronated; in the latter case the posterior scapular muscles have a tendency to work harder than the pectorals. Double arm bending and stretching, AR, may be given from initial positions that entail greater exertion, such as stretch sitting (with the back unsupported) , or stretch arch forwards lying ; under these circumstances the erectors of the spine (in addition to the above-mentioned muscles) are especially affected. Hanging Trunk Raising with the Arms, PA. The patient assumes the hanging position, generally with the palms of the hands looking forwards {i.e., the forearms are pronated), although under certain conditions they may look back- wards {i.e., the forearms are supinated). The patient raises himself up towards the bar by adducting his shoulder-joints and flexing his elbows to the maximum, keeping the trunk and legs still. The reverse movement is then executed. The adductors of the shoulders and flexors of the elbows (see p. 50) are first concentrically and then excentrically contracted. Abduction and adduction of the shoulder-joint also enter into certain other movements, such as (1) standing double arm stretching outwards, PA (p. 53) ; (2) walk standing double arm circling, PA (p. 130), &c. (2) Of the Thumb and Fingers. Abduction and adduction of the thumb can be prescribed in cases of weakness of the muscles that perform these movements. Abduction and adduction of the fingers can be prescribed to exercise the interosseous muscles ; the dorsal interossei are called into action in abduction, AR, adduction, PR, the palmar ones in abduction, PR, adduction, AR. (3) Of the Hip-joint. Lying Double Leg Abduction, AR, Adduction, PR. From the lying position the patient, keeping the knees fully extended, separates his legs (i.e., performs abduction of the thighs), while the assistant, supporting the heels, applies resist- ance over their outer aspect with traction away from the pelvis. 94 ELE.VENTS OF KELLGRES'S MANUAL TREATMENT Adduction is then executed with PK. Tliis movement may also be executed from half lying position. The abductors of the hip-joint are exercised. If the heels are not supported by the assistant then the patient has also to call into action the flexors of the hip-joint and fixators of the pelvis. Side Lying Leg Lifting, AR, Pressing Down, PR. The patient assumes the side lying position. The assistant applies one hand over the outer surface of the ankle of that leg which is uppermost ; with the other hand he steadies the hip. He then performs traction away from the pelvis, and resists while the patient abducts his leg as much as possible (see p. 44), after which the reverse movement is executed with PR. The pelvis must be kept immovable, otherwise some flexion or extension of the hip-joint will enter into the movement (fig. 42). The muscles required to fix the pelvis and the abductors of the hip-joint are placed in action. Lying Double Leg Flexion, PA, Abduction, AR, Adduction, PR. The patient assumes the lying position, and then performs double leg flexion, PA, through an angle of about 30'. Steadily GYMNASTIC MOVEMENTS 95 maintaining this degree of flexion, he separates his legs as far as possible while the assistant, keeping up traction away from the pelvis, resists over the outer aspect of the heel. The reverse movement is then executed with PE (fig. 43). The flexors and abductors of the hip-joint and fixators of the pelvis are exercised. Crook Half Lying Double Knee Abduction, AR, Adduction, PR. From the crook half Ij'ing position the patient separates his knees as far as possible, keeping his heels together all the time, with AR over the outer side of the knee-joint. The reverse movement is then executed with PR (fig. 44) . At first abduction with external rotation of the hip-joint takes place, and then the reverse. The muscles actively engaged are the abductors, and some of the external rotators of the hip-joint. The psoas and iliacus are not in action. The above exercise may be performed while the patient lifts himself off the couch somewhat, resting on his shoulders and heels. Under these circumstances he lifts up the whole pelvic floor and levator ani, an action that exerts a powerful corrective effect on tendencies to prolapse of the rectum (and in female patients of the vagina and uterus). 96 ELEMENTS OF KELLGREN'S MANUAL TREATMENT This exercise may also take the form of abduction, PE> adduction, AR, i.e., the patient resists while the assistant (whose hands are placed on the inner aspect of the knee-joints) separates his knees, and then the reverse. By these means, blood is sent to the pelvic organs, whereas in the former case (abduction, AR, adduction, PR), blood is drawn away froixi them (cf. Thure, Brandt 1). 'Massage bei Frauenleiden," 1897, pp. 99, 100. GYMNASTIC MOVEMENTS 97 ROTATION (TURNING). By the above term is meant rotation on the axis which is vertical in the fundamental standing position. I.— Of the Upper Extremity. (1) At the Shoulder-joint. Kotations at this joint can be given with the arm in heave position and the elbow supported. The assistant's grasp is over the wrist-joint, and by means of movements of the forearm through the sector of a circle (the centre of which is the elbow) passive or duplicate movements of internal and external rotation of the humerus are accomplished. In internal rotation, AR, external rotation, PR, the sub scapularis, pectoralis major, latissimus dorsi and teres major are exercised; in external rotation, AR, internal rotation, PR, the teres minor and infraspinatus are in action. (2) At the Wrist-joint. Anatomy text-books as a whole ignore the possibility of passive rotation at this joint. That it exists, however, can easily be demonstrated. The radius and ulna are fixed by the assistant's one hand ; the other, grasping the hand of the patient, turns it first in one direction and then in the other.-^ Such passive rotation of the wrist-joint can be used in order to free that joint in cases of adhesions, stiffness, &c. Active rotation of the wrist is, of course, impossible. II. — Of the Lower Extremity. (1) At the Hip-joint. The patient is usually in .half lying position; the toes are moved through the arc of a circle whose centre is the heel. The ' Wide is not aware of the fact that such rotation exists. See " Haudbok i Medicinsk Gymnastik," 1896, p. 358; "Handbook of Medical Gymnastics," 1899, p. 207 ; " Handbok i Medicinsk och Ortopedisk Gymnastik," 1902, p. 299 ; " Hand- book of Medical and Orthopaedic Gymnastics," 1903, p. 297. 7 98 ELEMENTS OF KELLGREX'S MANUAL TREATMENT knee-joint being fully extended rotation at these joints is rendered impossible : the whole movement is in consequence transmitted to the hip-joint. To convert the exercise into a duplicate one resistance is applied over the outer side of the metatarsus in the case of external rotation, AR, and over the inner side in the case of internal rotation, AR; or, better still, over the outer and inner surfaces of the knee-joint, as in the latter case traction can be more effectually applied. One of the assistant's hands is placed over the knee-joint, as mentioned, while the other guides the foot in its course, both performing traction away from the hip. The muscles exercised are the external and internal rotators of the hip-joint respectively. When the assistant's grasp is over the foot alone, the eversors and inversors respectively of the tarsal joints are placed in action in order to maintain the position of the foot.' (2) At the Knee-joint. Rotation exercises are not often applied to this joint, as the muscles performing the movements can be exercised in other ways. III.— Of the Head. The assistant places one hand on the patient's forehead and the other over his occiput (as in iig. 4-5). Applying traction upwards all the time, the patient's head is first turned to one side, and then to the other, passively or with resistance as the case demands. The movement chiefly affects the joint between the atlas and axis. In order to prevent over-extension of the spinal cord, the head sinks somewhat during the rotation, and becomes elongated again during the reverse movement. - The muscles used to perform the turning are those which rotate the joint mentioned, and those which rotate the cervical vevtebrfe. ' Wide states that in tliis exercise most of the muscles of the leg are put into action. See " Handbok i Medicinsk Gymnastik," 1895, p. 118; "Handbook of Medical Gymnastics," 1899, p. 117 ; " Handbok i Sledicinsk och Ortopedisk Gymnastik," 1902, p. Ill; "Handbook of Medical and Orthopiedic GjTnnastios," 1903, p. 125. - Henke, " Handbuch der .^natomie uud Mekanik der Geleuke," 1863, p. 9G. GYMNASTIC MOVEMENTS 99 Rotations of the head combined with flexion maj' also be given (see flexion, p. 75). IV.-Of the Trunk. Loin Lean Stride Standing Alternate Rotation, AR. The patient assumes the initial position with neck firm. The assistant grasps the patient round the elbows, and lifting the trunk upwards brings it passively into turn position. The reverse movement is then executed witli AR in front of the posterior elbow and behind the anterior one (more especiall\' the latter), with traction upwards as before. The whole process is repeated on the other side (fig. 46). This movement may also 1)6 performed from ride sitting or loin lean stride kneeling position . In this exercise the trunk is rotated on the vertebral column in its dorsal region. Suppose the patient to be placed in right turn position ; the muscles which bring him back to the original position may be classed in three great divisions : — (1) External loo ELEMENTS OF KELLGREN'S MANUAL TREATMENT oblique and external intercostals of the right side. (2) Internal oblique and internal intercostals of the left side. (3) Eotator muscles of the trunk, i.e., multifidus spinas and rotatores spinae of the right side, semi-spinales of the left side, &c. In addition, the posterior scapular, upper dorsal and cervical extensor muscles are powerfully contracted in order to maintain the position of the arms and head. The effects are similar to those induced by lateral flexion of the trunk (p. 84). The abdominal contents are stimulated directly and reflexly (see p. 78) ; the flow in the portal vein, inferior vena cava, lower two azygos veins and the intercostal veins is promoted. The lymph flow in the abdomen and intercostal spaces is furthered. The spinal cord is probably stimulated and its venous circulation promoted. GYMNASTIC MOVEMENTS PRONATION AND SUPINATION. These movements occur only with regard to the radio-ulnar joints. The patient's forearm is flexed to about a right angle, in order to ehminate as much rotation as possible at the shoulder-joint.' The assistant then fixes the elbow-joint with one hand, and with the other grasps that of the patient as if he were going to shake hands ; the movements of pronation and supination, passive or duplicate, are then executed {fig. 47 shows supination, AR, pro- nation, PE). In ordinary life, pronation and supination are effected by first grasping some object with the hand and then trying to turn it one way or the other. This means that the flexors of the fingers and fixators of the wrist-joint are called into action. With regard to supination it is not usually mentioned in text-books that the triceps has to work hard in order to counteract the tendency on the part of the biceps to produce flexion of the elbow-joint. ' It cannot be entirely eliminated ; a slight amount of rotation at this joint always enters into pronation and supination. Sec Hultkranz, "Das EUenbogen- gelenk und seiner Mekanik," 1897, pp. 81, 82. lor ELEKlilSTS OF KELLGREN'S MANUAL TREATMENT In the exercise of pronation, AK, and supination, AE, with the assistant's grasp as above, the pronator group and some of the flexors of the front of the forearm, and the supinator group and some of the extensors on the back of the forearm are respectively in action. The flexors and extensors of the forearm can, how- ever, be ehminated b}' transferring the grasp of the assistant to above the wrist-joint, in which case there is complete isolation of the pronator and supinator group respectively. INVERSION AND EVERSION. These movements onl}' occur in connection with the foot. The patient is usually placed in half lying position with the lower leg fixed by the assistant's one hand in the same waj' as m foot flexion and extension (p. 69), the other hand being placed over the inner side of the foot in inversion, AK, and eversion, PR, and over the outer side in inversion, PR, and eversion, AR. In every case traction away from the lower leg should be maintained while the movements are being executed. The muscles brought into action are the inversors and eversors of the foot respectively. The movement takes place chiefly at the mediotarsal joint. GYMNASTIC MOVEMENTS 103 CIRCUMDUCTION OR ROLLING. The range of movement obtained by rolling is greater than tbat obtained from the other classes of exercises. I.— Circumduction of the Upper Extremity. (1) Of the Shoulder-joint. Half Lying Double Arm Rolling, PP. (Also called Arm " Flying.") The patient assumes the stretch half lying position, with the forearms either in the mid-position or pronated. The assistant grasps the patient's hands in his own and performs a series of circumductioi:s of the shoulder-joints by causing the elbows to describe a circle, as follows : — (1) He extends the patient's shoulders and flexes the elbows until the upper arms lie against the side of the thorax and the forearms are in extreme flexion. (2) By drawing the patient's hands outwards and upwards, thus bringing about abduction of the shoulders and extension of the elbows, he gets the patient's arms into heave position. (3) Finally, by drawing the patient's hands upwards and inwards, completing the movement mentioned in (2), he brings the arms back into the original position (see fig. 41, p. 92). The division into three parts is merely for the sake of clearness of description ; in practice the rolling should be done as evenly and continuously as possible, its various phases merging into one another without a break. The movement is repeated from six to ten times, this consti- tuting the first half of the exercise ("from within outwards"). It is then executed a like number of times in the reverse direction (" from without inwards "). The whole process is then repeated. This exercise may be carried out quickly and energetically. Its effects are then as follows : — I04 ELEMENTS OF KELLGREN'S MANUAL TREATMENT The muscles of the whole limb and shoulder girdle are exercised, and become better supplied with blood ; the nerves ate stimulated ; the joints involved are rendered more supple, and iiuy stiffness, deposits (gouty or otherwise), or adhesions that may be present will tend to be removed. The circulation in the arteries and veins will be furthered, the latter being partly affected by Braune's suction and pumping apparatus (described on p. 48). An additional effect is produced on the venous flow through the inertia of the blood and the presence of valves in the veins. While the arm is passing from stretch position downwards towards the body, the venous blood of the forearm, which tends to accumulate in the hand in consequence of its inertia, is prevented from doing so because of the valves in the veins, and thus moves in unison with the forearm. When the arm is drawn up again the blood in the forearm continues to move towards the heart by its own inertia. A similar mechanism comes into play in leg rolling (see p. 107). The lymphatic circulation in the arm is promoted, and the onward passage of the contents of the thoracic duct is hastened (p. 49). The exercise also acts bene- ficially on the respiratory apparatus from the alternate lifting up and down of the chest. This exercise ma}' be carried out slowly, e.g., in the case of heart disease patients, in whom it is desired to produce the reaction slowly, or if it is intended to convert the exercise into a purely respiratory movement. In the latter case the patient inspires deeply as the arms are brought into stretch position, and makes a deep expiration when the process is reversed. Under such circumstances the stimulatory effects on the arms are not so great as when the movement is executed rapidly ; the exercise, becoming identical with a passive chest expansion, acts chiefly on the lungs. Sitting Arm Circling, PP. In the movement just described it is impossible to apply any traction excepting at the very moment that the arms are brought into stretch position. If, therefore, an inflammatory condition of the shoulder-joint or a freshly-reduced dislocation be under treatment, it may be necessary to give the rolhng in such a position and in such a way that traction of the arm away from the shoulder can be exercised. This is effected by placing GYMNASTIC MOVEMENTS 105 the patient in the sitting position ; the shoulder of the arm that is to be rolled is fixed by the assistant's one hand ; if necessary, his fingers are placed round the head of the humerus to prevent re-dislocation. His other baud is used to grasp the forearm just below the elbow-joint, which he semi-flexes, at the same time abducting the humerus to about a right angle. Then, perform- ing traction away from the shoulder, the assistant moves the elbow in a gradually increasing circle first in one direction and then in the other (fig. 48). This movement is executed slowly and through a compara- tively small radius ; its main efi'ects, therefore, are the furthering of the venous and lymphatic flow and the prevention of adhesions and inflammation in the neighbourhood of the shoulder-joint. Should a case arise demanding even greater traction, arm circling may be carried out with the arm in yard position, i.e., the elbow is fully extended. The patient is then conveniently in half lying position. The assistant uses one hand to fix the patient's shoulder, and the other grasps the patient's hand (fig. 55). Applying traction of the latter away from the trunk, the assistant moves it in a gradually increasing circle first in one direction and then in the other. io6 ELEMENTS OF KELLGREN'S MANUAL TREATMENT Ann circlinid- (1) Light. (2) Strong. (B) Complex Forms. (1) Suction vibrations. (2) Dispersing vibrations. (3) Nipping vibrations. I3S ELEMENTS OF KELLGREN'S MANUAL TREATMENT (A) Simple Fonms. (A) Stationary Vibrations. Are executed by one or more phalanges of one or more digits, which, having been placed with the palmar aspect on the part to be treated, set up a continuous vibration on the same spot. I. — U}} and Down Vibrations. The movement may be generated from : — (1) The finger-joints. — The movement is performed by the flexors of the fingers, the wrist-joint participating as little as possible. («) If the excursion of the movement be kept to the minimum, there will result the most minute vibrations possible ; these I have expressly termed " very fine." (b) A slightly larger excursion will proportionately increase the amplitude of the vibra- tions, which, however, can still be termed "fine." Such "very fine " and " fine " vibrations may be used in cases requiring great delicacy of manipulation, e.g., in acute conditions of the eyes. (2) The wrist and finger joitits. — If the wrist-joint be allowed to participate as well as the finger-joints, then the flexors of both the wrists and fingers will be in action, (a) The " gentle " vibra- tions are produced by the excursion of the movement and the pressure applied being kept at the minimum, (h) "Medium" ones are produced by an increase in both, (c) " Strong " are produced by a still further increase. The pressure is in every case applied from the elbow-joint by means of contraction in the triceps, the shoulder being fixed. The method just described is the most usual one of executing vibrations, and is employed unless indications exist for producing them in a different way. (d) For the " very strong " or "pressure" vibrations, the tip of the thumb is used, the forefinger being applied to it so as to steady it. It is placed on the part to be treated and then vibrates while simultaneously strong pressure is applied. This manipulation is generally maintained for only a few seconds at a time ; it is employed for some deep-seated nerves, such as the great sciatic in the buttock, in cases where powerful stimulation IS required. GYMNASTIC MOVEMENTS 139 (3) The elhoio-joint. — When it is ueces'sSiy to lift a structure and then vibrate it, the manipulation is termed a "lift-vibration," and is generally given with the movement generated from the elbow-joint (see uterine lift-vibration, p. 237). The flexors and extensors of that joint are the muscles placed in action. Accord- ing to the amplitude of the movement the vibrations are "medium" or "strong." This form of yjbration is also found in the bitemporal movement (p. 217). , , : : (4) The shoulder, elbow, and zvrist joints. r— In certain very rare cases, where strong stimulation becomes necessary, the vibration, with simultaneous pressure, may be generated from all the joints of the arm. This method, however, should never be employed on nerves ' under any circumstances, as it to a great extent eliminates the tine sense (jf touch. It is, moreover, extremely tiring, and cannot be continued with evenness and regularity for more than a minute or so. II.— Side to Side Vibrations. Are executed by a rapid alternating radial and ulnar flexion of the wrist, the elbow being kept still. They may be employed when treating the head. III. — Rotator ij Vibrations. Are given in the same manner and for the same conditions as rotatory shakings, but the movement is a much finer one, the amplitude being much smaller. (B) RuxxiXG Vibrations. During the course of a running vibra,tion the vibrating digit or digits, instead of remaining continually on one spot, are moved along a structure in the line of its long axis. Either the soft parts of the distal phalanges of the forefingers and thumb or el.se the backs of the nails of one or more fingers are employed. According to the speed and strength with which running vibra- tions are executed they are classified into "slow" and "rapid" ' Tokaroff erroneously supposes that this is the method ordinarily employed by Henrik Kellgren in treating nerves ; see " Nervenvibrationen, eine neue manuelle Behandlungsmethode," in Allgem. Wien. Med. Zeit., 1888. See also Reibmayr, " Die Techuik der JIassage," 1898, p. 29. I40 ELEMEXTS OF KELLGREN'S MANUAL TREATMENT forms, either of which may he " hght " oi' " strong." The slow form is sometimes called a vibratory stroking, if used as a substitute for stroking over an cedematous or congested area {see pp. 180, 205). (B) Complex Forms. (1) Suctivn vibrations. — These are made use of when it is desired to prevent absorption by the tissues and to concentrate lymph in the part, to favour pointing of an abscess, &c. The fingers and thumb are spread well out round the area to be treated, as in fig. 68 ; then, being set into vibration, the metacarpo-phalangeal and interphalangeal-joints are flexed so that the fingers and thumb, which move as one with the skin of the patient, are approximated to one another, a certain amount of pressure being meanwhile applied. With the extension of the joints of the fingers and thumb the pressure is removed, or the digits may be lifted right off the part until they are again in the original position, when the movement is repeated. (2) Dispersing vibrations. — These are made use of when it is desired to favour absorption from small effusions, &c. They differ from the above (1) in this respect that the pressure is applied during the extension of the fingers and thumb, and removed during the flexion. (3) Nipping vibrations. — These are used in connection with certain skin diseases in order to cause a gentle exudation of the GYMNASTIC MOVEMENTS 141 contents of the catarrhal cells of the skin. The skin is gently pinched between the forefinger and thumb, which vibrate simul- taneously. Vibrations may be administered with varying speeds, the maximum being about 12 per second, the minimum about 6 per second.' Figs. 69 and 70 give graphic representations of vibra- tions. Fig. 69 represents vibrations generated from the fingers, Fio. G9. Time tracing, every two secoads. Fig. 70. Time tracing, every two seconds. the wrist-joint not participating. The method of recording was by means of an indiarubber ball, as described on p. 135, but placed under the finger-tips instead of under the palm. The rate can be seen to be about 12 per second. In fig. 70, with the indiarubber ball in the same position, vibrations from the wrist and finger- joints are represented, the rate being slightly less than 7 per second. ' Reibmayr erroneously gives the number of vibrations according to Kellgren's method as 200-300 per minute {vide " Die JIassage und ihre Verwerthung in den verschiedenen Disciplinen der Praktischen Medicin," 1893, p. 14, and "Technik der Massage," 1898, p. 32). Saquet gives even a lower estimate, i.e., "hardly more than 200 a minute " (vide " De la trepidation mecanique locale ou vibration," 1898, p. 2. Also Lavalette " De la sismotherapie," These de Paris, 1899). Hj. Ling states that shakings and vibrations have a speed of about 1,000 per minute {vide " De Forsta Begreppen af Riirelselaran," 18G6, p. 149, and " F.irkortad Ofversigt af .\llman Borelselara, " 1880, p. 71). 142 ELEMEXTS UF KELLGREX'S MANUAL TREATMENT •■ FllICTION. (A) Nerve Friction. The nerve to be treated must first of all be exactly located, if possible by the sense of touch.' Any muscles or other structures that lie over the nerve must be uncontracted and relaxed. The fingers are then drawn sharply across the nerve as much as possible at right angles to its long axis. The manipulation causes the nerve in question to be set into vibration. In the case of deep-seated nerves the fingers move in unison with the structures that lie over the nerves. In the case of cutaneous nerves, however, the fingers are moved across the skin in which they lie. The following are the various forms of nerve friction : — (A) Simple Forms. (A) St.\tionaey. \.—Sloic. (1) Light. (■2) Medium. (3) Strong. (4) Very strong (called "pressure friction"). II. — Rapid. (1) Light. (2) Medium. (8) Strong. (B) Running. I. — Slow. (1) Light. (2) Medium. (3) Strong. II. — Rapid. (1) Light. (2) Medium. (3) Strong. ' Reibmayr denies the possibility of being able to feel a nerve {vide "Die Massage und ihre Verwerthuiig in den verschiodeuen Disciplinen der Praktischen Medicin," 1893, p. 16, and " Die Teclinik der Massage," 1898, p. 28, &c.) The only explana- tion of this is that either Reibmayr never tried to feel the ulnar nerve at the elbow, the facial nerve as it comes round the angle of the jaw, or the brachial plexus in the axilla, &c., or else he really failed to feel them after careful endeavour. GYMNASTIC MOVEMENTS 143 (B) Complex Forms. (1) Friction vibrations. (2) Friction vibrations with suction. (A) Simple Forms. (A) Stationary Nerve Frictions. Are executed in the manner just described, and if repeated take place at precisely the same point in the course of the nerve. They may be repeated at either a slow or a rapid rate. If it is desired to render them "light," "medium," or "strong," the variation is produced by the distal phalanx of one or more fingers with or without pressure from the elbow-joint. " Pressure frictions," on the other hand, are administered in the same manner as pressure vibrations, frictions being substituted for the vibrations. (B) KuxxiNCi Nerve Frictions. May be administered with the distal phalanges of two or more fingers, or else with the tips of the forefinger and thumb placed in apposition. The method is the same as for stationary nerve frictions ; but the fingers, instead of repeating the friction at the same point of a nerve, are moved either up or down the nerve trunk, so that the frictions take place at different points of its course. Such running nerve frictions maj' be repeated at either a slow or a rapid rate ; and, according to the amount of pressure applied, they are termed " light," " medium," or " strong." (B) Complex Forms. (1) Friction vibrations. — While either medium or strong up and down vibrations are administered the fingers are simul- taneously used to execute small frictions. This manipulation is used on the head, and also at the margins of ulcers in order to stimulate the cutaneous nerves. (•2) Friction vibrations with suction. — These are executed in the same manner, suction vibrations being substituted for ordinary vibrations. They are used in the treatment of dis- charging abscesses, i!i:c. 144 ELEMENTS OF KELLCREN'S MANUAL TREATMENT Whether a stationary or a running friction, or a stationary or a running vibration be administered on a nerve, the nerve is set into vibration. I venture to propound the following as the possible explanation from a physical point of view of the different physiological effects resulting from different methods of nerve treatment ; — A friction across a nerve causes torsional, transverse, and, to a less extent, longitudinal vibrations in it. A running vibration or friction along a nerve causes longitudinal and, to a less extent, transverse vibrations in it. Vibrations given continuously on the same spot on a nerve cause transverse and, to a slight extent, longitudinal vibrations in it. From the very nature of all these manipulations the venous and lymph return in and around the nerves will be promoted. It has also been established by experiment that certain kinds of vibrations stimulate nerves if administered with sufficient intensity.' The precise effect of vibrations and frictions on nerves will be considered on pp. 149, &c. (B) Frictions on other Structures. The modus operandi of these will be discussed on pp. 194, &c. For purposes of convenient description the shakings, vibra- tions, and frictions will be divided into three groups : — I. — Vibrations and Frictions on Nerves and Ganglia. 11. — Vibrations and Shakings on Other Structures. III. — Frictions on Other Structures. I.- — Vibrations and Frictions on Nerves and Ganglia. History and development. — A kind of nerve-pressing was used by P. H. Ling^ {cf. Sonden,^ Georgii,^) ; he also employed nerve ' See Langendorff, " tjber Tetanisirung von Nerven durch rhythmische Dehnung," iu Centralbl.f. d. Med. Wissensch., Feb. 15, 1882, pp. 113-115. Axenfeld, " Vibra- tiouen der Stimmgabel als Nervemeiz," Cc)^(^■ai6i. /. Fltysiologie, 1892, vol. vi., pp. 299-300. Uexkull, " Zur Methodik der meclianischen Nervenreizung," Zeitsdtr. f. Biologic, vol. xxxi., pp. 148-167; " Uber Erschiitterung und Eutlastung der Nerven," ibid., vol. xxxii., pp. 438-445. " Zur Muskel und Nervenphysiologie von Sipunculus Nudus," ibid., vol. xxxiii., pp. 1-27. "Der Neurokinet; ein Beitrag zur Theorie dermechanischen Nervenreizung," ibid., vol. xxxviii., pp. 291-299. Boruttau, " Weitere Erfahrungen iiber die Beziebung des N. Vagus zur .\tbmung und Ver- danung," Archiv f. Physiologic, vol. Ixv., p. 26; also Schafer, "A Simple Apparatus for the IMechanical Stimulation of Nerve," in Journ. of Phys., vol. xxvi., pp. xxii., xxiii. - " Gymnastikens AUmiinna Grander," 1834 (1840), p. 71, (1834) 1840, pp. 15.3, &c. ' " Tankar ofver praktisk Medicin," in Hygein, 1840, JIareb No., p. 122. ' " Kinetic Jottings," 1880, p. 73. GYMNASTIC MOVEMENTS- 145 strokings.' Brantiug, in 1844, referred to phrenic and lumbar nerve pressings as being something new - ; in 1846 similar manipulations on the spinal accessory and sacral nerves were advocated by him.^ A few years later nerve pressings with or without simultaneous trembling movement were used a good deal; sometimes blunt pointed sticks were employed by the operator in the case of deep- seated nerves. The modus operandi is described by Eothstein,* Neumann,^ Eoth," and Eulenburg,' and is referred to in several writings of the latter,* as well as in those of Georgii,' de Betou,"* Blundell," Branting,'- and Hj. Ling.'^ Georgii'* makes one reference to a " friction plus ou moin legere sur le trajet d'un nerve," and Eoth '^ to a "friction along the course of a certain nerve" ; but such manipulations are not described by them, and the term is not mentioned by them elsewhere, nor, I believe, in any of the works of the other authors above mentioned. The method with sticks was after a time abandoned as useless, and even the manual nerve pressing became of infrequent use, the benefit obtained being inconsiderable. The enthusiastic Neu- mann, who in 1852 said, concerning direct nerve treatment : ' " Gymuastikeus Allmaaua Gruuder," 1866, pp. 583-584. -Address to the Graduates of the G. C. I., delivered on April 1, 1844. 'Address to tlie Graduates of the G. C. I., delivered ou April 1, 1846. See also Bock, " Lehrbuch der Pathologischen Anatomie," 1847, p. 572. ' " Die Gymnastik nach dem System des Schwedischen Gyrunasiarchen, P. H. Ling," 1847, pp. 67, &c. *"Die Heilgymnastik," 1852, pp. 211, 6ic. "Lehrbuch der Leibesiibungen des Jlenschen," 1856, pt. ii., pp. 265, &c. ' " Handbook of the Movement Cure," 1856, pp. 178, &c. ' " Die Heilung der chronischeu Unterleibsbeschwerden," 1856, pp. 42, &c. ^ " Mittheiluugen aus dem Gebiete der Schwedischen Heilgymnastik," 1854, p. 34. " " Kinesith^rapie," 1847, p. 54; ."Kinetic Jottings," 1880, pp. 73, 81, 93, 160, 161. ""'Therapeutic Manipulation," 1851, p. 11. " " Medicina Meohanica," 1852. '■• " Address to the Graduates of the G. C. 1., April 1, 1844, and April 1, 1846 " Efterlemuade Skrifter," 1882, pp. 178, &e. '^"DeFiirstaBegreppen af Rcirelseliiran," 1866; " Forkortad Ofversigt af Allman Riirelselara," 1880, in which repeated references are made. See also his preface to Branting's " Eft3rlemnade Skrifter," 1882, pp. xxxi. , xxxii. " "Kinesitherapie," 1847, p. 54. '^" Handbook of the Movement Cure," 1856, p. 6. 10 146 ELEMENTS OF KELLGREX'S MANUAL TREATMENT " This is a part of the movement cure which up to the present has been least developed by Ling's pupils, although they, espe- cially Branting, quite well recognise the fact that it ought to be one of the most important parts," ' in 1856 made the following statement about nerve pressings : " For my part I now consider that these manipulations . . . can quite well be dispensed with, as they can with advantage be entirely replaced by duplicate concentric movements." - Hartelius, at the time when electrical treatment was so much vaunted, combined it with medical gymnastics, but his experience led him to the conclusion that medical gymnastics given alone were productive of greater benefit ; he even in some cases found that electricity had the effect of destroying the improvement effected by medical gymnastics. So electricity was not used any longer, and nerve pressing also fell into disuse. In the whole of Hartelius's " Liirobok i Sjukgymnastik " ' the only descriptions of nerve manipulations are those of arm and leg nerve pressing, to which hardly twenty lines are allotted ; as regards other nerves, a few of them (trigeminal, facial, vagus, phrenic, intercostal, great sciatic) * are casually referred to. Meanwhile, however, Henrik Kellgren, in the early days of his practice {circa 1865-1868) elaborated his own methods of friction and vibration for the purpose of directly stimulating and soothing nerves, and in the late sixties he was using the new methods with great success. Gradually, in the course of years, many medical men came to hear of them, but reliable information w'as disseminated slowly owing to the fact that Kellgren himself refrained from publishing any details, and those of the profession who were interested lacked the practical knowledge and technique, without which it was impossible to write any accurate accounts. Amongst those who referred to the subject may be mentioned Drs. Wretlind and Glatter. The former, himself a graduate of the G. C. I., spoke in 1873 of Kellgren's nerve treatment as ' " Die Heilgymuastik," 1852, p. 359 (translated). - " Lehrbuch der Leibesiibungen," 1856, pt. ii., pp. 265, 266 (translated). ' 1st Edition, 1870, pp. 88 & 89. 2nd Edition, 1883, pp. 90 & 91. 3rd Edition, 1892, pp. 88 & 89. ' See also Hartelius, " De Fysiska Lifsyttringarna hos Mennisljan," 1868, pp. 120, &c. ; " Om Sjnkgj-mnastiska Rcirelsers Verkan och Anvandning," in Tidskrift i Gymnastil; vol. ii., 1890, pp. 201, 202. GYMNASTIC MOVEMENTS 147 something new.^ Glatter, writing in 1875, refers to Kellgren's nerve treatment as applicable to pneumonia. - In February, 1888, Prof, von Nussbaum, at a lecture given by him, said (translated):' "At the present moment very great attention is being awakened at a 'Kuranstalt,' where Kellgren in various nerve diseases selects the affected nerves and gives passive movements called nerve vibrations, thereby obtaining results which are so striking that the scientific world cannot but take notice of them. These nerve vibrations are, beyond doubt, a new and great cure for nervous diseases." In 1888 Arvid Kellgren, during his course of sixteen demon- strations given at Pola in the winter of 1888-1889, gave the first detailed account of some of his brother's nerve frictions and vibra- tions. It was published in " Vortrage iiber Massage," 1888,'' and his " Technic of Ling's System of Manual Treatment," 1890. In the winter of 1886-7 Dr. A. Levin of the G. C. I. visited Henrik Kellgren and returned to Stockholm with a certain amount of theoretical and practical knowledge of Kellgren's nerve treatment.' His return to that city was promptly followed by a communication at a meeting of the Stockholm Gymnastic Association from A. Wide on nerve pressing'' and a paper ^ develop- ing his views. Wide had never before published anything con- cerning this branch of the subject, but now emphasised the importance of the new manipulations. In his paper " Om Nervtryckning," and in " Handbok i Medi- cinsk Gymnastik," 1896* and "Handbok i Medicinsk och Ortopedisk Gymnastik," 1902-3," Wide gives a list of the nerves most commonly pressed. In " Handbook of Medical Gymnastics," 1899, and " Handbook of Medical and Orthopaedic Gymnastics," 1903, which are somewhat abridged, this list is omitted, showing that, after all. Wide must assign to these manipulations a very unimportant position. ' " Bref fran Dr. Wretlind," in Hygeia, 1873, March No., pp. 142, &c. - " Allgemeine Betrachtungeu iiber den Wertb der Heilgymnastik," in Wiener Medicinische Presse, 1875, Nos. 8, 9, 11, 13, 14, 15, 18, 21, 23. "The lecture has been reproduced as " Neue Heilmittel fiir Kranke Nerven." *"■ Statistischer Sanitatsbericlit...fur 1888," pp. 163, &o. ^ See " Om Massage vid Blindtarmsinflammatiou," in Tidskrift i Gymnastik, 18S3, pp. 687, &c. " Tidskrift i Gymnastik, 1887, pp. -594, &c. ' " Om Nervtryckning," in Noi-diskt Mcdicinskt Archiv, 1887, vol. xix.. No. 10. ^ Pp. 279-284. "Pp. 237-240. 148 ELEMENTS OF KELLGREN'S MANUAL TREATMENT Wide's nerve pressings of the present day are on new prin- ciples, and differ radically from the nerve pressings of the Ling school as administered formerly, and from Kellgren's nerve treat- ment, as can readily be seen from the following extracts from " Handbook of Medical and Orthopaedic Gymnastics," 1903. " The gymnast puts both his hands at once round the extremity, exercising nerve-pressing in such a way that the somewhat separated and bent finger-tips make the pressing while a slight tremble-shaking is also given. As the gymnast repeats this pressing several times, each point of the nerve is met by it, and the movement will thus be a nerve pressing, but still more a kind of muscle kneading. The movement is very agreeable to the patient, but unnecessarily tiring to the gymnast, so that in most cases it should be replaced by muscle kneading." "Nerve-pressing can either be one quickly passing as when one snaps a string, which is often repeated, or continual for minutes or hours." " Wide also makes an attempt to describe nerve frictions on the head, but says : " Nerve frictions, performed on other parts of the body, are as agreeable as head-nerve-friction, and certainly possess a stimu- lating influence, but as the therapeutic value is not yet satis- factorily explained, I shall not class nerve-frictions on the extremities and trunk as special forms of movement. Ordinary nerve-massage and nerve-pressings could easily replace nerve- frictions." ' (No details are given of any method of actually performing nerve-massage.) Physiological Effect!^ of Nerve Vibrations and Frictions. As far as I am aware no experimental work has been done in connection with the above, although many observers have studied the effects of nerve elongation and nerve compressing. The ensuing account of the physiological effects of nerve vibrations and frictions is therefore based on clinical evidence only. The following will be considered in detail : — (a) Effects produced by a stationary vibration on a nerve given ' P. 68 ; see also " Handbok i Medicinsk och Ortopedisk Gymnastik," 1902, p. 57. - P. 72 ; see also " Handbok i Medicinsk och Ortopedisk Gymnastik," 1902, p. 62. ■'P. 81. GYMNASTIC MOVEMENTS 149 with medium strength from the wrist and finger-joints continu- ously for the space of a few minutes. • (b) Effects produced by stationary friction across a nerve given with a medium amount of strength and repeated for a varying amoimt of time from a few seconds up to a minute. As regards the other groups of manipulations it is very difficult to trace clearly their different efiects as these vary greatly with different patients, according to their degree of nervous excitability, the nature of their malady, &c. ; each set of manipulations can be modified at will so that its effects coincide with those of another set which has also been modified. Thus the effects produced by the above two methods respectively, which are at their extremes diametrically opposite, can theoretically be united by an infinite number of intermediate stages. (a) EFFECTS OF NERVE VIBRATIONS. (1) Removal of hyperexcitability of nerves. (2) Diminution of any pain if originally present. (3) Eemoval, either partial or complete, of the signs and symptoms of neuritis or neuralgia (if present), and removal of lymph and venous stasis (if present) in the neighbourhood of the nerve, without, however, causing any paralysis of sensation. (4) Decrease of temperature (sometimes). In other words the effects are sedative and analgsesic. (b) EFFECTS OF NERVE FRICTIONS. I. — Direct Effects. (1) Raising of the nerve functiunabilitij {considerable). — In con- sequence of the vibrations set up by the friction being transmitted both peripherally and distall}' from the point of application, the nerve is stimulated not merely locally, but also in a greater part of its length. (2) Sensory effects. — The moment a friction is applied to a healthy sensory nerve a sensation of pain arises in it at the point of application, also shooting down its ramifications ; this, however, disappears in a very few seconds. The sensation in question is very similar to that induced by electrical stimulation. A friction of the same intensity on an irritated or painful nerve I50 ELEMENTS OF KELLGREN'S MANUAL TREATMENT causes a temporary increase of the pain already present, followed by a greater diminution. (3) Motor Effects. — Frictions on a motor nerve cause increase in the tonicity of the muscles supplied by it. Sometimes actual contraction occurs ; this is generally seen to advantage in spastic conditions. In the case of cramp or spasm of muscles a friction on the nerve supplying them will cause a temporary increase in the cramp or spasm, usually followed by a greater diminution. (4) Secretory effects. — Increase in the amount of perspiration (either general or local) is the usual result of nerve frictions, although in certain cases {e.g., phthisis) diminution is the consequence. (5) Sijmpathetic-motor and vaso-motor eff'ects. — These can sometimes be obtained directly, but are usually reflex. Seep. 152. ll.—Beflex Effects. The subject of reflex effects inducible by nerve friction is very extensive, and not yet fully investigated ; it will therefore, be only briefly dealt with. (1) Muscles. — -Reflex contraction of muscles results sometimes from frictions given on sensory nerves, whether cutaneous or deeper lying. Even when no visible contraction takes place there is still a tendency towards stimulation of the muscles. Through irritation of the skin the metabolism of the muscles, even when no visible contractions appear, is most markedly increased. In consequence of the centripetal sensory stimula- tion the muscles are urged by the spinal cord to increased metabolism; there is greater production of carbonic acid and warmth (J. Munk.') The paths travelled by the reflex during the foregoing phenomena of contraction of muscles are very difierent. The following are some examples taken from my practice : — (rt) Sensory nerve to spine, lateral half of one spinal segment, motor nerve to muscle. Examples : the ordinary skin reflexes. In one case of hemiplegia I observed that a friction over the radial nerve at the second metacarpal bone caused a greater amount of involuntary extension of the wrist and fingers than could be effected voluntarily. In one case of commencing spastic ' " Physiologie des Menschen uud der Saugethiera," 1897, p. 426, translated. GYMNASTIC MOVEMENTS 151 paraplegia a single friction on the long saphenous nerve caused involuntary coarse twitchings of the muscles of the thigh of the same leg ; these persisted for nearly a minute. (b) Sensory nerve to spine, down spinal cord of the same side, motor nerve to muscle. Example : In some cases of hemiplegia a friction given on the sensory division of a spinal nerve in the cervical region of the affected side will call forth twitchings of the muscles of the leg of that side. This may also be seen, only to a lesser extent, in some normal persons. (c) Sensory nerve to spine, across the spinal cord to the corresponding segment on the opposite side, motor nerve to muscle. I have only been able to observe one case in which this took place, i.e., a hemiplegia, when frictions on the posterior divisions of the cervical nerves on the unaffected side caused twitchings in the (affected) arm of the opposite side. (d) Sensory nerve to spine, across to and down spinal cord of the opposite side, motor nerve to muscle. E.xample : In the cases mentioned under (b) frictions on the corresponding nerve of the healthy side sometimes produce the same phenomena, only to a less extent. (e) Sensory nerve to spine, up the spinal cord of the same side, motor nerve to muscle. Example : In sclerosed conditions of the crossed pyramidal tracts, a friction given on the internal plantar nerve with a moderate amount of energy will, after a latent period of about half a second's duration, cause involuntary extension of the toes ; if given more energetically, involuntary flexion of the hip occurs, accompanied, if the patient be in half- lying position, by passive flexion of the knee-joint. (Arvid Kellgren mentions this in " Technic of Ling's System of Manual Treatment," 1890, p. 54.) This phenomenon, which I will term Kellgren's plantar sign, no doubt results through the same channel as Babinsky's plantar sign, and the two are nearly always found together. In some cases, however, where there is no doubt as to the case being organic and not functional, Kellgren's sign may be present, but not Babinsky's. if) Sensory nerve to spine, up spinal cord of same side, across to spinal cord of opposite side, motor nerve to muscle. Example : In the case referred to under (e) similar involuntary movements of the opposite thigh took place when an energetic plantar nerve friction was being administered. This I will term Kellgren's crossed plantar sign. 152 ELEMENTS OF KELLGREN'S MANUAL TREATMENT (g) Sensory nerve to spine, up and down spinal cord of same side, across to and up and down spinal cord of the opposite side, motor nerve to muscle. In a few cases of very excitable ner- vous system, an energetic friction on any large nerve-trunk may cause general twitchings of the whole body. From the above it must be admitted that in some cases it is possible through nerve frictions to stimulate the spinal cord to conduction transversely and longitudinally both upwards and downwards ; there exists consequently a direct means of exciting the sensory columns, the internuncial fibres and the anterior horns of the grey matter of the cord. (2) Blood-vascular system. — That a moderate stimulation of sensory nerves brings about cardio-acceleration and vaso-con- striction, a strong one cardio-retardation and vaso-dilatation, is the (generally accepted) result of electrical stimulation, although the same consequences do not always follow from mechanical irritation.^ Stimulation of sensory nerves of the skin causes vaso-con- striction thereof if executed lightl}', but the reverse if executed energetically. Frictions on sympathetic ganglia or nerves or on the cerebro- spinal nerves in physiological communication with them generally cause contraction of the blood-vessels supplied by these nerves, with compensatory dilatation of the arteries in other parts of the body (see p. 161). The latter sometimes gives way immediately afterwards to vaso-dilatation which is again followed b}' a vaso- constriction, and so on ; a series of waves is set up, causing alternate decrease and increase in the size of the arteries. The final result may be either a return to the original condition, a vaso-dilatation, or a vaso-constriction, depending on the frequency and intensity with which the frictions are administered, and on the nature of the malady under treatment. (3) Sensation. — Various reflex sensations can be induced ; some of these will be referred to under the individual nerves themselves. The sensation induced by stimulation of sympa- ' See Tigerstedt, " Lehrbuch der Phj-siologie des Kreislaufes," 1893, pp. 282, &o. ; " Lehrbuch der Physiologie des Menschen," 1893, p. 211. Hill, " The Mechanism of the Circulation of the Blood," in Schafer's "Textbook of Physiology," vol. ii., 1900, pp. 58, &c. Hunt, quoted, p. 156. Kleen, " Uber den Einflusa mechanischer Muskel und Hautreizung auf den arteriellen Blutdruck beim Kaninchen," in Skmid. Archiv f. Phys., vol. i., 1889, pp. 247, Ac, and in Nm-diskt Medicinskt Archiv, 1888, vol. XX., No. 10. GYMNASTIC MOVEMENTS 153 thetic nerves or ganglia themselves is different from that induced by frictions on cerebro-spinal nerves. (4) Internal organs. — Frictions on some sensory nerves of the skin cause an increase in the depth of respiration. Frictions on sympathethic ganglia or nerves or on the cerebro-spinal nerves in physiological communication with them can, probably through the same segment of the spinal cord, reflexly stimulate internal organs. Actual contraction of the muscular fibres of such organs in some cases manifests itself. (5) Glands. — Frictions on the nerves that lie over glands or that are in physiological communication with the secreto-motor nerves of the latter, as a general rule cause an increase in the secretion from those glands. Sometimes, however, secreto- inhibitory effects are obtained.' (6) Pupils. — Reflex dilatation of the pupils can be brought about by frictions on many nerves, both cerebro-spinal and sympathetic {e.g., subtrapezial plexus), (generally, a series of waves of alternating contraction and dilatation is set up, these continuing for from a few seconds to a minute or even longer. In the case of direct manipulation of sympathetic nerves, there is usually a latent period of from a half to three seconds' duration. (7) Pyretic conditions. — Nerve frictions given to patients with pyrexia cause decrease in the temperature. The physiological explanation of this is not obvious. (8) Conditions of lowered vitalitij through inflammation, trauma, dx. — It would be interesting to determine whether or not frictions over the nerves leading to or from an inflamed or otherwise pathologically damaged area bring about an increased tendency to repair, by improving the local circulatory reaction, which as is known is due in great part to the central reflex mechanism (although it can occur when the vessels are cut off from the nervous system). Some Other Points in the Physiological Effects of Nerve Frictions. Summation of inadequate stimuli.- — In many cases it can be demonstrated that, whereas one nerve friction is insufficient to ' This, for example, has been showu electrically in the case of the great sciatic nerve and pancreatic secretion. See Edkins in Schafer's " Textbook of Physiology,' vol. i., 1898, p. 548. - Cf. Wiindt, " Untersuchungen zur Mekanik der Nerven," &o., 1871, vol. i., p. 198. 154 ELEMENTS OF KELLGREN'S MANUAL TREATMENT produce a desired result, this result may j'et be obtained through a series of frictions given, as far as it is possible to judge, with the same intensity and at the same spot. Summation of adequate stimuli. — In cases of hemiplegia this can frequently be demonstrated as follows : — One friction on the posterior interosseous nerve of the affected arm produces only slight twitchings in the paretic extensors, v?hereas a series of frictions in rapid succession, given, as far as it is possible to judge, with the same intensity and at the same spot, produces strong contraction in them. Simultaneous stimulation of a nerve trunk at two points of its course remote from one another. — This produces an extra effect just like electrical irritation similarly applied. Example : In cases of atrophic paralysis of a leg, &c., frictions may be administered simultaneously on the internal plantar and great sciatic nerves of the same side. Simultaneous stimulation of several nerve trunks. — This may be resorted to in order to obtain a great additional effect. Do all points of the same nerve respond equally to the same stimulus';* — This is a question of considerable interest, which, however, I cannot definitely answer. Observers on sudden nerve compression by means of tetanomotors or similar apparatus are at variance on the subject, as are also those who have experi- mented with electrical stimuli. (Hallsten in 1875,' Tigerstedt,- Hallsten in 1881,' Efron,^ Beck,'' Weiss,* Munk and Schultz,' Eikhoff.*) ' " Studier i Vafnadselemeateus Physiologie. Irritabiliteten pi olika stallen af samma Nerv," in Finska Liikaresdllskapets Handlingar, 1875, pt. 2. - " Studien iiber mechauische Nerveureizuug," 1880. "' Zur Kecntniss der mechanischeu Reizung derNerven," Archiv fiir Anat. u. Phys., Physiol. Abtheilung, 1881, pp. 90-104. ' " Beitrage zur Allgemeine Nervenphysiologie," iu Archiv f. d. ges. Phys., 1885, vol. xxxvi. , pp. 467-517. '" Die Erregbarkeit verschiedene Stelleu desselben Nerven," in Arch. f. Anat. u. Phys., Physiol. Abtheil., 1897, pp. 415-425; and " Zur Untersuchungen der Erreg- barkeit der Nerveu," in Archiv f. d. ges. Physiol., 1898, vol. Ixxii., pp. 352-359. " " Untersuchungen iiber die Erregbarkeit einen Nerven an verschiedenen SteUen seines Verlaufes," in Archiv f. d. ges. Phys., 1898, vol. Ixxii., pp. 15-50; "Neue Untersuchungen iiber die Erregbarkeit eines Nerven an verschiedenen Stellen seines Verlaufes," ibid., 1899, vol. Ixsv., pp. 265-302. The latter contains a list of the literature on the subject. '"Die Reizbarkeit des Nerven an verschiedenen Stellen seines Verlaufes," Archiv f. Anat. uiid Phys., Physiol. Abtheil, 1898, pp. 297-316. ^ " Uber die Erregbarkeit der motorischeu Nerven an verschiedenen Stellen ihres Verlaufes," Arch. f. d. ges. Phys., 1899, vol. Ixxvii., pp. 156-195. GYMNASTIC MOVEMENTS 155 Nerve Frictioxs and Vibrations v. Nerve Pressings. From their very nature there can be no possibility of frictions and vibrations causing any damage to the nerves or paralysing them. The stronger a friction is administered the more marked are the resulting phenomena, and a vibration over a painful nerve vi^ill, even if it entirely removes the pain, not cause any paralysis of ordinary sensation after the manipulation is over. As Grotch ' says, " The methods of Uexkiill (i.e., nerve vibration by the ' nerve-shaker,' see p. 144), or modifications of these, are likely to be of great service in the future, as their employment is not accompanied by nerve injury." I have in some cases of nervous disease tried the effect of both nerve friction and nerve pressing. Although sometimes I have found a muscular response to the former, but not to the latter, I have never found the reverse, and in every case the response has been greater when administering a friction than vi^hen applying a pressing. On the other hand, the law that " a slight pressure stimulates a nerve, a stronger one induces pain, and a still stronger one paralyses it," has been known to Swedish gymnasts ever since the days of P. H. Ling.- Even a pressure of medium strength, if kept up for some length of time, will cause a certain amount of paralysis, and cannot do otherwise than bring about venous and lymphatic stasis in the nerve itself, and the tissues immediately surrounding it. A long-continued pressure repeated daily can only result in permanent damage. Differences between the results obtained from stimulating a nerve by electricity and friction respectively. — This is a matter which (as far as I know) has up to the present received no experimental attention. Not having had the opportunity of investigating the subject myself, I shall only give the following examples taken from clinical observation : — (1) In some cases of paralysis a motor effect can be obtained from a friction, but not from electrical stimulation. (2) The effects of a friction endure for some time after the manipulation is over ; the effects of electric irritation do not. ' Vide Schiifer's " Textbook oJ Physiology," vol. li., 1900, p. 468. ^" Gymnastikens AUmanna Gruuder," 1834 (1840), p. 71 ; see also Hj. Ling, "De Piirsta Begreppen af Rorelselaran," 186G, p. 106 ; " Forkortad Ofversigt af Allmau Riirelselara," 1880, pp. 53, &c. 156 ELEMENTS OF KELLGREN'S MANUAL TREATMENT Some of the chief differences ' between the results obtained respectively from other forms of mechanical excitation and from electric stimulation of a nerve may conveniently be referred to here : — (1) Continued compression of a nerve produces paralytic symptoms in the nerve trunk itself; continued electric excitation does not. (2) Regarding the heart and blood-vessels, Asp - found that mechanical stimulation of the sciatic plexus of a dog caused cardio-retardation, an electrical one cardio-acceleration. Hunt ^ found that kneading of the muscles of a leg from w^hich the skin had been removed caused a fall of blood pressure, while electrical stimulation always caused a rise in the same. (3) The diminution in the excitability of a nerve in the kathelectrotonic area after opening a constant current is much less evident in the case of mechanical than in tiiat of electrical stimulation (Tigerstedt^). (4) The only change in a nerve after mechanical stimulation is a slight one in its elasticity, which, moreover, soon passes off (Tigerstedt^). (5) Slow rhythmical vibrations of a rate considerably less than 30 per second with Uexkiill's apparatus (see pp. 144, 155), induce tetanus in muscle as well as secondary contractions ; the latter, however, do not fuse. This result differs from that obtained from electrical stimulation (Uexkiill ''). Detailed Consideration of the Individual Nerves and Ganglia. The sites mentioned in connection with the finding of indi- vidual nerves, &c., have special reference to the most conveniently ' That difierences do exist was known to the Ling school at least as long ago as 1866. See Hj. Ling, "De Fiirsta Begreppen af Eiirelselaran," 1866, pp. 64 and 96 ; " Porkortad Ofversigt af Allmau Rorelselara," 1880, p. 38. - " Beobaehtungen iiber Gef.Hssuerven," in Berichte der Sticks. Gesellschaft der Wissenschaft, Math-phys. Classe, 18G7, pp. 165, &c. '■' " The Pall of Blood Pressure resulting from the Stimulation of Aiierent Nerves," in Jotirnal of Physiology, 1895, vol. xviii., pp. 381-410. '"Die durch einen constanten Strom in den Nerven hervorgerufenen Veran- derungen der Erregbarkeit mittels mechanischer Reizung untersucht," in iVittlieil. an der physiol. Labor, des Car. Mcd.-Chir. Inst., 1882, pt. 1. "' " Studien iiber Meohanische Nervenreizung," 1880, p. 48. " " Der Neurokinet ; ein Beitrag zur Theorie der mechanischen Nervenreizung," in Zeitschrift fi'rr Biologie., vol. xxxviii., pp. 291-299. GYMNASTIC MOVEMENTS 157 accessible points for applying the frictions and vibrations. In the majority of cases I have described merely frictions on nerves, but the sites mentioned are the same for giving a stationary vibration. (A) Nerves of the Head and Neck. (1) Great occipital nerve is found as it emerges through the trapezius muscle and runs upwards and outwards m the scalp. There must be some very intimate connection between this nerve, although spinal in origin, and the brain, as it so often happens that morbid conditions of the latter are associated with great tenderness in the former. In some cases the tenderness of this nerve is more marked than that of many of the other nerves of the scalp, which are cranial, not spinal, in origin. (2) Small occipital nerve and (3) Posterior auricular nerve are found as they run over the mastoid process. (4) Supraorbital nerve is found at the notch or foramen of that name, and in its course in the scalp. In some cases there appears to be a physiological continuity between this nerve and the eyeball itself, and the same may be said of some of the other nerves of the orbit and the eyeball. In one case of retinitis pigmentosa and one case of optic atrophy after retrobulbar hfemorrhage that I treated, there was greatly impaired sensation in the nerve ; in two cases of exophthalmic goitre, great hyper- sesthesia. In one patient suffering from convergent strabismus I noticed that frictions on the supraorbital nerve corrected it for a second or two, the divergence was then re-established, and could be again corrected. In the course of about six weeks permanent improvement resulted. I may add that the patient was under treatment for an old poliomyelitis anterior acuta in the lumbar region of the cord. (5) Supratrochlear and infra trochleccr nerves are found at the inner side of the orbit. (6) Nasal nerve is found as it passes over the lower edge of the nasal bone. Sensation in this nerve is usually diminished in the case of atrophic conditions of the nasal mucous membrane ; the reverse obtains in the case of hypertrophic conditions. In normal persons frictions on this nerve will frequently induce sneezing. 158 ELEMENTS OF KELLGREN'S MANUAL TREATMENT (7) Nerves of the eyeball itself and the eyelids are found as follows :— (a) The patient's eyelids having been closed, the tip of the forefinger is placed just internal to the vertical diameter of the eye. Light frictions applied here produce a peculiar sensation in the ej'eball, and sonaetimes also in the frontal region. That the seat of this sensation is chiefly in the eyeball itself is shown by the fact that if the patient be asked to turn his eyes to one or the other side while the frictions are being applied, the peculiar sensation is greatly diminished, the loss not being made good until the cornea again lies under the forefinger. (6) There is a certain spot situated in the coronal sutivre over the site of the motor area for movements of the head and eyes. Frictions given on it often cause a peculiar sensation as of pressure in the eye- ball ; unless the paint be found exactly, no such feeling results. This spot does not lie in the main trunk of the supraorbital nerve ; moreover, the sensations induced by friction on the former do not resemble those evoked by friction's on the latter, (c) There is another spot on the scalp where a similar sensation can be obtained. It is situated in or near the line of the occipito- parietal suture at about the level of the occipital protuberance. The muscular fibres of the pupil can be affected reflexly through many nerves (see p. 153). (8) Lachrymal nerve. — A branch (most probably from this nerve) is found where it passes round the outer edge of the orbit, just at the outer canthus. The lachrymal gland can be fefiexly affected through most of the sensory nerves of the face, which come from the fifth cranial nerve. (9) Facial nerve is found as it comes around the ascending ramus of the lower jaw ; it can, as a general rule, be quite easily felt. Filaments can also be felt over the zygoma. A peculiar sensation in the face, and sometimes in the pharynx and ear, results from frictions on the main trunk. (10) Sensory branches oj the fifth nerve that lie in the masseter. — Frictions on these will often in a few minutes, or even seconds, cure neuralgic toothache. (11) Infraorbital nerve is found as it passes out of the foramen of that name. (12) Mental nerve is found as it emerges from the mental foramen vertically below the supraorbital notch. GYMNASTIC MOVEMENTS 159 (18) Lingual nerve is found high up internal to the posterior part of the horizontal ramus of the lower jaw. The submaxillary ganglion can be stimulated by a friction from behind forwards between the gland and the lower jaw, at a point about midway between the angle and the symphysis menti. (14) Hypoglossal nerve and (15) Glosso-pharijngeal nerve are found below and internal to the horizontal ramus of the jaw. These three nerves just mentioned can all be conveniently stimulated at the same time ; in order to effect this the head must first be passively flexed to the side on which lie the nerves it is desired to manipulate (IG) Superior laryngeal nerve is found at the posterior end of the upper border of the thyroid cartilage. Sensation in the larynx, ear, pharynx, and top of the head, sometimes even a sense of constriction round the skull, are felt in many subjects on stimulating this nerve, and a cough is frequently induced. (17) Inferior {recurrent) laryngeal nerve is found at the side of the trachea low down. A sense of constriction in the larynx is usually felt on stimulating this nerve, and a cough often results. In addition a slight feeling of vomiting may be felt ; this is most probably a reflex rhrough the vagus. On giving a friction on the top of the sternum a sense of constriction in the larynx can be induced similar to that resulting from friction on the inferior laryngeal nerve. The peculiar sensation in question is in some persons felt in the bronchi as well. (18) Vagus nerve is found as it lies under cover of the sterno- mastoid between the internal jugular vein and the internal and common carotid arteries. The sterno-mastoid having been relaxed by bending the head forwards or sideways, the finger is passed either in front of the muscle or behind it (depending on the situation in the neck where it is desired to stimulate), and the frictions given transversely across the nerve. This manipulation will in some persons produce cardio-retar- dation ' ; in others, eructations or even vomiting will result. (19) Phrenic nerve is found low down in the neck behind the clavicular insertion of the sterno-mastoid. Nerve pressings on it ' Cf. Tigerstedt, " Lehrbuch der Physiologie des Kreislaufes," 1893, pp. 237, &c. ; also Waller, " Oa the Compression of the Vagus Nerve, &c.," iu Practitioner, December, 1870. j6o elements of KELLGREN'S MANUAL TREATMENT were formerly used by the Ling ^ school to reheve diaphragmatic spasm. In many such cases, owing to the difficulty in finding the nerve, it would be better to resort to subcostal shaking iS ELEMENTS OF KELLGREN'S MANUAL TREATMENT (2) Bitemporal Movement. The assistant stands behind the patient and places the respective hypothenar eminences of his two hands on the two sides of the patient's skull in the anterior part of the temporal fossa, as in fig. 85. He then applies pressure in an inward direction, i.e., he tries to approximate his hypothenar eminences directly towards one another. While doing this he causes his GYMNASTie MOVEMENTS 219 hands to vibrate, simultaueously performing a circumductory movement with them, the patient's scalp moving continually with his fingers. The direction of the 7U0vement is negative as seen from the patient's left, and the circle described is about one inch in diameter. This manipulation is of great use in dealing with congested or hyperaemic states of the brain and increased intracranial pressure, but the precise anatomical and physiological reasons for the benefits obtained are very difficult to explain.^ (3) Occipital Suction Movement. This manipulation is frequently administered together with head vibration. While one hand of the assistant performs the vibration, the fingers of the other hand are placed over the patient's head, as in fig. 86, p. 'I'll. The scalp moving with them they are drawn sharply downwards and then lightly back again, thus accelerating the venous (and also the lymphatic) flow from the connection between the veins of the scalp and the sinuses in the scalp. As there is an intimate connection between the vems of the scalp and the sinuses in the brain, the latter can be afl:ected through the medium of the former. ' Cf. Hj. Ling's remarks on " tumporaltryckning " in Brantiug's " Efterlemnadc Skrifter,"1882, p. xxii. The popular remedy of relieving headache by pressure on the temples is well known. 220 ELEMENTS OF KELLGREN'S MANUAL TREATMENT SPECIAL MANIPULATIONS OF VARIOUS REGIONS AND ORGANS. In certain cases when it becomes necessary to treat specially a particular region of the body (such as the head, eyes, arm, &c.), sets of manipulations are often executed in a definite order so as to affect in a given succession the vessels, nerves, muscles, &c., of the part in question. Such sets of manipulations are conveniently referred to under the one comprehensive term " exercise " ; thus the term "head exercise " denotes a definite sequence of ma- nipulations. The descriptions which follow are only intended to outhne such sequences. The assistant must not adhere slavishly to every detail, but must use intelligence and discrimination in varying the scheme to suit each patient. (1) Head. Sitting Head Exercise, PP. There are two distinct types of head exercise in common use, between which, however, no hard and fast line can be drawn ; the exercise actually administered may be of a kind anywhere intermediate between the two types, as required. In complex cases it becomes necessary to devise a new modification for each patient. The two types are as follows : — (A) For cases such as fevers or chronic headache from hyper- aemia cerebri, where it is desired to soothe and reduce cerebral excitement. The assistant (1) Performs head lifting ; (2) Vibrates or works on those parts of the head demanding special attention ; (3) Gives nerve frictions, general, and also local if required ; (4) Repeats head lifting. The following are the commonest forms of this type of head exercise: — GYMNASTIC MOVEMENTS One hand administers Double supraorbital nerve friction or, vibration, or frontal vibration. Coronal suture vibration. ,'■ Sagittal suture vibration. Double parietal vibration. ' The other hand administers I Double great occipital nerve friction. J Double second cervical nerve friction. I Occipital suction movement. > Occipital vibration. Fig. 86 represents coronal suture vibration, with occipital suction movement ; fig. 87 represents frontal vibration with double upper cervical nerve friction. In cases of fever it is generally possible by means of the above type of exercise to cause a hot head to become cool ; and in some cases an actual reduction in temperature will result, as can be seen by comparing thermometer readings (from either axilla or rectum) taken just before and after the manipulation. In cases of hypersemia or congested states of the brain not accompanied by fever, amelioration or even cure may be effected b}^ the same means. (B) For cases of disseminated cerebro-spinal sclerosis, general paralysis, &c. (a much more stimulatory exercise). The assistant — (1) Performs head lifting ; 222 ELEMENTS OF KELLGREN'S MANUAL TREATMENT (■2) Administers strong vibrations with one hand on the sagittal or coronal sutures, while the other hand administers strong frictions on the great occipital nerves ; (8) Executes biparietal and bitemporal movements ; (i) Administers strong nerve frictions around the sides of the skull (fig. 88), and in the line of the superior longitudinal sinus ; also on individual nerves if required ; GYMNASTIC MOVEMENTS 223 (b) Administers strong cervical nerve frictions, with pressure vibration on the sagittal or coronal suture ; (6) Repeats head lifting. The first of the above two types is generally continued for a longer interval of time than the second, for which two to five minutes should suffice. (2) Throat. Sitting Throat Exercise, PP. The assistant — (1) Performs head lifting ; (2) Keeping the patient's head erect or even a little flexed forwards/ with one hand either steadies the head or administers cervical nerve frictions (paying particular attention to the second pair) ; and with the other vibrates or shakes the submaxillary region, larynx, trachea, inflamed glands, &c., in whole or in part according to the nature and site of the lesion ; (3) Administers frictions on the nerves of the affected part, especially the superior and inferior laryngeal ; (J-) Repeats head lifting. This throat exercise can be administered in a quiet soothing manner, or energetically to be more stimulating, according to the condition of the patient. Many continental works on massage and gymnastics ascribe to Gerst - the credit of having been the first to use local manipula- tions for the throat. This is, however, quite a mistake. Such manipulations are mentioned in the 1840 ^ edition of P. H. Ling's works ; and in the 1866 * edition it is stated that " the (various) parts of the throat can be treated by stroking, pressure, or shak- ing." Branting ' in 1842 referred to a local throat movement. ' If the head is beut backwards, the omoliyoid and sternomastoid compress the iutenial jugular vein and thus tend to cause congestion of the parts mentioned in (2) ; see page 74. -Gerst's original article on effleurage of the throat was published in " TJber deu Therapeutisohen Werth der Massage " in 1879. "'Gymnastikens AUmanna Grander" (1834), 1840, p. 160. *Ibid., 1866, p. 530. ' Address to the Graduates of the G. C. I. on April 1, 1842. 224 ELEMENTS OF KELLGREN'S MANUAL TREATMENT (3) Eye. Sitting Eye Exercise, PP. The assistant — (1) Performs head hfting ; (2) Vibrates the eye or eyes using either one or both hands ; (8) Administers frictions on the various nerves of the eye- lids and orbit, i.e., infraorbital, supraorbital, infra- and supra- trochlear, nasal, and the areas in the scalp described on p. 158, first and second cervical sympathetic ganglia, &c. ; (4) Administers a few light vibratory strokings on the upper lids in the direction of the venous flow ; (5) Repeats head lifting. A head exercise may be added if symptoms point to congestion or other morbid states of that part on which the eye symptoms wholly or partly depend. All head, throat and eye exercises given for conditions depen- dent on congestion or hyperaemia, should be followed by deriva- tive movements, especially such as increase the venous return in the internal jugular vein. I have frequently seen it stated that the treatment of eye disease by local gymnastic methods was originated by Donders' in 1872. However, the priority belongs to the Ling school, and probably Branting was the first to use such manipula- tions in this connection (Hj. Ling-). (Although P. H. Ling^ refers to " light manipulations over the eyebrows " for head- ache, this does not justify the statement that he ever undertook the treatment of cases of eye disease.) Neumann refers to eye vibra- tion and eye diseases in 18.52, ■* 1855,^ and 18.57," and Melicher (a pupil of Branting and Georgii) treated eye disease by gymnastic methods in 1852," 1853,' 1854,^ 1855,'° 1856 ('?), 1857," &c. ' Donder's first publication is in Klinische Monatsbliitter far Aiigeiiheilkunde, 1872, p. 302. - Brantiag's " Efterlemuade Skrifter," 1882, p. xxvi. ' " Gymnastikens AUmauua Grander " (1834), 1840, p. 160. < " Die Heilgymnastik," 1852, pp. 292, 379, 882. ' " Bericht iiber das zweite Jahr des Instituts fiir Heilgymnastik in Berlin," in Athencpmn fur Rationelle Gymnastik, vol. ii. , 1855, part 3, p. 256. " " Therapie der Chronisohea Kraukheiten," 1857, pp. 280, &c. ■ " Erster Bericht iiber das Institut fiir Schwedisehe Heilgymnastik und Orto- piedie," 1853, p. 5. " " Jahresbericlit fiir 1858 iiber das erste Institut fiir Schwedisehe Heilgymnastik und Ortopffidie zu Wein," 1854, p. 37. ' " Jahresbericht fiir 1854," &c., 1855, p. 21. '" " Jahresbericht fiir 1855," &c., 1856, p. 31. " " Jahresbericht fiir 1856 und 1857," &c., 1858, p. 38. GYMNASTIC MOVEMENTS 225 (4) Ear. Sitting Ear Exercise, PP. The assistant — (1) Performs head lifting ; (2) Administers vibrations or shakinfjs in the meatus itself, or of the meatus through the tragus, or from behind through the root of the pinna ; (3) Performs shaking of the whole pinna and external meatus ; (4) Administers vibrations or shakings over the mastoid process ; (5) Administers vibrations or frictions on the posterior auri- cular, great auricular, and facial nerves ; (6) If necessary, administers vibrations or frictions on the glosso-pharyngeal and fifth nerves, and on the second cervical sympathetic ganglia ; (7) Executes running frictions on the scalp in front of, above, and behind the pinna ; (8) Treats the pharynx if necessary ; (9) Bepeats head lifting. Neumann' refers to gymnastic treatment for ear diseases, and Melicher mentions cases treated by him in 18.52,'^ 1853,'^ 1854, ■* 1855,5 1856,« 1857,' &c. (5) Upper Extremity. Sitting Arm Exercise, PP, PA, &c. (Or PP, PE, AR, if duplicate movements are included.) The assistant — (1) Rapidly kneads the muscles of the arm as a whole, with particular attention to parts specially affected ; (2) Administers finger rolling ; kneading of any affected joint ; ' " Lehrbuch der Leibesiibuugen," 185G, part ii., p. 301; " Therapie der Chrouischen Krankheiten," 1857, pp. 287, &c. -' " Erster Bericht," Ac, 1853, pp. 4, 5. »" .Jahresbericht fiir 1853," &c., 1854, pp. 3G, 37. ' " Jahresbericht fiir 1854," &e., 1855, pp. 20, 21. ■' " Jahresbericht fiir 1855," &c., 1856, pp. 30, 31. " " Jahresbericht fiir 1856 und 1857," &c., 1858, pp. 37, 38. 15 226 ELEMENTS OF KELLGREN'S MANUAL TREATMENT movements at the interphalangeal and luetacarpo-phalangeal joints either PP, PA, PR, or AR ; (3) Administers hand rolling ; kneading of wrist-joint ; move- ments of wrist-joint either PP, PA, PR, or AR ; (4) Performs pronation and supination either PP, PA, PR, or AR ; (5) Administers elbow-joint kneading ; flexion and extension of that joint either PP, PA, PR, or AR ; (6) Administers shoulder-joint kneading, movements of that joint either PP, PA, PR, or AR ; (7) Executes nerve frictions, general or local, on the nerves supplj'ing any affected joints, or paralysed, &c., muscles ; (8) Performs hacking or clapping of the arm as a whole ; (9) Performs arm traction sideways, PP. It is, of course, hardly ever necessary to carry out all the above, and manipulations specified in (2) to (6) are only necessary in cases where the parts particularly referred to are affected. (6) Lower Extremity. Half lying Leg Exercise, PP, PA, &c. (Or PP, PR, AR, if duplicate movements are included.) The assistant — (1) Rapidly kneads the muscles of the leg as a whole, witli particular attention to parts specially affected ; (2) Performs toe rolling ; kneading of any affected joint ; movements of the various joints of the toes either PP, PA, PR, or AR ; (3) Performs foot rolling ; kneading of any affected jonit in the tarsus and the ankle ; movements of such joints, either PP, PA, PR, or AR ; (4) Performs knee-joint kneading; movements of that joint either PP, PA, PR, or AR ; (5) Performs hip-joint kneading ; movements of that joint either PP, PA, PR, or AR ; (6) Executes nerve frictions, general or local, on the nerves supplying any affected joints, or paralj'sed, &c., muscles ; (7) Performs hacking or clapping of the leg as a whole ; (8) Performs leg traction, PP. GYMNASTIC MOVEMENTS 227 (7) Abdomen. (Exclusive of the genital organs). Half lying Stomach Exercise, PP. The patient assumes neck firm half lying position. The assistant sits at the patient's right side, so as to look towards his face, as in fig. 89. The right hand of the assistant is placed on the front of the patient's abdomen, so that the fingers (which are somewhat separated) lie in its left lumbar region, the thumb (which is abducted) in its right lumbar region, and the palm of the hand in its umbilical and hypogastric regions. The anterior abdominal wall and the hand of the assistant are then moved as one over the underlying structures. The fingers and thumb should first of all be somewhat flexed, so as to close on the middle part of the abdomen where the small intes- tines lie ; then the actual movement is carried out in the line of the large intestine in a negative direction as seen from the front, i.e., in the direction of the normal onward passage of the fffical contents. The thumb has to apply a certain amount of pressiu'e and travel over the ascending colon and hepatic flexure to the com- 22S ELEMENTS OF KELLGREN'S MANUAL TREATMENT luencement of the transverse colon. This is effected b}' pronating the forearm somewhat, moving the hand upwards, and then, when the thumb lies in the right hypochondrium, moving the hand upwards and inwards, adducting the thumb at the same time. The fingers, which then lie on the transverse colon, take up the movement ; they apply a certain amount of pressure and travel along the large intestine down to the sigmoid flexure. The fore- arm is therefore somewhat supinated, and the hand travels at first outwards and downwards, then directly downwards, and, finally, downwards and inwards ; meanwhile the amount of supination is gradually increased, and the fingers are gradually flexed at their metacarpo-phalangeal joints, so that in the left iliac fossa they lie fairly deep down in the sigmoid flexure. During the movement on the left side of the abdomen the pressure on its right side is relaxed through the increasing supina- tion, and the thumb is thus brought lightly down into the right iliac fossa. The movement is continued by the forearm being again somewhat pronated, and the hand moving upwards and outwards. Thus the thumb exerts pressure on the right iliac fossa, and is moved up to the right lumbar region, when the manipulation is continued as already described. Meanwhile, the pressure on the left side of the abdomen is relieved in consequence of the pronation of the forearm and extension of the metacarpo- phalangeal joints, and the fingers are brought lightly back to the transverse colon again. During the whole of this the grasp of the middle part of the abdomen must never be lost ; the hand itself describes a small circle and acts chiefly on the small intestines, while the fingers and thumb describe a segment of a large circle and act chiefly along the large intestine. In this way the contents of the abdomen, especially the intestines, are kneaded. The other hand of the assistant can be placed over the thumb to help it in its onward course. The above division of the manipulation into separate parts is merely for the sake of description ; in reality the various parts should merge into one another evenly and without a break. Physiological effect of stomach exercise. — The various resulting physiological phenomena are so intimately bound up together that it is impossible either to distinguish them separately or to state definitely how far primary are modified by secondary effects. GYMNASTIC MOVEMENTS 229 Also they vary according to the force and duration of the manipulation. The following are the effects of stomach exercise as ordinarily given in order to act beneficially on the digestive apparatus : — (1) From the alternate application and removal of pressure, and alternate lengthening and shortening of the vessels, the venous return is hastened in both the portal vein and the inferior vena cava. Unless the exercise be carried out very energetically so as to cause vaso-constriction, there is vaso- dilatation of the arteries of the splanchnic area. As regards the further effect on the latter, it is difficult to generalise, for different cases yield different results. Perhaps this is due to varying degrees of excitability of the vagus and abdominal sympathetic. Vaso-dilatation of the splanchnic arteries is accompanied by a fall in the general blood pressure ; with vaso-constriction the opposite is the case. (2) There is reflex slowing of the heart ; this arises from almost any form of stimulation of the abdominal viscera (the so- called Goltz^ phenomenon). It is probably a reflex through the vagus (Goltz) . If executed very energetically, however, stomach exercise may cause cardio-acceleration. It is a point of interest that observers are frequently at variance regarding the effect of "abdominal massage" on the heart; this is no doubt due to differences in the method, strength, and time of the manipulation. (3) The mechanical application and removal of pressure, together with the improved circulation, stimulates the abdominal viscera, i.e., increased peristalsis results, with consequent increased growth in the muscle of the intestine- and stomach proper. This reacts on the venous return. "Peristalsis of the intestine greatly promotes the portal venous flow." (Hill.^) (4) There is an increased churning up of the contents of the intestine and stomach proper, brought about partly by increased vital activity in these parts, and partly from the mechanical alternate application and removal of pressure. The contents 'Sec "Vagus u. Herz " in Virchow's Archiv, 1863, vol. xxvi., pp. 1-33; and " tjber den Einfluss des Centralnervensystems auf die Blutbeweguug.," in ibid, 1863, vol. xxviii., pp. 428-432. -Hj. Ling considered that this was partly brought about by reflex action through stimulation o£ the abdominal parietes. Cf. " De Fiirsta Begreppen a£ Rorelselaran," 1866, pp. 62, &c. ; "Forkortad Ofversigt af AUman Rorelseliira," 1880, pp. 18, &c. ; preface to Branting's " Efterlemnade Skrifter," 1882, pp. xxxi. , &c. "In Schiifer's " Textbook of Physiology," vol. ii., 1900, p. 121. 230 ELEMENTS OF KELLGREN'S MANUAL TREATMENT of both stomach and intestine will pass on quickei' ; this will in itself stimulate the intestine to increased contraction. (5) Improvement takes place in the secretion of gastric and intestinal juice. (6) Increased absorption by the lacteals results. (7) The kidneys are stimulated. (8) The liver is stimulated. This is partly due to reflex irritation from the intestine, and partly to promotion of the portal flow, and partly for the reason given in (3). (9) Probably the pancreas is affected, the secretion of its juice being improved. (See p. 153.) (10) The abdominal parieties are stimulated, but only to a slight extent, as they move together with the assistant's hand. Reflex contraction of these muscles, as in phthisis pulmonum, cardiac conditions and intestinal disorders, can, however, be over- come by properly applied stomach exercise at first given gently. (11) Sometimes there is an effect on the cerebro-spinal system. This effect has as yet hardly received any attention, but in some cases it is quite undoubted. In one case of paralysis agitans I observed that the tremors were entirely suspended during the stomach exercise, to return again at its close. Frictions and vibrations on the abdominal intercostal nerves and abdominal sympathetic produced no such effect. If the stomach exercise be given very gently, as in cases of acute peritonitis, acute enteritis, &c., which are on the way to recovery, the effects are chiefly as follows : — (1) The venous return is promoted without a vaso-dilatation ensuing. (2) Excess of peristaltic action is removed. (3) Pathological increase in the secretions is diminished. (4) Pain is removed. (5) Adhesions are broken down so gently that no irritation results. (6) Reflex contraction of the abdominal muscles is removed. Comparison between Kellgren's Stomach Exercise and the "Abdominal Massage" of other Schools. (1) " Abdominal massage " is frequently administered on the bare skin. This method carries with it the drawbacks of pre- GYMNASTIC MOVEMENTS j ■ [^231 venting perspiration and probably giving rise to massage eruptions, as in the case of massage of muscles (pp. 211, 212), and also comes into conflict with the objection which exists to uncovering the abdomen in female patients. (2) " Abdominal massage " is usually executed with a great deal more force, the gymnast's forearm being at right angles to the patient's abdomen, his wrist dorsiflexed as far as possible and his hand dug deep into the abdomen. This is the cause of the frequently mentioned fact that " the first few massage seances are spent in overcoming the reflex contraction and irritation of the abdominal muscles." I myself have hardly ever seen this reflex contraction of muscles excepting in the case of patients especially sensitive to tickling, or, of course, in acute inflammatory con- ditions of the abdomen. (3) When performing " abdominal massage," the gymnast is nearly always placed so as to look transversely across the patient's abdomen.' Not merely is this position more awkward than the one adopted for carrying out Kellgren's stomach exercise, but the mianipulation itself becomes more clumsy and the proper direction of the movement less easy to maintain ; it also becomes more difficult to watch the expression of the patient's face, which is one of the best indicators of a tender area being handled. Lists of the literature on the physiological effects of " abdom- inal massage " can be found in the books quoted on p. 212. For Various Organa of the Abdomen. (Exclusive of the genital organs.) (1) Stomach proper. — Shaking or vibration may be performed with tbe fingers gently pressed in fairly deeply at the left costal margin anteriorly at about the eighth to ninth ribs ; the direc- tion of the manipulation should be downwards and somewhat inwards. Frictions on the sixth to eighth left dorsal nerves near the spine (see p. 164) can be executed simultaneously. (2) Liver and gall-bladder. — These organs may be stimulated ' C/. Wide, "Handbok i Mediciusk Gymnastik," 1825, p. 50; "Handbook of Medical Gymnastics," 1899, p. 49; "Handbok i Medicinsk och Ortopedisk Gym- nastik," 1902, p. 47; "Handbook of Medical and Orthopfedic Gymnastics," 190.3, p. 07. 232 ELEMENTS OF KELLGREN'S MANUAL TREATMENT by means of running vil)rations or frictions along the lower costal margin of the right side ; or the gall-bladder and sixth and seventh right dorsal nerves may be worked simultaneously. One hand attends to the latter, as directed on p. 164, while the terminal phalanges of the third and fourth fingers of the other hand execute frictions downwards and inwards (in the direction of the ducts) at the inner end of the ninth and tenth costal cartilages. Shaking or vibration of the liver may be performed with the finger tips placed under the right costal margin anteriorly ; the manipulation is applied in an upward and outwai'd direction. (3) Spleen. — The fingers are placed under the left costal margin and the frictions are executed directly inwards at the level of the tenth rib. The ninth and tenth dorsal nerves of the left side (see p. 165) can at the same time be conveniently stimulated. Vibrations over the spleen can also be executed with the fingers placed over the ninth to eleventh ribs in about the mid- axillary line. (4) Individual parts of the small or large intestine.— Frictions, shakings, or vibrations can be executed over any part that is the seat of local pain, distension, &c. The direction of the manipula- tion depends on the site affected ; as a general rule it is in the direction of the progress of the intestinal contents. In some cases of intestinal obstruction, however, it is carried out in the opposite direction, so as to diminish the tension and thereby aid in removing the obstruction. Vibrations may be executed over any part that is acutely inflamed, either locally or generally. A good example of the former is appendix vibration (see appendicitis). (5) Pancreas. — The fingers of each hand are placed about mid- way between the umbilicus and the xiphisternum, about an inch from the middle line, and the frictions administered inwards and upwards; clinical experience teaches that this is the best method, although the precise reason has not yet been ascertained. (6) Kidneys. — Frictions or vibrations may be executed trans- versely across these glands just below the twelfth rib at the outer edge of the erector spinse. The method of reaching the kidneys from the front has been described on p. 167. If one kidney be treated at a time, one hand manipulates from the front, and the other treats the tenth, eleventh and twelfth dorsal nerves, as described on p. 165. GYMNASTIC MOVEMENTS za (7) Bladder. — Suprapubic vibration and shaking has been fully entered into already (pp. 168, 169). (8) Anus. — Frictions may be made use of in cases of an incom- petent sphincter. It is often useful in these cases to make the patient do rectum lifting, PA, while the frictions are being administered, as follows : the patient must try and draw up his rectum and close the sphincter, thus exercising the muscles that retain control over the fasces. Vibrations of the anus given with the last phalanx of one or two fingers are useful for irritative or inflamed conditions, and for hfemorrhoids. (9) Of the anal canal. — The forefinger is passed in as in the ordinary way for making a rectal examination, and then vibrations are set up. If spasm of the sphincter be present, the finger should vibrate from the beginning of the attempt to obtain its passage ; this will generally succeed in overcoming the spasm with the minimum amount of pain. (8) Genital Organs. (A) Male. (a) Prostate gland. — The patient assumes crook half lying or half lying position, with the knees somewhat separated. The assistant places the terminal phalanx of his forefinger about an inch behind the symphysis pubis and executes vibrations, shakings, or frictions, as the case demands, from behind for- wards. That the sympathetic nerves are stimulated is shown by the fact that in some patients a rush of blood to the head takes place, just as in consequence of shaking over the bladder. {b) Testicle, dc. — The assistant very gently grasps the testicle from above with the fingers and thumb of one hand, while his other hand grasps it from below. Or he may employ only one hand, and very gently grasp the testicle between the fingers and thumb respectively. He then administers the vibrations. The epididymis, after being very gently grasped between the fingers and thumb, may also be vibrated. (c) Sperviatic cord. — Vibrations and frictions at right angles to its course may be executed over this structure as it lies in the inguinal canal. 234 ELEMENTS OF KELLGREN'S MANUAL TREATMENT (B) Female. Disorders of menstruation were treated by P. H. Ling, and a few cases of female pelvic disease were from time to time treated by Branting/ Neumann,^ Melicher,' &c. To Thure Brandt/ however, belongs the credit of having devised a sys- tematic gymnastic method for treating uterine and ovarian disease. The following are among the movements most commonly employed by Henrik Kellgren : — I. — Non-Pregnant. (1) Uterus. Heave Grasp Standing Suprapubic Kneading, PP. The patient assumes heave grasp standing position. The operator, sitting on a low stool in front of her and rather to her right side, places the left hand over the sacrum to steady the" patient, and the right hand over the lower part of the abdomen, so that the proximal part of that palm rests above the pubis and the rest of the hand over the hypogastric region, with the fingers pointing directly upwards. The fingers and thumb are then somewhat flexed, and the thumb and little finger somewhat opposed- Thus the lower part of the abdomen, and with it, of course, the uterus, is grasped in the hand. Then, continually applying a certain amount of pressure upwards, so as to lift this part, a series of circular movements is made in a negative direction as seen from the front, \vith alternating application and removal of lateral pressure from the thenar and hypothenar eminences. This exercise promotes the circulation in the uterus and pelvic organs as a whole. It also tends to correct pendulous abdomen. The bladder is sometimes stimulated to contraction, resulting in a desire for micturition. ' See gymnastic prescriptions in " Efterlemnade Skrifter," 1882. - "Therapie der chroulschen Krankheiten," 1857, p. 213. ■' " Erster Bericht," &c., 1853, pp. 4, 5 ; " Jahresbericht fur 1853," 1854, pp. 35, &c. ; "Jahresbericht fiir 1854," 1855, pp. 20, &c. ; "Jahresbericht fur 1855," 1856, p. 30; "Jahresbericht fur 1856 und 1857," 1858, pp. 36, &c. ' Tlie following are the chief works of Thure Brandt : — " Om Behandliug af Uter- inlidanden och Prolapser med Medikal Gj'mnastik," 1864 ; " Nouvelle niethode gymnastique et magnetique pour le traitement de maladies des organes du bassin et principalement les affections uterines," 1868 ; "Massage bei Fraucnleiden (Behaud- lung weiblicher Geschlechtskrankheiten)," 1890, 1893, 1897. GYMNASTIC MOVEMENTS 235 For all the following movements the patient is to be placed in half lying or crook half lying position. (a) External Treatment. Sitprapuhic uterine frictions. — In some cases the uterus can be stimulated to contraction by executing frictions at the side of the symphysis pubis about two inches from the middle line. Uterine vibrations through the ahdotninal tvall. — The tips of the fingers and thumb are placed over the uterus, grasping it if convenient, and then vibrations are set up. Uterine frictions through the abdominal tvall. — May be executed with the fingers in the hypogastric region over the uterus in a direction from above downwards. Bimanual uterine liftinrj through the abdominal wall. — The operator stands at the patient's head and looks towards her feet. The hands are then gently pressed in on either side in the iliac fossEe low down, in an inward and downward direction, until the fingers close on the lower part of the uterus. They then lift that organ in an upward and forward direction. This lifting may be carried out with simultaneous vibration. (b) Internal Treatment. It isi mperative that all cases of internal treatment be handled only by a very skilled operator and in such a way as to cause absolutely no sexual excitement. Uterine vibration (internal). — The forefinger is passed in the usual way into the vagina until it touches the cervix and is then set into vibration. Uterine frictions (external) with uterine vibration (internal). — In cases of obstinate chronic inflammatory conditions of the uterus or leucorrhoea from that organ, these two manipulations can be combined. Uterine lifting (internal). — The forefinger of one hand is passed in in the usual way, and when it has reached the cervix is gently pushed up, vibrating all the time, so that the cervix (and rvith it, of course, the uterus) is lifted upwards. The other hand may be used if necessary through the anterior abdominal wall to guide the uterus in its course and prevent displacement. 236 ELEMENTS OF KELLGREN'S MANUAL TREATMENT In cases of bad prolapse with or without inversion, the proce- dure is practically the same, i.e., gently lifting up the protruding parts with simultaneous vibration. This should be supplemented by strong frictions on the posterior sacral nerves and on the sub- trapezial plexus. Bepositions of malplacements of the uterus. — No special direc- tions can be given, as each case must be treated according to its nature. Simultaneous vibration of the manipulating hands often facilitates the replacement of this organ. (2) Ovaries. Frictions ' on the ovaries. — The patient assumes the half lying position. The palmar surfaces of the distal parts of the fingers of both hands are placed respectively one on each side of the abdomen about two inches internal to and two inches below the anterior superior spine. Then, generating the movement almost exclusively from the metacarpo-phalangeal joints, and keeping the joints of the fingers extended, the frictions are gently executed in a direction downwards and inwards. Vibrations on the ovaries can be executed with the fingers placed over on the same spot as for executing frictions. There is no reason why the treatment should be discontinued during the menstrual period ; on the contrary, in most cases it is better to continue with it during that time. Exercises of an exerting nature or that draw blood from the pelvis (excepting in cases of menorrhagia or metrorrhagia) can be omitted ; but the rest of the daily treatment should be carried out as usual. It is noteworthy that female patients, when under the manual treat- ment, often show greater improvement just after menstruation than during the rest of the previous month. I have personally verified this even in cases of such diseases as chronic adhesive pleurisy and facial paralysis, which it might be imagined would be unaffected by menstruation. This tends to show that the flow can act as a general eliminator in conditions apart from pelvic disorders. ' " Frictions" is not really a good term, as the movement is in most cases a very gentle one, but there is no better word to replace it. In atrophic conditions of the glands, however, as in premature menopause, the manipulation is executed more energetically and in reality becomes " frictions." GYMNASTIC MOVEMENTS 237 II. — Pregnant. Respiratory exercises aud trunk movements carried out during pregnancy in order to promote the abdominal circulation and strengthen the muscular walls of the abdomen' will often have a very beneficial effect on the patient. Such exercises as loin lean stride standing alternate rotation, AR, ringing, PP ; sit lying back raising, PA, &c., are very suitable, and I have never known them to cause the slightest symptom of threatening abor- tion — on the contrary, in conjunction with other manipulations, they can sometimes counteract the abortive habitus. In such cases the amount of resistance or force applied should, of course, be moderated somewhat, and during the course of all the above exercises the patient must draw her abdomen upwards and inwards as much as possible. Stomach exercise, given with a moderate amount of energy, may be administered to all pregnant patients without danger of abortion. It should, however, in cases of abortive habitus or where symptoms of pelvic pressure are manifested, be supplemented by the so-called " uterine lift-vibration " (see p. 139) as follows : The patient assumes the half lying position ; the operator places his hand very much as for suprapubic kneading (see p. 234), so that his thumb and fingers gently close on the lower part of the uterus. Pressing gently upwards with the proximal part of his palm, the fingers are slightly approximated, and then lift the whole uterus upwards ; they then vibrate that organ for one to five minutes. In one case of threatening abortion at the sixth month, with uterine " pains," in a patient who had continually been having miscarriages ever since her first confinement twenty years previously, this uterine lift-vibration given at intervals for about an hour, stopped the uterine pains and prevented abortion. This movement, together with other trunk and leg exercises, was performed daily, and at the ninth month a normal confinement took place with satisfactory issue. III. — During Labour. Frictions on the posterior sacral nerves (especially the third and fourth) and on the lumbar nerves, executed during each ' Cf. Georgii, " Kinetic Jottiugs," 1880, p. 87. 238 ELEMENTS OF KELLGREN'S MANUAL TREATMENT uterine pain, seem to aid materially in the expulsion of the foetus and afterwards of the placenta ; they certainly diminish the pain in the back that is so often present, and make the patient feel more comfortable. Strong vibration on the coronal suture during the pains has in many cases a stimulatory effect. IV. — POST-PARTUM AND PUERPERIDM. As soon as possible after the expulsion of the foetus stomach exercise should be given, alternating with uterine suction vibra- tions or friction vibrations with suction, given with the hand placed over the fundus. In cases of inertia uteri or post- partum hemorrhage, frictions on the posterior sacral nerves and on the uterus itself can be used simultaneously. If these fail to stop the hsemorrhage, the latter can sometimes be arrested b}' passing the fingers of both hands deep into the abdomen at the side of the uterus just above the symphysis pubis and setting up very strong vibrations or shakings. For the first week or so after the confinement, stomach exercise, uterine suction vibrations or frictions and spinal nerve frictions (especially sacral and lumbar) should be administered morning and evening. During the second and third week they need, as a general rule, be only administered once a day. About the fourth day after the confinement, i.e., when the danger of puerperal fever is over, the patient, if otherwise strong and healthy, should be encouraged to get up and move about, and one or two mild trunk movements may be performed in order to exercise the anterior abdominal muscles and to promote the abdominal circulation, e.g., sit lying back raising, PA, (with assistance if needed). The recumbent position during the puerperium has always been advocated by the profession chiefly for the following reasons : — (1) To enable the patient to regain strength. (2) To prevent prolapse and displacements. (8) To enable the abdominal muscles to recover their tone. (4) To enable the uterus to return to its proper size. (5) To prevent the entrance of septic matter. In Kellgren's methods the reasons for preferring gymnastic exercises are as follows : — (1) The patient is enabled to regain strength by exercising the GYMNASTIC MOVEMENTS 239 muscles of her body as a whole. Voluntary muscles do not gain strength by being kept in a state of prolonged rest after the effects of the fatigue of the actual labour have passed away. (2) Prolapse is prevented by the strengthening of the pelvic and abdominal muscles through passive manipulations such as stomach exercise and uterine and sacral nerve frictions, and, what is far more important, through active exercises in which the patient has to use her own powers to contract these muscles and improve their tone. In cases where there is a tendency to backward displacement, prolonged rest in bed wilt, instead of preventing such a malposition aid in its establishment, as then the force of gravity acts continually on the uterus, tending to draw it towards the sacrum. (3) The uterus is better enabled to perform involution to the correct amount through movements carried out to promote the venous and lymphatic return (and thus getting rid of the waste products) and through stomach exercise and other manipulations carried out to stimulate it to contraction, than by keeping the patient in a position of rest by means of which a tendency to venous and lymphatic stasis and hypostatic congestion is produced. (4) The entrance of septic matter is prevented just as easily with the patient up and walking about ; and the danger of its obtaining a foothold in the case of entrance into the uterus is much less when the uterus is in a healthy active condition than when it is inactive through prolonged rest. An exercise often prescribed as a general tonic is known as Forwards Lying Back Exercise, PP (and PA). The patient assumes the forwards lying position. The assistant — (1) Executes head to foot running nerve frictions ; (2) Performs length hacking ; (3) Administers a rapid stroking, only once, on the posterior aspect of the body from shoulder to heels. The assistant's manipulations being ended, the patient performs back arching, breathnig, PA. CHAPTER VI. CONCLUDING REMARKS TO PART I. I HAVE now briefl}- described the more important exercises and manipulations as practised by Henrik Kellgren. It is, how- ever, possible to vary them infinitely ; they may be specially modified and adapted to each particular case in order to produce the maximum beneficial effect. This has already been specially insisted on in more than one instance. In some cases it may become necessary to alter exercises so much that the process practically amounts to inventing new ones. As a general rule, passive movements lend themselves far more convenientlj' to modification than duplicate ones, especially such complex forms as head exercise, stomach exercise, &c. Experience alone can enable the assistant to suit these movements to each patient, and to adapt them day by daj' to his progress. Modifications may be made as regards : — (1) The initial position. The greater the difficulty of assuming the initial position, the less can the patient concentrate his energj' on the actual movement performed from it. This may or may not be of advantage. When patients are confined to their beds all movements are, of course, given to them while they are in lying, half lying, side lying, or sitting positions; in acute cases the patient may be allowed to occupy whatever posture is most comfortable, provided it neither impedes the administration of the actual manipulation nor impairs its beneficial effect. The rule that all initial positions must be carefully and correctly assumed and maintained during the whole performance of a movement from beginning to end may in such cases be suspended. Devia- tions from the same rule are also permitted when certain passive movements are administered to a patient occupying lying or sitting positions, e.g., there can be no objection to letting a patient change the position of a foot for comfort's sake during the time that he is undergoing a length}- head exercise. CONCLUDING REMARKS TO PART I. 241 (2) The energy with which passive movements are given, or with which the opposing force is offered in duplicate movements. (3) The rapidity with which a movement is performed. (4) The frequency of repetition, or period of application (in active and passive movements respectively). (5) The length of the pause between the repetitions. (6) The order of arrangement of the exercises in the daily programme. For example, two consecutive exercises which call the same muscles into action will be more tiring than if separated by movements involving other muscles. (7) The administration of two or more passive manipulations simultaneously. (8) The withdrawal or reversal of direction of the whole or part of the resistance ; e.g., ride sitting arm abduction AE, adduc- tion PR, exercises the abductors ; but if given as abduction PR, adduction AR, the antagonists (adductors) are exercised. As an example of possible variations I may specify the following : half lying foot flexion and extension (already described on pp. 69, 70). Extension. Flexobs. EXTENSOBS. Flexion. s. 'H-S i 3.S 1 1^ d * 0" ll PP. PP. PP. PP. PA. PA. PA. PA. AR. AR. AR. AR. PR. PR. PR. PR. PP. PA. AR. PR. PP. PA. AR. PR. PP. PA. AR. PR. PP. PA. AR. PR. X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X From the very nature of Swedish medical gymnastics various persons have argued that it would be possible to devise mechanical 16 242 ELEMENTS OF KELLGREN'S MANUAL TREATMENT appliances,' wbich, if constructed with weights and levers for the active movements, and furnished with an engine to supply the motive power for the passive ones, would advantageously replace the assistant's hands in administering the exercises ; and during the last fifty years such machines have been invented and constructed. They have gained great popularity amongst a certain class of gymnasts, chiefly on account of the following reasons : — Firstly, no manual skill is required on the part of the gym- nast; secondly, the gymnast saves himself fatigue and expenditure of time ; and, thirdly, he can have many more patients under his care at once. All these conditions are advantageous to the manipulator, but the reverse to the patient, as the following considerations will show : — (1) Machines can only partially adapt themselves to differences in the size, adiposity, &c., of different patients. (2) They cannot adapt themselves to the daily variation of each individual patient. (3) They cannot encourage the patient by admonishing him to do his best. (4) They cannot by themselves regulate the specific rate of the movement. (6) They cannot prevent the patient from turning a passive movement at a joint into an active one. (6) Only a limited number of initial positions are permitted by them, and only a limited number of movements can be executed by them. (7) They cannot administer an exercise that involves pain for many days running, as the patient will (even insensibly) adopt some means of nullifying it, such as a faulty position, or a wrong muscular action. (8) Some exercises can under no circumstances be executed by a machine ; the human hand, guided by the human brain, is often the only possible agent of manipulation. No machine has yet been constructed capable of correctly giving such complicated and varying movements as stomach exercise or arm nerve frictions (on the deep lying trunks) ; I think I may add that no such machine will ever be produced. ' Under mechanical appliances I do iint, of course, include such apparatus as couches, chairs, horizontal bar.s, &c., which are used to enable the patient to assume different initial positions, and also for isolation or steadying purposes. CONCLUDING REMARKS TO PART I. 243 (9) They cannot observe in the patient changes for the ivorse, or new symptoms pointing to complications, &c., and then act accordingly. (10) They cannot apply traction and graduate it to suit each patient. (11) The question of manual v. machine vibrations has been discussed on pp. 182, 183. The G. C. I. never employs machines to replace the manual method, and Branting,^ Hj. Ling,^ Georgii,^ Th. Brandt,"* and Hartelius ^ always considered the latter method the superior one. An exception might possibly be made in the case of vibrations and shakings-; P. H. Liug,^ Branting,' and Hartelius,* say that machines may be used to administer these manipulations instead of the hand. I cannot acquiesce in the statement that P. H. Ling on several occasions declared that machines might be constructed to perform certain active exercises hitherto executed manually, as is implied by Zander ; ' the latter, however, confesses that it depends upon verbal evidence only. No machines of any descrip- tion were used when I was a student at the G. C. I. I need scarcely add that Kellgren's treatment rigidly excludes all such mechanical appliances ; it relies solely on the skilled hand governed by the intelligent brain. I wish to take the opportunity of stating that it is utterly impossible for anyone to learn this treatment by reading descrip- tions of the movements and watching trained students execute them. A tyro might as well expect to become an expert per- former on the piano or violin by learning the theory and watching the performances of professionals. Several }'ears are necessary, even for those with natural talent, both mental and manual, to gain a thorough mastery of the technique of the various move- ' Address to the graduates of the G. C. I., April 1, 1842. -"Porkortad Ofversigt af Allmiin Rurelseliira," 1880, p. 97. '"Kinetic Jottings," 1830, pp. 102, 103, 131-1.37. ' " Massage bei Fraueuleiden," 1897, pp. 19, 20. ' " Gymnastiska lakttagelser," 1863, pp. 50, &c. ; "DenManuella Metoden och Maskinmetoden inom Sjukgymnastiken," in Hygeia, June, 1873. ° " Gymnastikens Allmiinna Grander," 1SG6, pp. 5S1, 585. ' " Efterlemnade Skrifter," 1832, pp. 167, 168. "'Larobok i Sjukgymuastik," 1883, p. 103; 1892, p. 101. See. also Murrav, Levin, Thure Brandt, &c., in Liedbeck, " Vibratorn, dess Andamal, Beskrifning och Anvandning," 1891, p. vi.; English translation, 1891, p. vi. '" Svar pa ' Nagra ord till belysning af fragau om de tvenne olika gymnastikme- toderna, den manuella oeh den mekaniska,' " 1872, p. 5. 244 ELEMENTS OF KELLGREN'S MANUAL TREATMENT nients." But there is also a great deal to learn over and above the actual technique. Capability of judging the proper duration of an exercise and of knowing what movements are best suited to the particular case is essential, as is also practical experience in knowing what effects can or cannot be obtained. In serious cases insufficient knowledge and judgment may prove as dangerous as in any other branch of medical practice. No amount of viere theory can ever teach one the practical part ; to achieve the proper standard of executive capacity requires long and patient experience. He who shirks the latter will merely become a gymnastic machme that will never attain the requisite skill. In addition, after having reached a certain level, he will in all probability fail to maintain it, and his treatment will degenerate accordingly. It has lately become fashionable amongst some medical men, who consider that the actual practice of gymnastics is quite beneath their dignity, to confine their attention to making out the diagnosis of their cases and writing the gymnastic prescription, leaving the ad- ministration of the movements to others. This can only have one result, namely, that any skill they may have attained to degen- erates, and that they lose their sensibility of touch and the power of estimating by feeling the condition of the patient. This tendency of the present day may to some extent account for the variety of misinformation and number of errors which abound in books on massage and gymnastics. PART II. PRACTICAL APPLICATION OF THE TREATMENT, ILLUSTRATED BY CASES. PREFACE. I shall now proceed to consider the practical application of Kellgren's manual treatment, illustrating my remarks from clinical experience. In each of the cases quoted (unless specially mentioned) Kellgren's treatment was the only therapeutic agent employed, and in consequence the specified beneficial results were due "entirely to the merits of that method as opposed to any other. I have definite reasons for describing so many cases in great detail. Frequent and recurring enquiries are made by medical men who have interested themselves in Kellgren's treatment as to the disappearance of or change in one particular symptom of a disease under cure. Further, the rapid course that acute ailments take under Kellgren's treatment is of extraordinary interest, and calls for detailed account ; it is, indeed, not too much to say that some of the results to be obtained will cause a revolution in the hitherto ordinarily accepted ideas concerning symptoms, duration, prognosis, sequelae, and mortality. With regard to some cases, the principles on which the gymnastic prescription depends is explained at length ; with regard to others, however, the gymnastic prescription is left to explain itself in the light of what has already been said. The cases themselves are nearly all from my own private practice, and they date from July, 1898, to December, 1902. Most of them occurred while I was in practice at Sanna, which is situated about two-thirds of a mile from the town of Hus- kvarna, and about three miles from the town of Jonkoping, in the province of Smaland, in Sweden. CHAPTl-ll I. DIAGNOSTIC EXERCISES. Diagnostic; exercises are mentioned in the writings of P. H. Ling,' Neumann,^ liicbter,^ Hj. Ling,' and others. Active exercises may be used : — (i) To diagnose stiffness or adhesions ; (2) To determine the cause of pain, whetlier local or reflex ; (3) To diagnose paresis or paralysis of groups of muscles or individual muscles ; (4) To determine coordinating or inhibiting power ; (.5) To diagnose spastic conditions, and determine the presence or absence of tremor ; (6) To settle various points in connection with irritability of the heart, power to control prolapsus uteri, herniae, the efficiency of the respiratory function, &c. ; (7) To determine the state of voluntary muscle action as controlled by the intelligence in persons who are imbecile or mentally deficient ; (8) To determine the causes that have brought about de- formity, such as malposition, occupation, &c. Passive movements at joints may be used to determine : — (1) The degree of mobility at a joint ; (2) The looseness or weakness of a joint ; (3) Whether pain is local or reflex ; (4) The presence of spastic conditions ; (5) The degree of extensibility of various muscles ; (6) The presence of adhesions, stiffness, crepitus, &c. '" Gymnastikens Allmaana Grunder," 1834, 1840, pp. O'J, 154, 171, 172; ibUL, 1866, p. 536. ^ " Therapie der chronischen Krankheiteu," 1887, pp. 32, &c. ■' " Bericht iiber neuere Heilgymnastik," in Schmidt's Jahrbiicher, 1854, vol. Ixxxii., pp. 260-264. ' " De Forsta Begreppeu af Rorelselarau," p. 1866, 164 ; " Piii-kortad Ofversigt af Allmiln Rorelselara, " 1880, p. 84. 248 ELEMENTS OF KELLGREN'S MANUAL TREATMENT Nerve vibrations and frictions may be used to determine : — (1) Whether pain is local or reflex : (•2) The degree of the motor response ; (3) The degree of the sensory response; (4) The degree of the vasomotor response ; (5) The condition of efficiency as regards various reflex func- tions of nerves, such as vesicomotor, cardiomotor, &c. In a similar manner the same movements may be used for prognostic purposes. The use of the sense of touch as an aid to diagnosis. This method has been systematically developed by Henrik Kellgren, though up to the present there exists no literature on the subject. The ability to properly employ this method can onlj' be acquired through years of practice ; it cannot he acquired theo- retically. Long experience is indispensable, presupposing a certain amount of general natural aptitude for applying Kellgren's treatment, which latter gradually develops in every adminis- trator a great delicacy of touch. It is exceedingly difiicult to provide a description of this method which shall be intelligible to those who have not had the opportunity of actually employing it ; I will, therefore, limit myself to the following remarks. When executing such a manipulation as head or stomach exercise, a trained hand at once recognises very slight abnormal fulness, pulsation, fluctuation, heat, stifiness of muscles, &c. But sometimes, even in the absence of definite abnormalities, the assistant is cognisant through his touch that the part under manipulation does not feel perfectly healthy. This part is then treated until the trained hand either feels that the part is once more normal, or else that no more can be done for it for the time being. It is difficult to overrate the usefulness of the sense of touch in this connection. It also frequently enables the operator to determine which parts of the patient need special treatment, and also how long such parts should be manipulated ; and finally it is often successful where other methods fail entirely. CHAPTER 11. GENERAL PRINCIPLES IN THE APPLICATION OF THE MANUAL TREATMENT. The object of the manual treatment is to replace pathological conditions by physiological ones.' This is effected by executing movements in physiological harmony with the requirements of the particular case, as follows — I. Local treatment over the specially affected parts. II. General treatment, by which is meant treatment of the constitution as a whole. The reasons for the former are obvious enough, but the reasons for the latter are not so widely understood ; and in fact the modern practitioners of Ling's system in a great many cases only treat locally. Treatment of the patient's constitution as a whole should, however, always form part of the remedial course, how- ever local be the pathological condition. There are several reasons for this : — (1) Normally there are a great many toxins and waste matters in the general circulation, but no harm results, as the body by means of vital chemical changes and natural power of resistance is able to reject them ; but should it become unable to do so, then disease, either general or local, sets in. By treating the consti- tution, however, steps are taken towards restoring or retaining this power of elimination. (2) Any local lesion will itself in the course of time become a source of production of toxins and waste matters other than those just referred to. These new products will tend to lower the vitality, and should the body fail, as it were, to " rise to the occasion," then the constitutional symptoms may become very severe, and if not checked the result may be fatal. Even if the ' C/. Neumann, "Das Muskelleben das Menschen in Beziehung auf Heil- gymnastik und Turnen," 1855, p. 21. 250 ELEMENTS OF KELLGREN'S MANUAL TREATMENT body is able to throw off these toxins, &c., a considerable effort will be required, and in either case the manual treatment will materially assist the process of elimination. (3) If there is a tendency for waste products to accumulate, these will tend to do so in the weakest parts of the body, i.e., those which have the least physiological power of resistance ; thus such parts must be continually stimulated in order to avoid their becoming secondarily affected. (4) The actual cause of the disease may be overlooked, should general treatment be omitted. As an example I may take spinal curvatures. These may be due to a tender or irritative con- dition of some internal organ, such as an ovary or kidney ; deformities in the vertebrae will arise in the course of time from the reflex contraction of muscles over these parts. These causes are usually not mentioned in the literature on spinal curvatures, ' they are, however, very important indeed. To simply treat the deformity without attacking the cause will, of course, only yield a very slightly beneficial result, if indeed any at all. The experi- ence of Henrik Kellgren tends to show that the cause of many Puffections in peripheral parts is more often to be found in diseases of the internal organs than is generally supposed. The manual treatment, local and constitutional, greatly inci'eases the physiological power of resistance, both locally and generally. This is a very important factor in the cure, especially as the curative influence is not purely external ; it is endeavoured to render the patient himself the source of remedy. It is of paramount importance to develop the active elements in the patient, however weak and feeble at first, by getting him to use his own muscles, his own nerves, his own brain. The first sign of his beginning to use these is the first sign of returning power of resistance to disease ; it must be remembered that a cure doe.s not commence with the first application of treatment (external assistance), but with the moment that the patient's body begins actively to lend support towards the result that the treatment is striving to obtain (internal co-operation) . ' Wide, who is considered a specialist ou spinal curvatures, does not mention them in his handbooks. CHAPTER III. SPECIFIC INFECTIOUS DISEASES. . The experience of the Lino; school has tended to show that acute fevers, whether specific infectious or otherwise, do not enter into the sphere of medical gymnastics. There have been a few successful efforts, such as Branting's ^ case of acute pneu- monia, but on the whole the Ling school condemns attempts to apply gymnastic manipulations to such conditions (c/. P. H. Ling,- Georgii''). Wide ' is, of course, opposed to gymnastic treatment for acute specific infectious diseases. In applying Kellgren's treatment to acute specific infectious diseases the following are the objects in view : — (A) During the Acute Stage. I. — To improve the local condition or conditions, and thereby raise the local power of resistance. This is effected by : — (1) Promoting the circulation both of the blood and lympb, and causing vaso-constriction of over-dilated arteries, by means of passive manipulations such as vibrations, shakings, frictions, nerve frictions, &c., and occasionally by means of passive move- ments of joints. (2) Raising the nervous functionability by stimulating the nerve trunks by nerve frictions. II. — To diminish the constitutional disturbance by raising the power of resistance of the body as a whole, and thus also presum- ably aiding in the process of the natural antitoxin formation. ' See p. 311. - " Gymnastikeus AUmanna Grander " (1834) 1840, pp. 180, 181. »" Kinetic Jottings," 1880, pp. 166, 206. '" Handbok i Mediciusk Gymuastik," 1896, p. 149; "Handbook of Medical Gymnastics," 1899, p. 148; "Handbok i Jledicinsk och Ortopedisk Gymuastik," 1902, p. 189 ; " Handbook of Medical and Orthopaedic Gymnastics," 1903, p. 1.5G. 252 ELEMENTS OF KELLGREN'S MANUAL TREATMENT This is effected l)y means of the so-called " general treatment for fever, " which is executed so as to :— (1) Diminish cerebral excitement ; (2) Stimulate the nervous system as a whole ; (8) Quiet the circulatory disturbances ; (4) Stimulate the organs that bring nutrient matter to the l.ndy; (5) Stimulate the assimilatory organs ; (()) Stimulate the excretory organs ; (7) Stimulate the spleen. This so-called " general treatment for fever " comprises : — (1) Head exercise ; (2) Spinal nerve frictions, especially cervical ; (3) Heart vibration or shaking ; (4) Side shaking, and inducing the patient to take a few deep respirations ; (5) Stomach exercise ; (6) Kidney vibration or friction ; (7) Spleen vibration or friction ; (8) Vibration or shaking over the bladder (usually). Begulations as to diet and rest in bed. — I have never imposed the slightest restriction on diet, but, on the contrary, have always allowed my patients (when I have had the case in hand from the beginning) to act in this respect exactly as they wished, and I have never had the slightest cause to regret this procedure. It seems that Kellgren's treatment greatly assists the powers of assimilation, and this is a powerful factor in keeping up the patient's strength and cutting short the disease, &c. I have like- wise almost invariably allowed my patients to get up if they wished to, provided that the room was warm and they were kept from draughts, except in cases accompanied by delirium, when I have endeavoured to keep my patients quiet in bed. I must not be misiinderstood in this respect ; the profession must not believe that I make my patients eat heartily and make them get up; I merely leave them to act on the dictates of Nature, whom I regard as the best judge under the circumstances. I consider compulsory prolonged rest in bed a powerful factor in reducing the vitality as a whole, in aiding general venous stasis, and in promoting hypostatic congestion, especially of the kidneys, all of which are the very conditions to be avoided. SPECIFIC INFECTIOUS DISEASES 253 (B) During the Convalescent Stage. The treatment during the convalescent stage, having more or less different objects in view, is different from that administered during the acute stage. It may be conveniently termed " general treatment for convalescence." Its objects are as follows : — (1) To stimulate the organs or parts that have been the seat of any local lesion. (2) To improve the constitution as a whole by means of circulatory and respiratory exercises, movements to stimulate the assimilatory and excretory organs, and stimulatory nerve manipulations. Purely active and duplicate exercises should be given as soon as possible. From a clinical point of view the following are the chief results obtainable in the majority of instances by applying Kellgren's treatment to cases of fever : — (1) Delirium is prevented, or removed if present. (2) The general condition of the patient is improved there and hen, nearly always from a subjective, and frequently from an objective point of view. (3) Pyretic and hyperpyretic temperatures are lowered, some- times at once, sometimes an hour or so after the conclusion of the treatment. (4) The progi'ess of the disease is cut short. (5) Complications are reduced to a minimum. (6) Convalescence is hastened. (7) Sequelae are prevented. (8) The cure is absolute and permanent ; in some cases the patients will continue in much better health after the disease has passed than they had enjoyed for many months preceding. (See appendix.) In any of the fever charts appended, if two points are marked in the same temperature column, they represent the temperature immediately before and immediately after the treatment. Two figures in the pulse column mean the same as regards the pulse. Typhoid Fever. C. G., male, aged 24, came under the manual treatment on March 30, 1902. Previous history. — Quite good. 254 ELEMENTS OF KELLCREN'S MANUAL TREATMENT History of present illness. — He believed he caught a chill on March 20, which manifested itself in general weakness, fatigue, and headache. His condition remained unchanged during the ensuing week ; during this time, however, he did not feel so imwell as to be obliged to cease work at the Huskvarna iron factory. During the evening of March 28 he was suddenly seized with pains in the legs and chest, which were so severe that he had at once to go to bed. A masseur was called in, who administered massage on the painful areas without improving matters. March 29. — Morning. Condition about the same ; patient in bed all day. More massage administered. Evening. Condition worse ; pain chiefly in abdomen. " Abdominal massage " made him still worse. March 30. — Morning. During the night patient felt very ill ; had violent attacks of abdominal pain, and slept very badly. No motion since March 27. An attempt to administer " abdominal massage " failed on account of the pain induced, and I was called in. Examination. — March 30, 2 p.m. The patient looked feverish, and was lying in bed with his legs drawn up. He complained of continued severe pain in the right side of the abdomen ; any attempt at movement or at straightening his legs made it worse. Occasionally there were acute exacerbations of the pain. The appetite was very poor ; only bread and butter and milk had been consumed during the last three days. There was a good deal of eructation, but no vomiting ; and no motion had taken place that day. The respiration was entirely thoracic ; any attempt to use the abdomen in breathing caused severe stabbing pains in that region. The anterior abdominal muscles of the right side were firmly contracted ; those of the left side partially contracted. Great tenderness to pressure existed on the right side, some also on the left. Deep palpation of the abdomen was impossible. The patient had his first and only rigor the same morning. (For temperature and pulse see separate chart, fig. 90. Cf. effect of treatment with ordinary records.) After treatment the patient could stretch his legs without discomfort, and the pain in abdomen was lessened ; he could also to a slight extent use his abdomen for respiration without extra pain. Evening. Condition about the same. No motion. Treatment repeated. SPECIFIC INFECTIOUS DISEASES 255 Treatment henceforth administered twice a day. March 31. — Morning. Patient had slept fairly well. Pain less. Patient felt like having a motion, but failed to induce one. Evening. Motion, normal in appearance, at 2 p.m. ; there- after a good deal of pain in the abdomen, which, however, soon passed off. Patient sat up most of the afternoon. General condition otherwise about the same. April 1. — Morning. After breakfast (8 a.m.) some severe pain, which, however, soon disappeared. 11 a.m. Pain in abdomen much less than yesterday ; contraction of abdominal muscles present, but considerably diminished by treatment. Deep pal- pation of the abdomen was possible for the first time, and by its means I could feel that the risht iliac and right lumbar MARCH APRIL DATE 30 31 , 1 , 2 3 i 4 ; 5 1 6 i 7- 1 a 1 9 10 11.12 13 14 13 ! 16 IT 18 19 20 21 22 23 24 25 25 1 TIME < EM E J EM E,M E:» E i E H EM E.H E|M E:m EM E A EM E H EM E'M EM EH EM EH EM EM EM EM EM EM E| F" Moi th A / \i \/ A A / ^^ 1 ^J ^ / 1 s/ " \ / S,' K-S — - V / \ 1 PULSE 100 ;8a 84 86 .64. BZ 90 105 100 105 90; 36 871 81 86 86 100 102 100 90 78 84 74 74 84 86 68 iSl i8, ,68 84 76 72 71. 68 67 78 74- 76 60 62 BOWELS 0|ll0|l|O|lll|l]O|l!3l34i2ll|2i2|2|2|2 1 1 1 1 2 2 : 1 1 regions were filled up by a lai-ge, softish, boggy mass, very tender to touch. On executing vibrations over it, gurgling sounds were heard and felt. Evening. About the same. No motion during the day. April 2.- -Motion, apparently normal, during the morning; after it some pain. Appetite better ; patient, who had been living for the last week on bread, butter, and milk, ate some fish. April 3. — Contraction of abdominal muscles still less. Appetite better. Patient up during the greater part of the day in an arm-chair ; walked about at intervals. Pulse markedly dicrotic from to-day onwards during the following week. April 4. — Motion, apparently normal, during the morning. The large mass in the abdomen was smaller and less tender. 256 ELEMENTS OF KELLGREN'S MANUAL TREATMENT Patient up all day. Appetite, however, not quite so good as during the previous day. April 5. — Eiise of temperature. Patient rather worse, but able to sit up all day in an arm-chair. In the evening I was told that patient had had a foul-smelling, yellowish-green diarrhoeic motion, after which there was very much abdominal pain. I did not see the motion, as it was thrown away at once. April 6. — Morning. Further rise of temperature. Patient looked and felt worse. He was able to sit up in an arm-chair until '2 p.m., but then felt so ill as to be obliged to go to bed. 3 p.m. Pain in abdomen worse ; more contraction of abdominal muscles. At 5 p.m. attack of epistaxis. Evening. Condition still worse. Diagnosis of typhoid fever rendered positive. A culture taken from the next motion revealed the characteristics of typhoid bacilli, and not those of bacillus coli communis. Patient apathetic ; did not speak unless spoken to first ; answered questions slowly and sadly. Cheeks flushed, eyes bright ; typhoidy appearance of face. Pupils dilated. Tongue coated, redness of fauces. He " lies low in bed," con- stantly on his back. More pain and tenderness in abdomen, specially in the right iliac and right lumbar regions ; marked swelling of the right side of the abdomen. Spleen and liver not enlarged. Urine highly coloured, scanty. Pulse dicrotic ; no weakness of first cardiac sound. Lungs normal. No subsultus tendinum. During the ensuing fortnight I tested the urine twice daily for albumen (nitric acid in the cold), but never found any, and auscultated the heart, but never found weakness or muffling of the first sound. I likewise tested for enlargement of the liver and spleen, but could never detect either. The patient's relatives were instructed henceforth to examine all motions for blood or tar-like substance, &c., but they invariably reported that none was ever found. April 7. — Morning. During the night another motion similar to the previous one, and after it much abdominal pain. Patient had slept very badly. A good deal of eructation, as also during the previous day. Eight side of abdomen softer. No rash. Evening. Temperature lower and general condition better than during the previous evening. April 8. — Morning. Patient had slept better. Another attack SPECIFIC INFECTIOUS DISEASES 257 of epistaxis at 8 a.m. Abdomen not so swollen and less tender. Tongue tremulous. Marked typhoid odour. Evening. Patient distinctly better. Temperature once more lower. Patient had been lying on his side during part of the day. Motion this afternoon (first time since evening of April 6) similar to the last one, but no pain after it. Patient had con- sumed nothing but milk since April 5. No rash. April 9. — Morning. Peasoup-like motion during the night. Patient had slept very well. Temperature normal. Patient looking more lively ; spoke without being spoken to first, and laughed for the first time since the commencement of his illness. Less pain in abdomen, very little contraction of abdominal muscles. Evening. Two peasoup-like motions since the morning. Urine clear and of normal colour. Two rose-coloured spots on the abdomen. Patient had consumed some eggs and milk. April 10.— Mornmg. Temperature (both morning and even- ing) about normal from now onwards. Patient sat up in bed most of the day (first time since April 6). One peasoup-like motion during the morning. Breakfast, milk and eggs ; dinner, fish ; supper, milk, bread and butter. Evening. Two more motions during the day, same colour, but not so loose as the morning one. Less tenderness in abdomen. April 11. — Morning. One motion at 5 a.m., darker in colour, but diarrhceic ; another at 7 a.m., same colour as last, but of ordinary consistency. Evening. Patient got up and sat in an arm-chair for an hour this afternoon. Rash disappeared. Another diarrhceic motion during the evening. Diet same as during the previous day. April 12. — Morning. Yellowish somewhat diarrhceic motion during the morning. BVeakfast, milk, one egg, a little fish, bread and butter. Evening. Patient had sat in an arm-chair most of the day, and had been walking up and down in his room at intervals. No pain in the abdomen, but still some tenderness to deep pressure, and a sense of fulness on palpation. I administered a fairly gentle stomach exercise to-day for the first time. Dinner, soup and milk ; supper, fish and milk. April I'd. — Only one motion to-day, light brown and diarrhceic. 17 258 ELEMENTS 01- KELLGREN'S MANUAL TREATMENT Eructations, which had been persisting since April (5, almost disappeared. Breakfast, same as the last, with the addition of a little coffee ; dinner, a small piece of mutton ; supper, same as the last. April 14. — Apathj' entirely disappeared : appearance of face normal. Two motions during the daj', both of normal consistenc}-, although light in colour. Mutton both for breakfast and dinner. April 15. — Typhoid odour gone. Two motions, one normal as regards colour and consistency, the other lighter in colour and looser. Breakfast, two eggs, pancakes, milk, coffee ; dinner, soup, fish ; supper, fish, one egg, bread and butter. April 16. — Two motions just like those of the previous day. Breakfast, two eggs, milk, coffee; dinner, fish, pork chop and potatoes ; supper, fish, bread and butter, milk. Patient went out for half an hour's walk. April 17. — Two apparently normal motions. From to-day onwards the motions presented no abnormality as far as could be detected by inspection and odour. Patient took an hour's walk during the morning and half an hour's walk in the afternoon. April 18. — Patient was out walkmg altogether for three hours. Two motions. April 19. — Patient walked to my house for treatment (distance one mile). Treatment once a day henceforth. Beyond a slight sense of resistance in the right half of the abdomen and general weakness patient was normal. Several active movements were performed from to-day onwards, including sitting trunk extension and flexion, PA, which, however, the patient could not execute unaided. One motion. Patient was out walking altogether for five hours. April 20. — Loin lean stride standing alternate rotation, AE, ringing, PP, given from to-day onwards. One motion. April '21. — Patient daily getting stronger. One motion. April 22. — Two motions. April 23. — ^No motion. April 24. — Two motions. April 25. — One motion. April 26.^ — One motion. Patient able lo-day to do sitting trunk extension and flexion, PA, without help. April 27. — lS!ot treated. Two motions. April 28. — One motion. Patient weighed himself to-day and SPECIFIC INFECTIOUS DISEASES 259 found that he weighed 64 kilos, as compared with 68 kilos, in the l)egiuning of March. April 29, 30. — One motion. May 1. — Not treated. One motion. May 2. — One motion. May 3. — One motion. Patient said that he felt quite as strong as before his illness. Was treated for the last time. May 5. — Patient returned to his usual work at the factory. Treatment. Head exercise, spinal nerve frictions, vibrations over the right side of the abdomen given in a somewhat upward direction, stomach exercise confined to the left side of the abdomen, side shaking, and patient had to attempt abdominal respiration ; spleen and kidney frictions and frictions over the lateral abdomi- nal nerves. As improvement set in the vibrations were executed more energetically, and with greater firmness and pressure ; and later on, when the reflex contraction of the abdominal muscles permitted it, the stomach exercise was performed on the right half of the abdomen as well. During convalescence some active exercises for the abdomen were added (see above). No restrictions were placed on the diet or on the length of time that the patient had to remain in lied ; lie was allowed absolute freedom in both respects. Whooping Cough. A. W., female, aged 4, came under the manual treatment on October 16, 1901. Previous history. — Patient had been quite strong and healthy until seven months previously when she had an attack of diph- theria, from the effects of which she had never completely re- covered. History of present illness. — Patient had often plajed during the summer with several children about her own age, three of whom developed whooping cough about the middle of September. A week later she began to cough a little, but her mother took little notice of this, thinking that she suffered merely from an ordinary cold. After a week, however, the paroxysmal stage of whooping cough set in. Patient had typical attacks of whoop- ing, which sometimes came spontaneously and were sometimes 26o ELEAIENTS OF KELLGREN'S MAWAL TREATMENT induced by cryiug or emotion ; they frightened her considerably, and during their progress she became blue in the face, with start- ing of the eyes. On occasions vomiting immediately followed the cessation of the whoop. The average of attacks had been fairly constant during the past fortnight ; some three or four took place during each day and from ten to twenty during each night. Catarrhal condition of the bronchi was evident on auscultation. There was no fever. Treatment administered once a day hence- forth. October 17. — Patient had twelve attacks during the night, and none at all during the day. October 18. — Patient coughed a good deal during the night, but there was no whooping. October 21. — One whoop during the day, after which no more occurred. Patient slept all night. November '21. — Bronchi normal. No cough. December 6. — Treatment continued daily to this date, then stopped. Patient had not coughed at all since about November '■21. Treatmriif. Chest vibration, side shaking, shaking over the bladder and in the subcostal angle, inducing patient to attempt several con- secutive deep respirations, spinal nerve frictions, specially inter- scapular, vibrations on the medulla, stomach exercise. Later on (about November 12) chest clapping was added. Measles following on Whooping Cough. E. P., female, aged 17 months, came under the manual treat- ment on August 30, 1902. Previous history. — Quite good. History of present illness.— Pa,tient had been suffering for the previous three weeks from whooping cough in the paroxysmal stage, the malady having been most severe during the third week. She experienced eight to twelve attacks of whooping during the day, and several during the night. About August 26 her parents noticed that she had a continual loose cough, and thought that she must have caught cold. August 27, patient worse. August 'IH, patient still worse and alHicted with watering of the eyes and running from the nose; parents thought she was feverisli. SPECIFIC INFECTIOUS DISEASES 261 August 29, patient still worse, parents could hear loud bubbling sounds in the chest; during the evening they noticed redness of the skin. August 30, chest symptoms worse, and measly rash fully developed. I was called in during the evening of the same day. Exatni/iation. — Patient in bed, very restless, cryuig continually and perspiring freely ; had eaten nothing during the day. Much lachryniation and nasal coryza. Typical measles rash over the whole body. Alse nasi working with respiration, which was laboured ; some cyanosis. Loud coarse rales heard at some distance from patient and on auscultation over both lungs ; no percussion dullness. Patient had been suffering from diarrhoea to the extent of four or five motions daily, but her mother informed me that the child was just cutting two teeth and that she always suffered from diarrhoea on such occasions. Tempera- ture 1022'", respiration 88, pulse 186 before treatment ; 101'3°, 64 and 160 respectively after treatment. Patient went to sleep. Treatment twice a day henceforth. August 31. — Morning. Patient had had a fairly good night, and during the morning had been sitting up and looking about, which she did not do at all during the previous day. Not so restless or irritable, less lachrymation, rash fading. Temperature 1016°, respiration .58, pulse 176 before treatment ; 101"3', 67, 16.5 respectively after treatment, .liter I left patient consumed some milk. Evening. Patient better ; had been sitting up during most of the day and had consumed a fair amount of milk. Only three diarrhoeic motions. Rash still more faded; less lachrymation and coryza, and not so many rales in the chest. Temperature 102°, respiration 84, pulse 166 before treatment ; 101'8°, 80 and 160 respectively after treatment. September 1. — Morning. Condition of patient slightly im- proved. Temperature 100'6°, respiration 88, pulse 160. Desqua- mation commenced. Evening. Patient very irritable, and cried during the whole of the treatment, so I did not count her pulse or respiration. Temperature 100"8°. September 2. — Morning. Patient had perspired very much during the first half of the night, and then went to sleep. On awakmg, much better ; sat up during the greater part of the 262 ELEMENTS OF KELLGREN'S MANUAL TREATMENT luonmig. Appetite poor however ; diarrhoea still the same as on August 31. Rash faint. Lungs clearing up. Temperature 98"6°, respiration (?2, pulse 150. During the course of the day patient coughed very much, but was free from whooping. Evening. Temperature 100', respiration 72, pulse 150. September 3. — Morning. Patient much better ; appetite normal again ; diarrhoea less, liash hardly visible on face. A few fine crepitations in the lungs were the only abnormal sounds to be heard. Temperature 99'7% respiration 48, pulse 132. Evening. Some return of the attacks of whooping during the day ; otherwise better. Temperature 99"1°, respiration 50, pulse 136. September 4. — Treatment once a day henceforth, each morn- ing. Patient stronger ; less cough. Lungs almost normal. Temperature 98'8°. September 5. — No more whooping. Lungs normal. Tem- perature 37°. Still some diarrhoea. September 6. — Temperature 984°. Patient had not passed urine for eighteen hours ; micturition, however, took place imme- diately when I administered shaking over the bladder. Diarrhoea ceased. September 7. — Some return of attacks of coughing, resem- bling whooping cough to some extent. September 9. — Cough less. September 11. — Slight cough left, no resemblance at all to whooping cough. Lungs normal. Rest of patient normal. Treatment for the last time. (The temperatures were all taken j;e/- rectum.) Treat iiiriit. During the acute stage : — Head exercise, including vibrations on the medulla, fronto-nasal running vibration ; chest vibration, side shaking ; spinal nerve frictions, specially interscapular : stomach exercise, liver, spleen and kidney frictions, shaking over the bladder. During the convalescent stage : — Chest vibration, side shaking ; spinal nerve frictions, especially interscapular, forwards lying back exercise, stomach exercise, spleen and kidney frictions, shaking over the bladder; double arm rolling ; leg rolling. SPECIFIC INFECTIOUS DISEASES 263 Measles. H. L., male, aged 8i, came under the manual treatment on August 6, 1902. Previous history. — At the age of about nine months it was noticed that he had a cyst in his neck near the clavicular insertion of the left sterno-mastoid, and this caused a chronic irritative croupy-like cough every winter since his birth. During the month previous to his attack of measles patient had had large numbers of furuncles appearing in crops at intervals ; these discharged pus and itched so that he was driven to scratch them. When I first saw patient he had eighteen of these furuncles situated on his trunk and arms, each of which (together with its margin) was about the size of a threepenny bit. History of present illness. — On August B the parents noticed that he had a slight cough, which on August 4 was worse, and was accompanied by an appearance of obvious ill-health. During the afternoon of that day patient was feverish, and the cough still worse ; in addition there was running at. the nose and redness of the eyes, but no vomiting. August 5. — Aggravation of all the symptoms ; during the evening the parents noticed a commenc- ing rash. During the ensuing night patient slept very little. On the morning of August 6 a measly rash had developed, and I was sent for. Owing to pressure of work I was unable to attend the patient until 8 p.m. Ejiammation. — Patient very irritable, restless, and crymg continuously ; suffering from great redness of the eyes and con- tinued running from the nose. Typical measly rash over the whole body, most marked on the face. Signs of acute diffuse bronchitis with diffuse rales, the latter audible at a distance of some feet. Temperature 102-6°, pulse 154. After treatment patient was much less irritable and restless (this happened after every treatment in the fever stage), and was able to look at a picture-book. Temperature 101"1°, pulse 144. Hal f-an-hour after- wards a normal motion took place. August 7. — Morning. Patient had slept very little. General condition better, eyes less red, and less discharge from nose. Temperature 99';j°, pulse 160. After treatment he dressed and was up for an hour, after which he lay down again for the rest of the day, occasionally, however, getting up and walking about for a few minutes. 264 ELEMENTS OF KELLGREN'S MANUAL TREATMENT Evening. Patient had eaten nothing during the day except two small biscuits, and was very irritable and restless. Hash quite out, except on hands. Temperature 10'2-6°, pulse 165 ; after treatment 102° and IGO respectively. August 8. — Morning. Patient had slept very little, and had taken a little milk for breakfast. Eyes less red; slight de- squamation on cheeks. Temperature 98'3°, pulse 120. After treatment patient was up for two hours, and spent the rest of the da}' alternately in lying down and getting up and walking about. Evening. No motion during the day. Patient had eaten nothing since breakfast ; was very irritable and crying con- tinuously. Eyes no longer red ; very little discharge from nose. Rash more marked on hands, but fading on face and legs. Temperature 103'1°, pulse 156 ; after treatment 102"2° and 150 respectively. August 9. — Crisis during the night ; at about 4 a.m. profuse sweating, after which patient fell sound asleep ; on awaking (at 8 a.m.) better in every respect. Took milk, bread and butter for breakfast ; normal motion followed. 11 a.m. Patient up and walking about ; much more cheerful, and hardly irritable at all. Rash fading away rapidly ; desquama- tion on rest of face and trunk ; cough much less ; lungs clearing up. Temperature 968°, pulse 120. Treatment only once a day henceforth. At 2 p.m. patient ate an egg, and then slept until 8 p.m. August 10. — Patient had slept well the whole night. Appetite still poor. Desquamation proceeding on arms and legs. August 11. — Lungs quite cleared up. No expectoration from bronchi. August 12. — No more desquamation visible. Patient went out for a walk of ten minutes. August 13. — Patient very well ; appetite normal. Furuncles, which had been healing rapidly since the crisis, now represented by pink spots. August 17. ■ — No treatment. August 18. — Patient walked to my villa and back for treat- ment (distance three-quarters of a mile each way). August 22. — Normal motion every day since the 10th. Patient quite well and strong. Scars of the furuncles light pink in colour. Treatment for the last time. SPECIFIC INFECTIOUS DISEASES 265 (The temperatures were all taken jjer rectum.) Treattnent. During the acute stage : — Head exercise, vibration of the cyst in an outward direction to relieve the pressure on the larynx, spinal nerve frictions ; fronto-nasal running vibration ; chest vibration, stomach exercise, liver, spleen and kidney frictions. During the convalescent stage : — Chest vibration, stomach exercise, kidney frictions, forwards lying back exercise, and a few general strengthening movements. Scarlet Fever. During the spring of 1902 there occurred a small epidemic of scarlet fever, together with some cases of mumps, in a group ot workmen's houses close to where I was practising at Sanna. My endeavours to isolate the patients and thus stop the progress of the epidemic were not always successful ; this was due to a lack of co-operation on the part of the patients them- selves, who did not and apparently could not understand the risk they were running both for themselves and for others. The manager of the estate reported that he frequently saw my patients, while yet desquamating and hardly free from fever, walking about out of doors. Also, in order to save themselves and their relatives trouble, some of the patients would, as soon as allowed out of bed, when they wished to effect a rectal evacuation, walk out of doors to the closets, which as is usual in Sweden were situated in a separate building removed from the dwelling houses by a distance of about some fifty yards. The following was the routine treatment adapted for uncom- plicated cases : — During the acute stage ; head exercise, vibrations or shakings on the tonsils, submaxillary region, and on any inflamed lymphatic glands in the neighbourhood, frictions on the nerves of these parts ; spinal nerve frictions, heart vibration ov shaking, side shaking, stomach exercise, kidney frictions, spleen frictions. During the convalescent stage; forwards lying back exercise, PP, kidney frictions, stomach exercise, and a few purely active or duplicate movements for the circulation, and to strengthen the entire body. The treatment for mumps will be found described on p. 290. The same method of testing for albumen was used throughout ; 266 ELEMENTS OE KELLGREN'S MANUAL TREATMENT nitric acid was added in the cold, and the test tube allowed to stand for fifteen to twenty minutes before drawing a definite negative conclusion. The following account comprises all the cases of the scarlet fever epidemic, together with some of the cases of mumps. Case 1. — Scarlatina Anginosa. A. C, female, aged 15. Previous history. — Had always enjoyed excellent health. History of present illness. — Patient had been feeling quite well until the evening of February 20, 1902, when she began to feel ■^EB MARCH DATE 21 22 23 24 25 26|27 28 1 2 3 TIME M E M E M E M E M E M E M E M E M E M E M E 105° 104° 103° 102° 1 o r 100° 99° 98° 97° 96° A) ^ y Ia v / y •^ \ / PULSE -"f 4>% ^% ^^^ 96 90 82 90 100 95 96 100 94 100 72 80 70 73 BOWELS 1 1 2 O 1 1 1 1 1 1 ill and slept badly. At 5 a.m. on February 21 she was attacked with bad pain in the head, throat, back, and abdomen, and also with vomiting. The vomit was of a greenish colour, and per- sisted at intervals for about seven hours, when it suddenly ceased. Examination. — February 21, 1.30 p.m. Patient had eaten nothing during the day. She complained of bad headache, of SPECIFIC INFECTIOUS DISEASES 267 pain in the throat and back, and to a lesser extent of pain in the abdomen. The tongue was white, and both tonsils were swollen. The abdominal muscles were contracted, and there was general tenderness of the abdomen, especially in the epigastrium. A sample of the vomit that was shown to me contained large quantities of bile. The urine was highly coloured, scanty in amount, and contained no albumen. For temperature and pulse see separate chart (fig. 91). Treatment three times a day hence- forth. 5 p.m. Patient had vomited once since last treatment. Headache worse ; pains in both legs bad set in. More swelling of tonsils, which were redder ; white patch of membrane on left tonsil, none on right ; cervical glands not swollen. A bacterio- logical examination of a portion of the membrane cultivated in gelatine for twenty-four hours at a temperature of 75° F. revealed a number of whitish spots, which under the microscope were identified as cocci, some being arranged in pairs and encapsuled, others being in irregular groups. 8 p.m. No more vomiting had taken place. Scarlatinal rash commencing on face, chest, and abdomen. Skin harsh and dry. Headache worse ; pains in back and limbs less severe. Membrane on left tonsil larger. No albumen, but nitrate of urea formed on adding nitric acid. February 22. — Morning. Patient had slept very little. Very little pain in back and legs. Headache better. Face very red, except just around mouth. Eash on trunk fully developed. Membrane on both tonsils. Strawberry tongue. No albumen. Afternoon. No pains in back. More pain while swallowing, but membrane about the same. Enlarged cervical glands. Rash on arms, but not on legs. No albumen. Evening. Headache almost gone. Large erytbematous-like patches on forearms ; rash on legs, but not yet on feet. Tonsils about the same. No albumen from urine, but nitrate of urea formed on adding nitric acid. February 23. — Morning. Rash on feet visible ; face less red ; desquamation commencing on it. Tonsils about the same. No headache. Afternoon. Patient had eaten again after two days' fasting. Throat much better ; much less difficulty in swallowing, and membranes smaller in size. Urine clearer ; no albumen, but 268 ELEMENTS OF KELLGREN'S MANUAL TREATMENT iiitnile of urea formed on adding nitric acid to all samples collected during the day. Desquamation over entire face. Evening. Throat better. Patient had consumed a good deal of milk. February 24. — Morning. Patient had slept fairly well. No desquamation on body as yet. Urine : no albumen, but nitrate of urea formed on adding nitric acid. Evening. Patient had been sitting up during most of the day. Only a slight difficulty in swallowing. Urine : no albumen ; from to-day onwards no nitrate of urea formed on adding nitric acid. February 25. — Morning. No difficulty in swallowing. Mem- brane on tonsils gone, and the latter only slightly red. Desquama- tion on neck, not on body. Temperature normal. Treatment twice a day henceforth. Evening. Patient said she felt very well, although weak. Up during most of the day. No albumen. February 26. — In consequence of her mother being to-day attacked with scarlet fever, patient was up all day and attended to cookmg and housekeeping, in the absence of anybody else to do the work. Morning. Face hardly red at all. Desquamation on hands and chest. Patient stronger than yesterday. No albumen. Treatment once a day henceforth. February 27. — Desquamation over whole body, but not yet on hands. Patient stronger, and went out during the day agamst my orders. No albumen. February 28. — Patient stronger. No albumen. March 1. — Desquamation on hands, but not yet on feet, which in fact never peeled at all. No albumen. March 2. — Patient felt almost restored. No albumen. March 3. — Patient felt quite well ; had been out during the greater part of the day since February 28 against my orders. Desquamation onl}' on left hand ; rest of body normal. No albumen. Treatment interrupted for three days. March 6. — Desquamation finished. Patient quite strong. No albumen. Treatment for the last time. The heart remained unaffected throughout. October 8, 1902. — Patient had continued in perfect health ever since her illness, and stated that she felt better than previous to it. SPECIFIC INFECTIOUS DISEASES 269 Case 2. — Scaklatina Anginosa. Mrs. H. C, aged 39, mother of A. C. (Case 1, p. 26(3). Previous history. — Quite good. History of present illness. — Duriirg the evening of February 2-5, 1902, patient, after feeling tired all day, was attacked by a bad headache. During the night she slept badly, and during the next morning had fever, sore throat and pains in the whole of the body, the headache being much worse ; she suffered from rigors all the morning, but not from vomiting. FEB. vlARCH DATE 26 27- 28 1 2 3 1 TIME MAE MAE MAE M E M E M E 105° 104° 103° 102° 101° 100° 99° 98 ° 97 ° 96 ° Axifla A n \ 1 \ 1-1 ^ / 1 / '' 4—^ / PULSE ^1? ..^ % 60 62 63 \7Z 601 Examination. — February 26, 12 noon. There was redness of the throat, and a large patch of membrane on the left tonsil ; the cervical glands were enlarged. A bacteriological examination of the membrane revealed the same features as in the case of her daughter (p. 267) . For temperature and pulse, see separate chart (fig. 92). Treatment three times a day henceforth. 6p.m. Headache worse ; pains in legs worse. No vomiting. Rash on face except around mouth. No urine passed as yet 270 ELEMENTS OF KELLGREN'S MANUAL TREATMENT 9 p.iu. Headache and pains in legs better. Hash on face, but nowhere on trunk or hnibs. Urine passed at (i p.m. ; no albumen. P'ebruary 27. — Morning. Patient somewhat better. ^leiu- brane on both tonsils. No albumen. Afternoon. Great pain in lumbar region. No albumen. Evening. Face not so red ; throat better. Patient had eaten an orange. Strawberry tongue. No albumen. February 28. — Morning. Patient much better. Face no longer red. Membrane on left tonsil gone. Temperature normal. No albumen. Afternoon. Patient complained only of weakness and of a difficulty in swallowing. Blight desquamation on face. No albumen. Evening. Membrane on right tonsil smaller. No albumen. March 1. — Morning. No pains in back, but some in both sides over lower ribs ; however, I could find nothing objective in this area. Pain removed by treatment. Patient felt weak ; otherwise complained only of a slight difficulty in swallowing. Treatment twice a day henceforth. Evening. Patient had been sitting up all day. Slight mem- brane on right tonsil. Desquamation on face finished. No albumen. March 2. — Patient very well and up all day. Eating her usual fare. No membrane on tonsil. Throat normal. No albumen. March 3. — Patient went out during the course of the day (temperature below freezing point). No albumen. Treatment once a day henceforth. March 6. — Patient quite strong. No albumen. Treatment finished. Patient went back to work on the estate as usual. The heart remained unaffected throughout. October 8, 1902. — Patient had continued in excellent health ever since her illness. Case 3. — Scarlatina Anginosa. E. J-i., female, aged lof. Previous history. — Quite good. History of present illness. — Patient felt quite well until the evening of February 27, 1902. She slept badly, and on getting SPECIFIC INFECTIOUS DISEASES 271 up on February '28 experienced headache, pain in back and legs, and difficult}' in swallowing, but did not vomit. She walked over to my villa at 9 a.m. Examination. — Patient looked feverish, and I could see a membrane on the left tonsil. I told her to go home at once, which she did. On arrival home she was seized with a rigor lasting ten minutes. FEB. MARCH DATE 28 1 2 3 4 3 6 7 8 9 TIME M A ;E MAE MAE M E M E M E M E M E M E M E F° 106' 105° 104° 103° 102° 1 01° 100° 99° 98° 97° >fl ixillz ) /s I \ ^ \ r \/\ / N A J M n .A \l ' I J V Y \l V \ PULSE 112 !^I12 '"^ no 105 <$. % 90 82 79 72 72 63 66 63 81 63 58 56 M BOWELS 1 1 1 1 1 1 1 1 1 1 For temperature and pulse see separate chart (fig. 93). I requested patient's mother to keep all the urine passed, and during each visit I estimated the amount, took the specific gravity and tested for albumen. (See p. 273 for results of this examina- tion.) Treatment three times a day henceforth. 3 p.m. Headache very bad, but better after treatment. Patient perspiring freely. 9 p.m. Patient had been asleep during the afternoon, and drank some milk on waking up. Headache better. Membrane on both tonsils ; considerable difficulty in swallowing. 272 ELEMENTS OF KELLGREX'S MANUAL TREATMENT March 1. — 9 a.iu. Patient had slept fairly well. Scarlatinal rash on body and face, except just around mouth. Less diffi- culty in swallowing; membrane on left tonsil smaller. White tongue. Pain in right ear ; removed by treatment, not to return. 3 p.m. Patient had been sitting up. Eash on arms ; that on body less red. Strawberry tongue. 9 p.m. Patient feeling very well in spite of the amount of fever present. Enlarged lymphatic glands on right side below angle of jaw. March 2. — Morning. Patient had slept very well. Motion to-day for first time since commencement of illness. Rash well marked on arms, hairds and feet ; desquamation commenced on face. Membrane on left tonsil almost gone, and that on right tonsil much smaller. Evening. Condition about the same. Treatment twice a day henceforth. March 3. — Desquamation on hands. No membrane on tonsils. Patient better, and up during part of the day. March 4. — Bash almost disappeared. Desquamation on face nearly finished ; hands and feet never peeled at all. Difficulty in swallowing almost gone. Patient up all day. Headache bad during the afternoon. March 5.— During the morning bad headache and pains in stomach and side ; nothing objective, however, in the areas where they were felt. Desquamation almost finished. Patient resumed usual diet, and was up all day. March 6. — Ko headache ; throat normal ; pain in back and sides, but not so bad as during the previous day. Nothing objective in sides. March 7. — Pain in one side ; patient otherwise normal, except for slight weakness and the last remains of desquamation. March 8. — Desquamation finished. March 9. — Patient went out (temperature — 7'C.), and was in normal health. Treatment finished. March 10. — Patient out all day. The heart remained unaffected throughout. The treatment was on the lines already indicated, with the addition of vibrations, shakings, and nerve frictions over the pain- ful areas in the back and sides, and on one occasion (March 1) ear exercise, PP. SPECIFIC INFECTIOUS DISEASES 273 Unne. Date in^Cub?' Total Speoiflc Cent. Gravity Feb. -28 .. Evening ... 136 136 ... 1033 ' Morning ... 150 | ( 1034 March 1 ... \ Afternoon ... 180 530 ... I 1030 Evening ... 200 ) ( 1030 ■ Morning ... 260 | I 1031 Afternoon ... 130 ,1- .540+ .. \ 1029 ( Evening ... 150+) ( 1029 I Morning ... 310 I ^-qn , ' 1025 t Evening ... 320+)" ^^"+ ■■■ ] 1022 (Morning ... 220+) „,„, (1026 ] Evening ... 520 f '*"+ ■■■ \ 1018 ( Morning ... 520 ) .„„ ( 1020 (Evening ... 170+ f '^" ■ -■ 11019 Morning ... 560 1 „„„ f 1017 Evening ... 430+ 1 ^"+ ••• 11015 f Morning ... 750 [ „„„ ( 1016 I Evening ... 200+) ^^~^ ■■ (1016 ( Morning ... 390 ) „,- f 1017 I Evening ... .525+ f '^ + •• (1018 Morning ... 360 ... .. 1017 About six weeks later patient took a situation as a general servant ; the last news I had of her (September, 1902) reported her to be in very good health indeed. Case 4. — Scarlatina Simplex. G. C, female, aged U, who was under treatment for apoplexia cerebri, and was living in one of the houses in the group previously specified, was the next to be affected. The attack, which was a very mild one, began on March 1. Patient com- plained of headache, pain in the back, and difficulty in swallowing. Beyond very slight fever (maximum 99'6° in the axilla), redness of the tonsils, and slight redness of the chest, the latter dis- appearing the following day, there were no objective symptoms. The urine remained practically normal, the highest specific gravity reached being 1025, and I never found any albumen. No desquamation took place. The treatment was administered twice a day during seven days, after which patient came to me again every day to resume the previous treatment for her nervous condition. (The latter will be found reported on pp. 407-414.) The heart remained unaffected throughout. 18 274 ELEMENTS OF KELLOREN'S MANUAL TREATMENT Case 5. — Scarlatina Anginosa. Mrs. E. K., aged 28. Previous history. — Patient had al\va3s been anaemic since about the age of twelve, especially from about her fourteenth to her twenty-second year. History of present illness. — Patient was attacked with scarlet fever simultaneouslj^ with one of her daughters on March -5, 1902. MARCH DATE 5 6 7 1 8 9 1 10 1 II TIME AE MAE MAEiM EM EM EM E 105° 104° 103* 102° 1 OI° 100° 99° 98° 97° 96 ° Axi Ha ■ \ 11 1 ■ ^ , A ft \ , 1 \ f\ ^ , "^1 V V Sj r 1 PULSE 96 90 "•^flf 96 78 78 76 80 IsS 84 83 All the morning of that day she had rigors, great frontal head- ache, and pains in throat and back. She felt inclined to vomit, but did not actually do so. Examination. — Fever (for fever and pulse see separate chart, fig. 94) ; redness of tonsils and fauces. No albumen in the urine. Treatment three times a day henceforth. Evening. Membrane on right tonsil. No albumen. March 6. — Morning. Patient had slept badly. Pain in throat SPECIFIC INFECTIOUS DISEASES 275 worse, but headache better. Scarlatinal rash on face, excepting around mouth, but none on body. Strawberry tongue. Mem- brane on both tonsils. Evening. Face had typical scarlatinal look ; general con- dition about the same. No albumen. March 7. — Morning. General condition improved. Throat better ; face not so red. Evening. Patient much better ; had been up during the afternoon washing dishes. Membranes on tonsils disappeared ; only some redness left. No albumen. March 8. — Treatment twice a day henceforth. Morning. Patient complained of headache (menstruation commenced to- day), but was up all day attending to household duties. Desqua- mation on face commenced. No albumen. March 9. — Excepting for slight difticulty in swallowing and weakness patient felt normal. No albumen. March 10. — Patient was up all day, and baked bread ; while so doing she exposed herself, together with her two children (see cases 6 and 7), to a strong draught for about three hours during the course of the afternoon, the temperature being con- siderably below freezing point. Stiffness and pain in the muscles of the back and neck, resulted with tenderness to pressure in the cervical region as well as below the angle of the jaw, also swelling of both parotids. Treated specially for this with muscle knead- ing, muscle frictions, and frictions on the nerves supplying the muscles, duplicate movements involving them ; vibrations and frictions on the parotid glands. No albumen. Mr.i'ch 11. — Pain in neck about the same, but less stiffness in the muscles. March 12. — Muscles normal ; no swelling of parotid. Desqua- mation on face finished. Treatment finished. The heart remained unaffected throughout. On April 18, 1902, patient returned to treatment, in con- sequence of menstrual disorders, from which she had been suffering, unknown to me, for the past fifteen months. The flow came on irregularly at intervals of two to four weeks, and lasted from three to nine days on each occasion. Patient was given the manual treatment until May 10, when menstruation was once more normal. She was still in very good health when I left Sweden in October of the same year. 276 ELEMENTS OF KELLGREN'S MANUAL TREATMENT Case 6. — Scarlatina Gravior with Middle Ear Disease. M. K., aged G months, daughter of Mrs. E. K. (see Case 5), was attacked simultaneously with her mother, i.e., on March 5, 1902. Previous Jiistorij. -Fsitient was born at full time, and had always heen healthy. History of present illness.-The rash came out on March (i, the temperature reaching 10'2° (per rectum) ; there were no throat symptoms beyond slight redness of tonsils. On March 9, desqua- mation had commenced ; the temperature was normal. On March 10 patient was exposed to a draught for three hours as mentioned on p. 275, in consequence of which acute suppurative middle ear disease set in on the left side. On March 13 the abscess perforated the tympanum, and the discharge continued to be yellowish in appearance until about March 30, whereupon it became watery, and, gradually diminishing, ceased on April 10. The treatment for the ear condition was ear and mastoid vibration and syringing. I was only able to test the urine on March 6, 12, 18, and 14. It contained no albumen on any of these occasions. October, 1902. — Child apparently in perfect health. Hearing normal. No ear symptoms. Case 7. — Scarlatina Anginosa, followed by a Chill with Spinal Symptoms, and Epidemic Parotitis. (?) E. K., aged 2i daughter of Mrs. E. K. (Case 5, p. 274.) Previous history. — Quite good. History of present illness. — During the course of March (3, 1902, mother noticed that the child was irritable, always wanting to lie down, and that during the afternoon her face was very red. I was sent for in the course of the evening. Examination. — I found patient with a scarlatinal rash on trunk and face, except just around the mouth ; some membrane was present on both tonsils. There was fever (for fever and pulse see separate chart, fig. 95). The urine contained no albumen. March 7. — Rash on arms and legs. Membrane on tonsils about the same. Patient consumed some bread and milk during the course of the day, and got up and walked about during the afternoon. No albumen, but one sample of urine gave a pre- SPECIFIC INFECTIOUS DISEASES 277 cipitate of nitrate oE urea on adding nitric acid. Treatment three times during the day. March 8. — Treatment twice a day henceforth. Rash less red. Membranes on tonsils less; strawberry tongue. No albumen or nitrate of urea. Patient up during most of the day. March 9. — Desquamation commenced. Appetite returned. Ordinary diet. Patient up all day. No albumen. March 10. — Condition about the same as during the previous day. Patient exposed to a draught for three hours, as mentioned on p. 275. No albumen. MARCH DATE 6 , 7 1 8 j 9 i 10 II 12 [ 13 ' 14- 13 16 17 18 19 j20 TIME M E MAE'M E M EM E M e!m e M E'M E M E M E M E M E M EW E 106° 105° 104° 103° 102° 101° 100° 99° 98° 97° R ;cti m \ hv k \A A \ \ / u ^, \ ./ / s A / t^ / y\ A . •^ / ■/ i/ PULSE leo ^^^^'^40 131 140 120 136 130 140 136 140 130 159 IS6 154 152 130 46 153 130 140 20 129 March 11. — Desquamation finished, tonsils normal. Eise of temperature. Patient ate nothing during the whole day. No albumen . March 12. — Patient better. Fever less. During the after- noon, in the absence of her mother, patient ran out in the open air without either shoes or stockings on, the temperature being considerably below freezing point. During the evening she was worse, and suffered from great irritability, retraction of head and photophobia. No albumen. 27S ELEMENTS OF KELLGREN'S MANUAL TREATMENT March 13. — Temperature still higher. Retraction of head more marked, slight stiffness of muscles of both lower limbs. Exaggerated patellar reflexes and slight ankle clonus on both sides. Extreme tenderness over dorsal spinal nerves, and some tenderness over most areas of the bodj'. Incontinence of urine. I could not test for albumen. March 14. — Condition about the same. I could not test for albumen. March 1.5. — Patient better ; temperature lower. No retrac- tion of head ; no stiffness of nniscles. Reflexes normal. No tenderness over dorsal spinal nerves or rest of body. No incon- tinence of urine. No albumen. During the evening bilateral swelling of parotids and sub- maxillary glands (epidemic parotitis?) March 16. — Swelling of salivary glands worse. March 17. — Swelling about the same. March 20.— Swelling better. March 24. — Swelling almost disappeared. No albumen during the last nine days. April 3. — Patient normal ; swelling quite disappeared. No albumen during the last ten days. Treatment finished. The heart remained unaffected throughout. October, 1902.^ — Patient had continued in excellent health ever since her illness. Treatment. The ordinary treatment for scarlet fever ; from March 12 until 16, vibrations over dorsal nerves and spinal cord for about ten minutes, and shaking over the bladder were added. March 1.5 to 24, ordinary treatment for mumps. March 25 to April 3, ordinary treatment for convalescence from fever. Case 8. — Mild Case of Scarlatina Anginosa. T. J., male, aged 16 ; occupation, stoker in a factory. Previous historij. — Quite good. History of present illness. — On waking up at about the usual hour on March 7, 1902, patient felt ill, had a headache and pain in the back, and his mother noticed that his face was red. I saw patient at 11 a.m. of the same day. SPECIFIC INFECTIOUS DISEASES 279 Examination. — Scarlatinal rash 011 face, except around mouth, and on body. Membrane on both tonsils. Fever (for fever and pulse see separate chart, fig. 96). No albumen. Treatment twice a day henceforth. Evening. Headache worse ; pain in throat had set in. No pain in back. Lymphatic glands of neck swollen. Rash as before. No albumen. After treatment no headache. March 8. — Morning. Face less red. No headache, no pain in throat. Patient better, and got up during the course of the day. DATE 7 8 9 10 II 12 13 TIME M E M E M E t E M M H lOS" 103' 102' lOl" 100' 99* 98" 97' 96 ■ Axi la \^ ^. > fi \^ ^ - PULSE 10 100 lot Ob aa 84. ec rz Evening. Membrane only on right tonsil. Patient felt nearly well. No albumen. March 9. — Membrane on right tonsil almost gone. Patient up all day. Temperature normal. No albumen. March 10. — Morning. Patient eating as usual (meat included). Desquamation on hands and face. Patient went out during the afternoon (against orders). Evening. No membrane on tonsils, but lymphatic glands of neck still somewhat enlarged. No albumen. March 11. — Patient practically normal. No albumen. Treat- ment once a day henceforth. March 12. — Desquamation finished. Patient went out of doors during the afternoon for three hours (temperature a good deal below freezing point). No albumen. 28o ELEMENTS OF KELLGREN'S MANUAL TREATMENT March 13. — Patient normal. Out all day. March 14. — Treatment for the last time. Patient resumed work as stoker. The heart remained unaffected throughout. Patient had a motion every day of his illness. October 8, 1902. — Patient had continued in excellent health ever since his illness. Case 9. — Scarlatina Anginosa. E. W., male, aged 23. Previous history. — Quite good. History of present illness. — During the evening of March 16, 1902, he began to feel ill, and was feverish. During March 17 he felt pains in the head, throat, back, and abdomen, and vomited fairly continuously from 9 a.m. until 6 p.m. I first saw patient in the evening. Examination.— Face very red, except around mouth ; scar- latinal rash on body ; membrane on both tonsils. Fever (for fever and pulse see separate chart, fig. 97). Urine (see p. 281). MARCH DATE 17 18 19 20 21 22 23 TIME E M E M E M E M M. M F° 106° 105° 104° 103° 102° lOT 100° 99° 98° 97° MOL ith ^ r^ s ^ L v» *^ PULSE 100 96 88 a* S2 69 80 72 68 65 SPECIFIC INFECTIOUS DISEASES 281 March 18. — Treatment twice a day henceforth. Moi'ning. Rash on hands and feet. Membrane on tonsils about the same. Headache better ; pain in back better ; no pain in abdomen. Evening. Membranes on tonsils gone, only redness left. Strawberry tongue. March 19. — No pain in bead or anywhere else. Swallowing normal. Desquamation commenced on face. Patient ate two eggs and meat for dinner; until then had only taken milk. Patient got up during the course of the day. Evening. Desquamation on hands. March 20. — Patient feeling very well. Up all day ; no fever. Desquamation on body. Ordinary diet, although appetite not yet quite good. Evening. Slight pain in lower part of back. Tonsils no longer red. Desquamation on feet. March 21. — Patient up all day. No pain in back. Desquama- tion on body finished. Treatment once a day henceforth. March 22. — Desquamation on hands finished ; only the ears left peeling. March 23. — Patient very well indeed. March 27. — Desquamation only on ears. No albumen during the past four days. Treatment finished. March 30. — Desquamation only on right ear. April 1. — Desquamation finished. Urine. Owing to his misunderstanding my directions the patient did not invariably keep all the urine passed, but sometimes threw some of it away. Date March 18 „ 19 „ 20 „ 21 „ 22 ,, 23 ' Morning 1 Evening j Morning \ Evening ( Morning ( Evening uantity ill cc. Specific Gravity 220+ . 150 + 1040 1085 250 + 155 + 1033 1028 300+ . 120+ . 1030 10-28 250+ . 1022 450 + 1021 300 + 1025 Albumen none 282 ELEMENTS OE KELLGREN'S MANUAL TREATMENT The heart remained unaffected throughout. Patient remained in veiy good health until about the middle of June, 1902, when he emigrated to America ; since then I have heard nothing of him. Case 10. — Scarlatina Anginosa followed by Epidemic Parotitis. S. N., female, aged 7. Previous history. — Patient had never been very strong. History of present illness. — Patient complained of headache and sore throat during the morning of March 18. She slept very badly, and during the morning of March 19 complained of pain in the throat, head, legs and back. She felt a desire to vomit, but did not actually do so. Three diarrhoeic motions took place during the course of the morning. Her mother noticed that the patient's face and body were red. I first saw patient at 3 p.m. on March 19. Examination. — Scarlatinal rash on face excepting around mouth, also on body, but none on hands or feet. Some fever (for fever and pulse see separate chart, fig. 98). Membrane on both tonsils. Urine, no albumen (see p. 284). Treatment twice a day henceforth. Evening. Patient ate sausages and brown beans for dinner, and took milk at intervals during the course of the day, also some coffee ; had two more diarrhoeic motions. Rash on hands. Pain in back very severe, pain in throat about the same ; both much relieved by treatment. Some headache. March 20. — Patient had slept very well during the night. Non-diarrhoeic motion during the morning. No headache, only slight pain in back and throat. Desquamation commenced on body and face. Patient got up during the course of the day, and ate her usual fare. March 21. — Morning. No pain in back or throat ; some membrane on the tonsils still present. Patient up all day. Evening. Membrane on tonsils almost gone. Eise of tem- perature, and all the signs of mumps on both sides (one brother had the latter disease about three weeks ago and another brother developed it yesterday). SPECIFIC INFECTIOUS DISEASES 283 March 22. — Membrane on tonsils gone. Mumps fully developed. Patient complained of a sense of pulsation in right ear. Membrana tympani normal. Patient up all day. March 23. — Mumps subsiding ; no difficulty in swallowing. No pulsation in ear. Desquamation on face finished, and finish- ing on body. Hands and feet never desquamated. Patient up all day. March 24. — Swelling still less, only slight in right parotid, none in left. Patient felt very well. MARCH DATE 19 20 21 22 23 24 25 TIME A E M E M E M E M E M E ^ E F° 104° Axil la t \ A A 100° \ \ /^ /I r 99° 98° U k^ \/ PULSE 144 120 \3i 120 135 lie 104 I33| IOC 96 98 90 100 March 25. — Patient felt quite well. Treatment only once a day henceforth. March 2G. — Desquamation finished. Patient out all day. No albumen. March 27. — Only slight swelling in right parotid. No albumen. March 81.— Patient normal. Treatment finished. The heart remained unaffected throughout. 284 ELEMENTS OF KELLGREN'S MANUAL TREATMENT March 19 „ 20 Eveniug f Morning i Evening J Morning 1 Evening j Morning (Eveniug ( Morning I Evening (Morning {Evening I Morning I (Evening | Urine. Quantity 70 '200+ I 160 I 2G0 I 150+ I 325 1 350 / 375 I 100+ ) 260 ) 135+ 1 620 Total 70 360+ 410+ 675 475 + 395 + 620 lirav.ty 1020 11018 ( 1018 ( 1023 ■( 1018 (1016 1 1017 (1013 (1014 (1010 '( 1012 1016 Albumen none Patient remained quite well until April "24, 1902, when she left the district : I have not heard of her since. Case 11. — Scarlatina Anginosa with Epidemic Parotitis. A. N., male, aged (5^ months, brother of S. N. (Case 10). Previous history. — Patient was a full-time child and had never been ill. Was stroilg and big for his age. History of present illness. — During the evening of March 28, 1902, patient vomited, and during the night slept very httle, vomiting almost every half hour. The mother examined him carefully for any signs of a rash, but found none. (1 had told her to report to me at once if any more of her children began to look red in the face or have a rash on the body.) I first saw patient on the morning of March 29 ; nothing objective except slight fever (100"). During the afternoon, however, he developed symptoms of scarlet fever and mumps simultaneously. Examination. — Scarlatinal rash on face except around mouth, also on body; membrane on right tonsil; swelling of both parotid and submaxillary glands, the swelling passing downwards into the neck. For temperature see separate chart, fig. 99. Treat- ment twice a day henceforth. March 30. — Morning. During the previous day patient ate nothing, but to-day took the breast as usual. Membrane on tonsil gone. Strawberry tongue. Rash on arms and legs. Evening. Better. March 31. — Morning. Patient had slept very well. Des- SPECIFIC INFECTIOUS DISEASES 285 quamation on back. Swelling of parotid and submaxillary glands better. April 1. — Redness on body diminisbing. Swelling of salivary glands less. April 2. — Redness almost disappeared. Desquamation on back finished. Rise of temperature, but I could find nothing objective to account for this. April 8. — Desquamation on abdomen, face and legs. Hands never desquamated at all. Treatment only once a day henceforth (during the evening). MARCH ^PR L DATE 29 30 31 12 3 4 5 1 6 7 8 9 TIME M E M EiM EiM EM EJ E i E E ' E E E E F° 106' 105° 104.° 103° 102° 1 1° 100° 99° 98 ° 97 ° Rectun 1 / \ A / \ K \ / \ / V V Sk. N V ^*N ^ April 4. — Desquamation on feet commenced. April 5. — Swelling of parotids much less. April 6. — Desquamation only on feet. April 14. — Desquamation finished. No .swelling of parotid or submaxillary glands. Patient normal. Treatment finished. The heart remained unaffected throughout. I was only able to test the urine once, on the fourth day of the illness. It contained no albumen. 286 ELEMENTS OF KELLGREN'S MANUAL TREATMENT Case 12. — Scarlatina Simplex followed by Epidemic Parotitis. I. J., female, aged lii. Previous history. — Patient of a very neurotic temperament ; bad fainted on occasions, and twice during the year had had hysterical attacks. Had always been rather anaemic. History of present illness. — Patient was attacked during the evening of April 4, 1902, with pains in the head and back ; 1 saw her at 9 p.m. of the same day. Examination. — Temperature 101° (for temperature and pulse see chart, fig. 100), otherwise nothing objective. Throat un- affected. Urine (see pp. 287, 288). APRIL DATE 4- 5 6 7 a 9 10 TIME . E MAE M E M E M E .A- -A F° 106° 105° 104° 103° 102° 101° 100° 99° 98° 97° MOL jth 1 A A N JV \ \A V V \ \ -^ /' PULSE • 108 <% 104 101 rs 84 69 70 62 92 April 5. — Morning. Patient had been vomiting ; she had suffered from great frontal headache and pain in the back, but had no difficulty in swallowing. Scarlatinal rash on face, except around mouth, also on body ; not yet on arms. Redness of both tonsils. SPECIFIC INFECTIOUS DISEASES 287 Evening. Patient had eaten nothing during the day. Pains in head and back better. Rash on arms. Treatment three times. April 6. — Morning. Patient felt better. No pain in the back ; but still some headache present. Strawberry tongue. Patient ate pancake for breakfast. Evening. Headache better, but pains in knees. Rash on body disappearing, entirelj' gone from both arms. Treatment twice a day henceforth. April 7. — Rash on body gone; only slight redness of face, on which desquamation had set in. No pains anywhere. Patient got up, and remained up during most of the day ; felt weak but otherwise normal. Evening. Desquamation on hands. April 8. — Patient resumed ordinary diet, including meat, coffee, &c. During the evening the urine formed nitrate of urea on adding nitric acid. April 9. — Treatment once a day henceforth. Patient up all day. Desquamation nearly finished. April 10. — Desquamation only on one finger. April 11. — Desquamation finished. Patient went out (against my orders) for a two-mile walk (temperature considerably below freezing point). April 12. — Patient was out for three hours (against my orders). April 13. — Pains in both knees and muscles of anterior tibio- fibular regions of both sides ; removed by treatment (vibrations, muscle kneadings, foot rolling, PP, flexion, AR, extension, PR, anterior tibial nerve frictions, PP). April 14. — An attack of mumps supervened, the temperature rising to 100"4° F. Treatment twice a day henceforth. April 15. — Fever gone. Swelling of salivary glands less. April 19. — Hardly any signs of mumps left. Treatment this morning for the last time. April 22. — No sign of mumps left. The heart remained unafl:'ected throughout. Urine. April 5 ( Morning jEveniDg Quantity 100+1 90+ f Total 190+ ... Specific Gravity (1042 ) 1042 j ilorning (Evening 200 ) 250+ 1 450+ ... fl040 1 103G 288 ELEMENTS OF KELLG REN'S MANUAL TREATMENT Date ^^"^'^ity Total |P^^,i.Jj Albumen \nril 7 (Morning ... 260 I 20+ ^'^^^^ - '^°'^^ April I ... |K^,3ni„g 160+) ^''"+ - "(1036 (Moi-niDg ... 250 I „„ J1030 ■■• 1 livening ... 240+ [ "'""'" ■•• (1034 „ 9 ... ... ... 910 910 1031 ... „ ,, 10 ... ... ... 860+ 860+ •■■ 1028 Patient, excepting for catching a bad cold about a fortnight later, remained in very good health until June of the same year ; in that month she took a situation as servant and I heard no more of her. Case 13. Ur. Harry Kellgren has kindly allowed me to publish the following case treated by him, January-February, 1901 : — H. A., aged 7. Previous history. — Patient when quite young had measles, but otherwise had always been strong and healthy. Since attending school, patient had from time to time felt very tired in his eyes and occasionally had headaches together with a slight amount of fever and vomiting. History of present illness. — In consequence of patient looking ill, I was sent for during the evening of January 25, 1901. Examination. — Patient complained of headache, vomiting, some cold in the head, and pain in the throat on swallowing. On inspection the tonsils were red, the tongue rather furred ; the eyelids swollen, and could only be opened with difficulty. Photophobia. Skin somewhat raw. No fever; pulse full and strong. Lungs and heart healthy. January 2G. — Morning. The symptoms ah-eady mentioned unchanged. Light red eruption on the trunk. Temperature 40'2°, pulse 110. Motion during the morning. Urine very scanty, and concentrated, but not otherwise abnormal. Treatment three times a day. January 27. — Morning. There had apparently been high fever during the night. Temperature 40"4°, pulse 120. Noon. Headache and sore throat much better. No vomit- ing. Strawberry tongue. Evening. Typical scarlatinal rash, very marlced over the whole body, excepting on the forehead and around the mouth. SPECIFIC INFECTIOUS DISEASES 289 Frequent micturition ; urine contained urates. Temperature 39'5', pulse 110. January 28. — Morning. Patient had slept well ; disposition much more cheerful ; appetite returned. Kash a little paler. Temperature 37'6°, pulse 90. Evening. Temperature 37'5°, pulse 100. Desquamation con- siderably advanced. Eyelids better. Tonsils normal ; tongue no longer furred. Appetite good ; patient cheerful. January 29. — Morning. Temperature 37"3°, pulse 84. Patient's appetite and frame of mind very good. The kidneys, which had throughout been very sensitive, no longer so tender. Urine normal. January 30.— Temperature 37"2°, pulse 74. Motion during the day. General condition very good. Desquamation not yet quite completed. Kidneys still rather tender. Urine normal. The treatment up to date had been : head exercise, throat exercise, spinal nerve frictions, stomach exercise, kidney frictions, shaking and vibration over the bladder ; stretch lying running nerve frictions, PP. January 31. — From to-day onwards tlie patient underwent a general strengthening treatment. February 5. — The treatment was administered for the last time. The patient was then quite cured, and felt stronger and better than before his illness. Epidemic Parotitis. The following was the worst case that occurred during the epidemic referred to on p. 265 : — G. J., male, aged 9. Previous histori/. — Patient suffered from tuberculous glands in the neck for a year, 1898 to 1899, but recovered, and since then had always been fairly strong. History of present illness. — Patient went to school as usual on April 10, 1902 ; during the evening of that day he experienced a slight pain in his neck. He passed a bad night, and was much worse the following morning (April 11) ; there was more pain, and swelling had arisen on both sides of his neck. I was sent for at 10 a.m. 19 290 ELEMENTS OF KELLGREN'S MANUAL TREATMENT Examination. — Swelling of both parotid c,'laiids, extending down side of neck, and swelling of both submaxillary glands ; thickness of speech, difficulty and pain on talking; pain on swallowing. Great tenderness over the swollen glands. Tem- perature 102°, pulse 100. Treatment twice a day henceforth. Evening. Condition about the same ; temperature 102", pulse 100. Patient had eaten nothing during the day. April 12. — Morning. Swelling less. Temperature 99"6°, pulse 84. Evening. Swelling less ; temperature lOO'B"', pulse 84. Patient had drunk some milk and eaten some rusks. April 18. — Morning. Swelling less ; hardly any pain at all on swallowing. Temperature 98"6°, pulse 82. Appetite had returned, and usual food w'as taken. Patient got up, and, against my orders, went out during the afternoon. Evening. Swelling still less; temperature 98' 1°, pulse 90. Swallowing normal. April 14. — Morning. Temperature 98'4°, pulse 84. Patient out all day. Evening. Temperature 98°, pulse 76. Swelling still less, and confined to the parotids. Submaxillary glands normal. April 15. — Morning. Temperature 99°, pulse 78. Evening. Temperature 98°, pulse 72. Swelling still less. April 16. — Morning. On my arrival I found that patient had felt so well that he had gone to school as usual. Evening. Very little swelling of parotids ; temperature 98'4°, pulse 74. Treatment as usual. April 17. — Hardly any swelling of parotids. Treatment once a daj' henceforth. April 20. — No swelling. Treatment finished. The temperatures were all taken in the mouth. Treatment. Vibrations and shakings, followed by frictions on the salivary glands and on the swollen lymphatic glands; running vibrations from above downwards along the sterno-mastoids ; frictions on the facial nerves and on the nerves lying in the submaxillary region. General treatment for fever. SPECIFIC INFECTIOUS DISEASES 291 Diphtheria. Nasal, tonsillar, pharyngeal, and laryngeal diphtheria occurring in myself ; treated December, 1899, to January, 1900. Edgar F. Cyriax, aged 2.5. Previous history. — Patient had been feeling more or less weak and fatigued for several months, and had been attending continually to a child with diphtheria from November 27 to December 8, 1899 ; this had caused a considerable extra strain (see appendix). History of present illness. — On December 2 he felt some uneasiness in his tonsils. He slept badly during that night, and on December 3 there appeared redness and swelling of both tonsils ; during the evening of the same day a small patch of membrane could be seen on the left tonsil. December 4. — Membrane had spread to right tonsil, and was of a gray colour. Swallowing was difficult ; tonsils were very much swollen. During the course of the day the uvula became enlarged, and the voice slightly husky. December .5. — ^During the night a further increase took place in the size of the uvula, which became so long that it continually touched the patient's tongue and fauces, preventing any sleep ; a great amount of salivation was set up. The voice became more and more hoarse during the course of the day. During the evening the bacteriological laboratory reported that a culture taken from patient's throat the day before contained diphtheria bacilli. Some thick stringy mucus from nose had been continu- ally coming away during the day ; sometimes it was tinged with blood. For temperature and pulse see separate chart, fig. 101. December 6. — Patient delirious during the night ; slept very little indeed. On waking voice reduced to a whisper. Bloody mucus from nose in great quantity. December 7. — Occasional delirium during the night ; patient hardly slept at all. Symptoms much the same as before, excepting that salivation was slightly less, and swallowing a trifle easier. December 8. — Patient slept fairly well. Membrane diminish- ing in size, salivation much less. Bloody mucus from nose less in amount. December 9. — Tonsils smaller, and in consequence patient 292 ELEMENTS OF KELLGUEN'S MANUAL TREATMENT was enabled to see, on examining with a looking-r^lass, that the pharynx was full of gray membranes. Decemer 10. — Only a small patch on right tonsil. Very little bloody mucus coming from nose. December 11. — Patient coughed up blood clots continually. December 12. — Patient still coughing up blood clots. December 13. — Membranes on tonsils and in pharynx almost gone ; some inflammation still visible. Swallowing quite easy. December 14. — Some inflammation of right tonsil ; left tonsil normal. Voice no better (still a whisper). DEC. DATE 5 6 7 B 9 10 1 1 12 13 14 15 TIME E MAE MAE MAE MAE MAE MAE MAE M E M E M E 106° 105° 104° 103° 102° 1 r 100° 99° 98° 97° Re ctu n \ ft A A A h f A \v V P i V* \, / ^ y w PULSE 106 % % '"•> % % % % 76 66 70 63 66 December 17. — Patient went out for a short walk (temperature about — 10° C). Tonsils and pharynx normal in every respect. December 18. — Patient went out for a drive of one hour. The treatment was now stopped until December 21, owing to unavoidable circumstances. Patient was treated December 21, 22, 28 ; then there was another break, and after that the treat- ment could only be administered about every other day, the actual dates being December 28, 29, January 1, 8, 6, 8, 10, 11, 12 ; after SPECIFIC INFECTIOUS DISEASES 293 the latter date the treatment had to be stopped altogether. Already, on December 21, the voice had begun to come back ; after January 12 it continued to improve by itself. By February 10 the voice was normal, and patient could sing as usual. A slight attack of peripheral neuritis supervened, causing no inconvenience beyond a feeling of pins and needles in the hands and feet. After lasting three weeks or so, it disappeared without treatment. The lungs and heart remained healthy throughout. Treatment. At first shakings and vibrations of the larynx, pharynx, and trachea, &c. ; frictions over the nerves in these parts, chiefly the superior and recurrent laryngeal, also great occipital and spinal nerves ; general treatment for fever. Patient did not remain in bed during the acute stage ; he got up every morning and spent most of the day sittuig up or walking about. Diet was whatever patient liked, but the amount of food taken was limited, in con- sequence of the severe pain induced on attempting to swallow. During the convalescent stage, the treatment was specially directed towards stimulation of the nerves of the larynx, and also of the nervous system generally. No serum was used, the patient absolutely declining any. March, 1902. — Patient had been very well ever since. In May, 1902, however, an attack of rheumatic fever and erythema set in. The case will be found described on pp. 300 to 308. Erysipelas Migrans Bullosum. In the town of Huskvarna several cases of erysipelas occurred during the summer of 1900. The case described was one of three occurring in the same street. K. O., female, aged 5, came under the manual treatment on August 29, 1900. Previous history. — Quite good. History of present illness. — Everything was apparently normal until the morning of August 26, when, after a restless night. 294 ELEMENTS OF KELLGREN'S MANUAL TREATMENT patient said that she felt ill, and complained of pain in the right inguinal region ; she also experienced several shivering attacks. Patient's mother noticed nothing unusual except that the child seemed feverish, and that there was a small scratch on the front of the lower leg at about the junction of its middle and lower third. During the afternoon patient got up, said she felt quite well again, and played about as usual. On getting up on August 27 she felt fairly well ; but after a little she experienced further shivering attacks and some fever, and went to bed again at about 11 a.m. The parents observed that around the scratch noticed during the previous day there was a bright red patch about the AUG. SEPT DATE 29 30 31 1 2 3 4 5 6 7 8 t 9 [10 II 12 I3|l4.| TIME E MAE MAE M E M E M E M E M E M E M E M E M ElE E E E E 106' lOS" I04° 103* 102" lOl" 100" 98 • 97* Rect im ^^ j / > / ^H A \ '^\ i iA A h t )/^ A / / / / J ^ / / Y / , y y V r PULSE 32120 110 120:il6 13512^ 32K2II0 120!% 120120 90 120 90 108 lUlOS 04 104 78 106 B5 110 96 lie rr 122 88 94 96 90 90 100 14 IB 16 OD 00 size of a shilling. On August 28 the general condition was worse, while the red patch had grown to about three inches in length. On August 29 the general condition was still worse and the red patch still larger, and I was called in. Examination. — August 29, 6 p.m. Patient in bed, looking very worn out (she had hardly had any sleep for two nights), feverish and shivering. Temperature 103'6°, pulse 132. (For temperature and pulse, see separate chart, fig. 102.) Eight lower leg and foot swollen ; a large, bright red, inflammatory patch could be seen extending right round the limb from about the scaphoid bone to about two inches below the knee-joint. On the patch many buUffi (some about an inch long) filled with SPECIFIC INFECTIOUS DISEASES 295 yellowish exudation ; in some places they communicated with one another. In between the bullae the red area was tense, glazed-looking, and slightly oedematous ; the uiargins were raised and well defined Some oedema of the foot. Great feeling of irritation in the affected area ; not much pain in it, but great ten- derness to touch. Several enlarged lymphatic glands about the size of a walnut in the right grom ; kidney and spleen tender ; urine scanty and highly coloured. Heart sounds normal. After treatment patient went to sleep. Treatment henceforth three times a day. August 30. — Patient had slept fairly well, better than during any night since the 27th inst. Morning. The inflammation had spread up about an inch since the previous evening. Treatment administered with in- creased energy. Afternoon. The bullte larger. The inflammation had spread downwards on the foot about half an inch since the morning. The original scratch becoming lighter; the skin around it beginning to get white. The spleen still very tender, but the kidneys not so much. The urine still dark. Evening. The inflammation still spreading up the leg, but only slowly, the amount being about one inch during the day. There had been an almost entire absence of rigors. August 31. — Morning. Patient had slept very well during the night. The inflammation had spread externally to about the middle of the external condyle of the femur ; internally it had hardly spread at all during the last twenty-four hours ; it extended now to the top of the tibia. Some urine passed during the morning was almost normal in colour. Afternoon. Most of the bullae opened ; no new ones forming. The inflammation had spread externally to the top of the external condyle ; internally it had not spread at all during the day. Evening. Leg in about the same condition as during the afternoon. Treatment henceforth twice a day. September 1. — Morning. Patient said that she felt better. Externally the inflammation had spread up nearly to the middle of the thigh ; internally it had reached the lower border of the patella. Below it had extended over the whole foot and reached the toes. The whole inflammatory area was, however, less red 296 ELEMENTS OF KELLGREN'S MANUAL TREATMENT and the original scratch uuicli ])aler ; there were some white patches around the middle of the lower leg, and desquamation had set in. No new bullae. Urine apparently normal. Motion for first tnne since August 27. Evening. Patient had consumed some bread and milk during the day. September 2. — Morning. Patient had slept very well. The inflammation had spread up as far as the middle of the thigh externally, but the redness from the knee upward was fading away ; internally the inflammation had not spread at all. The white patches on the lower leg were larger. Patient ate some bread and butter and drank some miik, and sat up most of the day. No motion. Evening. The inflammation had not spread any further, and the redness was paler. Some minute new bullse were forming on the outside of the thigh. Desquamation was proceeding over the greater part of the lower leg, and had begun in the foot. September 3. — Patient slept very well. The inflamed area reached its maximum size. Above, it extended externally to about the junction of the upper and middle thirds of the thigh, anteriorly to about the middle of the thigh ; internally to about the lower border of the patella, posteriorly to about the junction of the lower and middle thirds of the thigh. Below, the inflamed area extended over all the toes. During the course of the day the patient ate some meat, an egg, and some bread and butter, and drank some milk. One motion. Evening. Inflammatory area the same size as during the morning ; lower leg pale red or white in most places. The original scratch had healed up. Desquamation of the whole lower leg and most of the foot ; the latter, however, still swollen. September 4. — Patient had slept very well. Appetite almost normal. One motion. Patient remained up most of the day. Redness in the thigh continuing to fade. Glands in inguinal region only about half the size they were when I first saw them. September b. — Appetite normal. Patient up nearly all day. Eedness further diminished ; desquamation on the thigh had set in. Foot still swollen. September 6. — Foot less swollen. Glands in inguinal region no longer swollen. One motion. SPECIFIC INFECTIOUS DISEASES 297 September 7. — Improvement continued. Desquamation over the whole of the inflamed area in the thigh. From to-day onvi^ards patient up all day and walking about as usual. September 10. — Treatment henceforth only once a day. September 12. — Only slight redness of the thigh left. Desquamation finished on the lower leg, but still actively pro- ceeding on the thigh and foot. Foot hardly swollen any more. Motion daily since September 8. September 20. — Desquamation finished. Foot not swollen. Beyond some roughness of the skin, the leg normal. Patient otherwise normal. Treatment finished. The knee-joints and hip-joints remained unaffected through- out. The ankle-joint was sometimes a little painful at first, but passive flexion and extension, together with traction away from the lower leg, executed through a small, but gradually increasing radius, removed it in every case for a few hours. After Sep- tember 5 the ankle-joint was not affected. The heart remained unaffected throughout. Trea tmen t. Is conveniently considered in three sections : — (1) During the acute stage. — I treated the fever in the usual way by head exercise, frictions over the spinal nerves, kidneys and spleen, heart and side shaking, stomach exercise, &c. On the leg the movements were executed in a direction contrary to the venous and lymphatic flow. I tried by means of centrifugal running vibrations, shakings and gentle kneadings given over the affected part of the leg with a piece of lint interposed between it and my fingers, to prevent the upward spread of the disease and to further the secretion into the bullje. The consequence was that the inflammation, which during the two days previous to the treatment had spread right up the lower leg, thereafter only spread an inch a day at most. In addition the nerves of the leg were stimulated. (2) During the subsiding stage. — After I had observed that the inflammation had not spread for two days and that the redness was considerably diminished, I used passive movements at the joints of the leg to further the circulation. The intensity of these 298 ELEMENTS OF KELLGREN'S MANUAL TREATMENT movements was increased day b}' day, and after some time active movements were added (about September 8). In addition nerve frictions on the leg and, of course, tbe constitutional treatment were used throughout. (3) During the convalescent stage. — Ordinary treatment for convalescence after fever. The above manipulations on the leg caused but little pain ; even this disappeared after the fourth day, and patient began to like the treatment and said she felt it did her good. I saw patient again on October 6 of the same year (1900). She was very well and the only abnormality was a slight rough- ness of the skin of the right leg. On October 20, when I again saw her, this had disappeared. During August, 1902, I saw patient for the last time ; she had been in excellent health since our last meeting. Epidemic Cerebro-Spinal Meningitis. In the town of Huskvarna instances of the above disease were continually being notified; during the summer of 1899 there seemed to be more notifications than usual. The diagnosis of the following case was not absolutely certain ; the case might have been regarded as one of another peculiar form of fever which is endemic to the town, a fever with no special symptoms beyond cerebral irritation, lasting from six to eight days and ending by lysis in favourable cases. Accounts were furnished me of several other children (living within a short distance of the patient whose case I am going to describe) who showed nearly the same symptoms, and who, after lying ill with high fever, great irritation and occasional opisthotonos, died on about the tenth to fourteenth day of illness. E. S., male, aged 2^ years. Previous Jiistonj. — Quite good. History of iiresent illness. — Patient was seized on August 2, 1899, with sudden fever and pain in the head. A medical man who was called in prescribed antipyrin, and a few days later camphor and antipyrin ; no diagnosis was given. On August 18 Dr. A. Moller and I were called in. Examination. — Patient lay with retraction of the head, photo- phobia, and great tenderness over the skull and cervical nerves. SPECIFIC INFECTIOUS DISEASES 299 Parents said they had occasionally noticed spasms, and once a condition of opisthotonos ; none of the latter symptoms were, however, manifested during our visit. Patient seemed quite conscious. Pulse 172, temperature not taken. Treatment. — Head exercise, spinal nerve frictions, side shak- ing, stomach exercise and spleen frictions, &c. August 19. — Morning. Condition about the same. Tempera- ture 103°. Pulse 160. Treatment as before. Afternoon. Patient worse, semi-unconscious. Pupils some- what dilated, great tenderness manifested on slight percussion of DATE 19 20 El TIME A E[M EiM E F° 104' 103" 102" 100' 98" 97" 96 ■ A) (Ilia 1 ! — 4 \ \ r y / / y the head, and on spinal nerve frictions. Patient occasionally got somewhat opisthotonic and threw himself about. Temperature 104° (axilla), 10-5° (rectum) ; pulse 19'2, irregular (see fig. 103). Treatment as before. After twenty minutes, temperature (axilla) 102'5°, pulse 178, and patient perspiring very much ; after another forty-five minutes, temperature (axilla) 101".5°, pulse 172, and patient perspiring a good deal. Evening, temperature 98'6°, pulse 90. Treatment. August 20. — Temperature during the morning was 98"5°, no treatment was, however, administered until the evening ; patient irritable ; temperature 103'8°, pulse 140. After treatment, tem- perature 102'6°, pulse 120. August 21. — Treatment once. Temperature 96'8°, pulse 72. After treatment, temperature 96°, pulse 65. 300 ELEMENTS OF KELLGREN'S MANUAL TREATMENT August '2"2. — Treatment once during the evening. Patient apparently normal. Temperature 99.4°. August '23. — Appetite returned ; patient sitting up and has been walking about ; rather weak, but otherwise normal. August 24 to 28. — ^Treatment once daily until the 2Sth, when it was finished. Patient normal. October, 1900. — Beyond a slight cold once during the summer child has been very well ever since illness. Rheumatic Fever and Erythema. Kheumatic erythema and rheumatic fever, occurring in myself, treated May to July, 1902. Previous history. — Before marriage my father suffered from rheumatic fever which left a mitral lesion and subsequent aortic incompetence ; his brother died of rheumatic fever, and one of my sisters has had the same disease. Personally, I have had the following attacks : 1889, rheumatic fever ; 1893, rheumatic ery- thema ; 1895, ditto ; 1897, rheumatic fever ; 1899, rheumatic erythema twice. Between the above attacks, for all of which the manual treatment was the only therapeutic agent employed, I have enjoyed absolute and complete immunity from rheumatic symptoms of any kind, and have never felt any bad effect from wet feet, being out in all weathers without an overcoat and in general paying no particular regard to damp, rain, or cold. During the mouths February to May, 1902, I had an excep- tional amount of work to do ; I felt that it was becoming too heavy a burden and that I was losing the energy and strength necessary to administer the manual treatment for twelve or more hours a day. During May 10 to 13 I attended almost continu- ously a patient suffering from typhoid fever ; the case is briefly described in the appendix. History of present illness. — May 13. — Slept from 6 a.m. until 10.30 a.m. ; then attended to my practice until 8 p.m. Felt very tired all day. May 14 and 15. — Felt very tired but worked as usual. May 16. — Slept very badly and awoke with pain in throat, and difficulty and pain in swallowing. On examination, pharynx, tonsils, uvula and fauces red. I worked all day as usual, although I felt weak and tired. During the evening, temperature 101°, pulse 110 (for temperature see separate chart, fig. 104). SPECIFIC INFECTIOUS DISEASES 301 May 17.— Slightly delirious during the night (I easily become so when feverish). Slept very little. Morning, pulse 100. Too ill to attend to my practice. During the course of the day salivation increased (being sometimes blood-stained) ; bloody mucus on blowing the nose. During the evening erythematous patches, circumscribed, raised, tender, and with a well-defined margin, appeared on the legs. A large, hard, subcutaneous swelling was felt on the flexor aspect of the right forearm ; it caused little pain, but a good deal of stiffness. Great swelling and redness of the penis, and a soft, well-defined, movable, boggy mass (blood?) manifested itself above the left testicle, inside the scrotum. Throat about the same. Urine thick, no albumen. Pulse 100. May 18. — Delirious during the night, more so than during the previous night. Slept very little. Throat about the same ; 302 ELEMENTS OF KELLGREN'S MANUAL TREATMENT palate very red. Neuralgic pains in finger-tips, back, and legs. Colour of penis darker, and swelling in scrotum smaller. Erythe- matous patches larger ; some new ones also present. Morning, pulse 80 ; evening, pulse 90. May 19. — No delirium during night ; slept better. General improvement in all the symptoms : swallowing easier, throat less red, erythematous patches smaller, penis regaining normal size. Ever since commencement of illness I had got up as usual, and I walked about in ray room and outside in the open air whenever I felt able to do so. During the morning of this day I went for half an hoar's drive, and during the afternoon played billiards for an hour. May 20. — Slept well. Much better. Resumed my medical practice (see below). Afternoon. Swellings of left fifth metacarpal and left cuboid bones, which were hard, rather painful, and very tender. Throat, penis, and scrotum practically normal. May 21.— Slept very little. Morning. Worse. Swelling oyer fifth metacarpal had extended to cover whole of back of hand ; new swellings like the last over the right knee and right os calcis. Could not walk witliout considerable pain. INIany new erythematous patches. Throat worse ; coughing up blood at intervals. Evening. Managed to walk about ; this improved the pain so much that I was able to go out of doors for half an hour's stroll. All symptoms improved during the course of the day. May 22. — Slept fairly well. All swellings and erythematous patches better, but a new swelling present in the flexor aspect of the left wrist and the right gastrocnemius. Went out for an hour's walk during the afternoon, then played billiards for an hour. May 23. — Slept very well. General condition better, but both olecranon processes tender, and both knee-joints stiff. Throat better. I only coughed up very little blood during the day. May 24.— Better. May 25. — About the same. May 26. — Several of my patients (including one case of pulmonary tuberculosis in the third stage), who had been com- pelled to stop treatment during my illness, having become so much worse for want of it, I was obliged to do some work at my practice, otherwise I feared that some fatal results might occur. SPECIFIC INFECTIOUS DISEASES 303 From to-day onwards, until May 29, I worked about two hours in the morning and one hour in the evening. During the evening of Maj' 29 the symptoms of rheumatic fever set in. During the course of the afternoon I felt uneasy in the region of the heart. I began to feel very tired indeed at about 7 p.m., and at 8.30 p.m. I went to bed. I then noticed that my heart was beating very irregularly, and that its action was becoming intermittent. In about au hour my condition was such that at every beat my whole bodj' shook, and every third or fourth beat was missed. I also experienced some cyanosis and breathless- ness. On auscultating my heart, a loud blowing systolic murmur was heard in the mitral area, also great irregularity in the inten- sity of the heart sounds. Pulse 130 per minute. I had administered to me heart vibration and shakmg with frictions on the left fourth and fifth dorsal nerves near the spine, together with stomach exercise, the treatment lasting two hours. In consequence m)' heart was much improved and the iuter- •mittency and irregularity almost disappeared, while the pulse was reduced to 108. At midnight I fell asleep. May 30. — I woke at 3 a.m., with the heart in the same condi- tion as during the previous evening. I underwent the same treatment, and at 4 a.m. the heart was again relieved. Pulse 100. I then slept again until 8 a.m. 8 a.m. Awoke with great stiffness in both legs and right deltoid. From to-day onwards great perspiration during sleep ; on waking up I generally found myself drenched with sweat, which had a bad odour. Urine thick, with unpleasant odour ; however, it contained no albumen at any time during my illness. Heart better, no intermittencies ; more regular, and the murmur I heard yesterday disappeared. Pulse 112. Temperature, see separate chart, fig. 104. During the evening both feet swelled up and the ankle-joints showed the typical rheumatic fever swelling ; they were red, glazed looking, extremely painful and tender ; walking was very difficult. Treatment twice a day henceforth (see p. 308). May 31. — Morning worse ; had slept very badly. Feet very bad ; walking almost impossible. Evening. Feet slightly better. June 1. — Morning. Feet improving, but left knee and left shoulder affected. 304 ELEMENTS OF KELLGREN'S MANUAL TREATMENT Evening. Knee and sLoulder better, but left wrist very bad, causing intense pain for two hours or more. Heart quite normal beyond slight acceleration of pulse. June 2. — Slept about three and a half hours during the night. Morning. Wrist a good deal better. Evening. Eight wrist bad. Before going to bed I walked round the room three times ; my feet were still so bad that this quite tired me out. June 3. — Morning. Diarrhoea, four motions during the day. Right knee very bad ; I could not walk at all. Evening. Slightly delirious until sleep supervened at midnight. June 4. — Morning. So far I had generally spent most of the night in an armchair ; but on this day I remained in bed until 8 a.m. All affected joints better, and no new ones involved. General feeling of stiffness, and mild neuralgia-like pains in the whole of body. Evening. Better. Slight diarrhcea from to-day onwards until June LI. June 5. Slightly delirious during night. Morning. Left foot, left shoulder and left gastrocnemius affected. Evening. About the same. June 6. — Morning. Felt worse ; ascribed this to the rainy weather, as hitherto it had been very fine. Right knee affected. Evening. Daring the course of the day right metacarpal and right second and fourth toes swollen. At about 10 o'clock left acromio-clavicular joint became bad and kept nie awake all night. June 7. — Morning. Left knee and whole of right hand affected. Evening. About the same. June 8. — Morning. Right hand and left acromio-clavicular joint worse. Unable to write. Evening. I resumed smoking (one cigar a day) to-day, having stopped since May 29. June 9. — Morning. Left knee and right elbow affected. June 10. — Morning. Spent all night in bed (had not done so since June 4), and did so from to-day onwards. Both knees, both feet and left hand and lumbar portion of erector spinas affected. Evening. Left hand very bad ; stiffness of all muscles of right side of the neck. June 11. — Morning. Left hand still bad, but legs nearly well. SPECIFIC INFECTIOUS DISEASES 305 Very weak, but I went out of doors for a walk of a few minutes for the first time since May 30. June 12. — Morning. Right knee bad. During the afternoon I went out for about fifteen minutes. Evening. Eight sciatic nerve and right shoulder affected. June 13. — Morning. Worse again. Both knees and right shoulder very bad. Unable to walk. Evening. Very weak all day. June 14. — Morning. Eight hand affected ; right shoulder still bad. Able to walk again. Evening. Diarrhoea stopped. June 15. — Slept about six hours during the night. Shoulder still bad. June 16. — About the same. At intervals walked up and down my room for two hours. June 17. — Slight desquamation of hands and scrotum had been taking place, the Jast week. Eight shoulder still bad ; during evening right hand and flexors of right forearm affected. June 18. — Both shoulders and both hands bad. Went out during the afternoon for ten minutes' walk. June 19. — Eight wrist bad. June 20. — Left wrist and left knee bad ; flexors of right fourth finger very stiff and contracted. Diarrhcea again, four motions. AVeight in clothes, 85 kilos, (it was 103 in April). Went out for half au hour during the afternoon. Left foot bad during the evening. June 21. — Left shoulder affected, all other joints well. June 22. — Left knee and ankle and right elbow affected. Played the piano and sang for an hour during the afternoon. June 23. — Left knee and left ankle worse. During the evening the latter better, but right ankle bad. No more perspira- tion during sleep. June 24. — Eight shoulder and right little finger affected. Went out during the afternoon to an adjacent villa about 500 yards off; took forty-five minutes to do so. Had the treatment administered, and walked back in fifteen minutes. June 25. — Getting stronger. All joints of right arm bad, but legs feeling very well and much stronger. Out for two hours during the day. June 26. — Hardly any joint affected. I went for an hour's 20 3o6 ELEMENTS OF KELLGREN'S MANUAL TREATMENT walk, covering a distance of one and a half miles. During the evening left forefinger very bad. June 27. — Left internal malleolus bad. During evening right second linger very bad. June 28. — Finger very bad during night, keeping me awake until 5 a.m. Eight malleolus bad during afternoon. June 29. — Treatment once a day henceforth. Eight shoulder bad ; malleolus better. June 30. — Stronger. Left shoulder bad during afternoon. July 1. — Some pain in both shoulders, but none elsewhere. July 2. — Left shoulder and left forefinger bad. Went out for ten minutes' walk from one villa to another in pouring rain ; the temperature was 9° C, and a fairly strong wind was blowing. Got my shoes and socks damp ; no bad results. July 3. — Left forefinger affected ; in evening left second finger affected. July 4. — Slight stiffness of both shoulders and feet. Stopped taking my temperature. July 5. — Desquamation of hands and scrotum finished. July 6. — AVent out for a walk for two hours, and played billiards for an hour during the morning, and two during the afternoon ; also took a drive for half an hour. AVeight in clothes, 87 kilos. July 7. — Getting stronger every day. Slight stiffness in left foot. Tried to dance (waltz) during the evening, but had to give up the attempt very speedily through giddiness. July 9. — My appetite for the last four or five days had been enormous ; an hour after a heavy meal I felt as if I could eat another. July 10. — AVent out in the rain, and got my shoes and socks damp ; no bad effects. July 13. — Some stiffness in the left shoulder during the last few days was all that remained of my rheumatism. AVent for a ride on horseback for fifty minutes. AVas caught in the rain, and wetted through to the skin. On coming home changed all my clothes. July 18. — Took a ride of two and a half hours during the afternoon. On coming home had supper, and then walked about for one and a half hours. July 23. — During the morning I treated at his home the SPECIFIC INFECTIOUS DISEASES 307 patient whose case is found described on'pp. 339, &.c. ; from this day onwards, until August 1, I treated him at his home every morning. Took a ride of three and a half hours during the afternoon. July 27. — While out riding I got absolutely drenched to the skin. Changed my clothes on coming home. August 1. — Not yet as strong as I used to be, but otherwise, excepting for slight stiilness of left shoulder, quite normal. Commenced working at my practice again, this occupying me for four to five hours per day. Weight, 95 kilos. August 2. — Bathed in the neighbouring lake for the first time since taken ill ; temperature of water, 14° C. Treatment finished. August 3. — Took a bic3'cle ride of twenty-eight miles, the last seven miles of which I accomplished in thirty-five minutes ; felt no bad results at all. T)ratment. During the acute stage I took none of the precautions cus- tomary in the treatment of rheumatic fever. I never remained m bed all day, but instead got up and walked into another room if possible, even though doing this, with the help of two other persons, at first caused very acute pain ; and every now and then during the course of the day I would make efforts to walk about and move my stiff joints ; this always after the first seconds diminished the stiffness and pain. As soon as the weather was warm enough I went out of doors. I slept in a cotton night-shirt between sheets. My diet during the whole period up to about July 1 (regardless of fever), was about as follows: — Breakfast, two poached eggs with a piece of dry toast, two small pieces of toast with jam or marmalade, and a pint of milk. Dinner, plate of soup, ordinary sized helping of meat with potatoes and vegetables, followed by fruit and cream or some such dish. Supper, meat, potatoes, vegetables and glass of milk. I left off coffee until June 12, after which date, in addition to the food already specified, I took during the course of the afternoon a large cup of coffee with some bread and butter, a few biscuits, &c. After about July 1 my appetite began to increase, and in a few days became enormous (see July 9). About the end of July it began to diminish and in a week or ten days was normal again. 308 ELEMENTS OF KELLGREN'S MANUAL TREATMENT Gymnastic treatment. — Vibrations over the painful joints and passive movements combined with a great amount of trac- tion — without this they would have been quite unbearable on account of the pain — frictions on the nerves leading to and from the affected parts. General treatment for fever, including heart vibration and shaking. My kidneys were tender during the whole course of the fever. I made the interesting observation on myself that the inability to move any joint from pain therein did not always depend entirely on the local condition. For example, one day I was unable, on account of the pain induced, to abduct my shoulder through more than an angle of 4.5° ; after treatment of both renal plexuses (which were extremely tender) from the front, I could abduct it through about 135° with very little pain. On another occasion when I could not move my ankle-joint a painful spot was discovered in the great sciatic nerve of that leg high up, the pain in it almost disapppeared after local vibrations and frictions had been administered, and I could perform the move- ments at the ankle-joint with much less pain. During convalescence (on and after July 1) the treatment was as follows : — (1) Sitting arm exercise, PP, AR. (2) Heave lean standing chest expansion, PA. (3) Forwards lying back exercise, PP. (4) Loin lean standing alternate rotation, AR, ringing, PP. (5) Stretch stride standing bending forwards, PA. (6) Half lying double arm rolling, PP, bending and stretching, AE. (7) Half lying double foot rolling, PP, flexion and extension, AE. (8) Side lying leg lifting, AE, pressing down, PE, side length hacking, PP. (9) Stretch grasp toe standing hanging, breathing, PA. (10) Half lying stomach exercise, kidney frictions, PP. Subsequent history. — August, 1903. — A slight amount of crepitus can be felt when internal rotation of the left humerus is performed ; it causes, however, no pain or inconvenience. Apart from this I have enjoyed excellent health ever since, excepting that a slight stiffness in the left knee-joint occurred in January, 1903, for a period of three days ; this was removed by appropriate treatment. SPECIFIC INFECTIOUS DISEASES 309 Erythema Nodosum.* E. S., male, aged four years, came under the manual treatment on February 26, 1902. Previous history. — Patient had never been very strong since his birth, and had always been very backvs'ard ; for example, he did not begin to speak until two and a half years of age. History of present illness. — During the last fortnight he had been looking rather pale and tired, and had complained of head- ache and also pains in the knees and right side. On February 26 =EB. MARCH DATE Z7\Z&\ 1 2 3 4 5 6 7 8 9 10 II 12 I3| TIME mT M E M E M E M E M E M E M E M E M E M E M E M E M E M E 106° ids' 104.° 103° 102° 101° 100° 99° 98 ° 97 ° Axi lla A t\ il 1 1 ) / hl\ h A v V \^\ / Ua ^ \ r^ y^ L [^ L/ V, /• v^ PULSE 132 100 132 120 135 108 120 no 120 115 126 108 118 100 120 115 116 96 100 mo 100 no 112 too 106 102 no 100 patient remained in bed most of the day, complaining of pain in the right side. I saw patient during the evening of the same day. On examination. — Tenderness on pressure over the lower ribs of the right side, but no pleural friction or abnormal lung sounds. Temperature and pulse normal. I administered a few general strengthening exercises, together with vibrations over the painful area ; the pain thereupon disappeared . ' I have ventured to include this disease in this chapter, on account of its relationship to rheumatic fever and because the description of a case of the latter involved describing the rheumatic erythema vrhich preceded it. 3IO ELEMENTS OF KELLGREN'S MANUAL TREATMENT February 27. — Morning. Patient looked rather ill, but said he had no pain. Great tenderness over the kidneys. Treatment as .before. Evening. Patient complained of pains in the head and legs. Examination. — Several typical nodular red swellings, num- bering about fifteen altogether, were visible on the front of both lower legs ; these swellings were oval, elevated, pale red, about a half to one inch in diameter, and painful on pressure. Very great tenderness over spinal nerves and kidneys. Fever (for temperature and pulse see separate chart, fig. 105). Treatment. — General treatment for fever, including special attention to the spinal nerves and kidneys. February 28. — Morning. General condition improved. Evening. No new swellings. March 1. — New swellings present, one on right knee, two on left knee, and one on right gluteal region. March 2. — Morning. Swellings on knees disappeared. Evening. New swelling on right forearm. March 3. — New swelling on left gluteal region. March 4. — Swellings on right leg nearly disappeared ; those on left leg brownish. Some new swellings on back, which were slightly tender. Evening. More swellings on back of forearm. March 5. — New swelling on left forearm and back of hand. March 6. — Swellings fading. General condition improved; patient looking much better. Less tenderness over kidneys. March 8. — Swellings disappeared. Some cough. March 22. — Patient normal. Treatment finished. Patient had undergone treatment once a day since March 13 ; previously he had been treated twice a day. During the whole time he was under treatment patient was allowed to be up and to eat what he liked. The heart remained unaffected throughout. Subsequent history. — -I saw patient again in September, 1902. He had continued well and strong ; and both his parents con- sidered him to be in much better health than before his illness. CHAPTER lY. DISEASES OF THE RESPIRATORY ORGANS. Acute Croupous Pneumonia.' In 1847 Brantino; successfully treated acute pneumonia by gymnastic methods, and his achievement was mentioned by him- self in the same year,^ and later on by Georgii^ and Hj. Ling^ (see also Blundell'^). His attempt was not, however, repeated until Henrik Kellgren made another essay. Even the enthusiastic Neumann^ makes no mention of using the treatment for such cases, otherwise than by advocating deep respiration, with, perhaps, a few passive movements in addition, to assist the ordinary course adopted. Neumann ' even wondered whether exudative pleurisy was fitted for gymnastic treatment; from this it may almost certainly be deduced that he would regard acute pneumonia as unfitted. Henrik Kellgren had as long ago as 1873 been treating acute pneumonia successfully by means of gymnastic methods ; and his successes were referred to by Wretlind * and Glatter ". Wretlind, who learnt the viodiis operandi, was able at a later date to test its efficacy himself '". About 1888-1890 several ' I have for convenience sake included pneumonia amongst diseases of the respi- ratory organs instead of placing it under specific infectious diseases. ■^Address to the graduates of the G. C. I., March 31, 1847. '"Kinetic Jottings," 1880, p. 206. 'Branting's " Efterlemnade Skrifter," 1882, p. xxvi. ' " Medicina Mechanica," 1852, p. 98. ""Die Athmungskunst," 1857, p. 103, &c. ; and Neumann und Schreher, ■ • Streitfragen der Deutschen und Schwedischeu Heilgymuastik," 1858, p. 26. ■"Referat iiber das ' Erster Bericht iiber das Institut flir Schwedische Heil- gymuastik und Ortopedie z\x Wien,' " in Athetieum fur Rationelle Gymnastik, 1854, pp. 73-79. »" Href frau Dr. Wretlind," in Hygiea, Nov., 1872— Feb., 1873. ■' " AUgemeine Betraehtungeu liber den Werth der Heilgymuastik," in Wien. Med. Prcsse, 1875, No. 8. '" See "Om Rorelsekuren eller Kinesitherapien," 1874, pp. 55, 56 ; "Bokanmiilan," &o., in Eira, April 15, 1899, p. 203 ; " Helsooch Sjukvardsliira," 1899, p. 90. 312 ELEMENTS OF KELLGREN'S MANUAL TREATMENT authors^ made references to the Kelln;ren treatment of pneumonia. They one and all seemed to think that any gymnastic treatment for this condition was strongly inadvisable. Presumably this view was the outcome of the knowledge of their own inability to do any good with their gymnastic methods. In 1890 Arvid Kell- gren ^ spoke with great confidence of the success that he himself, and his brother before him, had had in applying the manual treat- ment to pneumonia. During the last ten years, as far as I know, nothing has been published on the subject. The objects of the manual treatment in cases of pneumonia are as follows : — (I.) To diminish the virulence of the inflammatory process in the lungs by raising the vital activity of these organs and remov- ing the tension by promoting the venous return. This reacts favourably on the heart. (II.) To treat the constitution as a whole. This is accomplished by : — (1) Removing the impediments to respiration which lie in the muscular apparatus. These are found to be : — Contractions in the intercostal muscles over the affected lobe or lobes ; these are removed by administering vibrations and frictions over the con- tracted areas and frictions on the corresponding dorsal nerves simultaneously (see below). Deficient action of the diaphragm, with or without marked contraction of the abdominal muscles ; this is treated by means of vibration and shaking in the subcostal and suprapubic regions, subdiaphragmatic suction and stomach exercise. In addition, these impediments can to a great extent be removed by inducing the patient to respire deeply. Small respi- rations must be taken at first, and the volume then graduall}' increased ; gentle pressure with one hand on the abdomen during expiration will greatly facilitate the process. 'See KleeD, " Handbok i Massage," 1888, pp. 222, 223. Gustafson, " Om Massage, dess Utfurande och Anv.iQdniiig," 1888, pp. ii, &c. Nebel, " Bewegungs- kuren mittelst Si'-hwedischer Heilgymnastik und Massage," 1889, page 184. Dollinger, "Die Massage fiir Aerzte uud Studirende," 1890, p. 158. Hasebroek, '• Die Erschiitterung in der Zanderschen Heilgymnastik," 1890, p. 1. See also Hiinorfauth, " Handbuch der Massage," 1887, pp. 88, 89. Dolega, " Die Massage, ihre Technik und Auveudung," 1892, p. 102. Reibmayr, " Die Massage und ihre Verwerthung," &c., 1893, p. 75. - " Techuic of Ling's System of Manual Treatment," 1890, p. 69. DISEASES OF THE RESPIRATORY ORGANS 313 (2) Eeinoving the impediments to respiration that He in the lungs themselves. This is partly effected by restoring the muscular mechanism to its normal condition, as described. In addition, vibrations are executed over the affected areas in order to relieve the congestion. (3) Removing the impediments to respiration that lie in the pleura (if present) by administering : — Vibrations, stationary or running, over the inflamed pleura ; this will promote the venous and lymph flow and remove the contraction of the intercostal muscles ; the latter will react favourably on the former. Frictions on the intercostal nerves supplying the affected spaces. Deep respiration ; although one or two of these cause an increase in the pain, yet several taken successively nearly always diminish it for some hours (see expansion, pp. 12-4, &c.). (4) Stimulating the nervous elements of the lungs. Frictions are executed over the dorsal nerves near the spine (see p. 164) ; the nerves on the affected side over the affected lobes are always tender. Frictions should be executed especially over those nerves that supply the intercostal spaces where contractions exist, as already described. (5) Guarding against heart failure by diminishing the resist- ance in the lesser circulation (as mentioned already), and by quieting its over-excited action through heart vibration and shaking, and reflexly through stomach exercise. Frictions over the left fourth and fifth dorsal nerves near the spine in addition may be executed while applying the local heart treatment. Better cardiac action brings in its turn improvement in the lesser circulation. (6) Treating the constitution as a whole by means of head exercise, cervical, dorsal, and lumbar nerve frictions, kidney frictions, &c. I must here mention that, in two cases of pneu- monia I have treated, the kidney region of the affected side was much more tender to touch than that of the opposite side. Stomach exercise should also be administered. It acts bene- ficially by reflexly quieting the heart's action (as already mentioned) and acting depletingly on the lungs. The objects of the manual treatment during convalescence from pneumonife are as follows : — (1) To improve the lungs by means of chest clapping, side shaking, &c., and by means of active respiratory exercises. 314 ELEMENTS OF KELLGREN'S MANUAL TREATMENT (2) To stimulate the nervous elements of the lungs by means of dorsal and intercostal nerve frictions. (3) To improve the constitution as a whole. K. S., aged 33, coachman, moderate drinker of alcohol, came under the manual treatment on March 28, 1900. Previous history. — -Patient always well and strong with the exception of a bad attack of pnemrtonia ten years previously. History of present illness. — Patient said he caught a chill on March 24, and felt rather weak for the next few days. On March 27 he drove in from Sanna to Junkoping, distance about three miles, but felt very weak, had a shivering attack of ten minutes' duration, and was obliged to go home at once and take to bed. March 28. — 1.30 p.m. Patient in bed ; complained of severe headache. Temperature 104'9", pulse 140. Nothing abnormal in lungs or heart. I administered the ordinary treatment for fever. During the evening I paid a second visit. Patient was drowsy, and I did not examine his lungs or heart. I administered a short treatment, and he said he would go to sleep. Tempera- ture 104-2°, pulse 120. March 29. — Patient had slept badly. High fever. Tempera- ture 10.5"5°, pulse 122, respiration 41. The left side of the thorax did not move quite so well as the right during respiration, which was accelerated and shallow. No pain on deep respiration. There was tenderness over the fourth to eleventh dorsal nerves near the spine on the left side ; the intercostal muscles in the fifth to ninth spaces were contracted. On percussion there was some dulness over the fourth to tenth ribs posteriorly and sixth to eighth laterally. The breathing over this area was harsh vesicular, and some fine crepitations were audible. No sputum. Treatment four times during the day. For temperature, res- piration and pulse see separate chart, fig. 106. March 30. — There was absolute dulness on percussion over the left lower lobe from the fourth to eleventh ribs posteriorly, and sixth to ninth ribs laterally. The breathing in this area was tubular, with no crepitations unless on very deep inspiration, and the vocal fremitus and resonance in it were markedly increased. Treatment three times during the day. During the evening frothy sputum. DISEASES OF THE RESPIRATORY ORGANS 315 March 31. — Patient experienced continued great pain in the left half of the thorax over about seventh and eighth ribs in the mammary hne, and laterally over the fifth to seventh ribs. The sputum very thick and here and there streaked with blood. April 1. — General condition about the same as during the previous day. The spinal nerves, as before mentioned, still very tender. Treatment three times. April 2. — Patient wandering in his mind during most of the day. Sputum now partially greenish, and streaked with blood. Treatment five times. During the evening patient ate a little soup. Since March 28 he had taken hardly anything except a little milk. MARCH APRIL DATE 28 ' 29 30 i 31 ! 1 i 2 ^ 3 1 4 1 5 1 6 1 7 a 9 TIME A EM A E MAE MAE M A E M A E MAE M A e:m A E MAE M E M E M E F" 106' 105' 104" 103" I02" 100' 99" 98' 97" A f\ (\ A. yt'j lA \ \ h \ / ^ - V, ,__? '\ \ 1 \ /^ \ , l' \ 1 i Rectu 1 V ,^ y \ PULSE 123110,120 112 92105113 100112 115 IQOIIIO 116 116 116 112 120 I40I201I22I25I02II2 121 104117 I2I06I30I24 ! 112 120 106 108 104 108 00 ISO 96 14 100 104 00 104 100 98 180 76|68 75 98 108 88J 1 80 70 RESR \iZ 42 38J39 43 40|38 40 3843 43 40ft2 41 42t*0 40 46 43 44 38 fM 44 44 40 38 36130 28|23 E4( 20 16 April 3. — Patient wandering in his mind during most of the day. The lung symptoms about the same, but less pain in the side. Treatment six times. April 4. — Pulse dicrotic. Herpes labialis. 05 per cent, albuminuria. Patient wandered in his mind until about G p.m. ; then he recovered his senses, and temperature, respiration, and pulse all sank somewhat. (Pseudo-crisis.) Treatment six times April 5. — Temperature higher, pulse and respiration more rapid again. Patient clear in his head during most of the day, excepting the morning. '0.5 per cent, albuminuria. The tem- perature could be taken again properly ; on April 3 and 4 there 3i6 ELEMENTS OF KELLGREN'S MANUAL TREATMENT had been great difficulty, as patient would not keep still. Treat- ment four times. April 6. — -Patient did not wander in his mind at all. "1 per cent, albuminuria. Patient felt very sleepy at 5 p.m., and began to perspire very much indeed. Crisis commenced. Treat- ment three times. April 7. — Patient slept almost without stopping until 8 a.m. He then woke up feeling well, but very weak. He perspired most profusely during the night ; his clothes were changed several times for the sake of dryness, but the process did not wake him. Morning. Temperature 98'8°, pulse 80, respiration 30. The left side moved somewhat with respiration ; there was no dulness on percussion, but many sounds were to be heard over the affected area, varying from fine crepitations to coarse ones. Appetite good. Patient remained in bed all day. Treatment twice. The spinal nerves already referred to still very tender. April 8. — Some fine crepitations to be heard, otherwise nothing marked. Patient got up and said tliat he felt well, though weak. He had, however, sufUcient strength to walk about a good deal. April 9 to 10. — Treatment twice. Fine crepitations still audible ; patient coughed up some white frothy stuff. April 11. — Patient went out of doors for a few minutes. Treatment once. Lungs normal. No crepitations ; no sputum. April 12 to 1-5.— Treatment once daily. Patient went out during the 15th for half an hour. April 16 to 22. — Treatment once daily. During the 22nd patient did several odd pieces of work, such as carrying window- frames about, taking them out, &c. April 29. — Patient drove out for one hour. May 1. — Patient drove out one and a half hours in a snow- storm. He said that he felt very strong. May 9. — Patient quite well and strong. Present weight, 74| kilos. He stated that just before his illness he weighed 74 kilos. Treatment finished. July, 1903. — Patient had been quite well ever since his illness. Acute Bronchitis. Mrs. L., aged 27, came under the manual treatment on Feb- ruary 28, 1900. Previous history. — Patient had for the last ten years had a DISEASES OF THE RESPIRATORY ORGANS 317 fairly well compensated mitral incompetence, following on rheumatic fever. History of present illness. — Patient was attacked by acute bronchitis on February 26, 1900 ; she could not assign any cause for the attack. The onset was fairly sudden, and was marked by a rigor. Fever set in, with a sense of oppression in the chest, which soon gave way to pain behind the sternum, and a cough came on which increased the pain. Pains in the right side, arms, and legs also made their appearance. February 27. — General con- dition worse ; secretion from bronchi commencing. February 28. — Patient being still worse, I was called in. Examination. — Patient complained of headache, fever, pains in the chest, arms, and legs, difficulty in breathing, and severe cough. She had been coughing up lumps of yellowish matter all day. There was no percussion dulness. On auscultation, loud bubbling sounds were heard all over the chest, and these were audible, even without the aid of a stethoscope, at a distance of several feet. There was great tenderness between the scapulte. Temperature 103'5°, pulse 110, respiration 40. Treatment forthwith administered. March 1. — Treatment twice a day henceforth. Morning. Temperature 108'2°, pulse 103, respiration 36. Headache better. Evening. Temperature, 104-2° and 103-7°, pulse 117 and 100, respiration 42 and 42, respectively before and after treatment. March 2. — Morning. Patient better. Temperature 102-8^ and 102-4, pulse 100 and 96, respiration 38 and 36, respectively before and after treatment. Evening. Less bronchial secretion. Temperature 103-3° and 101-6°, pulse 96 and 96, respiration 36 and 38, respectively before and after treatment. March 3. — Patient much better ; she got up for an hour or so during the afternoon, feeling, however, very weak. Less bronchial secretion ; hardly any headache ; no pains in arms or legs ; difficulty in breathing only when patient out of bed. Morning. Temperature 101-3° pulse 100, respiration 28. Evening. Temperature 102-8° and 101-7°, pulse 100 and 96, respiration 33 and 30, respectively before and after treatment. March 4. — Patient up during most of the day. Appetite returned ; ordinary diet resumed. 3iS ELEMENTS OF KELLGREN'S MANUAL TREATMENT Morning. Temperature lOOli^, pulse 84, respiration 23. Evening. Temperature 100'8°, pulse 93, respiration 28. March 5. — Patient stronger, and up all day. Treatment once only during the morning. Hardly any bronchial secretion. Temperature 100'4°, pulse 100, respiration 20. March 6. — Patient normal, excepting for slight weakness. Treatment during the afternoon. Temperature 99"7°, pulse 88, respiration 20. March 7. — Patient normal. Temperature 98"6°, pulse 68, respiration 18. Treatment for the last time. June, 1902. — Patient still feeling quite well. Treatinent. Head exercise, thorax vibration and shaking, heart vibration and shaking, side shaking, practising deep respiration, stomach exercise, vibration over the bladder, frictions on the spleen, kidneys, and spinal nerves, specially the interscapular. From March 5 onwards chest clapping and some active breathing exercises in addition. Acute Pleurisy. Neumann ^ was doubtful whether exudative pleurisy should come under gymnastic treatment, as advocated by Melicher.^ Hartelius, in 1864," stated that "it is, of course, not acute pleurisy, but only the more or less severe sequelae that can be treated by gymnastics"; and, in 1865,* he further stated that gymnastics can effect nothing if an exudation remained, together with great weakness and a cachectic condition. In his handbook ^ he repeated his dictum that gymnastics can only be employed for pleurisy as an after-cure. The manual treatment for acute pleurisy during the acute stage is as follows : — ' Quoted on p. 311. ■ Cf. Hj. Ling, in Brantiug's " Efterlemnade Slirifter," 1882, p. xxvi. ■■"'Om Sjokgymnastiken vid Gymnastiska Central Institutet under ar 1863," 1864, p. 46. '"Gymnastiska lakttagelser," 1865, p. 78. "'Laroboki Sjukgymnastik," 1870, p. 245; 1883, p. 258; 1892, p. 251. DISEASES OF THE RESPIRATORY ORGANS 319 (1) Local. — This has already been described under pneumonia (see p. 313;. (2) General, i.e., treatment of the constitution as a whole by means of general treatment for fever. During the convalescent stage it is as follows : — (I) Local. — -Movements to promote the circulation of the blood and lymph in the pleura, i.e., passive manipulations such as vibrations, hackings, running vibrations, &c., over the affected parts of the pleura ; passive trunk flexions ; active trunk flexions, unresisted or resisted. (•2) General. — Treatment on the lines of " general treatment for convalescence." H. S., male, aged 1-5, came under the manual treatment on the morning of November 19, 1900. Previous history. — Quite good. History of present illness. — On November 18 patient was suddenly attacked with rigors, pain in the right side, fever and loss of appetite ; he remained in bed all day, and ate nothing ; and during the ensuing night slept very badly. During the following morning I was called in. Examination. — Patient complained of pain in the right side over the fourth to seventh ribs from about the sternum to the anterior axillary line. Coughing and attempting deep inspiration made the pain much worse, so that patient felt as if a knife were cutting him. The abdomen did not move at all with respiration, and the right half of the thorax only moved in its upper part. The movements of the left half of the thorax were normal. The intercostal muscles were contracted over the painful area. Auscul- tation, pleural friction over the fifth and sixth interspaces in about two inches of their course ; breathing harsher in type, expiration more audible than normal ; fine crepitations. Urine high-coloured. Temperature 103"6°, pulse 11.5. After treatment less pain, temperature 103°, pulse 110. Evening of same day. Pain in the right side worse than during the morning. Great tenderness to touch over the fifth to seventh dorsal nerves on the right side. Pleural friction more intense on auscultation, and perceptible to the fingers. Urine still darker than during the morning. Temperature 103'4°, pulse 104. After treatment temperature 103^, pulse 102. 320 ELEMENTS OF KELLGREN'S MANUAL TREATMENT November '20. — Morning. Patient bad slept fairly well. Still a good deal of pain in the side, but no pleural friction to be detected on auscultation. Patient cougbing up frothy stuff streaked with blood. Urine very dark. Temperature 104°, pulse 102. After treatment, pain very much less, temperature 103'5°, pulse 102. Evening. Patient still coughing up frothy stuff streaked with blood, but pain in side much less, and general condition improved. Respiration partly abdominal. Patient had begun to eat again. Temperature 102'2°, pulse 88. Treatment morning and evening. November 21. — Morning. Patient had slept very well. No more cough ; very little pain in right side. Urine clear. Tem- perature 99'2°, pulse 60. During the course of the day patient got up and felt tolerably well, although weak. Evening. Only slight pain on deep respiration. Temperature 100-2°, pulse 58. Treatment morning and evening. November 22. — On deep respiration patient said that he felt a little uncomfortable in his right side. Bespiratory movements normal. No fever ; temperature and pulse normal. Treatment once. Patient up all day. November 23. — No treatment. November 24. — No pain. From to-day onwards patient was treated once a day^ and walked to and from his home to my house, a distance of two-thirds of a mile each way. November 2.5. — Slight pain returned in side. It finally dis- appeared after this day's treatment. November 26. — Patient said that he felt much stronger. November 27, 28 and 29. — Treatment. On 29th, patient went back to his work as engraver at Huskvarna factory, and worked for five and a half hours. November 30. — Patient worked at factory all day, excepting for one and a half hours during which he walked to my house, was treated, and walked back again. December 2. — Patient was normal, and said that he felt quite strong. Treatment for the last time. October, 1902. — Patient had been very well ever since his illness. DISEASES OF THE RESPIRATORY ORGANS 321 Chronic Pleurisy. The treatment of both chronic pleurisy with eiifusion and chronic dry pleurisy is essentially the same, the objects being to remove the effusion and gently break down the adhesions, and thereby restore the normal functions of the pleura and respiratory apparatus. This is effected by means of : — (I.) Local treatment, ivhich comprises : — (1) Stationary vibrations, shakings, hackings, &c., over the affected areas. (2) Running vibrations and frictions from before backwards in the affected intercostal spaces. (3) Nerve frictions on the posterior divisions of those spinal nerves which correspond to the affected spaces. (4) Respiratory exercises. (.5) Lateral trunk flexions, active as well as passive. (6) Shaking or vibration over the bladder. (II.) General treatment of the constitution as a whole. In his handbooks of 1896,i 1899,^ 1902,^ and 1903,^ Wide makes the astounding statement that he was the operator to "introduce gymnastics into new spheres, as, for example, in the after-treatment for acute pneumonia and pleurisy." This asser- tion can only be explained by a complete ignorance on his part of all the literature on Swedish gymnastics, for cases of this kind have been written about ever since 1846. Wide must have over- looked even the productions of Dr. Siitherberg, formerly head of the Gymnastic Orthopaedic Institute in Stockholm, whose very successor Wide himself is at present. The following are some of the older works (up to 1870) that mention either convalescence from pneumonia or pleurisy, chronic pleurisy and scoliosis arising from the latter, as having been treated by gymnastic methods. From the Gymnastic Orthopaedic Institute : — Siitherberg. " Gymnastiskt-Ortopediska Institutet i Stock- holm," 18.50, pp. 4, 5, &c. ' " Handbok i Jledicinsk Gymuastik," 1896, p. 210. ■-"Handbook of Medical Gymiiastics," 1899, p. 197. ■' " Handbok i Mediciusk ooh Ortopedisk Gymnastik," 1902, p. 188. ' "Handbook of Medical and Orthopaedic Gymnastics," 1903, p. 203. 21 322 ELEMENTS OF KELLGREN'S MANUAL TREATMENT Siitherberg. " Arsrapport friin Gymnastiska Ortopediska Insti- tutet for ar 1857," in Hygiea, November, 1858, p. 641. Siitherberg. " Gymuastik och Ortopedi," 1862, p. 4. Siitherberg. " Gymnastiska Ortopediska Institutet, dess Stiill- ning och Verksamhet," 1868. From the G. C. I. and other practitioners of Ling's system : — Branting. Speech to the gi-aduates delivered on April 1, 1846, quoted by Georgii, " Kinesitherapie," 1847, p. 99. Riecke. " Beitriige zur Heilung der Empyems und der Scoliose," in v. Walther's und v. Ammon's Zeitschr. f. Chir. unci Augenheilk., vol. vi., 1846, part 2. Puothstein. " Die Gymnastik nach dem Systeme des Schwed- ischen Gymnasiarchen P. H. Ling," 1847, p. 93. Eichter. " Organon der Physiologischen Therapie," 1850, p. 201. Branting. " Efterlemnade Skrifter," 1882, in section devoted to the year 1851, pp. 21, 23, 62, &c. Neumann. " Die Heilgymnastik," 1852, p. 287. Mehcher. " Erster Bericht," &c., 1853. Eulenberg. " Die Schwedische Heilgymnastik," 1853. Melicher. " Jahresbericht flir 1853," 1854. Eichter. " Bericht iiber neuere Heilgymnastik," in Schmidt's Jahrbucher, 1854, vol. Ixxxii., pp. 248, 251. Friedrich. " Die Heilgymnastik in Schweden und Norwegen," 1855, p. 41. Neumann. " Die Einfiihrung der Heilgymnastik in Lazareth und Khnik," in Athcn.f. Bat. Gi/m., vol. ii., 1855, part 1, p. 1. Melicher. " Jahresbericht fiir 1854," 1855. Weber. " Einige Worte iiber den Werth . . . der Heil- gymnastik," in Athen.f. Bat. Gym., vol. iii., 1856, part 2, p. 89. Melicher. " Jahresbericht fiir 1855," 1856. Melicher. " V. Jahresbericht fur 1856 und 1857," 1858. Eichter. " Bericht iiber neuere Heilgymnastik," in Schmidt's Jahrbucher, 1858, vol. xcviii., p. 126. Steudel and Giirtner. " Dritter Bericht uber das Heilgym- nastische Institut in Stuttgart," 1858, p. 23. Ulrich. "Jahresbericht iiber das Institut fiir Schwedische Heilgymnastik in Bremen," 1858, pp. 38 Sc 64. Mehcher. " VI. Jahresbericht fiir 1858 und 1859," 1860. Eichter. " Grundriss der Inneren Klinik," 1860, vol. ii., pp. 239, 248, 252. DISEASES OF THE RESPIRATORY ORGANS 323 Branting. " Arsrapport . . . ar 1861," p. 30.. Branting. " Arsrapport," &c., 1863, pp. 29, &c. Nycander. " Aarsberetning fra Institutet for Svensk Medi- cinsk Gytnnastik i Kjobenhavn," 1863, pp. 14-16. Hartelius. " Om Sjukgymnastiken vid Gyiunastiska Central Institutet under ar 1863," 1864, pp. 44, 78. Hartelius. " Gymnastiska lakttagelser," 1865, p. 77. Hartelius. " Arsberiittelse i Sjukgymnastik," &c., in Svenska Gyvinnstik-Fdrenigens Tidskrift," 1866, p. 49. Hartelius. " Gymnastiska Notiser," 1870, p. 6. " Larobok i Sjukgymnastik," 1870, p. 245. Case 1. E. M., female, aged 26 years, domestic servant. Previous history. — Quite good. History of present illness. — Patient on October 19, 1901, was attacked with violent stabbing pains in the right side, accom- panied by fever, rigors and perspiration. She managed to keep up for a week, but was then compelled to take to her bed. No medical aid was summoned until seven weeks after the onset of the illness ; this was in part due to the fact that patient lived in the country many miles away from any member of the profession. At last, when aid arrived, a diagnosis of effusion into the right pleura was made, and patient was recommended to the hospital in Jonkoping. Two days afterwards she was admitted to the latter institute, and she remained there until January 16, 1902. Five punctures were made at different times into the right pleura, but no effusion was found. Patient slowly became better, and on leaving she was recommended gymnastic treatment. Patient consulted me on February 3, 1902. Examination. — Patient complained of a continued sense of constriction and pain in the whole right side of the thorax. This pain was only slight on ordinary respiration, but deep respira- tion very much aggravated it, so that sharp stabbing pains were experienced. She also complained of constant pain down the right side of the spine, from the second to the twelfth rib, about an inch from the middle line. The right side of the thorax moved much less with respiration than the left ; on deep inspiration the distance from the xiphister- 324 ELEMENTS OF KELLGREN'S MANUAL TREATMENT num horizontally backwards to the spinous process of the corre- sponding vertebra was 36 J cm. on the right side, as compared with 39 cm. on the left. On percussion of the right side there was dulness, almost absolute, posteriorly from the third to the tenth ribs for about three to four inches external to the vertebral column, and anteriorly in the clavicular and mammary regions. Over the rest of the right thorax the note was partially impaired. Pleural friction could be heard almost everywhere in the right thorax, the amount varying from "creaking leather" sounds to " fine friction." In some cases the friction was palpable. The breath sounds and vocal resonance were diminished over the whole right thorax, and in places the former were either inaudible or else masked by pleural friction. Treatment. (1) Heave grasp standing chest clapping, side shaking, PP. (2) Half lying double arm rolling, PP, bending and stretch ing, AK. (3) Stretch stride standing bending forwards, PA, with back hacking, PP. (4) Forwards lying back exercise, PP. (5) Hip lean walk standing lateral flexion, PE, extension, AE. (6) Loin lean stride standing alternate rotation, AE, ringing, PP. (7) Eight stretch left side lying running nerve frictions, including the intercostal nerves, PP, side length hacking, PP. (8) Walk standing double arm circling, breathing, PA. (9) Half lying vibration over the right thorax, especially the most affected parts or where pain was felt most, with running vibrations along the intercostal spaces, PP. (10) Half lying stomach exercise, PP. (11) Stretch grasp toe standing hanging, breathing, PA. Progress. — Pain was experienced by the patient in various parts of the right thorax for the following three weeks, the locali- ties of the pain generally differing from day to day. February '20. — The pain along the side of the spine had dis- appeared. March 4. — -Patient very much better. Pleura normal except over third to fifth interspaces under mammary gland where DISEASES OF THE RESPIRATORY ORGANS 323 friction was heard ; the friction was, however, not loud, and normal breath sounds were audible in this area. On deep inspi- ration, circumference of right lung, 38 cm., left lung, 39^ cm. April 4. — Pleura normal, no friction. On deep inspiration, circumference of both sides, 40 cm. Treatment finished. During July, 1902, I heard that patient was still keeping quite well. Case 2. A. F., male, aged 4.5, worker in an iron factory. Previous history. — Very good indeed. History of present illness. — Patient went through an attack of pleurisy with effusion, which commenced December 24, 1901 ; he stated that he had fever for sixteen days, and was kept to bed for a month. He was then allowed up, but was so weak that he could not walk. About the middle of February, 1902, he was allowed out of doors for five minutes a day, during the next week for ten minutes a day, and so on, gradually increasing the time ; by March 8 he was strong enough to take a walk of two miles. On March 20 his medical man recommended him to me for gymnastic treatment. Examination. — March 21, 1902. Patient complained of continued feeling of heaviness and tiredness in the left half of the thorax, and difficulty on respiration. No pain on deep respira- tion, but only a sense of uneasiness in the left side. Intercostal spaces of left side of thorax somewhat indrawn, and the whole left side remained immobile, even during deep respiration. Circumference of left half 41 cm., both during deep inspiration and deep expiration, as compared with 44 cm. and 42^ cm. on the right side. Posteriorly, absolute dulness on percussion from the fourth rib down to the base of the lung, and the same in the axilla ; anteriorly, the dulness extended round so as to blend with the cardiac dulness. Vocal fremitus and resonance almost absent over this area ; no breath sounds heard over it. Plem-al friction in third and fourth interspaces posteriorly, in fifth and seventh laterally, and fifth and sixth anteriorly. Some crepitations at both apices. Heart sounds closed, though muffied in the mitral area. General weakness and emaciation. Appetite poor. Ten- dency to free perspiration. 326 ELEMENTS OF KELLGREN'S MANUAL TREATMENT Treatment. (1) Heave grasp standing chest clapping, PP, side shaking, PP. (2) Hip lean walk standing lateral flexion, PR, extension, AR. (3) Half l}'ing double arm rolling, PP, bending and stretching, AE. (4) Forwards lying back exercise, PP. (5) Left stretch right side lying running nerve frictions, PP, side length hacking, PP. (6) Eide sitting alternate rotation, AE, ringing, PP. (7) Halt lying vibration over left half of thorax, and running intercostal vibrations, PP. (8) Half lying stomach exercise, vibration over the bladder, PP. (9) Stretch grasp toe standing hanging, breathing, PA. Progress. — March 22. The left side beginning to move with respiration, and patient stated that he breathed more easih'. Deei3 inspiration, however, had for the last week caused stabbing pains in the left side of the thorax, the site of these pains varying from day to day. April 10. — The left side moved fairly well with respiration, the circumferences being 41 cm. and 42^ cm. as compared with 41 cm. and 41 cm. on March 21. Partial dulness posteriorly from the seventh rib downwards ; laterally the note somewhat impaired below the seventh rib ; anteriorly no dulness. Vocal fremitus and resonance more marked in these areas than before, and pleural friction now audible all over them. On deep respira- tion the inspiratory breath sounds audible. The crepitations at the apices had disappeared. No muffling of the sounds in the mitral area. General condition considerably improved ; patient stronger, and reported his appetite to be once more normal. May 4. — Patient had commenced to work again four hours a day in the factory. May 15. — Treatment finished. The stabbing pains referred to above almost disappeared. No difficulty in breathing, except after considerable exertion. Expansion of left side very good, the circumferences being 42 cm. and 44 cm., as compared with 43 cm. and 46 cm. on the right side. Posteriorly and laterally the partial dulness referred to on April 10 had almost disappeared, the note being but slightly impaired. Vocal fremitus and resonance posteriorly almost as plain as on the right side. Some pleural DISEASES OF THE RESPIRATORY ORGANS 327 friction heard posteriorly, but causing the patient no inconveni- ence beyond a sense of uneasiness from time to time. Breath sounds normal. Patient said that he felt qaite strong again. He proceeded to resume his full day's work (nine hours a day) at the factory. August 16. — I saw patient again. He had been working full time ever since he finished the treatment. The slight feeling of uneasiness referred to on May 15 was still occasionally felt, other- wise no abnormal subjective sensations. Condition of pleura showed no further change. Case 8. E. J., aged 16, domestic servant, came under the manual treatment on July 7, 1902. Previous history. — Not very good. Patient had never been very strong. She had rheumatic fever about four years pre- viously, which left her with a mitral incompetence. This, however, was quite well compensated, and had not given her any trouble. History of jrresent illness. — Patient was attacked with pleurisy in the right side on May 22, 1902. Her medical man never said anything about there being an effusion, and no punctures were made. She was kept in bed for two weeks, after which she was allowed up a little. At the end of a month she had so far recovered as to be allowed out of doors, although she was still weak, and had a great sense of opjjression and tiredness in the right side. Her condition improved only very slightly after that until July 7, 1902. Examination. — Patient thin and pale, complaining of weak- ness and continued feeling of heaviness and tiredness in the right side. The right side moved only slightly with respiration ; on deep expiration the circumference was 32 cm., and on deep inspir- ation 32^ cm., as compared with 31 cm. and 33 cm. on the left side. There was absolute dulness on percussion posteriorly from the fourth rib downwards, and in the axilla from the sixth rib downwards, the area of dulness fading off on proceeding forwards, and terminating about an inch in front of the anterior axillary line. Pleural friction was audible along the limits of the dull area, but not in the area itself, where there was complete absence 328 ELEMENTS OF KELLGREN'S MANUAL TREATMENT of vocal fremitus, vocal resonance and breath sounds. There was no aegophony. Treatment. (1) Forwards lying back exercise, PP. (2) Heave grasp standing chest clapping, PP, side shaking, PP. (3) Stretch side standing bending sideways, PA, given with hacking over the affected area on the right side, PP. (4) Reach grasp stoop fall standing double elbow flexion and extension, PA, with back hacking, PP. (5) Stretch half lying running nerve frictions, including the intercostal nerves, PP, side shaking, PP. (6) Half lying chest vibration given specially over the affected areas, PP. (7) Half lying stomach exercise, shaking over the bladder, kidney frictions, &c., PP. Progress. — Patient began after a few days to feel sharp stabbing pains in the right side of the thorax, the site of these varying from day to day. Pleural friction was audible over the whole dull area on and after July 20. August 7. — The dulness had diminished in extent, the upper limit being the sixth rib posteriorly, and it was now only partial, not complete. There was no dulness in the axilla. Pleural friction and faint breath sounds were audible in the whole dull area, and also in the axilla where the dull area used to be. August 21. — The expansion of the right side of the chest was as good as that of the left, the figures being 32^ cm. and 34^ cm. on both sides on deep expiration and deep inspiration respectively. A slightly dull area about three inches wide was found posteriorly from the eighth rib downwards ; the vocal fremitus and resonance were heard almost as well here as in the corresponding area on the left side ; the breath sounds were, however, somewhat fainter on the right side. There was no more pain or pleural friction anywhere. Patient looked much better, and said that she felt quite well and strong. Although not quite cured, patient had to finish treatment, otherwise she would have lost her situation. Further progress unknown. Case 4. S. W., male, aged 26, worker in Huskvarua factory, came under the manual treatment on April 4, 1902. DISEASES OF THE RESPIRATORY ORGANS 329 Previous historij. — Patient bad never been very strong ; had always had a narrow chest and been very thin. Historij of present illness. — During January, 1897, patient suffered an attack of pleurisy in his left side, which confined him to his bed for a month. The medical man who attended him made no punctures, and patient was never told whether he had an effusion or not. The result of the pleurisy was that the left side became indrawn and concave at its lower part, and a scoliosis resulted. When patient was allowed up he was very weak, and it took three months before he was strong enough to resume work again. He underwent two months' gymnastic treatment according to Ling's system, but stated that the course only did him very little good. Since then (June, 1897) his condition had remained the same. Patient consulted me on April 4 for catarrh of both lungs (non-tubercular). I considered the lung condition amenable to the manual treatment, and recommended patient to take a longer course of treatment than was necessary for the cure of his lungs, in order to obtain an amelioration in the condition of his pleura and in his scoliosis. Examination. — Patient had suffered from a good deal of cough for the last three months, and had been perspiring at night and getting thinner during the last two months, and he had been getting progressively weaker, having to cease work at the end of February, 1902. He complained of a continued heavy feeling in the left side of the thorax low down, with stabbing pains if he either bent his trunk over to the right side or stretched up. No pain was, however, felt in the area mentioned dm'ing deep inspiration. There was considerable emaciation of the whole body. A C-shaped scoliosis with the concavity to the left commenced at the first dorsal vertebra above and extended to the first lumbar vertebra below. A straight line drawn between the spines of these vertebras was 5 c. distant from the spines of the fifth and sixth dorsal vertebrae, where the point of maximum curvature is situated. The muscles 011 the concave (left) side of the curvature were hard and contracted, those on the convex (right) side soft and flabby. By means of voluntary effort the curvature could be slightly straightened so that its maximum point was only about 41- c. from the line drawn between the spines of the first dorsal and first lumbar vertebrae. 330 ELEMENTS OF KELLGREN'S MANUAL TREATMENT Left side of the thorax. The whole side was markedly con- cave, the point of maxiniuiu curvature being at the sixth, seventh and eighth ribs in about the mid-axillary line. Over an area here measuring about 5 inches from above downwards and 4 inches from side to side the intercostal spaces were indrawn and felt very resistant. There was absolute dulness on per- cussion here, except just at the edges of the area, where it was partial. No breath sounds were audible except at the edge, where they could be faintly distinguished, and slight pleural friction could be detected here and there on deep inspiration. Fig. 107 shows a photogra]Dh of the patient taken before the first day of treatment. There was no dulness on percussion of the apices, but fine and medium crepitations were audible at both apices and ante- riorly downwards as far as about the fourth rib on either side. The rest of the lungs were normal. The respiration was 33 per minute. The heart was displaced to the right ; the apex beat could be seen and felt in the fourth interspace 1 inch to the right of the nipple line ; the dulness on percussion extended to 1^ inches to DISEASES OF THE RESPIRATORY ORGANS 331 the right of the sternum. The heart sounds were normal, but the cardiac beat was accelerated ; the pulse rate when patient stood up was 116 per minute. Patient's appetite was poor. He had a motion daily. Treatment. (I) Heave grasp standing chest clapping, side shaking, PP. {'2) Loin lean stride standing alternate rotation, AE, ringing, PP. (3) Forwards lying back exercise, PP. (4) Arch forwards lying head flexion, PE, extension, AE. (5) Stretch stride standing bending forwards, PA, given with back hacking, PP. (6) Half lying double arm rolling, PP, bending and stretching, AE. (7) Left hip lean walk standing lateral flexion, PE, extension, AE. (B) Eide sitting trunk flexion, PE, extension, AE, (9) Half lying vibration over the affected pleura, running intercostal nerve frictions, side shaking, PP. (10) Stretch grasp toe standing hanging, breathing, PA. (II) Half lying stomach exercise, shaking over the bladder, PP. (l'2i Half lying trunk stretching, PA, right mid-dorsal spinal muscle frictions, PP. Progress. — April .5. More pain than usual in the area of dulness in the left side. April 10. — Pleural friction audible all over the area, and here and there for about 2 inches all round it. April 16. — Eespiration easier. Patient said that he felt his back to be straighter. Appetite normal again. April 28. — All the crepitations at the apices disappeared. Patient returned to work again. May 4. — Pleural friction very marked in the whole area of dulness in the left side. August 1. — In consequence of my own illness (rheumatic fever and erythema) I did not again examine patient until this date. During my inability to work, however, the treatment was applied daily by Dr. Harry Kellgren and others. The area of 332 ELEMENTS OF KELLGREN'S MANUAL TREATMENT former complete dulness was now only partially dull on per- cussion, and was also smaller in extent, measuring about 2 inches by 8 inches. Pleural friction was audible over it, and in a few small isolated patches round it. September 27. — Treatment finished. Owing to my temporary absence I did not examine patient until October 5. On that date he still suffered some pain in the left side, but it was never sharp and stabbing as it used to be. The spinal column was straighter. The point of greatest convexity was distant 4 c. from a line drawn between the spines of the first dorsal and first lumbar vertebrfe. On attempting to straighten the spine this distance could be reduced to 3 c. The left side was much less sunken in (see fig. 108). There was no dulness on percussion ; pleural fi-iction was audible over the area of former dullness and in the fifth and sixth interspaces for about 2 inches in their length outside the apex beat. The respiration was 19 per minute. The apex beat could be seen and felt in the fourth and fifth interspaces, about half an inch internal to the nipple line. DISEASES OF THE RESPIRATORY ORGANS 333 The pulse on standing up was 7'2 per minute. Appetite was good. General condition was stronger. Although this case was by no means cured, it shows what could be effected even when the abnormal condition had lasted for more than five years before coming under the influence of the manual treatment. It may not be out of place here to make some remarks on the treatment of spinal curvatures by means of combining gymnastic methods with mechanical support from a corset, Sec. I heartily agree with the doctrine of the Ling school,^ which has always been that such mechanical appliances, by giving support to the weakened muscles and thereby partially rendering their co- operation unnecessary, do more harm than good. The principle of their action is, in fact, directly opposed to the principle of gymnastic treatment, the object of the latter being invariably to strengthen the weakened muscles at the expense of their antagonists. Wide,^ however, recommends the use of such mechanical appliances. ^ See, for example, Hartelius, "Larobok i Sjukgymnastik," 1883, pp. 326,327; 1892, pp. 314, 315; and " Skolios och dess Behandling med Sjukgymnastik," in Tidskrift i Gymnastik, 1881, part 15, pp. 913, 914. - " Handbok i Mediciusk Gymnastik," 1896, pp. 429, &e. ; " Handbook of Medical Gymnastics," 1899, pp. 358, &c. ; " Handbok i Medicinsk och Ortopedisk Gym- nastik," 1902, pp. 363, &c. ; " Handbook of Medical and Orthopaedic Gymnastics," 1903, p. 357. CHAPTER V. DISEASES OF THE DIGESTIVE ORGANS. Acute Membranous Tonsillitis. K. I., male, aged 45, already under treatment for lateral sclerosis, came to my house for his usual daily treatment on October 16, 1899. During the evening of the same day patient felt feverish and had some difliculty in swallowing. October 17. — Aggravation of these symptoms ; during the course of the afternoon, delirium, lasting for about an hour, supervened at 4 p.m. I saw patient at 7 p.m. Examination. — Patient fairly clear in his head ; difliculty in swallowing ; both tonsils enlarged and swollen, and patches of yellowish membrane on them; uvula also swollen, but no mem- brane on either it or the pillars of the fauces. Fever and accel- erated pulse rate ; after treatment, temperature 104°, pulse 130. October 18. — Treatment twice. During morning, temperature 102"6°, pulse 125 ; after treatment, 102' and 115 respectively. During the evening, temperature and pulse 100"2° and 108, and 996° and 106 respectively before and after treatment. October 19. — Morning. Swallowing easier. Temperature 100"4°, pulse 112. Treatment, after which temperature 99"8°, pulse 102. Evening. Temperature 99"2°, pulse 98. Treatment, after which temperature 98'6°, pulse 96. October 20. — Patient got up and walked about. Swallowing much easier ; no membrane left, only some redness. Treatment once during the evening. Temperature 97'8°, pulse 65. October 21. — No redness. Temperature 98'6°, pulse 70. Treatment once. October 22. — Patient went out for a walk. October 23. — Treatment stopped as regards the throat afl'ec- tion, the throat being normal. DISEASES OF THE DIGESTIVE ORGANS 335 December 10. — Throat had remained quite well since I had last seen it. Treatment. Vibrations on the larynx, pharj'nx and sublingual regions ; frictions on the nerves of these parts. General treatment for fever. Acute Catarrhal Appendicitis. To Henrik Kellgren belongs the credit of having been the first to introduce gymnastic methods into the treatment of acute appendicitis. A. Levin of the G. C. I. made efforts in this direction, the incentive being, as be himself says, what he saw while studying under Henrik Kellgren during 1887 ; his results were published in 1892\ Hartelius does not mention appendicitis in his handbook.^ Wide, of course, strongly condemns all attempts at gymnastic methods for appendicitis. ■' The objects of Kellgren's treatment as applied to acute appendicitis are as follows : — (1) To diminish the inflammatory process in the appendix, and thereby prevent the formation of abscess ; and to diminish the tendency to the formation of adhesions, exudation, &c., round about the local lesion, or if such have formed, to remove them. (2) To diminish the tension in the abdomen, and thereby cause the blood and lymph flow to proceed better ; and to prevent stasis, which so powerfully predisposes to lowered vitality of the part. (3) To improve the constitution generally. These objects are gained by means of the following manipula- tions : — (a) Vibrations over the appendix and over any inflamed or painful area in the right iliac fossa. (6) Gentle stomach exercise administered at first only on the left half of the abdomen ; making the patient practise deep respira- ' " Om Massage vid BliudtarmsinflammatioD," iu Tidskrift i Gymnastik, 1892, pp. 684, &o. -■ " Larobok i Sjukgymnastik," 1870, 1883, 1892. » " Handbok i Medicinsk Gymnastik," 1896, p. 226; " Haudbook of Jledical Gymnastics," 1899, p. 209; " Handbok i Medicinsk och Ortopedislc Gymnastik," 1902, p. 201 ; " Handbook of Medical and Ortbopa?dic Gymnastics," 1903, p. 214. 336 ELEMENTS OF KELLGREN'S MANUAL TREATMENT tions, side shaking, vibrations or frictions on the lower intercostal nerves (thereby also affecting the splanchuics), &c. (c) General treatment for fever. Case 1. Mr. K., aged 43, came under the manual treatment on August 18, 1898. Previous history. — Quite good. History of present illness. — Patient was seized on August 17, 1898, throughout the abdomen generally with sudden pains, which did not seem to arise from any particular spot ; he could assign no cause for their coming on. In a quarter of an hour or so he felt very bad and went to bed. Fever set in some two or three hours later, and patient was then able to locate the pains in his right iliac fossa. He felt very weak and ill, and during the evening of the same day sent for his medical man. The latter diagnosed appendicitis, and, while making his examination, he palpated the right iliac region, which caused the patient ver}' much pain. An ice-bag was placed on the right iliac region, an enema given, and opmm prescribed. There had been no motion since the morning of August 16 ; the enema did not call forth one. Patient slept very badly ; the pains in the abdomen increased, and nausea set in, although no actual vomiting occurred. No motion took place, and the appetite disappeared. On August 18 the medical man said that if the temperature rose any more he must operate. Patient did not like the idea of an operation, and thought he would instead try the manual treatment. I was called in during the evening of August 18. Examination. — Patient in bed, with sunken eyes, looking very weak. He preferred lying on his back with his legs drawn up. He complained of continued severe pain in the right iliac region, and a sense of weight and oppression in the abdomen generally ; also of headache and general weakness. A sense of nausea was present, but no actual vomiting had occurred ; sometimes eructa- tions and also passage of flatus per rectum took place. Patient had eaten nothing all day, but had drunk some water at intervals. No motion had taken place since the morning of the 16th. The abdomen looked distended ; it was very resistant on palpation, especially in the region of the right iliac fossa, where DISEASES OF THE DIGESTIVE ORGANS 337 even slight pressure caused a good deal of acute pain, the pain being most marked at McBurney's point. There was reflex eon- traction of the abdominal muscles over the right half of the abdomen, and the abdomen did not move with respiration. The urine was dark and scanty. No rigors had occurred. No rectal examination was made. Temperature 102'4' ; pulse 115, weak. Treatment. Vibrations over the painful part, especially the point of greatest pain, which, however, often changed its place, the point of application of the vibrations being changed accordingly. In the course of a few minutes the pain diminished, and the patient could stretch out his legs without extra pain. After a few more minutes the contraction in the abdominal muscles grew less, and the vibrations could be administered with greater vigour. In addition, gentle stomach exercise, side shaking, kc, head vibration, and the ordinary treatment for fever. After the treatment patient looked and felt better. The head- ache had been perceptibly lessened. The abdomen was less distended, this being partially due to the patient having vented much gas from his stojiiach and passed a good deal of flatus per rectum ; but no motion had resulted. There was less contraction in the abdominal muscles, especially over the right iliac fossa, and much less pain in that region, where a circumscribed tumour could be made out, although the boundaries could not be well defined on account of the tenderness. Temperature 100'2° ; pulse 93. Patient remained fairly comfortable until about two hours after the treatment, when the pain in the right iliac fossa set in again. He slept fairly well. August 19. — 9 a.m. No motion yet. Patient had suffered a good deal of pain in the right iliac fossa ; it was, however, not so bad as when I first saw him, and he had been able to lie with his legs straight all night. The tumour was considerably smaller than during the previous evening. Temperature 100° ; pulse 100. Treatment as before. 3 p.m. Temperature 102° ; pulse 100. Treatment. 9 p.m. The tumour has been reduced to a small round mass. The urine was clearer, the quantity greater than during the 22 338 ELEMENTS OF KELLGREN'S MANUAL TREATMENT previous day. Teinperatiue 101 9" ; pulse lOG. Patient had consumed notliing during the day except a little milk. Treatment. Patient was treated three times during the course of this day, and each time the treatment almost entirely removed the pain in the right iliac fossa, it being then only perceptible on considerable pressure. August 20. — Patient slept very well. During the early morning he passed a copious, evil-smelling black motion. 10 a.m. Not much pain in the right iliac fossa. Temperature 99'8°, pulse 103. Treatment as before ; after it no pain on deep pressure in the right iliac fossa, only some tenderness. Sense of resistance was still present, but no tumour could be felt. After treatment patient got up and sat up in a chair ; he ate some bread and butter and drank some milk during the course of the day. Evening. Temperature 101'5°, pulse 108. Blight return of the pain, which, however, disappeared after the treatment. The urine was still clearer. Another motion during the evening. August 21. — Patient up all day. Appetite returning; one motion. No sense of resistance in the right iliac region. Tem- perature 99°, pulse 90. Treatment once during the evening. August 22. — Patient feeling normal, except for weakness ; he walked from his house to Sanna (distance three-quarters of a mile), and in addition to vibrations, &c., over the abdomen, and stomach exercise, performed some active exercises. No tender- ness any more in the abdomen. Urine normal. One motion during the course of the day. August 23. — Patient had eaten daring the previous day as usual, meat, vegetables, milk, &c. He did not, however, feel equal to walking to Sanna, and so was treated at home. Tem- perature 98°, pulse 8.5. August 24. — Patient drove to Sauna, where he was treated. August 25 to September 5. — Patient walked to Sanna and back daily. He received special treatment for the abdomen and a few active strengthening movements. Motion daily since August 22. September 5. — Treatment finished. Patient normal. Patient-, who had enjoyed excellent health ever since his illness, emigrated to America in February, 1901 ; I have not heard of him since. DISEASES OF THE DIGESTIVE ORGANS 339 Case 2. J. A. S., aged 35, male, came under the manual treatment on July 23, 1902. Previous history. — Patient had always been well and strong. History of present illness. — On getting up at 6 a.m. on July 22 he felt ill, but went to work as usual. The feeling of illness increased, and he was obliged to go home ; at about 9 a.m. he was seized with pains in the arms and abdomen, and had to go to bed. He vomited watery stuff all the morning, and perspu-ed very much. Towards afternoon the abdominal pain became more severe ; he was unable to assign its origin to any particular spot. At about 4.30 p.m. he had rigors, which lasted until 6 p.m., and the pain in the abdomen, which he could now locate in the right iliac fossa, became so severe that he screamed continually. He lay on his back with his legs drawn up, occasionally, however, rolling about in bed for sheer pain. At about 7 p.m. he was relieved somewhat by a motion which looked normal, although it smelt worse than usual. He did not sleep at all because of the pain, and at about 4 a.m. the following morning (July 23) had another rigor, this time of an hour's duration. At 10 a.m. I was sent for. Examination. — Patient was lying on his back, with flushed face ; there was no abdominal look. He preferred lying with his legs drawn up, especially the right one, but was able to lie with them straightened. He complamed of severe pain in the region of the right iliac fossa, and also to a less extent in the whole right half of the abdomen. There was contraction of the abdominal muscles of the right half of the abdomen ; tenderness on palpation, and great tenderness to pressure in the right iliac fossa ; cutaneous hyperaesthesia at McBurney's point. The whole right half of the abdomen was filled up by a large tender mass which was fairly hard, especially in the right iliac fossa. The left side of the abdomen was normal. The spleen and sixth to twelfth dorsal nerves of the right side were tender to friction. The urine was darker than normal. Temperature 101'3° (all the temperatures were taken jjer rectum), pulse 102, thready. After treatment there was no pain and very little tenderness, although the contraction of the abdominal muscles was only slightly improved. Patient looked better and said that he felt better. He drank some soup. Treatment twice a day henceforth. 340 ELEMENTS OF KELLGREN'S MANUAL TREATMENT Evening. The pain and tenderness had returned to some extent, and the abdominal muscles were more firmly contracted. Temperature 101 'S", pulse 90. No pain after treatment, and very little tenderness. Patient drank some more soup and went to sleep. July 24. — Morning. Patient had slept fairly well ; and eaten an egg for breakfast. Right iliac fossa very tender. Temperature 101'8°, pulse 76. Urine normal. Evening. Patient had at intervals been sitting up in bed, and had left it altogether while it was being remade. He ate an egg and some bread and butter during the evening. No motion. Temperature 100"6°, pulse 72. After treatment no pain and not much tenderness. July 2.5. — Patient slept well, and ate an egg and bread and butter, and drank some milk for breakfast. Morning. No pain at all ; tenderness in abdomen about the same as during the previous evening. Temperature 99'9°, pulse 65. Patient got up for a few minutes during the course of the day. He ate pancakes with cranberries and milk for dinner. Later, after fifteen minutes effort, he passed a motion consisting of a few very hard lumps. Evening. At supper, patient took the same food as at break- fast. Temperature 101.1°, pulse 72. July 26. — Patient slept well ; he ate during the day about the same as during the previous day. No motion took place. Morning. Temperature 101"1°, pulse 68. During the course of the day there was some return of the pain, and the tenderness was more marked. Evening. Condition improved. Temperature 101'.5°, pulse 72. July 27. — For breakfast patient ate an egg, some cold meat and some bread and butter, and drank some milk. Morning. Patient much better. Only slight tenderness left in right iliac fossa, none in the rest of the right side of the abdomen. The large mass in the right iliac fossa much smaller, only about the size of a billiard ball. Hardly any contraction of the abdominal muscles. Temperature 99'9° pulse .54. Evening. Patient had a motion during the afternoon which was rather hard, though otherwise normal, and was up for an hour. He had milk and bread and butter both for dinner and supper. Temperature 99°, pulse 60. DISEASES OF THE DIGESTIVE ORGANS 34i July 28. — Treatment only once a day henceforth, during the morning. Morning. Patient much hetter ; the mass in the right iliac fossa rapidly disappearing. Temperature 98"1°, pulse 54. Diet : breakfast, egg, milk and bread and butter ; dinner, meat, potatoes and milk ; supper, porridge and milk. Patient was up all the afternoon. No motion. July 29. — Morning. Temperature 97'9°, pulse .56. Patient up all day. Motion. July 80. — Slight tenderness in the right iliac fossa, otherwise nothing abnormal in the abdomen. Patient went out for a walk ; he would have done so the previous day had it not rained without ceasing. No motion. July 31. — Patient stronger. Motion. August 1. — Patient walked to my villa and back for treat- ment (distance nearly one mile each way). August 3. — No treatment. August 9. — Motion daily since August 1. Treatment finished. There had been no tenderness in the abdomen since the 5th, but patient had continued treatment in order to regain his strength. August 11. — Patient returned to the factory, working as usual for nine and a half hours a day. September 18, 1902. — Patient had been quite well ever since his illness. The treatment was practically the same as for the last case. Acute Rapidly Extending Peritonitis. Mrs. S., aged 39, came under the manual treatment on Feb- ruary 25, 1902. Previous historij. — Patient had suffered from chronic constipa- tion for the last twelve or fifteen years. She had had nine chil- dren. On February 8 she was delivered of her ninth child, the labour being normal in every respect. Historij of present illness. — On February 24 she went out for the first time since her confinement in order to go to the closet, which was in an outhouse (as is usual in the country in Sweden). She had not had a proper motion since her confinement ; this time, as usual, she had to wait some minutes before the motion came. It was very cold ( — 8° C.) and windy, and she felt that she 342 ELEMENTS OF KELLGREN'S MANUAL TREATMENT got a chill. During the evening of the same day she had a rigor lasting about five minutes, followed by attacks of sharp stabbing pains in the whole of the abdomen ; these recurred at ever shorter intervals. The midwife who attended her last confinement was called in, and administered an enema which resulted in a motion. During the night patient was feverish, felt very ill and had continued attacks of violent pain in the abdomen, which were so bad as to cause her to cry out. Slight relief was obtained by keeping her legs drawn up. The attacks lasted from ten to fifteen minutes, and the pauses between them lasted from two to three minutes only. She was quite unable to move without bringing on the attacks. On one occasion she vomited. FEB. MARCH DATE 25 1 26 27 128 1 2 3 4 5 6 7 TIME ^°M^^ ^W AM PM "^ ^ M t M E M E M E M E M E M F° 103" 102" lOl" 100 " 30" 9S' 97" 96' Mouth ^/" V V . ^ ^ A ' \ y ' I r^ \ J / PULSE IIZ 100 106 100 00 84 68 67 80 62 68 68 80 84 %> 84 82 84 73 78 66 76 73 74 68 72 Examination. — February 25. Morning, 9 a.m. Patient lying on her back with her legs drawn up, abdominal facies very marked. Complained of attacks of pain in the abdomen, chiefly the lower part, the pain being so intense as to cause her to cry out, and being aggravated by the slightest movement. Eeflex contraction of abdominal muscles present, especially in the hypogastric region. Respiration accelerated and purely thoracic, abdominal breathing impossible. Patient could hardly bear the slightest touch on her abdomen. Great tenderness over sixth to eleventh dorsal nerves near the spine. Vaginal discharge increased in amount, no bad odour. Micturition caused a burn- ing sensation and much pain. Thready pulse. (For temperature and pulse see separate chart, fig. 109.) DISEASES OF THE DIGESTIVE ORGANS 343 1 first executed very fine vibrations over the hypogastric region, gradually increasing their strength, and maintained these for three-quarters of an hour. During that time patient suffered only three attacks of pam, which were less severe than those occurring during the night and only lasted from two to five seconds, and the abdomen became less tender. I then executed vibrations over the abdomen as a whole and frictions on the ovaries and the dorsal and lumbar spinal nerves. I tried to get patient to breathe abdominally, but the attempt was attended with too great pain ; some eructation followed. 11.30 a.m. Pains less severe than during the night, but now experienced all over the abdomen. Tenderness in entire abdomen, especially in epigastrium. A good deal of eructations. 2 p.m. Patient had vomited twice since 11.30. Large amount of eructations. After treatment abdomen softer, and able to bear more pressure than before ; patient able to move in bed without pain ; abdominal respiration fairly easy and attended by little pain. 5 p.m. Patient had vomited once since last treatment. Pain less, chiefly in epigastrium. Fever less. Treatment, after which patient slept for three hours. 11 p.m. There had been no vomiting since the afternoon. Patient better. Treatment. February 26. — 5 a.m. Eather severe pain from 2 to 4 a.m. ; since then less severe Treatment. 9 a.m. Treatment repeated. 2 p.m. Abdomen moved unconsciously during respiration ; deep abdominal respiration only caused uneasiness. Pain much less severe. Fairly strong pressure could be applied to the abdomen, and a gentle stomach exercise was administered ; gurgling sounds from the intestines could be heard meanwhile. Patient passed flatus several times during the morning. 8 p.m. Patient had slept ever since I treated her last. Patient drank some soup during the afternoon. Treatment. 11 p.m. Not much pain ; vomiting entirely ceased since the previous day. Treatment. February 27. — 9 a.m. Patient had been sitting up in bed for two hours before my arrival, with hardly any pain. After treat- ment she got up and sat on the sofa while the bed was being made. Very little pain. 344 ELEMENTS OF KELLGREN'S MANUAL TREATMENT 3 p.m. Treatment. 8 p.m. Patient had been drinking milk and soup. I adminis- tered, among other manipulations, an ordinary stomach exercise. Hardly any pain. Patient treated twice a day henceforth. February 28. — 9 a.m. Patient had passed two motions dur- ing the night ; they were black and smelt very badly. After the first she had had some pain, but after the second none. She had eaten some bread and butter and drunk some milk. She began this morning to give her baby milk from the breast for the first time since her illness (I did not know of this until several days afterwards), and during the afternoon she sat on the sofa for two hours. 7 p.m. One tender spot in the right iHac fossa. A medium vibration executed on it for a few seconds caused a loud gurgling sound, followed by immediate cessation of the tenderness. March 1. — One motion. The tender spot in the right iliac fossa had returned, and there was still some tenderness over the lower dorsal nerves; distinct improvement in both after treat- ment. Patient up during most of the day. March 2. — A motion during the night ; for a while after it some pain, which then ceased permanently. The tenderness in the right iliac fossa had disappeared. Patient ate meat, eggs, milk, &c., and was up all day. March 3. — One motion. Patient ate her ordinary food and was up all day. During the evening she said that beyond a feeling of looseness and tiredness in the abdomen, and some weakness in general, she felt quite normal. March .5 to 10. — Motion daily. Active exercises prescribed, amongst others, sitting trunk extension and flexion, PA. On March 10 patient went out for a few minutes ; the temperature was — 7° C. March 13. — Some weakness still left. Patient was fulfilling her household duties as usual. Treatment once a day henceforth. March 22. — Motion daily ; patient normal. Treatment finished. July 12, 1902. — Patient had had a motion daily since above date. She said that she felt stronger than before her illness, that her digestion had also been better, e.g., she had been able to eat freely of fatty articles of diet, which before her illness she had never been able to do. August, 1903. — Still keeping quite well. DISEASES OF THE DIGESTIVE ORGANS 345 Acute Gastro-Intestinal Catarrh. Hartelius' states that acute gastric catarrh, when severe and combined with fever, is not amenable to gymnastic treatment. Miss L., aged 13, came under the manual treatment on December 19, 1900. Previous history. — Good. History of present illness. — Patient was taken ill on December 17, 1900 ; the onset was sudden, and accompanied by a rigor, fever, and severe headache. About an hour afterwards patient vomited some green matter, repeating this at intervals. Greenish diarrhoea appeared during the course of the day, the colour chang- ing to brown after a few motions. Patient slept very badly, vomited every half hour, and was delirious. December 18. — Patient vomited about once an hour during the day, the vomit being still greenish in colour, and she suffered from continued diarrhoea and high fever. She was again delirious during the night. On the morning of December 19 I was sent for. Examination. — Patient had been vomiting green matter all night at intervals of about an hour, and had had two diarrhoeic motions to-day. She had been delirious all night, and was so when I saw her ; on being asked questions she invariably replied : " I have a very bad headache." She had eaten nothing since December 17, and had only drunk water, which was invariably vomited after a few minutes. Temperati;re 104° ; pulse 138. The breathing was thoracic and laboured, the abdomen painful and tender, and in it continued gurgling sounds were audible, which were greatly increased on slight pressure. The heart and lungs showed nothing abnormal. The vomit had been thrown away, and I was therefore unable to see a specimen. Treatment. — Head exercise, abdomen vibrations ; after a few minutes I could administer a gentle stomach exercise. I also executed spinal nerve, kidney and spleen frictions, &c. After treatment patient became clear in her head, and was able to sit up. The abdominal pain was diminished, the headache alle- viated, and the general appearance improved. '"Om SjukgymnastikenvidGymnastiska Central Institutet under ar 1863," 1864, p. 48. 346 ELEMENTS OF KELLGREN'S MANUAL TREATMENT 6 p.m. same day. There bad been no diarrhoea or vomiting since my last visit. Tenderness in abdomen ahuost gone ; very little headache. Temperature 99'2°, pulse 102. Treatment as before. December 20. — Patient had slept very well, and appetite was returning. No vomiting since the previous evening ; one soft motion. Temperature and pulse normal. Patient got up and sat in a chair during the greater part of the day. Treatment once. December 21. — Beyond a general feeling of weakness, patient felt quite well. Treatment for the last time. August 2, 1902. — No return of the symptoms. Acute Intestinal Catarrh.' Mrs. S., wife of my coachman, aged 2S, came under the manual treatment on August 20, 1900. Previous liistory. — Patient had had incipient phthisis seven years previously, which was cured by the manual treatment. Since then she had been fairly strong. History of present illness. — On August 19, 1900, patient was employed during the greater part of the day in washing clothes, and getting tired she laid down in the damp grass to rest. During the evening she walked to a neighbouring town three miles off. She slept fairly well until 8.30 a.m., when she was conscious of severe headache, shivering attacks, and pain in the abdomen ; profuse and frequent diarrhoea came on, greenish in colour. I was sent for at 11 a.m. Examination. — Patient did not recognise me, and when I asked her questions, kept on saying that she had a headache. She perspired freely, and her head felt very hot. Temperature not taken as I had no thermometer with me ; pulse 140. Abdomen painful and gurgling and tender to touch. Treatment. — Vibrations over the abdomen ; head exercise, spinal nerve frictions, kidney and spleen frictions. In conse- ' See Wide, "Handbook of Medical and Orthopsedic Gymnastics," 1903, pp. 209, 210: "Intestinal catarrh, both acute and chronic is treated by Swedish gymnasts with abdominal movements. In acute intestinal catarrh this treatment should he advised against by everyone who knows that rest for the whole constitution and intestines, produced by suitable means, is effective within a few hours." Set' also " Handbok i Jledicinsk Gymnastik," 1896, p. 219; "Handbook of Medical Gymnastics," 1899, p. 204; "Handbok i Medicinsk och Ortopedisk Gymnastik," 1902, p. 20i. DISEASES OF THE DIGESTIVE ORGANS 347 quence the abdomen became less tender, and patient recognised me again. Pulse 110 after treatment. 4 p.m. Temperature 104°, pulse 108. Patient again wander- ing in her mind. Dia^rrhoea now greenish yellow, and more frequent, often five or six times per hour. After treatment, patient recognised me and said that she felt better, and then went to sleep. Pulse 100. Gentle stomach exercise added to treatment. 9 p.m. Temperature 101"3°, pulse 100. Diarrhoea not quite so frequent, three or four times an hour between 4 and 6 p.m., then only about twice an hour. Treatment ; temperature 100'8° and pulse 85 after it was over. August 21. — Patient slept badly. About six greenish-brown diarrhoeic motions during the night. 11 a.m. No headache, but patient very tired. Temperature 97-7°, pulse 74. Treatment. Evening, 8 p.m. Patient had had no diarrhoea from 9 a.m. till 12 noon ; then five or six times between 12 and 3. Then no more ; and after 3 o'clock she had been able to sit up and read the newspaper. Temperature 98'6°, pulse 65. Treatment. After it was over, patient ate some bread and butter and dranl< some milk for supper. August 22. — Patient slept well, and ate her usual breakfast during the morning. She said that she felt quite well though weak. No motion since 3 p.m. the previous day. Treatment once with a few active exercises, general nerve treatment, stomach exercise, &c. August 23. — Two normal motions during the day. Treat- ment once during the morning. Appetite normal. Patient said that she felt quite well and strong. Treatment finished. October, 1902. — Patient had been quite well ever since her illness, and went through a normal confinement (her third) in September, 1901. August, 1903. — Still keeping quite well. Chronic Appendicitis. Mr. W., aged 22, came under the manual treatment on August 27, 1900, on the advice of Dr. Engstrand (the head medical man in Joukoping). History of present illness. — Early in 1899 he had his first attack of appendicitis. His medical man prescribed morphia, rest 34S ELEMENTS OF KELLCREN'S MANUAL TREATMENT in bed and strict dietary precautions. The patient got over the attack rather quickly, remaining in bed only eight days ; but on first getting up again felt very weak. He never felt really well, and had a relapse in July of the same year, the second attack being about as bad as the first. He had another relapse in November, and a third in the middle of December. Each of these attacks lasted about eight days, the treatment adopted being invariably the same. On December 26 he tried massage and medical gymnastics (Ling's system) for a month ; but he had three further relapses during that time, and then decided to stop the gymnastic treatment, as he thought it was doing him harm. Ever since 1899 he had never been free from pain in the right iliac fossa, the pain being worse just after every meal ; and he suffered chronically from constipation. He had become markedly thinner since the first attack. He remained in much the same low condition until August 10, 1900, when he had another relapse, which, however, was not so bad as usual ; on this occasion he was only four days in bed. On August 26, Dr. Eng- strand recommended the patient to try the manual treatment. Examination.- — Patient was thin, pale and feeble looking. He complained of continual pain in the right iliac fossa, most severe just after meals. His appetite was bad, and he suffered from constipation, a motion coming on an average only every third day. There was considerable tenderness in the right iliac fossa, and pressure there caused pain. The thickened vermiform appen- dix, about an inch in diameter, could be plainly felt. Patient slept badly, and was somewhat depressed. Treatment. (1) Half lying appendix region vibration, kc, PP. (2) Side span standing drawing forwards, PP, kidney fric- tions, PP. (3) Side lying leg lifting, AE, pressing down, PE. (4) Sitting trunk extension and flexion, PA. (5) Stretch stride standing bending forwards, PA. (6) Forwards lying back exercise, PP. (7) Stretch span standing drawing forwards, PP, abdominal intercostal nerve frictions, PP. (8) Heave grasp standing chest expansion, PA. DISEASES OF THE DIGESTIVE ORGANS 349 (9) Eide sitting alternate rotation, AR, ringing, PP. (10) Half lying stomach exercise, PP. Progress. — August 30. — Less pain in the right iliac fossa. September 7. — Patient had been alternately worse and better during the last eight days ; on this day, however, he felt con- siderably better. There had been a motion every day since September 1. September 10. — Hardly any pain in the right iliac fossa. Patient said that he felt stronger. September '26. — Patient was obliged to stop the treatment to-day. His general condition was considerably improved ; he felt stronger and slept better ; also his appetite was better. A motion took place every day. There was no tenderness over the right iliac fossa, and the thickened vermiform appendix had quite disappeared ; that region of the abdomen was apparently quite normal. October 13. — In reply to a letter of mine, patient wrote, " I find myself in very good health, and the pains in my abdomen with which I was specially troubled are now quite insignificant. The last few days I have been troubled with diarrhoea from which I have quite recovered. On the whole I feel very well and strong." Constipation. The objects of the manual treatment as applied to constipa- tion are as follows : — (1) To improve the laxness of the anterior abdominal muscles ; the latter are nearl}' always found to be weak and thus easily allow dilatation of any portions of the intestine. By improving the strength of these muscles such dilated portions of the intes- tine are reduced in size, and the circulation through the abdomen is promoted. Increase of strength in the anterior abdominal muscles in all probability also acts reflexly in a stimulatory way on the abdominal contents. (■2) To improve the circulation in the abdomen and bring more arterial blood to the weakened intestine. (3) To stimulate the intestinal muscle to contraction ; this will in its turn promote the venous flow, promote absorption by the lymphatics, cause the intestinal contents to pass on more 3 so ELEMENTS OF KELLGREN'S MANUAL TREATMENT quickly, and improve the flow of intestinal juice. All this reacts in its turn in a stimulatory way on the intestine. Case 1. (From notes taken by Dr. A. Moller and myself.) Miss P., aged 35, came under the manual treatment on November 15, 1899. History of present illness. — Patient has been suffering from chronic constipation since 1881, occasionally getting better for a few months, and then becoming worse again. Patient informed me that she had been taking pills fairly constantly during the last eleven 3'ears, and had had perpetually to resort to enemas, &c. She had had no motion for several days, and of late eight days had often elapsed without one taking place. She likewise com- plained of severe headache and was nervous and depressed. The treatment was as follows : — (1) Reach grasp step standing knee flexion and extension, PA, sacral beating, PP. (2) Stretch grasp standing drawing forwards, PP, abdominal intercostal nerve frictions, PP. (3) Stretch stride standing bending forwards, PA. (4) Sitting trunk extension and flexion, PA. (5) Forwards lying back exercise, PP. (6) Sitting head exercise, PP. (7) Loin lean stride standing alternate rotation, AE, ringing, PP. (8) Stretch half lying running nerve frictions, PP, side shaking, PP. (9) Half lying leg rolling, PP, flexion, PA, extension, AR. (10) Half lying stomach exercise, including frictions on the ganglion impar, PP. Patient was ordered to stop all medicine, enemata, &c. Progress. — November 17. — Headache disappeared, and did not return during the month patient remained under treatment. November 20. — Normal motion. November 22. — Motion. After that patient had a motion almost every day until November 28. Then none until November 30, during menstruation. After that daily until December 15. Treatment then stopped, patient feeling very well. DISEASES OF THE DIGESTIVE ORGANS 351 She remained so until the middle of January 1901, when she gradually became constipated again ; her headaches returned also. She came back to me on May 14, 1900, with recurrence of the headache and constipation ; she had not had a motion for five days. The treatment was resumed, the gymnastic pre- scription being practically the same as before. After the first day of treatment, her headache disappeared and did not return ; she had a motion on the same day and also on May 16. She continued the treatment until June '20, and had a motion daily from May 16 until then with only two exceptions, on May '24 and June 5. September, 1900. — I heard that patient was keeping quite well and had a motion daily. In this case I made the observation that frictions on the ganglion impar produced at first no sensation ; as improvement took place, this sensation returned, and after about three weeks a kind of lightning feeling began to be felt throughout the abdo- men when the frictions were executed. Case 2. G. A., aged 9, had been constipated almost since birth. Temporary improvement took place when he underwent the treatment for facial paralysis two years previously, due no doubt to the exercises for improving the condition of the body in general ; but after it was over he relapsed again into his former condition. Often three days would pass without an evacuation, upon which his mother would administer an enema, which would produce the desired effect. He did not suffer from any special symptoms in consequence of this, although he was thin, small, and rather undersized for his age. The treatment was adminis- tered daily from June 23 to July 31, 1900 ; the constipation entirely disappeared, a rectal evacuation taking place daily during the last fortnight of the period specified. In September, 1902, patient's bowels were still acting regularly. The treatment was on the lines already indicated. Chronic Intestinal Catarrh. A. E., aged 4.5, male, came under the manual treatment on July 29, 1902. 352 ELEMENTS OF KELLGREN'S MANUAL TREATMENT Historji of ivesent illness. — Patient's motions had for some years ever}' now and then been loose, although he could not say that he actually suffered from diarrhoea. During the summer of 1901, however, the looseness developed into diarrhoea, and during the month of August he passed daily some two or three diarrhoeic motions. He was unable to ascribe any cause for this change. The condition got steadily worse ; and from January, 1902, on- wards he would have as many as four or five motions between 5 a.m. and 9 a.m., and as many more during the rest of the day. In January the motions were still brownish in colour, but then gradually paled to yellowish-brown, becoming also more watery. During March they became the colour of pea soup, and from June onwards were even of a lighter yellow. Patient had steadily become weaker and thinner during the last four or five months. Examination. — Patient had no pain in the abdomen, and his clothes did not irritate the skin of this region. He noticed very much gurgling in his abdomen, especially during the morning. He had had a dry cough for some years past, especially during spring and autumn, and the attack of coughing often terminated with a vomit ; he did not vomit otherwise. His appetite had remained good. The motions were now very watery indeed, and light yellow in colour, with an unpleasant odour. Patient had never noticed any blood in them. Some tenderness was manifested on administering stomach exercise, and loud gurgling sounds were heard meanwhile. The liver, however, was very insensitive to pressure below the costal margin, and to frictions on the gall- bladder ; and there was less sensation while receiving frictions on the sixth and seventh dorsal nerves on the right side posteriorly near the si^inal column than while receiving them on the rest of the spinal nerves, which on the whole were rather more than usually sensitive, especially the ninth to twelfth dorsal nerves. Patient had been steadily losing weight during the last few months, and had felt continually tired and weak. His weight was 54 kilos, at the time of examination. Treatment. (1) Stretch grasp standing drawing forwards, PP, liver and gall bladder frictions, and frictions on the right sixth and seventh dorsal nerves near the spine, PP. DISEASES OF THE DIGESTIVE ORGANS 353 (2) Half lying double arm rolling, PP, bending and stretchuig, AE. (3) Loin lean stride standing alternate rotation, AR, ringing, PP. (4) Stretch side lying running nerve frictions, PP, liver and right sixth and seventh dorsal nerve frictions, PP. (5) Lying double leg flexion and extension, PA. (6) Hip lean walk standing lateral flexion, PR, extension, AR. (7) Heave grasp standing chest clapping, PP, side shaking, PP. (8) Half lying abdomen vibration, PP. (9) Half lying stomach exercise, frictions on the abdominal sympathetic, PP. Progress. — Patient's condition steadily improved. August 13. — Only two loose motions between 5 a.m. and 9 a.m ; two more during the course of the day. They were browner in colour. August 28. — The motions had diminished to two loose ones before breakfast and none during the rest of the day ; they were of normal colour. Patient's weight -55 kilos. September 80.— The daily number of motions continued to be no more than two, which were of normal colour and consistence. Patient's weight 59y kilos. Patient felt quite well and strong. Sensation along the liver and in the corresponding spinal nerves was normal. Treatment finished. Diarrhcea. L. J. T., solicitor, aged 29, came under the manual treatment on February 6, 1903. Histonj of present illness. — On February 2 patient felt very tired all day ; during the morning he vomited his breakfast, and diarrhoea commenced, compelling him to evacuate every hour. Patient felt that the motions were watery, but did not notice their colour. He ate nothing all day, but was still able to attend to business. February 3. — Patient remained in bed all day ; he felt very weak, and had a continued feeling of diarrhcea ; light coloured watery motions occurred every hour or so during the day and every third hour during the night. There was no vomiting. Patient ate practically nothing, and took chalk mixture three times during the day. 23 354 ELEMENTS OF KELLGREN'S MANUAL TREATMENT February 4. — Patient was a little better ; he had a con- tinued feeling of diarrhoea, but managed to control it so that there were only three motions during the course of the day. His appetite was slightly better, and he ate a little boiled cod for lunch; chalk mixture t.i.d. February 5. — Condition the same; diet the same as during the previous day. Patient felt so weak that he took some brandy during the evening. Chalk mixture t.i.d. February 6. — Condition unchanged. I was called in at 6 p.m. Treatment. — Vibrations over the abdomen, gentle stomach exercise, spinal nerve frictions. Patient's appetite returned after treatment ; he ate some beef and drank a bottle of beer. Normal motion during the evening. February 7. — Patient felt quite well again, appetite normal : diet as usual. No motion at all during the day. Treatment for the last time. February 8. — Normal motion during afternoon. May 28, 1903. — I saw patient again ; he bad been quite well ever since his attack. CHAPTER VI. HEART DISEASES. Heart diseases were treated by P. H. Ling,' Branting,' Georgii,' Rothstein,* Neumann," Richter,^ Eulenburg,' Melicher,** Hj. Ling,^ Hartelius,^" and others.'^ The objects of the manual treatment as applied to heart disease are as follows : — I. — To enable the heart to act better by promoting the circula- tion and stimulating the heart directly. ' " Gymuastikens Allmanna Grunder," (1831) 1840, pp. 172, &c. See also Mass- jnann, "P. H. Liug'.s Schrifteu liber Leibesiibungen," 1847, pp. 75, 76. - " Efterleninade Skrifter," 1882, gj-muastic prescriptions for 1840, et seq. ; " Arsrapport till Kongl. Sundhets-Kollegium ar 1861," 1863, pp. 34, &c. See also Both, "Handbook of the Movement Cure," 1856, pp. 276, 367. ^ " Kinesitherapie," 1847, p. 50; "Kinetic Jottings," 1880, pp. 168-173, 197-199, &c. ' " Die Gymnastik nach dem Systeme des Schwedischen Gymnasiarcheu P. H. Ling," 1847, pp. 93, 102105 ; " Nachrichten iiber das Schwedische Centralinstitut fiir die Gymnastik," in Athencpum fiir jRationelle Gymnastik, vol. iii., 1856, pt. 2, p. 141. ^"Therapie der Chrouischen Krankheiten," 1857, pp. 314-316; " Lehrbruch der Leibesiibungen," 1856, pt. 2, pp. -302, &c. ; " Bericht iiber das erste Jahr," &c., in Athen. f. Rat. Gym., vol. i., 1854, pt. 1, p. 263; "Die Einftihruugder Heilgymnastik iin Lazareth uud Klinik," ibid., vol. ii., pt. 1, p. 1 ; " Bericht iiber das zweite Jahr," &c., ibid., vol. ii., 1855, pt. 2, p. 256. See also Roth, " Handbook of the Movement Cure," 1856, p. 277. ' " Die Neuere Heilgymnastik " in Schmidt's Jahrbiicher, vol. Ixxxii., 1854, p. 248. ' " Die Lingsche oder Schwedische Heilgymnastik " in Goschen's Deutsche Klinik, 1852, p. 350. ' " Erster Bericht." 1853 ; " Jahresbericht fiir 1853 " ; " Jahresbericht fiir 1854 " ; " Jahresbericht fiir 1855" ; "Jahresbericht fiir 1856 und 1857." ■'Preface to Branting's " Eftsrlemnade Skrifter," 1882, p. xxxix. '" " Om Sjuligymnastiken vid Gymnastiska Central Institutet under ar 1863,' 1864, pp. 32-42, 78; "Gymnastiska lakttagelser," 1865, pp. 69-73,91; "Arsberiit- telse i Sjukgymnastik " &c., in Svenska Gymnastik-Fureninrjens Tidskrift, 1866, p. 49 ; *' Kort PramstiiUning om Sveuska Gymnastiken .... under aret 1870," 1871, p. 22 ; "Larobok i Sjukgymnastik," 1870, pp. 193-211; 1883, pp. 197-225; 1892, pp. 194- 221; " Gymnastiska Notiser," 1872, p. 20; in Hf/jjea, 1877, pp. 145-154 ; "Ofversigt af patienter behaudlade . . . . ar 1884,'' in Tidskrift i Gyimuistik, 1885, pt. 5, p. 293 ; " Den Mekaniska Agentens Porhallande till Hjertsjukdomar," ibid., 1886, pp. 408, &c., 469, &c. " See for example Miinchenberg, " Zweiter Bericht," &c., in .ithen. f. Bat. Gym., vol. ii. , 1885, pt. 4, pp. 319, &c. 356 ELEMENTS OF KELLGREN'S MANUAL TREATMENT II. — To improve the constitution as a whole. Detailed practical consideration of the above • — I. — Under this heading it is necessary to refer briefly to the effects of : — (1) Respiratory movements. (2) Passive movements at joints. (3) Active movements. (4) Stomach exercise, PP. (5) Manipulations over the heart itself or on its nerves. (1) Bespiratory movements. — In the case of most cardiac lesions respiration is rapid and shallow, and frequently it can be seen that during inspiration the abdomen is drawn in. This means that there is a further increase in the already existing impedi- ments to the venous and lymph return in consequence of the cardiac lesion (see p. 126). It is of vital importance that such patients should learn to breathe correctly as soon as possible, and such passive respiratory movements as chest lifting, PP, &c., should be prescribed at once, and their beneficial effect will not fail to be noticed. Chronic diaphragmatic spasm can also be relieved by means of subcostal shaking, shaking over the bladder and subdiaphragmatic suction. (2) Passive movements at joints. — These, as already stated on pp. 38 to 40, promote the venous and lymphatic flow, and in proportion to the rate and radius through which they are executed, bring about varying degrees of vaso-dilatation of the arteries. Thus the circulation of the blood will be promoted, and the peripheral resistance lowered. Passive flexions and extensions do not produce such a wide- spread effect as rollings, because the former chiefly affect the flexor and extensor surfaces, whereas the latter affect also the lateral aspects of the parts exercised. The effect of ringing, PP, on the abdominal circulation has been referred to on p. 88. (3) Active movements. — Duplicate movements are generally administered instead of purely active ones, because their effect and the amount of muscular energy expended is better graduated. It has already been stated that duplicate movements, proj^erly executed, can be given to cause no extra strain on the heart, because by their means, although the muscles actually involved HEART DISEASES 357 contract more powerfully, the co-action of fixators of the neighbouring joints is elimiziated, and the patient is never allowed to forcibly hold his breath (see pp. 33, 34). Hasebroek ^ has given some details concerning the effects of duplicate movements on the blood-vessels. His observations were made with the sphygmograph and sphygmometer. He found that a correctly executed duplicate movement brought about a relaxa- tion (most probably also a vaso-dilatatiou) in the peripheral arteries. This, in the majority of cases, was followed by an increase in the pressure until the maximum was reached, after which the pressure sank to a point below what it was before tl^e movement commenced ; it then slowly returned to what it was originally. The initial rise in pressure was not due to vaso- constriction, but to increased cardiac action, brought about reflexly by impulses from the active muscles. Thereupon the vaso-dilatation that ensued gave the heart rest. In consequence of the vaso-dilatation in the peripheral parts, there will be a tendency for the quantity of blood in the heart, if excessive in amount, to be diminished, and thus dilatation of the heart, if it exists, will be lessened. Thus duplicate movements, if carefully executed, result in a strengthening of the cardiac action, and a lengthening of the diastolic period ; a beneficial circle is set up. In consequence of the improvement in the cardiac action the blood is pumped more vigorously through the lungs, and the circulation in the coronary arteries (which takes place during diastole of the ventricle) has more time for its adequate performance. Diminution in the diastolic distension of the left heart also favours the flow in the coronary arteries. All this reacts beneficially on the heart. In short, carefully executed duplicate movements quiet the heart's action. Patients who are not strong enough to execute duplicate con- centric movements can often quite well execute duplicate excentric movements, which almost entirely eliminate any tendency to temporary extra strain on the heart. In the case of very serious lesions passive movements only remain possible. (4) Stomach exercise. — The effects of this have been already ' " Uber die Gymuastisohe Widerstandsbewegungen in der Therapie der Herz- kraakheiten," 1895. 358 ELEMENTS OF KELLGREN'S MANUAL TREATMENT described at full length : I will therefore only suinniarise. They are as follows : — (a) Promotion of the arterial and venous flow in the abdomen. (b) Vaso-dilatation in the arteries. The further efifect of the above will be promotion of the abdominal circulation and diminution in the peripheral resistance. (c) Eeflex quietinf^ of the cardiac action. (fZ) Diminution of reflex contraction of the abdominal muscles if such exists, thus improving the muscular respiratory mechanism. (.5) Manipulations over the heart itself or on its nerres. These are as follows: — Shaking and vibration, clapping and hack- ing over the heart ; frictions on the left fourth and fifth dorsal nerves near the spinal column, and hacking on the shoulders. The effects of these have already been considered in detail. II. — Under this heading falls the consideration of the effects of some of the movements already discussed, i.e., respiratory exercises, passive flexions and rollings, purely active and duplicate movements, stomach exercise ; also of manipulations that stimu- late the cerebro-spinal system as a whole, and those that stimulate the kidneys, spleen, &c. It should here be mentioned that the spleen in some cases of heart disease is tender, even when no signs exist of back pressure in the caval or portal system. Executing spleen frictions or vibrations and frictions on the left ninth and tenth dorsal nerve near the spine will often relieve the patient, and in one case I noticed that the pulse rate sank from five to six beats per minute more at the conclusion of the daily gymnastic treat- ment if this si^leeu treatment was included than if it was omitted. Ling's system is hardly ever found mentioned in connection with gymnastic treatment for heart disease, although frequent references occur to two others, viz., Oertel and Schott. It is necessary to consider briefly the methods of these two latter. Oertel's ' treatment consists in reducing the amount of liquid food taken, in dietary precautions, in graduated uphill exercise and a kind of respiratory exercise executed with lateral com- ' See Oertel's " Aligemeine Tlierapie der KreislaufsstoriingeD," 1885 (vol. iv. of V. Ziemssen'.s " Handbuch der AUgemeinen Therapie ") and " Massage des Herzens," 1889, &o. HEART DISEASES 359 pressioii of the thorax during expiration. His method is, how- ever, obviously inapphcable to serious cases, such as involve the patient keeping in bed. Schott's treatment is one which has received a good deal of attention of late. The method, however, is not the invention of Schott,^ in spite of his asssertions that it is. The movements specified by Schott are a few of the most elementary ones of Ling's system executed without due regard either to the initial position or to respiration ; and Schott prescribes no passive move- ments of joints, no chest expanding ones, no local heart treatment and no passive circulatory furthering movements for the abdomen. These defects in the gymnastic methods are to some extent remedied by the use of carbonic acid baths. Why these two methods should have become so popular and widely known at the expense of other and better ones is not intelligible. Case 1. Mitral Incompetence. J. H., aged 18, came under the manual treatment on July 20, 1900. History of prese)it illness. — Four years previously he had suffered rather severely from rheumatic fever, his heart being affected in consequence. The cardiac condition was how- ever not very bad, and four months after the beginning of his illness he was able to resume his lathe work in Huskvarna factory. He consulted many medical men about his heart, and from time to time took various medicines, which, how- ever, did him no good. His condition remained the same until about November, 1899, when he began to feel worse, and suffered from dyspnoea, which was greatly increased on exer- tion ; some cough set in. At Easter, 1900, he was compelled to stop work at the factory. Examination. — Patient looked weak and thin ; his lips were somewhat cyanosed. He complained of a sense of oppression and continual uneasiness in the cardiac region, and sometimes of attacks of palpitation ; also of coughing a good deal, bringing up -Sec Th. Schott, " Zur Behandlung der Fettherzens," a paper read at the Eleventh Interaat. Med. Congr. at Rome, 1894 ; " tjber Behandlung Chronischer Herzkrankheiten im Jugendlichen Alter," 1899 ; see the references on p. 355. 36o ELEMENTS OF KELLGREN'S MANUAL TREATMENT frothy matter. His sleep remained fairly good. He suffered from breathlessness, which on slight exertion became much worse ; even walking at a moderate pace had this effect. The fourth, fifth, and sixth ribs on the left side in the cardiac region were prominent, and hypertrophied for about 2 inches in their course ; over this area cardiac pulsation could be both seen and felt. There was a heaving impulse in the fourth, fifth and sixth interspaces, and the apex beat was most prominent in the fifth space, 1 inch external to the nipple line. A thrill was felt over this area, coincident with the apex beat. Percussion showed enlargement of the heart on the right side. A loud blow- ing murmur, replacing the first sound, and propagated into the axila, was audible in the mitral area ; the second sound was clear in this area. There was marked accentuation of the second sound in the pulmonary area. The aortic and tricuspid sounds were clear. Pulse 120 per minute, fairly regular ; sphygmographic tracing, taken before treatment, is shown in fig. 110. The respiration was shallow. The lower ribs, as tested by means of side shaking, were hard, resistent and inelastic. The abdominal muscles were contracted, and did not move with respi- ration ; on asking the patient to make a deep inspiration, the upper part of the thorax moved most, the abdominal muscles being drawn in. Appetite not good. Motion daily. Urine normal. While this case was under my charge I ascertained the pulse rate both before and after treatment, as follows : — I requested the patient to come a little earlier than the time originally appointed, and to sit down and keep quiet until I was ready. I then placed him in half lying position, waited two minutes for the pulse to become regular and quiet again, and then counted it. The gymnastic treatment was then administered, and after it the HEART DISEASES 361 pulse was counted again, the patient being in half lying position as before. Treatment as follows : — (1) Plalf lying double arm rolling, PP, bending and stretching, AK (2) Forwards lying back exercise, PP. (8) Half lying double foot rolling, PP, flexion and extension, AK. (4) Heave grasp standing chest clapping, side shaking, PP. (-5) Sit lying knee flexion and extension, PP, extension, AR, flexion, PR. (6) Loin lean stride standing alternate rotation, AR, ringing, PP. (7) Half lying double leg rolling, PP, flexion, PA, extension, AR. (8) Half lying heart shaking, PP. (9) Walk standing double arm circling, breathing, PA. (This was administered at intervals several times during the daily course of treatment.) (10) Half lying stomach exercise, PP. Progress. — The pulse rate was as follows : — Date. Before tre.itnieiit. After treatment July 21 120 102 ,, 23 120 100 „ U 125 97 „ 25 120 90 „ 26 110 90 „ 27 102 86 „ 28 100 85 ,, 30 95 85 August 1 •2 102 88 84 84 3 90 88 i 100 90 5 100 90 6 100 90 „ 8 98 84 „ 9 98 88 „ 11 87 81 ,, 14 81 76 „ 20 82 78 „ 24 80 76 „ 30 80 74 September 4 8 81 80 76 72 10 80 72 „ 14 80 72 362 ELEMENTS OF KELLGREN'S MANUAL TREATMENT See figs. Ill to 117 for various spbygiuographic tracings taken after treatment. September 14. — Treatment finished to-day. Patient said he felt stronger ; the lips were no longer cyanosed. He could walk quicker without any breathlessness ensuing, and moderate exertion caused none. He said that he slept better and ate HEART DISEASES 363 better. The cough had ahuost disappeared. There was no sensation of oppression or uneasiness in the cardiac region. The abdominal muscles moved with respiration, and were much less hard and tense. The lower ribs moved to a greater extent with respiration, and were more elastic. The apex beat was about half an inch internal to the nipple, and was limited to the fifth interspace. Percussion showed a very slight enlargement to the right of the sternum. The murmur was as before, but less loud. Fig. 117 There was still accentuation of the second sound in the pul- monary area. Patient resumed work (lathe work) on October 1. 1 saw him again on November 12. He had been working steadily ever since October 1. He was feeling very well ; no unpleasant symptoms had arisen. The heart dulness and sounds were as before ; the 364 ELEi\JENTS OF KELLGREN'S MANUAL TREATMENT pulse, when sitting down, was 82. Spliygmographic tracing is shown in fig. IIH. I saw patient again on March 1, 1901. Patient had been working steadily since October 1, 1900, and said that he felt even better than when I last saw him ; he was stronger, and could work better. No unpleasant symptoms had arisen. The size of the heart was about the same as before, the apex beat being about half an inch internal to the nipple line. The mur- mur in the mitral area was less loud, and there was hardly any accentuation of the second sound in the pulmonary area. Pulse, when sitting down, 7'2 per minute. Sphygmographic tracmg is shown in fig. 119. Case 2. Mitral Stenosis and Incompetence. H. T., aged 13, came under the manual treatment on October 1, 1900. Historij of present illness. — He was attacked with rheumatic fever during November, 1899, and was in bed one month. In May, 1900, he had another attack, and was treated at the hospital, where the diagnosis of acute articular rheumatism and mitral incompetence was made. He remained at the hospital until the HEART DISEASES 365 middle of June, and then went to a summer health resort ; he did not, however, get rid of his rheumatic pains. In August he went through an attack of pleurisy with effusion, which was not so bad as to necessitate thoracocentesis ; after it had passed there remained continual rheumatic pains, a tendency to fever,' and general weakness. Examination. — The patient looked weak ; his lips were some- what cyanosed. He complained of continual pains in his wrist, finger and ankle-joints, sometimes also in the knee-joints. All these joints were visibly swollen, and were very tender. There was breathlessness on exertion, and difficulty in walking, the latter, however, due partly to the pain in the ankles and knees. Patient had no subjective cardiac symptoms. The apex beat could be seen in the fourth interspace, three- quarters of an inch external to the nipple line. Percussion of the right border shows enlargement to the right of the sternum. In the mitral area there was a presystolic murmm', and the first sound was replaced by a blowing murmur, which was propagated into the axilla. There was accentuation of the second sound in the pulmonary area. The aortic and tricuspid sounds were clear. The pulse was rapid, about 120 per minute, intermittent. The greatest number of intermittencies I ever counted was fifteen in one minute, but as a rule they averaged from five to ten. Sphyg- mographic tracing is shown in fig. 120. Great tenderness existed over the fourth and fifth left dorsal nerves near the spine. No signs of the pleurisy remained. Temperature, 99°. Treatment. (1) Heave grasp standing chest expansion, PA, followed by heart shaking, given together with frictions on the left fourth and fifth dorsal nerves near the spine, PP. 366 ELEMENTS OF KELLGREN'S MANUAL TREATMENT (2) Heave sitting double forearm extension and Hexion, AR. (3) Forwards lying back exercise, PP. (4) Side lying running nerve frictions, kidney frictions, PP. (5) Lying double leg flexion, PA, abduction, AR, adduction, PR. (0) Ride sitting alternate rotation, AR, ringing, PP. (7) Stretch stride standing bending forwards, PA. (8) Sitting hand and finger rolling, PP, flexion and extension, AR, joint kneading, PP, &c. (9) Half lying stomach exercise, PP. Progress. — The fever ranged from 99° to 101° for a few days; then the temperature became normal and did not rise again. After October 15 it never went above 99"5° in the evening. October 3. — Fifteen intermissions in the pulse in five minutes. October G. — Hand and finger-ioints less swollen. Three inter- missions in the pulse in ten seconds, then none for one minute and forty seconds. October 10. — No intermission in one and a half minutes. October 12. — No intermission in two minutes. October 1(5. — Pulse commencing to be slower. No rheumatic pains in fingers, wrists or ankles. October 19. — Pulse rate again somewhat increased. October 28. — Patient took a walk of three hours. Fingers, wrists and ankles had not swollen since October 16, and did not again become so. November 1. — Sphygmographic tracing taken ; depicted in fig. 121. November 3. — Pulse below 100 per luinute for the first time since October 1. November 7. — Patient visited Huskvarna factory and was on his feet three hours. November 9 to 13. — No intermission in five minutes. HEART DISEASES 367 November 14. — One intermission in five minutes. November 14 to 17. — No intermission in five minutes. November 18. — Treatment finished. Pulse rate. — Taken after treatment. 120 October 25 115 27 118 29 114 31 115 November 1 118 2 115 3 110 5 102 6 102 .■ 7 103 8 110 12 111 14 104 16 110 18 110 no 108 110 101 102 98 102 98 9G 92 92 94 96 The pulse as taken in the evening from November 12 to 18, averaged from 95 to 90. Examination. — November 18. Patient felt ver}- well and strong ; could walk quickly, and even run about a little without unpleasant symptoms arising; had been bicycling in modera- tion. Appetite, sleep and general appearance better. Lips not cyanotic at all. No subjective cardiac symptoms. No joint symptoms. The apex beat could be seen in the fourth interspace in the nipple line. Percussion of the right border showed hardly any enlargement to the right of the sternum. The mitral murmurs could still be heard and there was accentuation of the second sound in the pulmonary area. Sphygmographic curve taken November 17, see fig. 122. The tenderness over the left fourth and fifth dorsal nerves was very slight. 368 ELEMENTS OF KELLGREN'S MANUAL TREATMENT Subsequent jn-ogrcss. — On March '24, 1901, patient's father wrote as follows: — His son's condition was very good. There had been no return whatever of the rheumatic pains. The boy was out during most of the day and played with other boys. He had not complained of any feeling of fatigue to his father after so doing. His pulse was usually 7-5 during the morning and 90 to 95 during the evening. Case 3. Mitral Stenosis and Incompetence. A. L., aged 16, female, came under the manual treatment on August 21, 1902. History of present illness. — -When a young child she had had chorea three times, the last time being at 8 years of age, and after the last attack her medical man said that she had heart disease, but not to a serious degree. No cardiac symptoms troubled her until January, 1902, when she had influenza, and remained in bed for a month. After the influenza had passed off she was troubled with shortness of breath, especially on exertion; with a feeling of oppression in the cardiac region ; and also with a swelling of her feet and hands, which came on during the after- noon and got worse during the evening. Her condition had been getting slightly worse during the past two months. Examination. — Patient exhibited the typical flushed cheek and look of mitral disease. There was a slight bulging of the precordia. The apex beat was diffuse and heaving, and could be seen in the fifth and sixth, and also, though very slightly, in the seventh interspace, extending two inches below and one inch external to the nipple. Percussion showed the heart to be en- larged to its left side and also to the right of the sternum. On palpation in the mitral area a presystolic thrill was felt. On auscultation in the mitral area the ordinary first sound was re- placed by presystolic and systolic murmurs, the latter propagated into the axilla ; the second sound was closed. Auscultation in the pulmonary area revealed a reduplicated first, and a loud slapping second sound. The aortic and tricuspid sounds were clear. Patient was free from cough. Some cedema of the feet and ankles came on every afternoon, as already mentioned. HEART DISEASES 369 After patient had lain down for ten minutes, the pulse was 102 and the respiration '20 Sphygmographic tracing taken before treatment ; see fig. 123. 7^_A_J^v Aug. ^1- Before treatment Treatment. (V) Half Ij'ing double arm rolling, PP, bending and stretch- ing, AE. (2) Half lying side shaking, PP. heart shaking, PP, with frictions on the left fourth and fifth dorsal nerves near the spine, PP. (3) Forwards lying back exercise, PP. (4) Stretch stride standing bending forwards, PA. (5) Half lying double foot rolling, PP, flexion and extension, AE. (6) Heave lean standing chest expansion, PA. (7) Heave grasp standing chest clapping, PP, side shaking, PP. (8) Sit lying knee extension and flexion, PP, extension, AE, flexion, PE. (9) Half lying leg rolling, PP, flexion, PA, extension, AE. (10) Half lying stomach exercise, heart shaking, PP. The treatment was given dail}' until September 20. Examination. — Patient no longer exhibited the typical look of mitral disease, and her general condition was greatly improved. She suffered very little from shortness of breath, and could walk as fast as any of her girl school-friends without getting out of breath. There was no feeling of oppression in the cardiac region and no swelling of the hands or feet. Heart. — The apex beat, rather heaving in character, was limited to the fifth interspace in the nipple line. There was no enlargement to right of sternum. A presystolic thrill could be felt. Auscultation in the mitral area revealed a presystolic 21 370 ELEMENTS OF KELLGREN'S MANUAL TREATMENT murmur, but the systolic murmur had disappeared. Auscultation in the pulmonary area revealed no reduplicated first sound ; the second sound was slightly accentuated. After patient had lain down for ten minutes the pulse was 78 and the respiration IS. Sphygmographic tracing taken September 18 ; see fig. 124. Case 4. Rheumatic (?) Pericarditis, Cardiac Dilatation, and Mitral Disease. E. B., female, aged 14, came under the manual treatment on August 1.5, 1902. Previous history. — Patient had never been very strong ; she was small and undeveloped, had always had a rather yellowish complexion and somewhat purple lips, and had always suffered from breathlessness on exertion. Her heart had never been examined. History of present illness. — On August 13 patient was attacked rather suddenly by shooting pains in the arms and legs, and sharp stabbing pains in the region of the heart ; the latter pains disappeared every now and then, and when present were intensified by deep respiration. There was also fever. The following day patient's condition was worse, and as on August 15 it was still worse, I was called in the same morning. Examination. — Patient was in bed, lying on her back ; she said that she was unable to lie on her side. She com- plained of the pains already specified. Cyanosis was present ; the parents said it was more apparent than before her present illness. There was a certain amount of bulging of the precordia. The heart itself was dilated. The cardiac impulse was visible and palpable from sternum to nipple and from the left third rib do%Mi HEART DISEASES 371 to the left sixth rib ; percussion revealed an increase in the dulness to the right. Presystolic and systolic mitral murmur audible, the latter propagated into the axilla ; the second mitral sound closed and slapping ; the second sound in the pulmonary area accentuated. Aortic and tricuspid sounds clear. No cough or oedema. Temperature 108°, pulse 141, respiration 46. Great tenderness along the spinal nerves and over the kidneys. Evening. Patient had eaten nothing all day, and was some- what weaker. Heart about the same as during the morning. Temperature 103'5°, pulse 150, respiration 51. (For temperature, pulse and respiration, see separate chart, fig. 125.) *UG. SEPT DATE 15 j 16 1 17 IR IS ?n PI 2ZIZ3IE4 25|26'2r 28129130131 1 2 3 4iSI6|7l8l9llOI TIME M EM e!m E fi E 1 E « E \ E rr < E » E rt 4 E'M E < Erl E < EM E i l\* E < E i E \ E t E 4 EM E ) EM El F" Rectum /■ ^ h \ J ^, h A / > A J / / r A / / / A / k, / V / / t ^^ A y \ / \ / ^ ^ U^ PULSE IM 146 'EB '144 m- «a 153 m 36 n? 32 134 136 132 32 128 136' IZ8 36 135 128' 136 36 138 26 141 36 132 129 1Z8 40 124 120 IZ2 20 124 128 I2S 126 126 120 "I16 IZO 20 12U RE5P 28 ?.?, .1,5 XI ■M sr 4B 60 bi 58 51 t>tj 4U 54 44 44 52 4b 66 bS 52 54 42 4B 4-2 ^ _ Treatment morning and evening. August 16. Morning. Patient had hardly slept at all, and had been sitting up all night in consequence of great cardiac distress ensuing immediately on trying to lie down. Pain in precordia much worse, often causing patient to cry out. More pains in the arms and legs ; considerable dyspnoea, the larynx and alse nasi working with respiration, which was rapid and shallow. Cyanosis more marked. Heart's action somewhat irregular ; dilatation greater, the area of the impulse being more diffuse and extending beyond the nipple ; mitral murmurs as before ; re- duplicated first sound in pulmonary area ; aortic and tricuspid sounds clear. Between the nipple and the sternum was audible pericardial friction, which was intensified by pressure with the stethoscope, the latter procedure causing some pain. Treatment. 372 ELEMENTS OF KELLGREN'S MANUAL TREATMENT 11 a.m. " Canter rhythm " audible between the nipple and the sternum. Pulse 146. No treatment. 3 p.m. Patient about the same. Pulse 144, respiration 55. Treatment. 7 p.m. Patient worse. Marked orthopnoea, more cyanosis. Distension of abdomen, and great tenderness over the liver. There had been no motion since the 14th. Pulse 150, respira- tion 60. Treatment. 9 p.m. Patient somewhat better. Abdomen less distended ; pain less and pericardial friction less. Pulse 144, quite regular. Patient had been able to sleep for an hour during the day, but had eaten nothing beyond a piece of bread. No motion yet. August 17. — Morning. Patient had been able to sleep a little during the night, but had no appetite. Heart better ; friction less. Mitral murmurs and sounds in pulmonary area as before. Dilatation about the same. Afternoon. Patient somewhat worse. Pulse 144, not quite regular ; respiration 66. Some biscuits eaten at 6 p.m. Evening. Patient about the same. Pulse irregular. No motion during the day; abdomen, however, no longer distended. Treatment to-day three times. August 18. — I was sent for at 4 a.m. as patient had become rapidly worse since about midnight. Patient was in bed, half sitting up, semi-conscious, not answering unless spoken to several times in succession ; when she did speak it was only in a whisper, and after great effort. The complexion was bluish-grey, the lips very dark purple ; the respiration was laboured and irregular, 72 per minute. The pulse was hardly perceptible ; its rate was about 160 per minute. Heart's action very irregular and inter- mittent, every fourth or fifth pulse beat being lost. Heart very much dilated ; diffuse impulse visible from second to sixth interspaces from sternum to one inch outside nipple line, and pulsation palpable to the right of the sternum in the fourth and fifth interspaces, and in the left side up to just below the clavicle. Presystolic, systolic, and diastolic mitral murmurs ; reduplicated first and accentuated second sounds in the pulmonary area ; these could be quite easily felt through the chest wall with the finger. Aortic and tricuspid sounds muffled, though closed. Pericardial friction the same as during the previous day. No oedema anywhere. HEART DISEASES 373 I treated patient for one and a half hours, chiefly with heart vibration, side shaking, and stomach exercise ; at the close of this period she was better, and became quite conscious ; the pulse also was stronger, more regular, and markedly dicrotic ; rate about 150 per minute. 9 a.m. Patient somewhat better ; she had been to sleep for an hour. Treatment. II a.m. Patient still better, although unable to speak above a whisper ; she ate some biscuits. Heart's action stronger. Pulse 142, respiration 60. Treatment. 4 p.m. Pericardial friction ceasing; less cyanosis. Pulse 138, respiration 58. Treatment. 9 p.m. Patient had drunk some milk at 8 p.m., and was better. Apex beat only extended just beyond nipple. Pulse still markedly dicrotic ; very few beats missed. Treatment. Patient had lain absolutely still during the whole day, except- ing while eating and drinking, and even the latter actions entailed great exertion. No motion. August 19. — 5 a.m. Patient had been sleeping at intervals until about 3 a.m , when a change for the worse took place. The heart was again irregular, with frequent missed beats, and the pulse very dicrotic, about 135 per minute ; the respiration was 44. Treatment for an hour of same kind as early during the previous day. 11 a.m. Patient better. No more pain in the arms and legs, although still a good deal in the cardiac region. Pericardial friction no longer audible. Treatment. 4 p.m. Patient still better ; she ate some pudding at '2 p.m. No more dicrotism ; pulse quite regular. Dilatation and murmurs as before. Aortic and tricuspid sounds no longer muffled. Pulse 144, respiration 68. A good deal of perspiration during the day. Treatment. Patient drank some soup at 8 p.m. 9 p.m. Patient was still better, and her expression more lively. She was able to move about, and to move her arms and head without distress ; she was, however, as yet unable to lie down, and had to keep half sitting up. The apex beat could not be felt or seen outside the nipple. Treatment. No motion during the day. August 20. — -5 a.m. Another change for the worse, although not so marked as during the two previous days. Pulse irregular and somewhat dicrotic, 136 ; respiration 56. Treatment. 374 ELEMENTS OF KELLGREN'S MANUAL TREATMENT 11 a.m. Patient had drunk some milk and eaten some biscuits at 9 a.m. She was a good deal better, and wished to get up and walk about ; but on attempting to do so found that she was too weak. After treatment she was carried out of doors, and sat in an armchair for one and a half hours. She still complained of pain in the cardiac region, otherwise was fairly cheerful. 8 p.m. Patient could move her head and arms quite easily. There was less cyanosis and dyspncea. Pulse 140, quite regular, not dicrotic ; respiration 48. Treatment. Patient con- sumed an egg, some milk and biscuits at 8 p.m. 9 p.m. The parents stated that patient's face, except for some emaciation, looked the same as before her illness. The complexion was yellowish, and the lips somewhat purple. The heart was as dilated as during the previous day ; the sounds and murmurs were also the same. There had been some dry cough since the early morning ; pulse 132, fairly regular. I took a sphygmographic tracing (for the first time) before treatment (see fig. 1'26). Aug 20^-2 Before treatment No motion during the day ; no distension of abdomen. August 21. — 11 a.m. Patient had slept a little; she was able to talk again above a whisper without distress. 4 p.m. Patient had sat out of doors from 12 to 3, and eaten some biscuits and drunk some milk at 2 p.m. Pulse 138, respi- ration 60. Motion at 6 p.m. (first since August 14). Pain in cardiac region less during the whole day. 9 p.m. Heart not quite so dilated ; the apex beat could not be felt further out than half an inch internal to nipple line. Murmurs and sounds as before. Treatment three times a day henceforth. August 22. — 10 a.m. Patient's appetite returning ; she had HEART DISEASES 375 drunk milk and eaten biscuits for breakfast. Improvement in all subjective symptoms ; patient able to move easily ; she had even been walking about for a few minutes. Less pain in the cardiac reo;ion ; very little dyspnoea. After treatment patient sat out of doors for three hours. 3 p.m. No dyspnoea. Cardiac impulse not so diffuse. Patient had consumed some fruit soup for dinner. No motion during the day. August 23. — Morning. Sleep still poor. Patient stronger; had eaten veal and bread and drunk some milk for breakfast. She was coughing up a good deal of frothy mucus. No cardiac pulsa- tion in the first interspace, otherwise the condition of the heart was the same as before. Pulse 132, quite regular. Patient was up and walked about for half an hour during the morning. Dinner at 2 p.m., bread and milk. 4 p.m. Pulse 13.5, respiration .57. Supper at 8 p.m., bread and milk. 9 p.m. Patient could now He on her side without distress. No pulsation to right of sternum. No motion during the day. Treatment twice a day henceforth. August 24.— Morning. Patient sat up during most of the day, and walked about a good deal. Food : milk, bread and porridge. Motion during the day. Sphygmographic tracing taken before evening treatment (see fig. 127). During the ensuing four days, the heart remained about the same in size, although its action gradually became stronger. Motion henceforth usually daily, although sometimes every other day. August 25. — Evening. Pulse 128. Patient up and about the whole day. August 28. — Evening. Patient somewhat worse ; severe pain 376 ELEMENTS OF KELLGREN'S MANUAL TREATMENT in the cardiac region and some dyspnoea. Pulse irregular ; occasionally a few missed beats. Heart the same size as before. Sphygmographic tracing taken after treatment (see fig. 128). August 29. — Patient better. August 30. — Patient about the same. August 31. — Patient about the same; was up all day. Both sounds reduplicated in the pulmonary area. Aug. 28'- After treatmeni: September 1. — Patient better; very Httle pain in cardiac region. Sphygmographic tracing taken before the evening treatment showed a decided improvement (see fig. 129). September 2. — Evening. No more cardiac pain. Heart still the same size ; mitral murmurs as before. Both sounds in the pulmonary area reduplicated. Sept. I- Before treatment September 3. — Patient rather worse again ; weaker, and in consequence lay down during most of the day. September 4. — Patient had slept well for the first time since the beginning of her illness, and was a good deal stronger. Owing to unavoidable circumstances, the treatment could only be administered once a day henceforth. September 5. — Afternoon. Sounds in the pulmonary area no longer reduplicated ; mitral murmurs as before. HEART DISEASES 177 September 6. — Patient much stronger ; she walked about her room during most of the day. Appetite nearly normal. Sphygmographic tracing taken before treatment (see fig. 130). Sept. 6- Before treatment September 7. — Patient's sleep steadily normal. Cardiac dul- ness less, extending only slightly to right of sternum, to second rib above and to half an inch within nipple. During the after- noon patient walked to an open-air party held about 250 yards from home : she sat down and watched the proceedings from 4 to 8 p.m., and enjoyed herself very much. She was wheeled home in a chair. I visited her at 9 p.m. and found her very well. September 8. — Patient up and about all day ; she went for a slow walk of half an hour. September 10. — Getting stronger every day. September 11. — Morning. Pulse 114. September 12. — Patient was able to come to my villa for treatment (distance about 200 yards), and underwent the move- ments mentioned on p. 379. Pulse before treatment, after patient had lain down quietly for five minutes, 114. Sept. 15'-*! Before treatment September 13. — Pulse before treatment 112. September 14. — No treatment. September 1-5. — Pulse before treatment 108. Sphygmo- graphic tracing taken before treatment (see fig. 131). The area 3/8 ELEMENTS OF KELLGREN'S MANUAL TREATMENT in which the cardiac impulse could be seen and felt only about two inches in diameter. Triple mitral murmur and accentuated second sound in the pulmonary area. Patient's weight in ordinary clothes, 28 kilos. Pulse rate was as follows : — Before treatment. After treatiiisnt September 22 ... 100 96 „ 23 ... 100 96 24 ... 100 92 25 ... 96 96 26 100 100 27 ... 100 94 28 96 92 29 ... 98 92 30 ... 96 92 September 30. — Treatment finished. October 6. — I saw patient again. She said that she felt fairly strong, and was able to walk about without any inconvenience. She had tried to run, but became breathless. Cardiac impulse in fourth and fifth spaces internal to nipple ; no enlargement to right of sternum. Presystolic and systolic murmur in mitral area, closed second sound. Accentuated second sound in the pulmonary area. Pulse when lying down 94 ; sphygmographic tracing as in fig. 132. Motion daily. Oct. 6t-h -./-J Dr. Harry Kellgren sends me the following report on June 17, 1903 : — Patient remained in same condition until February, 1908, when, according to the parents, she had a similar attack to the one just described. She got over it quite well. Present con- dition : — Patient can run about a fair amount without getting breathless. The cardiac impulse can be seen in the second to fifth interspaces, and the apex beat is most prominent in the fifth interspace slightly external to the nipple line. A thrill can be felt in the pulmonary area. On auscultation in the mitral area a HEART DISEASES 379 harsh systohc murmur is heard, propagated into the axilla, followed by a diastohc rumbling sound. Both sounds in the pulmonary area clear, but there is a thrill between the two ; marked accentuation of the second sound. Aortic and tricuspid sounds clear. Pulse when sitting down 84 per minute, strong and regular. Sphygmographic tracing, taken before treatment had been recom- menced, is shown in fig. 133. June 17- Before treatment In this patient I observed on several occasions that dicrotism of the pulse, if present, could be removed by cervical nerve fric- tions, which also had the effect of reducing the pulse rate (on one occasion from 150 to 130 per minute) and rendering the cardiac action stronger. (This has been mentioned on p. IG'2.) Treatmi-uf. DuyiiKj the acute stage. — Heart vibration and shaking, gentle frictions over the left fourth and fifth dorsal nerves near the spine, chest vibration, side shaking, making patient take several deep respirations ; stomach exercise, kidney and spleen frictions ; head exercise, cervical nerve frictions. From August 22 onwards icere added : Hand rolling, arm muscle kneading, PP; foot rolling, leg muscle kneading, PP. From August 2.5 omoards were added : Hand flexion and extension, AH, foot flexion and extension, AR. From August 28 onwards were added : Half lying leg rolling, PP, leg flexion, PP, extension, AR ; double arm rolling, PP, bending and stretching, AR. From September 12 omoards were added : Forwards lying back exercise, PP ; loin lean stride standing alternate rotation, AR, ringing, PP ; walk standing double arm circling, breathing, PA. CHAPTER Yir. DISEASES OF THE BLOOD, LYMPHATICS, AND DUCTLESS GLANDS. Chlorosis. The objects of the manual treatment as applied to chlorosis are as follows : — (1) To aid the digestion, which is usually impaired, and to relieve the constipation so often present. (2) To further the circulation of blood and lymph by means of movements at joints, and thus to bring more nutritive matter for assimilation and lighten the work of the heart. (3) To stimulate the nerves of the body generally. (4) To assist and increase respiration, and thus to supply more oxygen to the body. All this will act on the constitution as a whole, and enable it to assimilate the iron that is brought into the body by means of the food. In case of great anaemia of the head, stimulation of the abdominal sympathetic, by causing vaso-constriction of the splanchnic area, will produce compensatory vaso-dilatation of the cerebral arteries, and thus effect amelioration. Case from notes taken by Dr. A. Muller and myself. G. A., female, aged 15, domestic servant, came under the manual treatment on November 14, 1899. History of present illness. — During the autumn of 1898, she began to feel weak and tired, and looked pale. Her medical man diagnosed chlorosis and prescribed iron. No improvement resulted. During the spring of 1899 her condition became worse, and she suffered from headache, breathlessness on slight exertion and constant fatigue. In spite of this she accepted for pecun- iary reasons a situation as servant, but became so much worse that she had to go home on November 10, arriving m a semi- DISEASES OF THE BLOOD, LYMPHATICS, &-€. 381 collapsed condition. Menstruation had commenced two years previously, but had been irregular, two months sometimes elaps- ing between the periods ; it had not taken place during the last two months. Exavunation. — November 14. Patient was very weak indeed. The complexion was markedly greenish-yellow ; the lips very pale. Even such slight e.xertion as moving an arm or leg was followed by breathlessness ; and patient had been in bed ever since she returned home. There was a well-defined mitral systolic murmur and a hruit de diable. No cardiac enlargement was present. After three days of treatment at home patient was much better, and on the fourth day walked to my house for treatment, a distance of about 800 yards. She was, however, still very feeble. She progressed steadily until November 27, when a slight relapse occurred ; she was treated at home during that day. On the '28th she was again able to come to me for treatment. Her headache left her, her colour become normal, she grew strong, and her menstruation returned normal in amount and regular. On January 18, 1900, she was quite restored and capable of active work. Treatment finished. During March she got a temporary situation as nurse. During January, 1901, she went into a laundry, and worked there steadily until July, 1902, when I agaui saw her ; she then said that she was in splendid health. Treatment. This at first consisted chiefly of a few passive movements, including stomach exercise. Other exercises were gradually added, and finally the gymnastic prescription was as follows : — (1) Half lying double arm rolling, PP, bending and stretch- ing, AE. (2) Stretch half lying running nerve frictions, PP, side shaking, PP. (3) Heave grasp standing chest clapping, side shaking, PP. (4) Half lying double foot rolling, PP, flexion and exten- sion, AR. (5) Stretch grasp standing drawing forwards, PP, kidney frictions, PP. (6) Forwards lying back exercise, PP. 382 ELEMENTS OF KELLGHEN'S MANUAL TREATMENT (7) Stretch stride standing bending forwards, PA. (8) Sitting trunk extension and flexion, PA. (9) Half lying leg rolling, PP, flexion, PA, extension, AE. (10) Half lying stomach exercise, PP. Lymphangitis. Under this heading will be considered the treatment of blood poisoning in consequence of infection from wounds, abrasions of the skin, &c. The manual treatment is applied as follows : — Locally, running vibrations and frictions, &c., are admin- istered centrifugallij down to the infected focus in order to prevent the condition spreading upwards, and to endeavour to cause the infective products, if possible, to pass back the way they came. (To appl}^ such manipulation centripetally, i.e., in the direction of the venous and lymph flow, would, of course, only result in great aggravation of the condition, see pp. 20.5, &c.) Constitutionally, exercises are prescribed to improve the con- dition of the body as a whole, and to promote elimination of the toxins that have already been absorbed. I append details of five cases treated by the above method ; no antiseptics were used. Case 1. E. L., female, aged 13f years, canie under the manual treat- ment on April 15, 1900. History of present condition. — During the whole winter patient had had a sore place in the right foot on the anterior surface of the first metatarsal bone at its distal end, caused by wearing tight shoes. Pain was felt in this area during the evening of April 13. During the following night patient slept badly, 'and the pain got worse during the ensuing day. At 6 p.m. on April 15 I was called in. Examination. — Patient complained of great pain in the right big toe and over various points on the inside of the right calf. There was continual pain in the lower leg, even when keeping the foot and leg still. Patient could only set her foot on the ground on its outer edge ; she could not place it flat on the ground on account of the -pain. Walking was almost impossible. DISEASES OF THE BLOOD, LYMPHATICS, &c. 383 There was an abscess, in which fluctuation could be detected, on the right great toe at the distal end of the first metatarsal ; around the abscess there was a red swollen area, extending right across the foot over the distal half of the whole metatarsus; similar areas were visible along the inner side of the calf, as in fig. 134 (the dotted part shows their extent). The entire foot was swollen, all the swollen parts being very tender. The inguinal glands were enlarged. There was fever. The pulse was 92. Treatment. — Suction vibrations round the abscess, causing the extrusion of a little pus and serum ; centrifugal running vibra- tions along the inflamed area down to the abscess. Vibrations over the inguinal glands ; stomach exercise. Kesult : no pain when foot was kept still ; patient able to walk much better and with less pain, even on the whole foot. General condition improved. April 16. — Morning. Patient had slept ve-y well during the night. Hardly any pain in foot, and patient said she felt as if nothing were the matter with it. Swelling of foot gone ; in- 384 ELEMENTS Of KELLGREN'S MANUAL TREATMENT tlaiumation and redness much better. Treatment ; a slight amount of pus was expressed from the abscess. After treatment pulse 72. Evening. No pain at all, not even on walking. No tenderness on pressure excepting over the tibialis anticus tendon. No redness along inner side of the calf. Abscess rapidly healing up. Treatment. April 17. — Patient had slept very well. No pain. Inflam- mation and redness gone. Treatment once. April 18. — Foot and leg perfectly normal, excepting for the wound on the big toe, which showed some scabs on it. Patient able to wear boot as usual. Treatment for the last time. April 19. — Patient went to school, it being the first day of the term. April, 190'2. — Foot had been quite well during the two years which had elapsed. Case 2. P. A., male, aged 9, came under the manual treatment on April 2, 1900. History of present condition. — Patient bad hurt his left wrist about four days previously ; he did not remember how. Swelling over the joint resulted and during the evening of April 1 he complained of stiffness in the shoulder-joint. On April 2 his mother noticed red lines on his forearm ; patient was brought to me at 7 a.m. Examination.- — Two small abscesses near the wrist, out of which the mother had during the same morning squeezed some pus. Large red lines marking swollen lymph vessels along front and external surface of forearm and inner surface of upper arm. Swollen glands in the axilla. Pain on pressure at the spots men- tioned at the wrist, and on moving the shoulder-joint ; otherwise no pain. Fever. Treatment. — Centrifugal running vibrations and frictions from upper arm towards wrist ; some serum exuded from the abscess cavities in consequence. Stomach exercise, &c. Patient said he felt better in consequence of the treatment. Similar treatment at 11.30 a.m. ; patient again sensible of improvement. Treatment at 5 p.m. ; patient better; less pain in axilla ; no fever. April 3. — Morning. Patient much better; treatment. Even- DISEASES OF THE BLOOD, LYMPHATICS, S-c. 385 ing. Lymphangitis bad disappeared. No pain in axilla. Affected areas near wrist much less red ; one of them almost gone, with a little scab remaining. Treatment. April 4. — Affected areas at wrist practically normal. Arm normal. Treatment for the last time. September, 1902. — Patient quite well. Case 'S. A. L., female, aged 9, came under the manual treatment on November 6, 1900. History of jyrexent condition. — Patient hurt her right thenar eminence about November 4 (date not quite certain). On November 6 patient noticed that the spot where she bad hurt herself was tender and red, and she came to see me about it. Examination. — There was an inflamed area over the base of the thumb, with a small abscess in the middle (at A in fig. 18.5). Along the front of the forearm was a red line, which opened into the median basilic vein at the elbow (B). Internal to this was some redness, which extended over the lower half of the fore- arm (C). The glands in the axilla were swollen. Temperature 101°, pulse 135. Treatment. — Locally, centrifugal running vibrations, &c., causing the pus from the abscess to be expressed. Constitu- tional treatment was also administered. 25 386 ELEMENTS OF KELLGREN'S MANUAL TREATMENT November 7. — No red lines, no fever ; pulse 120. Treatment as before. November 8. — No swollen glands in axilla. November 9 to 14. — A few centrifugal vibrations were adminis- tered every day. November 16. — No more pus. Wound healed up. Patienl normal. October, 190-2.— Patient quite well. Case 4. D. A., male, aged 11, came under the manual treatment on November 4, 1900. History of ]] resent condition. — Patient was bitten in his left hand by a rabbit on November 1. On November 4 the bitten place was painful, and there was also pain in the axilla ; patient v?as brought to me. Examination. — There was a wound about half an inch long with a scab on it, discharging pus, situated over the fifth metacarpal bone. One or two red lines marking out inflamed lymph vessels were visible on the forearm. The whole of the forearm on the ulnar side was very tender to pressure. There were enlarged glands in the axilla. Treatment on the usual principles. By its means some pus was expressed. November 5. — Less pain in the axilla. Red lines gone. Some more pus was expressed. November 6. — Glands in axilla could no longer be felt. Very little tenderness on pressure in forearm. Some pus could still l)e expressed from the wound. November 7 to 13. — Centrifugal vibrations were executed for two minutes once a day. November 13. — Wound healed up. No more pus. Patient cured. Treatment finished. July, 1902. — Patient quite well. Case o. J. S., aged 26, workman in Huskvarna factory, came under the manual treatment on February 14, 1902. DISEASES OF THE BLOOD, LYMPHATICS, A-c. 387 History of present condition. — Patient had hurt his left hand over the metacarpo-phalaugeal joint of the forefinger about a month previously by catching it in some machinery. The wound healed fairly well, but there was slight watery discharge until February 13, 1902. Patient slept badly, and on waking up suffered a good deal of pain in the sore place (which was again inflaming), and also in the forearm ; his forefinger was stiff, and there was pain on moving it. During the afternoon of the same day he experienced more pain and more stiffness, and the inflam- mation was worse ; the elbow and shoulder-joints had also begun to hurt. He slept very little, and had fever during the night. He came to me during the evening of February 14. Exaynination. — The original wound was much inflamed; it was about the size of a sixpence, with red lines leading from it along the outer side of the forearm and inner edge of the biceps in the upper arm. An enlarged gland could be felt just above the elbow on its inner side, and several others along the inner edge of the biceps and in the axilla. Temperature 101°, pulse 128. Treatment on the usual principles. By it some pus was expressed, and the patient felt better after it. February 15. — Patient had slept very well. No pain in wound. Less redness of forearm. Pain in axilla only on lifting arm. Enlarged lymphatic glands smaller. Temperature 98'8', pulse 80. Treatment twice. February 16. — Morning. No redness of forearm, glands smaller. A drop of pus was all that could be obtained from the wound. Evening. Glands not palpable any longer. Wound healing up very well. Treatment for the last time. October, 1902. — -Patient still keeping quite well. Exophthalmic Goitre. Miss S., aged 28, came under the manual treatment on March 7, 1902. History of present illness. — Patient was under Mr. Kellgren's treatment for enlarged thyroid in 1S90 ; the treatment lasted two months, and patient left cured. Since then she had been in good health until 1900. She was confirmed during the summer of that year, and had since been tormented by religious 3S8 ELEMENTS OF KELLGREN'S MANUAL TREATMENT doubts and fears and had become ver)^ emotional. The severe symptoms dated from December 31, 1901. Since that day she had been extremely nervous, irritable, and despondent, and able to sleep only an hour or two at the most in the night ; she was easily thrown into tears. She consulted a medical man during January ; he diagnosed neurasthenia and prescribed bromides. However, she became steadily worse. Examination. — Exophthalmos was well marked, and the palpebral aperture wide, the sclerotic being visible above and below the cornea. Patient winked continually, and was unable to keep her eyes still. On looking upwards the forehead did not wrinkle, and on looking downwards the upper lid did not follow the eyeball. Both pupils were dilated, and reacted only slightly to light and accommodation. The tension was + in both eyes, and on ophthalmoscopic examination there was pulsation in the retinal arteries and cupping of the discs. There was great tender- ness to pressure over the supraorbital nerves and anterior part of the temporal fossae. There was a continued sense of fulness in the throat ; the thyroid gland was considerably enlarged, forming a tumour about 3 inches from above downward, causing both sterno- mastoids to bulge outwards. The tumour did not extend down as far as the sternum, and the enlargement was equal on both sides. No pulsation was visible, but it could be felt in the gland. There were fine tremors in the arms on holding them out ; the handwriting was very shaky indeed. There was great weak- ness of all the muscles ; patient could hardly offer any resistance m her duplicate movements, and fine tremors of the whole body took place when performing them. Her appetite was poor ; she did not suffer from vomiting, but was subject to a good deal of eructations. She was constipated, but able to obtain a motion every other day by drinking Carlsbad water. There was great tenderness over the spleen, liver, kidneys, ovaries and spinal nerves. Patient was troubled with a feeling of throbbing in the arteries, especially in the head. The second sound in the aortic area was accentuated ; there were no murmurs. The pulse after lying down for ten minutes was 110 per minute. Patient suffered very much from headache, sleeplessness, irritability and despondency ; and cried easily. Babinsky's sign was not present ; tendo Achillis jerk was present, two or three jerks were felt on trying for ankle clonus ; the patellar reflexes were greatly exaggerated. DISEASES OF THE BLOOD, LYMPHATICS, &-€. 7,Sc) The urine contained a little sugar, as tested by Fehliug's solution, but no albumen. Patient had become much thinner of late ; her present weight was o3"2 kilos. Treatment. (1) Sitting head exercise, PP ; suction vibrations on the thyroid gland, PP ; double supraorbital nerve vibrations and frictions, PP. (2) Reach grasp standing head flexion, PR, extension, AR ; cervical nerve frictions, PP. (3) Sitting double elbow pressing downwards, PR, up- wards, AR. (4) Forwards lying back exercise, PP. (5) Side span standing drawing sideways, PP, spleen and kidney frictions, PP. (6) Sitting trunk extension and flexion, PA ; sit lying knee extension and flexion, PP, extension, AR, flexion, PR. (7) Heave grasp standing side shaking, PP, heart vibration, PP. (8) Ride sitting trunk flexion, PR, extension, AR. (9) Half lying stomach exercise, PP, ovary vibration, PP. Progress. — March 8. — Patient slept better during the night. March 10. — Patient slept badly again. March 1.3. — Patient slept better than she had done for months. Sense of fulness in the throat gone. March 1.5. — Less tenderness over the supraorbital nei"ves. March 22. — Patient slept very well every other night ; was much stronger and able to offer a good deal of resistance during duplicate movements. Less tenderness over spleen, kidneys, liver, ovaries and spinal nerves. March 2-4. — Weight .54-5 kilos. Pulse after lying down for ten minutes was 100 per minute. March 26. — Eyes not so prominent, pupils less dilated ; patient wrinkled her forehead slightly when looking up, and the eyelid followed eye downwards. Tension normal in both eyes. March 27. — Patient slept fairly well four nights running. April .3. — Thyroid smaller. Less nervous. Tendo Achillis jerk present. No jerks in trying for ankle clonus ; patellar reflex not so exaggerated. No glycosuria. April .5. — Treatment interrupted until April 15. Eyes reacted .390 ELEMENTS OF KELLGREN'S MANUAL TREATMENT nonuall}' to light and accommodation ; no pulsation in the retinal vessels, but cupping of the discs still present. Some exophthal- mos was the only abnormal eye symptom present. Less tender- ness over the supraorbital nerves. Thyroid much smaller ; very little bulging of the sterno-mastoids. Fine tremors only in hands. Patient stronger, she had taken several three mile walks lately. Appetite normal, bowels acting daily. No throbbing of the arteries. Accentuated second sound in the aortic area still present. Pulse after lying down for ten minutes 88 per minute. Tenderness absent over the spleen and liver but still present over the kidneys and lower dorsal nerves ; hardly any tenderness over the ovaries. Patient sleeping very well. Reflexes the same as on April 3. No glycosuria. Patient returned to treatment on April 15, having been to stay with some friends, who were astonished at the improvement she had made since they last saw her, which was in the middle of February. She had slept very well every night since her depar- ture excepting the last night. Her condition was about the same as on April 5. No glycosuria. May 17. — Treatment finished. Patient's general condition very good. Slight exophthalmos still present ; she winked much less than before, and could keep her eyes much more still. Her forehead wrinkled on looking up ; on looking downwards the lapper lid followed the eyeball. The pupils reacted normally to light, although sluggishly to accommodation. The tension oi the eyes was normal ; there was no pulsation of the retinal vessels. The thyroid gland was smaller, but could still be plainly felt. The sterno-mastoids hardly bulged at all. All the muscles were stronger ; there were hardly any fine tremors of the hands on holding them out, and none in any other part of the body, not even during strong duplicate movements. The handwriting was normal. Normal motion every other day. Appetite good. No tenderness over liver, kidneys, ovaries, or spinal nerves. No accentuation of second sound in the aortic area. No throbbing in the arteries ; cardiac action much quieter, the pulse after lying down for ten minutes was 70 per minute. Sleep very good ; despondency gone ; irritability gone. No tendo Achillis jerk or ankle clonus jerks present. Knee-jerks well marked. No glycosuria. Weight 55 kilos. I saw patient again on August 9 of the same year. She said she was feeling very well and had grown fatter of late. CHAPTER VIIT. DISEASES OF THE NERVOUS SYSTEM. These are conveniently considered under the following heads : — I. — Organic brain and spinal cord diseases, whether depen- dent on a sudden lesion such as inflammation or haemorrhage, or slowly progressive such as sclerosis. II. — Peripheral nerve diseases such as diphtheritic paralysis, neuritis, &c. III. — Functional nervous diseases. IV. — Sympathetic nerve diseases. I. — Organic Brain and Spinal Cord Diseases. Want of space compels me to consider only the treatment of the chronic stage of the above diseases. The object of the treatment is to restore the normal vital activity to the primarily degenerated nerve-cells and nerve-fibres, and to the secondarily affected muscles, &c. The following movements are employed : — (1) Manipulations which stimulate the central nervous system directly, especially nerve frictions, local and general. The affected motor nerves are treated by means of nerve frictions, stationary or riinning, hackings, &c. The affected sensory nerves are treated by means of nerve frictions, stationary or running, clappings, &c. The spinal cord is treated by means of peripheral nerve stimulation as just mentioned, hackings over it, strong vibration over any affected segments. Sec. The brain is treated by means of a short, sharp head exercise, with particular atten- tion to any specially affected area. The cerebro-spinal system as a whole is treated by means of running nerve frictions from head to foot, &c. 392 ELEMENTS OF KELLGREN'S MANUAL TREATMENT (2) Passive inauipulatioiis on any weakened or paralysed muscles. First and foremost, nerve frictions on the motor nerves leading to the muscles, as already inentioned. Secondarily, passive flexions, extensions, rollings, &c. For atrophic conditions these are administered energetically through the largest radius in order to cause : Promotion of the circulation of the hlood, and subsequently a vaso-dilatation in the part exercised, and promotion of the circulation of the lymph with increased production thereof. Stimulation of the nerves and muscles from alternate elongation and shortening and from the reinforcement of the reflex arc through shortening of the antagon- istic muscles. For spastic conditions where there is no atrophy beyond the atrophy of disuse, passive movements at joints are administered in a different manner. They are executed fairly slowly ; as soon as spasm arises the movement is wholly or partially stopped, and an endeavour made to overcome the spasm by gently elongating or shortening the muscle or muscles in which the spasm has arisen. When it has been overcome the move- ment is again continued. There is also a psychical encouraging effect ; the movement executed is one which perhaps the patient himself has been unable to achieve for years past and of whicli he has forgotten the sensation. He is thus encouraged to attempt its repetition. Thirdly, kneadings of any affected muscles. In atrophic conditions these have a certain amount of stimulatory effect, but by no means so marked a one as stimulatory manipulations on the nerves supplying these muscles. It must be remembered that the atrophy is practically always secondary to the nerve degeneration, and that, therefore, stimulating the muscles directly by kneadings, &c., cannot have the same effect as stimulating the nerves directly b)' frictions. (3) Active movements, purely active or duplicate, during which the patient has to try his utmost (within the physiological limit) to move any paralysed muscles or ataxic limbs, i.e., the patient has to try his utmost to restore the continuity in the interrupted motor or sensory paths. Such voluntary efforts excite the nerve-cells to increased activity, and aid in the restoration of the degenerated nerve-fibres ; each renewed effort of the will sends down a fresh nervous impulse which DISEASES OF THE NERVOUS SYSTEM 393 tends to overcome any obstruction. Such movements also train ordinarj' sensation' and the sense of coordination and inhibition. By means of various fixations of the Hmb all other muscles may be placed at rest except those it is desired to exercise, on which the patient is thus enabled to concentrate all his enerj^y. (4) Manipulations to improve the general condition of the patient, e.g., to better the circulation and promote the activity of the assimilative and digestive organs. Special attention should be paid to any secondarily affected organs, such as heart, bladder, &c. It is advisable to refer here to some points in the technique of the application of active movements to cases of paralysis. For purposes of illustration it is convenient to take a case where, in consequence of the anterior tibial muscles being affected, the patient states that he is unable to bend his foot by himself. It does not, however, follow in consequence of his statement that there is no voluntary muscle power in the anterior tibial muscles ; it is necessary to test further, as follows : (a) The patient is exhorted to try his utmost to bend his foot ; after a few seconds, or perhaps even only after a minute, a very slight amount of movement may manifest itself. This arises from summation of voluntary stimuli. (b) The patient's ankle-joint is flexed as far as it will go, and the patient then asked to resist his utmost while the reverse movement is executed. Some resistance may be felt (see pp. 37, 38). (c) The patient's ankle-joint is slowly flexed, the patient being requested to assist as much as possible. Some assistance may be felt (see p. 13). In some cases, even if the results are negative, voluntary power can sometimes be elicited after executing strong nerve frictions on the anterior tibial nerve followed by an energetic foot rolling given through the largest radius. It is often useful to eliminate the action of gravity, i.e., supposing a patient unable to abduct his right leg in left side lying position, he may yet be able to do so in half lying position, and so on. The golden rule for treatment of paralysis is : Try and teach ' Cf. " Optic .\trophy aud Tabes Dorsalis,'' by the author, in Lancet, June '^'J, 1901, p. 1861. j94 ELEMENTS OF KELLGREN'S MANUAL TREATMENT the patient to regain the voluntary power of those movements which he has lost in consequence of the nervous lesion. The treatment of crises such as occur in locomotor ataxia. — Special exercises should be administered for the benefit of the part affected dui'ing the crises, i.e., during gastric crises exercises chiefly for the stomach and abdomen should be administered, and so on. During one case of locomotor ataxia of eight years' standing that I treated in October — November, 1900, there occurred two gastric crises with fever ; the treatment (twice a day) was as follows : stomach vibration, frictions on the left sixth, seventh, and eighth dorsal nerves near the spine, stomach exercise ; general treatment for fever. The improvement in the patient's condition, which otherwise proceeded slowly, was marked for the two days immediately following each crisis. This tends to show that in some cases such crises can act as general eliminators, and that they might therefore be regarded as an effort of Nature towards attempting a cure. II. — Peripheral Nerve Diseases. (1) Neuritis (excluding neuralgia). Is treated in very much the same way as atrophic spinal paralysis. (2) Neuralgia. Is treated by means of sedative manipulations, such as vibrations over the painful nerves ; gentle passive move- ments at joints can be added where this is possible. As improve- ment sets in, frictions on the painful nerves are made use of; more energetic passive movements, duplicate movements, &c., can be added when possible. (8) Spasm of muscles from nervous causes. Is treated by means of stimulatory manipulations on the nerve, and by exercises to strengthen the antagonistic muscles (see p. 75). III. — Functional Nervous Diseases. It is impossible to lay down any general directions for the treatment of these ; each case has to be taken on its own merits. IV.— Sympathetic Nervous Diseases. These conditions ai'e not ordinarily accorded a place in text- books. It is, however, often found while examining a patient, DISEASES OF THE NERVOUS SYSTEM 395 say, for dyspepsia, that there is greatly diminished sensation in the abdominal prevertebral plexuses, or that no radiating sensation is experienced on executing a friction on the umbilicus, L^c. This leads to a diagnosis of deficient functionability in the sympathetic nerves of the part, although it is generally very difficult indeed to say whether this sympathetic condition is primary or secondary. It is, however, impossible to give a comprehensive account of the subject, or to lay down general directions for treatment ; each case must be taken on its own merits. I wish especially to emphasise the fact that the manual treatment should be given a trial as early as possible in cases of organic disease of the central nervous system, because experi- ence has shown, particularly in slow degenerative processes such as sclerosis, &c., that very little improvement can be expected in most cases from the administration of drugs and electricity. Cases treated by such methods without improvement are usually difficult to benefit by the manual treatment ; cases treated l)y such methods with improvement generally improve faster when the manual treatment is substituted. Cases which have never received any treatment, even if of many years' stand- ing, are often more easy to benefit by means of the manual treatment than correspondingly recent cases which have not improved under ordinary medicinal or electrical treatment. I have also had some opportunities of observing that cases which have improved by means of the manual treatment, and which have then for various reasons been removed from its influence and brought under that of drugs and electricity, nearly always either remain stationary or, in sclerosed conditions, become worse again ; whereas cases which have improved by means of the manual treatment sometimes continue to do so after the treatment has been stopped, provided that none other be made use of. I append a list of all the nervous cases I have been able to watch carefully, and in which there has been no doubt in my mind as to the diagnosis. By " cured " I mean that the patient was freed from all abnormal nervous symptoms, and that such cases were under observation at least one year, in many cases up to four years, from the date at which the manual treatment 3q6 elements OE KELLCREN'S MANUAL TREATMENT: was concluded, and that diu-ing that time no return of any abnormal nervous symptom took place. In all the other cases mentioned excepting two (see p. 397) improvement resulted from the treatment. Neuritis and neuralgia. — Sciatica, seven cases ; three cured. Tic douloureu.K, one case, lietrobulbar haemorrhage with optic atrophy, one case. Other neuritis, eight cases. Other neuralgias, ten cases ; five cured. Post-diphtheritic paralysis, two cases ; one cured. Convulsive tic, one case ; cured. Facial nerve paralysis. — Peripheral, two cases ; one cured. Central, one case. Congenital fsaralysis of brachial plexus, one case ; cured. Gunshot paralysis of ulnar and median nerves, one case. Spinal transverse myelitis, one case. Apoplexy of the spinal cord, two cases ; one cured. Infantile paralysis, eighteen cases ; two cured. Spastic paraplegia, seven cases. Locomotor ataxia, eight cases ; two cured. Compression of the spinal cord from scoliosis, one case. Tertiary cerebro-spinal syphilis, one case. Amyotrophic lateral sclerosis, one case. Gunshot wound of spine at level of fifth dorsal vertebra, one case. Bulbar paralysis, three cases. Sequelae of secondary syphilitic meningitis, one case. Hyperaemia of the brain, four cases ; three cured. Cerebral haemorrhage and embolism, six cases; one cured. Cerebral subdural htemorrhage, one case. Infantile spastic diplegia, two cases. Disseminated cerebro-spinal sclerosis, three cases. Hydrocephalus, five cases ; one cured. Paralysis agitans, six cases. Sequelas of concussion of the brain, three cases. Delirium tremens, one case ; cured. Chorea, two cases ; both cured. Epilepsy. — Grand mal, four cases; one cured. Petit mal, one case ; cured. Writer's cramp, two cases ; one cured. Hj'steria, fifteen cass ; five cured. DISEASES OF THE NERVOUS SYSTEM 397 Neurasthenia, mental overstrain, S:c., thirty-two cases; eleven cnred. Raynaud's disease, one case. Syphilitic dementia, one case. Mania, four cases ; two cured. Melancholia, one case. Insanity of menstruation, one case ; cured. The treatment was without effect in the following cases : — A child, aged 9, suffering from cerebral hiemorrhage of four years' standing. Previous treatment : drugs and electricity. Duration of the manual treatment : three weeks. A man, aged 42, suffering frona spastic paraplegia (spinal) which ran a rapid course : The patient first noticed that some- thing was wrong during June, 1899 ; he was compelled to cease work during July, 1899. During August and September of the same year he underwent five weeks of electrical treatment. Duration of the manual treatment: October 1, 1899, to January 10, 1900. Patient died during October, 1900. Embolism into the Internal Capsule. H. A., female, aged 39, came under the manual treatment on August 8, 1900. History of present illness. — Patient had been suffermg since 187G from heart disease, which was quite well compensated. During March, 1899, she had an attack of influenza, and got up too soon after it. A relapse took place, and during the night of April 1, 1899, she suddenly lost consciousness for an hour and awoke with complete paralysis of the left side of the body (face, arm, and leg), with transient aphasia which lasted twenty-four hours. After stopping at home for two weeks she was taken, on April 17, 1899, to the hospital in Hvetlanda, where she remained until May 19, 1899. Her condition did not improve much ; some power of movement at the elbow and slight power of movement in the lower extremity returned gradually. She then went to a convalescent home, and took baths for two months from June 1 to July 31, 1899. She then left, and under- went electrical treatment for a month, after which she went home. No further treatment was taken until May, 1900, when massage was resorted to ; this was continued until August, when patient came to me. 398 ELEMENTS OF KELLGREN'S MANUAL TREATMENT She said Unit none of the treatment undergone had ever seemed to do her any good worth mentioning, and that she only improved at the same rate (a very slow one) while massage or electricity was being administered as while not under treatment at all. Examination. — Patient still had some facial paralysis on the left side ; when smiling the right side of the mouth drew back, but the left remained stationary. She walked very slowly with the help of a stick, and swung her left leg round in a semi-circle. On her journey to Sanna she had to walk from one station to another ; the distance was only three-quarters of a mile, but took her three hours to accomplish. Left side of body : Reflexes. — There was slight knee clonus, and some ankle clonus; the patellar reflex was exaggerated. There was a biceps jerk, but not an extensor one. Frictions on the posterior interosseous nerve caused twitching of the fingers (dorsifiexion) . Frictions over the musculo-spiral nerve produced this to a less extent. Repeated frictions on the internal plantar nerve caused a little flexion of the hip-joint (see p. 151). Most of the muscles were stiff in the affected areas, excepting in the thigh, where some of them were flabby ; there was, how- ever, no actual wasting. Occasionally involuntary spasmodic movements took place in the fingers, but nowhere else. Voluntary movements : — Shoulder-joint. — Flexion, fair, through angle of 90° or so. Extension, hardly any. Internal rotation, good. External rotation, very little. Abduction, arm could not be abducted to right angle. Adduction, good. Elbow pressing backwards, upper arm could not be pressed backwards to form less than 45° with coronal plane. Patient could not put her arm in neck firm position, or keep it there when so placed for her while she was in half lying position. Elbow-joint. — Flexion, good, but muscles very stiff. Extension, weak. Radio-ulnar joints. — Supination, impossible to more than mid-position. Pronation, good. Wrist and finger-joints. — Flexion, normal, but patient unable to close her fist. Extension, hardly any ; extension of -thuml) a little better than that of fingers. ' Hip-joint. — Abduction, weak. Adduction, normal. Flexion, very little. Extension, fair. Rotations, very weak. DISEASES OF THE NERVOUS SYSTEM 399 Knee-joint. — Flexion, very weak. In forward 13'ing position patient was unable to lift her foot off the couch, although she was able to contract the hamstring muscles. Extension, good. Ankle-joint. — Flexion, none. Extension, good. Toe-joints. — Slight movements possible. Face. — See above. Sensation was quite good in the paralysed area. The pupils were normal. Heart symptoms. — Patient complained of a continued anxious feeling in the cardiac region. The cardiac impulse could be seen in the fifth and sixth spaces in the nipple line. On percussion, there was some enlargement to the right of the sternum. On auscultation, great arhythmia with pauses and intermissions ; the sounds were verj- indistinct, varied very much, and occasion- ally almost disappeared for a few beats. A diastolic murmur could be heard in the mitral area ; it was slightly propagated into the axilla. Pulse about 150 ; there was, however, great difiiciilty in counting it, owing to the great irregularity. Sphygmographic tracing taken before treatment see fig. 136. Treatment, (1) Sitting head exercise, PP, including frictions on the left facial nerve, PP. (2) Sitting left arm exercise, including arm abduction, Alt, adduction, PE : supination, AR, pronation, PR ; elbow extension. AR, flexion, PR ; finger and wrist extension, AR, flexion, PR : nerve frictions, specially on the posterior interosseous nerve, PP. (3) Half lying double arm rolling, PP, bending, PR, stretching, AR. (4) Half lying double foot rolling, PP, flexion and extension, AR. (5) Forwards lying Ijack exercise, PP, knee flexion, AR. extension, PR. (6) Half lying leg rolling, PP, flexion, AR, extension, PR. (7) Half lying stomach exercise, heart vibrations, side shaking, PP. Extra movements were often included, but the above formed the general prescription. ^All the movements had to be adminis- 400 ELEMENTS OF KELLGREN'S MANUAL TREATMENT iered carefully, in consequence of the cardiac condition. In many cases the first part of the duphcate movements, as in (2), were ^dven PP at first, then PA, and then AK, si'fidually increasing I'esistance being offered as the patient's strength came back. Progress. — August 8. — -After the first treatment the toes already able to move a little better. August 9. — The heart qnietei', according to the patient. Less DISEASES OF THE NERVOUS SYSTEM 401 feeling of anxiety in the heart, which could be felt to beat more slowly but just as irregularly. August 10. — Patient able to abduct her arm to more than a right angle. The extensors of the forearm stronger. Movements of the toes a little better. Patient able to walk better. The anxious feeling in her heart quite gone. August 15. — The facial paralysis disappeared. The extensors of the forearm and abductors of the shoulders stronger. Patient able to walk better and without using a stick. August 21. — -Improvement continued. Complete supination possible. August 24. — Extensors of forearm and abductors of shoulder stronger ; abduction now possible through 120°. September 3. — Abduction at the shoulder possible through 135°. The elbow could be drawn back to form an angle of about 22° with the coronal plane. September 15.— Further improvement in abduction, which was now possible through 150°. Patient could, in forwards lying position, flex her knee a little and resist during extension. The stiffness of the muscles previously felt while administering leg rolling and arm rolling almost gone, but the range of passive flexion and extension at the ankle not complete ; the toes able to move through an arc of only about 2 inches. Patient able to use the fingers of the left hand to button her clothes if the buttons were in a convenient position in front. September 18. — Patient took a walk of four miles, half of which was very much uphill. October 1. — Treatment now as follows : — (1) Sitting head exercise, PP, frictions on the left facial nerve, PP. (2) Heave grasp standing drawing forwards, PP, heart vibra- tion, PP. (3) Sitting left arm exercise, as before. (4) Half lying double foot rolling, PP, flexion, AR, extension, PR. (5) Half lying double arm rolling, PP, bending, PR, stretch- ing, AR. (6) Forwards lying back exercise, PP, knee flexion, AR, extension, PR. (7) Half lying leg rolling, PP, flexion, AR, extension, AR. 26 402 ELEMENTS OF KELLGREN'S MANUAL TREATMENT (8) Half lying stomach exercise, heart vibration, side shaking, PP. October o. — Abduction of arm possible nearly up to the vertical. Elbow could be drawn back to coronal plane. October 14. — Left arm could be placed m neck firm position (when patient in half lying position), and kept there with difficulty. October 23. — Patient able to extend fingers and wrist to lie in straight line with forearm. November 1. — Patient able to extend fingers and wrist to more than a straight line with the forearm ; able to walk quicker. Flexion of knee better. November 5. — Extension of thumb, PA, normal. November 28. — Sphygmographic tracing taken to-day half an hour after treatment, see fig. 137, Examination. — December 20, 1900. Patient able to walk much better than when she first came to me. The reflexes about the same as on August 8. Voluntary movements : — Shoulder-joint. — Flexion, good. Extension, weak. Internal rotation, normal. External rotation, good, possible with a good deal .of AR. Abduction good, possible to nearly the vertical. Adduction, good. Elbow pressing backwards, very good. Elbow-joint. — Flexion, normal. Extension, possible to a straight line. liadio-ulnar joints. — Supination, possible to full extent with AR. Pronation, good. Wrist and finger-joints. — Flexion, patient able to close her fist. Extension, fingers and wrist capable of extension to a straight line, or even a little more sometimes. Complete extension of thumb possible with All. DISEASES OF THE NERVOUS SYSTEM 403 Hip-joint. — Abduction, normal. Adduction, normal. Flexion, good. Extension, very good. Rotations, very little improvement. Knee-joint. — Flexion, in forwards lying position patient able to flex the knee to a right angle and resist in extension, PE. Extension, good. Ankle-joint. — Flexion, good. Extension, normal. Toe-joints. — Flexion, fair. Extension, good. Face. — Normal. Heart symptoms. — The apex beat nearer the sternum than before. The area of cardiac dulness less than when she first came under the manual treatment. On auscultation the diastolic murmur not so distinct as it was ; the heart sounds less faint and the irregularity less. Sphygmographic tracing (see fig. 138). Infantile Spastic Diplegia. A. J., male, aged H, came under the manual treatment on August 8, 1901. History of present illness. — Patient was a first child ; the labour was not abnormal, no forceps being used, and from first to last occupied about twenty hours. The condition of spastic diplegia was, however, noticed soon after birth, and had persisted ever since with hardly perceptible change. Several medical men who were from time to time consulted pronounced the condition to be incurable. Examination. — I am indebted to Dr. Harry Kellgren for the following description of the patient's condition on August 8. Face expressionless, very pale. Head large, hydrocephalic look- ing, circumference 55 cm. Intelligence weak, patient could hardly talk at all ; his vocabulary was hmited to five or six words. No nystagmus. Patient continually in the attitude characteristic of iiis disease — upper arms add acted and rotated internally ; elbows 404 ELEMENTS OF KELLGREX'S MANUAL TREATMENT semi-flexed, forearms pronated, hands semi-flexed and meeting anteriorly across the chest. Thighs markedly adducted, semi- flexed, rotated inwards ; knees semi-flexed, feet extended and inverted. Spine somewhat kyphosed. General weakness of all muscles. Cervical extensors very weak ; patient unable to hold his head up ; it always fell to one or other side unless supported. The arm muscles flabby, those of the legs somewhat spastic. The contraction in the adductor muscles so strong that the knees could passively be only very slightly separated. Patient unable to sit up unless with a great deal of support ; and unable to stand up against a wall unless with very complete fixation, the least relaxation of the support causing him to fall down in a heap. Arms very rarely moved ; attempts to get patient to move them voluntarily quite unsuccess- ful. Legs often moved ; and patient would move them when ordered to do so, although he was apparently unable to perform half lying leg extension, PA, after the thigh and knee had first been passively flexed. Patient unable to straighten his spine voluntarily. Eeflexes. Eyes reacted sluggishly to light. Babinsky's sign and Kellgren's plantar sign present. Tendo Achillis jer-k, ankle clonus, and adductor jerk present on both sides ; no knee clonus or crossed adductor jerk. Patellar reflexes very exag- gerated. The reflexes of both legs about equal. No reflexes in the upper arms. Defaecation : for the first six months of his life patient was constipated, and an enema was admin- istered daily. After that time the reverse condition set in, and patient had since had seven or eight motions per day. Micturition : this was frequent, often every hour during the daytime and severaltimes during the night. No incontinence either of faeces or urine ; patient had learnt to give the sign to his nurse when he wished to empty rectum or bladder. Treatment. (1) Sitting head exercise, PP. (•2) Half lying double arm rolling, PP, bending and stretch- ing, AB, arm nerve frictions, suprascapular nerve frictions, PP. (3) Stretch grasp standing drawing forwards, side shaking, PP. (4) Half lying double foot rolling, PP, flexion and extension. DISEASES OF THE NERVOUS SYSTEM ' 405 AE ; double leg rolling, PP, flexion and extension, AR, leg nerve frictions, PP. (5) Crook half lying double knee abduction, AR, adduction, PR. (6) Forwards lying back exercise, PP. (7) Sitting trunk extension and flexion, PA ; sit lying knee extension and flexion, PP, extension, AR, flexion, PR. (8) Stretcli half lying running nerve frictions, PP, shaking over the bladder, PP. (9) Half lying stomach exercise, PP. (10) Patient was made to try and walk, and to stand with as little support as possible. The above exercises could not, of course, be executed at once with the proper resistance ; several weeks of careful training were necessary before the patient could learn what to do. Progress. — I first saw patient on October 1. He was already better. The face had more expression, was more lively and had more colour. Patient was able to hold up his head by himself, and if properly balanced could sit up by himself without support for ten or fifteen seconds. He could also flex and extend arms. October 11. — While receiving forwards lying back exercise, PP, patient held up his head quite well. October 1.5. — When held up under both arms, patient was able to put one foot in front of the other so as to walk along, though this was accomplished with a good deal of difficulty ; the right leg moved more easily than the left. October 17. — While in forwards lying position, patient was able to resist while his head was pressed down on to the couch, and also to raise it again with AR. He had to a great extent lost the characteristic attitude of his disease. November 9. — Cervical extensors still stronger. Walking (with support) better. Patient able for the first time to stand upright with his back against a wall with hardly any support. He could now perform half lying leg extension, AR. November 18. — Patient able, when holding on to a sofa for assistance, to walk a few steps. November 23. — Intelligence improved ; face more expressive and of quite a good colour. Head smaller, and usually held up. Patient able to sit up by himself with only his back supported sometimes for fifteen or twenty minutes without falling ; and 4o6 ELEMENTS OF KELLGREN'S MANUAL TREATMENT able, when holding; on to a sofa, to walk fairly well. He went home for two days, but in consequence of his nurse leaving suddenly while at home, and his mother being unable to get another, he did not return to treatment. Winter set in, and his mother thought it better to keep him at home until the spring. During the winter patient had whooping cough, and a very bad attack of acute tonsillitis. He returned to treatment on May 5, 1902. The characteristic attitude of the disease had partly returned ; the forearms were constantly pronated, and there was more adductor contraction than during November. He was still able to hold his head up quite well. His intelligence was much improved, and he talked a good deal. He was unable to walk as well as when he left ; this was owing to the fact that his parents had not encouraged him to try and do so. Reflexes about the same, with the exception that there was no ankle clonus on the left side. Gymnastic prescription same as before. The treatment was continued until July 1, 1902. Examination. — July 1. — Patient had a lively expression, and talked and laughed like other children ; his speech was that of a child about 3 years of age. Head smaller, circumference SSi cm. His intelligence was much improved ; he understood everything that his nurse told him. The characteristic attitude of his disease was gone ; very little adductor contraction was left. He was much stronger, and able to use his arms and hands quite well ; he could, for example, take up a cup with both hands, drink out of it and set it down again without upsetting it. He was able to sit in a chair without support for periods sometimes as long as ten minutes. If he held on to the back of a sofa, he was able to walk along it, though this was done clumsily. He could stand quite easily if allowed to hold on to a chair. He had learnt to do all the duplicated gymnastic exercises quite well, and could offer a good deal of resistance during crook half lying double knee adduction, PR. Reflexes. The eyes reacted normally to light. The reflexes of the left leg were not so marked as those of the right. Babinsky's sign manifested itself in the right foot only after repeated efforts ; no tendo Achillis jerk ; no ankle clonus DISEASES OF THE NERVOUS SYSTEM 407 in the left foot, one or two jerks in the right toot. The patellar reflex was more exaggerated on the right side than on the left. Deffecation and micturition were practically normal. I again saw patient on September 1(5, 1902. His general condition was improved. He was as intelligent as any ordinary child of the same age. His memory seemed quite up to the standard. He used his arms quite easily. There was hardly any adductor contraction, and he was able to walk for an hour if he held on to something. Patient had, however, lately been having cramp in the muscles of his feet. The reflexes were more marked than on July 1 ; Babinsky's sign was easily obtainable in both legs ; ankle clonus was easily obtainable in right foot, and one to two jerks in left foot. Defsecation and micturition normal. Diplegia from Cerebral Haemorrhage. G. C, female, aged U, came under the manual treatment on January 7, 1902. History of present illness. — Patient had always been well until December 27, 1899, when she was the subject of an apoplectic seizure. She was heard during the night to scream suddenly ; for several hours after that she suffered from violent convulsions, retraction of the head, rolling up the eyes so that only the whites were visible, and screaming at intervals. The parents did not notice that the head was turned to any particular side. During all this patient was profoundly unconscious. After a few hours she quieted down somewhat and finally went to sleep. On waking up the following morning she seemed in a stupor, and was entirely unable to move any part except her head ; and her mother on trying to move her found that she was very stiff. Motor aphasia was present, and incontinence of fteces and urine. After a week or so partial power of movement was restored, com- mencing in the legs, and patient was able to say one word — " Mamma." Speech improved slowly, and was restored at the end of a month ; but patient was unable to move much, and remained in bed during eight months. The stiffness of the body and extremities improved slowly, and during May, 1900, she could sit up, but not stand. During August, 1900, she could stand and walk a few steps when her mother supported her on one side, using a stick on the other. During the following summer 408 ELEMENTS OF KELLGREN'S MANUAL TREATMENT she was able to waddle along very slowly and clumsily without help. Since then her condition had remained about the same. Several medical men were consulted, who at different times prescribed various medicines, but none seemed to do her any good. Since the summer of 1901, five medical men, consulted separately, declared that no improvement was possible by any method whatsoever. Examination. — January 7, 1902. — Patient walked extremely clumsily ; she was unable to progress in a straight line, and moved sideways, taking very small steps in a more or less circular path ; her body swayed about very much in so doing. She was unable to lift either foot more than one inch off the ground. There was internal rotation and adduction of both thighs, and inversion of both feet, so that while walking patient kept her toes almost touching and her heels at least 6 inches apart, being supported on the outer side of both feet. The right arm was kept constantly with the upper arm somewhat abducted, the elbow semiflexed, the forearm pronated, and the wrist and fingers flexed ; the arm could be passively straightened so as to hang vertically, but the least disturbing sound or putting a question caused it at once to resume its former position. Sensory phenoviena. — Patient was perpetually scratching her- self on the right arm and leg in consequence of itching feelings in the skin ; these were present to a less extent in the left hand and foot. She also complained of constant pins and needles sensations in the right hand and both feet. She generally referred a touch on the right leg to the left one, and could not well locate points touched on the right leg. A touch on the right arm was sometimes referred to the left arm. There was dimin- ished sensation in the right hand and both feet. Sensation in the left arm and leg was referred correctly. There was no cold shivers sensation on receiving cervical nerve frictions, nor any sensation in the hand or any part of the arm except at the point of application when receiving frictions on the brachial plexus in the axilla, nor in the lower leg or foot when receiving internal popliteal nerve frictions. The sight appeared to be normal ; I could not test patient with the test types, as she had never learnt to read. No reaction to accommodation was present, although that to light was par- tially present. Ophthalmoscopic examination revealed nothing DISEASES OF THE NERVOUS SYSTEM 409 abnormal. Hearing : Right ear J^, left ear j'^. Taste and smell were normal. Reflexes. — Swallowing normal. Micturition: there was per- petual incontinence of urine, which patient did not notice more than about once an hour or so, when apparently a larger quantity than usual was discharged. Deftecation : patient had at least three loose motions during the day, and the same number during the night ; she felt them coming, but could not keep them in more than half a minute or so. The skin reflexes, including Babinsky's sign, were absent. Other reflexes were as follows : — Kellgren's plantar sign Kellgren's crossed plantar sign (see p. 151 Tendo Achillis jerk Ankle clonus Patellar jerk Knee clonus Adductor magnus jerk Crossed adductor jerk Extensors of forearm jerk Supinator longus jerk Biceps jerk ... Triceps jerk ... Lett side. R -ht side. yes yes no yes .Ves yes no no exaggerated much exaggerated slight one kick back yes no Motor functions. — The walk has been described. Patient was very restless, perpetually on the move ; there were continual involuntary movements of the arms, especially of the right one. There was great weakness of many groups of muscles, and partial weakness of almost all others. When placed in a lying position on the floor patient was unable to get up by herself unless she had a chair or low stool to catch hold of ; even then she had great difficulty, taking from half a minute to a minute to complete the operation. The tongue was protruded easily, and in the middle line. The cervical extensors and spinal extensors were fairly strong. There was great weakness in all the muscles of the arms, and almost complete paralysis of both triceps muscles and the extensors on the back of the right forearm, those of the forefinger being better than those of the little finger. Patient was unable to abduct either arm to a right angle ; there was limited supina- tion of the right forearm. She never used her right arm for any- thing ; on being asked to use it to pick up a light article, such as a 4IO ELEMENTS OF KELLGHEN'S MANUAL TREATMENT match-box, from a table, she proceeded just as it' afflicted with chorea and generally failed to pick it up ; if she succeeded she generally dropped it a second or two later. When put on a chair she could touch her feet with her right hand, but not without lifting her foot off the ground at the same time. The left arm was also very weak, but she could use her left hand quite well, though choreic-like movements were often seen in it. At meals she used only her left hand. She was quite unable to dress herself, but could fasten a button in front of her dress with both hands, proceeding just as in a case of ordinary chorea, and taking from one to two minutes. She could not put her right arm into hip firm position, and could not keep her arms in neck firm position when they were passively placed so while she was lying down. There was complete paralysis of the external rotators of both thighs and eversors of both feet ; patient could not lie wdth her heels nearer than 6 inches apart. The glutei maximi were fairly strong. There was considerable weakness of the abductors of the thighs and partial contracture in the adductors of the left side. The extensors of the knees were in good condition, -and had suffered least in the general atrophy. There was almost complete paralysis of the flexors of the left foot. The anterior abdominal muscles were weak. When administering leg rolling, spasticity of the muscles could to some degree be felt. Such spasticity could not be detected in the arms or trunk. Measurements as follows : — Ankle, minimum just above Calf, maximum Thigh, minimum ... Wrist, minimum just above Forearm, maximum Upper arm, minimum just above elbow-joint Middle of upper arm Left side. Right side 15 cm. 15 cm. 22 „ 23 „ 25 „ 24i „ 11 „ 11 .. 15* „ "i „ 14 ,, 14 „ 13 ,, 13 „ Patient's intelligence was good, and her speech normal. She slept fairly well, but talked at intervals of a few minutes during most of the night ; sometimes she shouted and made violent movements, which occasionally woke her np. She also woke every time she was going to have a motion. The heart and lungs were normal. DISEASES OF THE NERVOUS SYSTEM 411 Treatment. (1) Sitting head exercise, PP. (2) Forwards lying back exercise, PP. (3) Half lying foot rolling, PP ; peroneal muscle kneading, PP ; eversion, PA, inversion, PR ; external popliteal and musculo-cutaneous nerve frictions, PP ; left foot flexion, PA, extension, PR. (4) Half lying leg rolling, PP, flexion, PA, extension, AR ; leg nerve frictions, PP. (5) Half lying double leg rotation externally, PA, internally, PR ; double leg abduction, PA, adduction, PR. (6) Half lying double arm rolling, PP, bending and stretch- ing, AR. (7) Half lying stomach exercise, PP ; shaking over the bladder, and sacral nerve frictions, PP. (8) Sitting left arm exercise, including supination, AR, pronation, PR; hand and finger extension, PA, flexion, PR; elbow extension, PA, flexion, PR, &c. (9) Sitting right arm muscle kneading, running nerve frictions, &c., PP. (10) Swim sitting double elbow pressing downwards, PR, upwards, AR. (11) Heave sitting double forearm extension, AR, flexion, AR. (12) Patient was made to practise walking round the room for a few minutes. Progress. — January 15. — Patient already able to walk better. February 4. — Patient able to walk better, and with feet straight {i.e., parallel to one another), in a room where there was a carpet, although she was unable to do so on bare boards ; she did not move her body so much while walking. Extensors of fingers and wrist of right hand better. Sensation in fingers during brachial plexus frictions in the left arm. February 6. — Sensation in fingers during brachial plexus frictions in the right arm. Abduction of shoulder-joint better ; patient able to hold out 1 kilo, at right angles with right arm, but not with the left. February 10. — Patient able to run a few steps very awk- wardly, but then obliged to stop or she would fall. 412 ELEMENTS OF KELLGREN'S MANUAL TREATMENT February 19. — Patient ran round the room four times (about twelve yards each time) in succession. February 28. — Patient able to pick up a pin off the table with right hand, although still with choreic-like movements. Involun- tary movements of arms much less. March 1 to 7.— Mild attack of scarlet fever (see p. 273), which seemed to have some beneficial effects. After it the incontinence of urine entirely ceased ; the eversors of the right foot and extensors of the right hand were stronger, and patient began to use the latter when eating. March 10. — Patient, when placed on the ground, able to get up without help and able, when standing, to lift things off the ground, although she did both awkwardly. March 24. — Walk still improving ; patient able to turn her feet out a little while walking. She lifted a cane chair off the ground, using both hands. Arms stronger. Concentric con- traction in the eversors of both feet. March 28. — Patient walked thirty times round the room (twelve yards each time) without stopping. Up to the present she had been wheeled in a mail-cart from where she lived to my villa (distance about 200 yards), but on this day she walked home with help. April 12. — Patient walked to and from her place of treatment without any help for the first time. April 24. — Patient walked with her feet turned outwards. Was able to lift a piece of fine wire off a table with her left hand. Involuntary movements of arms almost gone. Right patellar reflex normal, other reflexes about the same. Bladder quite well since March 8 ; still about 6 motions every twenty- four hours. Treatment changed on April 27, 1902, as follows : — (i) Sitting head exercise, PP. (2) Forward lying back exercise, PP; leg flexion, PP, raising, AE. (3) Half lying foot rolling, &c., as before. (4) Crook half lying double knee abduction, AR, adduction, PR, leg nerve frictions, PP. (5) Sitting arm exercise, as before. (6) Half lying stomach exercise, PP, shaking over the bladder, sacral nerve frictions, PP. DISEASES OF THE NERVOUS SYSTEM 413 (7) Reach grasp step standing knee flexion and extension, PA. (8) Stretch grasp standing drawing forwards, PP, spinal nerve frictions PP. (9) Ride sitting alternate rotation, AR, ringing, PP. (10) Practising to walk. The treatment had to be stopped on May 7, 1902. Examination. — May 7, 1902. — Patient was able to walk much better, and without assistance, at about the rate of an ordinary person {i.e., about three miles an hour). She turned out her feet while doing so, and was able to keep her arms hanging downwards against her sides. She could run about seventy- five yards without stopping, although this was done awkwardly. There was less inversion of the feet, and less internal rotation of the thighs. While sitting at ease the toes were kept together and the heels two inches apart. When her feet were placed as in the standing position patient could balance herself quite well. Sensory phenomena. — Less itching, no pins and needles sensa- tion. No diminution of sensation or wrong reference of touch. Sensation felt down the spine during cervical nerve frictions ; sometimes in the hand, and always in the upper arm during brachial plexus frictions ; and in the lower leg, although never in the foot, during internal popliteal nerve frictions. The pupils reacted very slightly to accommodation, and normally to light. Hearing : Right ear, |J, left ear, fg. Reflexes. — Micturition : normal, no more incontinence. De- falcation : three motions a day, but none during the night. When patient felt like having a motion she was able to restrain it for as much as half an hour. Skin reflexes absent. Other reflexes as follows : — Left .Side. RiKlit Side. Kellgreu's plantar sign slight slight Kellgren's crossed plantar sign . no no Tendo Achillis jerk no no Ankle clonus no no Patellar jerk less exaggerated . . less exaggerated than before than before Knee clonus Adductor magnus jerk Tendon reflexes in arms Motor functions. — Patient much less restless ; very few involuntary movements of the right arm ; hardly any of the left. Patient able to get up by herself without the aid of a chair, &c., Left Side. Right Sidi 16J cm. . 16 cm. m „ . .. 251 „ 27 „ .. 26 „ Hi „ . .. lli„ 17 „ .. 17i„ 14S ,, .. 15 „ Ui „ 15 „ 414 ELEMENTS OF KELLGREN'S MANUAL TREATMENT when placed in a lyinr; position on the floor. Muscles as a whole stronger. Patient able to perforin right forearm supination, AR ; able to pick up a needle at once with her right hand. When standing, able to bend forwards and touch her foot with her hand. Both hands used when eating. Patient able to partially dress herself, and when asked to fasten a button in front able to do so, exhibiting very few choreic movements, and taking five to ten seconds to accomplish the process. Patient able to keep her arms in hips firm and neck firm positions when stand- ing up. Eversors of both feet, flexors of left foot, external rotators and abductors of both thighs stronger. No spasticity of the leg muscles. Measurements as follows: — Aukle, minimum just above... Calf, maximum Thigh, minimum Wrist, minimum just above .. Forearm, maximum ... Upper arm, minimum just above elbovp-joint Middle of upper arm Intelligence better, general aspect of face more lively. Sleep unchanged. Sequelae of Meningitis (Syphilitic). 0. S., male, aged 32, came under the manual treatment on July 8, 1902. History of present illness. — ^Patient's occupation was that of worker in a brass foundry. Patient's father was ignorant of the nature of syphilis, but stated that from December, 1899, until February, 1900, his son seemed ill and weak, and had a number of large ulcers over his scalp and face, some of which were arranged in a kind of ring round the head ; they emitted a foul-smelling discharge. During the same period there were likewise ulcers on the mouth and tongue, and the patient was hoarse ; his breath smelt very foul. Patient's father had never noticed any sore on the penis or any rash. About February, 1900, patient began to complain of severe . headache, which was worse during the evening. On February 13, the headache was very bad and accompanied by throbbing feelings DISEASES OF THE NERVOUS SYSTEM 415 in the head, the pain causing patient to walk about holding his head between his hands. During the following day he was worse, but tried to work ; he was, however, compelled to go home. During February 16 he was so bad that he consulted a medical man, who gave him a prescription. While waiting at the chemist's to have it made up, patient suddenly felt very ill and lost consciousness. After a few seconds he came to and went through what looked very like an epileptic fit, although he was conscious meanwhile and did not fall into a stupor at its close. After it was over he was taken to a friend's house and soon became semi-unconscious and feverish, and had retraction of the head. During the same evening violent convulsions came on, lasting one and a half hours. A medical man was called in and diagnosed meningitis, stating that the temperature was 40° C. (104° F.) ; pot. iod. was prescribed. During the night a second attack of convulsions came on, lasting two and a half hours. After this patient was almost completely unconscious for a week ; l)ut subsequently he recovered slowly, and by about March 24 was so much better that he was allowed to return home. He was, however, by no means well at this date ; he seemed weak, apathetic, dull of understanding and slow in his movements. Since that time (March, 1900) he had slowl}^ become worse. Soon he only spoke when addressed, his reply being in a slow monotonous thick voice ; as time went on he could only be persuaded to speak with great difficulty, answering in whispers. After July, 1900, he ceased to speak, but still used to write m order to express any wish ; after a year he never wrote unless asked to do so, and at last, after November, 1901, he could not even be induced to write. During this time he gradually became slower in his movements, and his face assumed a look of deep depression. Treatment by medicine and baths did not have the least effect. Examination . — Ju\y 8, 1902. — Patient walked slowly with his head bent forwards and his eyes looking downwards, with an expression of intense melancholia. His face was flushed and the sterno-mastoids could be seen to stand out prominently. He was round shouldered and his chest was sunk in. He never spoke, smiled, or uttered any sound whatever. He was subject to continual twitching movements of the nose and mouth ; and the mouth was generally shaped as if pouting. He understood when 4i6 ELEMENTS OF KELLGREN'S MANUAL TREATMENT spoken to in a low voice, but executed orders to move, &c., very slowly. When told to sit down he would do so, and remain immovable for hours until told to get up and walk, whereupon he would again comply and slowly walk up and down until told to stop. There was a partially cataleptic state ; patient would keep his arms or legs in any position in which they were placed, however uncomfortable, for several minutes. Sensory phenomena. — There appeared to be complete absence of sensation ; patient would let wasps sting him and exhibit no sign. Patient's father informed me that this condition had existed for ten months past at the very least ; about nine months ago a medical man who was consulted tried the effect of a very strong electric current, but failed to elicit any sign. Sticking a pin into the patient's legs, arms, abdomen and face, and executing the strongest possible nerve frictions stimultaneously on both internal plantar nerves, both median nerves in the hands, cervical nerves on both sides, and the umbilicus, seemed to produce no impression whatever. The eyes, as mentioned already, always looked downwards, and patient did not move them upwards or sideways when told to do so. Patient could apparently see quite well, and got out of the way of chairs, &c., and he soon learnt to take up the proper initial position for his exercises. The pupils were somewhat dilated, and reacted normally to light ; the ophthalmoscopic ex- amination was negative. The hearing was apparently normal. Motor functions. — There was general weakness of all the muscles. Patient walked slowly, and only his left arm swung meanwhile ; be preferred using the left arm in preference to the right. He could lift up a chair and move it from one place to another when told to do so. In spite of the fact that sensation appeared to be wanting, patient's walk was normal excepting for slowness. He could walk to and from his house to mine every day ; the distance was about five miles and took him four hours. He declined, however, to walk all this at a stretch ; every mile or so he would stop for fifteen minutes, and could not be made to go on without a great deal of persuasion. He walked continually at precisely the same rate, and did not change even when told to walk more quickly. He showed no ataxic symptoms while executing his exercises. There was great stiffness of the muscles of the neck. Patient DISEASES OF THE NERVOUS SYSTEM 417 could not be induced to move his head either upwards, down- wards, or sideways ; the sterno-mastoids were hard and con- tracted, and the head could hardly be extended backwards on the cervical vertebra- in consequence. His food had to be cut up for liiui, as he was unable to use a knife and fork. When eating he opened his jaws very little, and masticated very slo^vly ; he had to be told every few minutes to take another mouthful, or he would stop altogether. The masseter muscles were hard and contracted. Patient could not be induced to protrude his tongue. He could neither be persuaded to make the least effort at shaking hands nor to grasp a pen when placed between his fingers. After a fortnight's treatment, however, he was able to execute his active gymnastic exercises quite well. The abdominal muscles were contracted. Both arm and leg muscles exhibited spasticit}' during passive movements at their joints. Beflexes. — Swallowing proceeded slowly. Defalcation: Patient was given castor oil each night, and during the next morning was told to go to the closet, which he sometimes did ; but on other occasions he did not move, nor go of his own accord later on. A great deal of straining was needed to effect a motion, and what passed was in small, round, hard lumps. Micturition was normal, but the urine was thick and darker coloured than normal. He never passed urine or fieces into his ciothos- Patient's father ran short of medicine six days before coming to see me, and his son had not had a motion during the week preceding the first application of the manual treatment. Other reflexes : — Ri.nlit. Left. Plantar reflex no no Kellgren's plantar sign no no Cremasteric reflex . . no no -Abdominal reflex yes yes Epigastric reflex yes yes Tendo Achillis jerk , yes yes Ankle clonus ... •3 or 4 jerks 5 or 6 jerks Patellar jerk exaggerated . exaggerated, althougli not quite so much as on the right side Knee clonu.s ... no no Adductor jerk .. no no Gluteal reflex . . no no Tendon jerks in arm . . no no 27 4i8 ELEMENTS OF KELLGREK'S MANUAL TREATMENT Patient's sleep was (jiiite good. There was no trophic disturli- ance beyond some wasting of tlie muscles. There were no ulcers anywhere. Patient's appetite was poor. He vomited every day ; every now and then this would get worse for a period of about two weeks, during which he would vomit after every meal. Tlie lungs and heart were healthy. The pulse, after patient had sat still for twenty minutes, was 60 per minute. There was no arterio-sclerosis. Treutincnt. (1) Sitting head exercise, including fronto-nasal running vibration, PP, bitemporal movement, PP, head rotation externall}', PP, internally PP ; head extension backwards, AR, flexion for- wards, PR ; jaw opening, AR ; closing, PR. (2) Reach grasp standing head fiexion, PR, extension, AR, cervical nerve frictions, PP. (3) Reach grasp stoop fall standing double elbow Hexion and extension, PA, executed with shoulder hacking, PP. (4) Forwards lying back exercise, PP. (6) Ride sitting alternate rotation, AR, nnging, PP. (6) Heave lean standing chest expansion, PA. (7) Heave grasp standing chest clapping, side shaking, PP. (8) Stretch stride standing bending forwards, PA. (9) Stretch grasp standing drawing forwards, PP, subcostal shaking, PP, abdominal intercostal nerve frictions, PP. (10) Half lying double leg rolling, PP, flexion, PA, extension, AR ; leg nerve frictions, PP. (11) Half lying stomach exercise, subdiaphragmatic suction, PP, practising deep respiration, PA ; prostate gland frictions, PP. In addition, patient sometimes received frictions simul- taneously on both internal plantar nerves, both median nerves at the base of the thumb, the anterior branches of the cervical nerves on both sides, and the umbilicus. The use of laxatives was prohibited. Progress. — July 14. — Patient did what he was told to do more quickly than before, and also moved more quickly from to-day onwards. After his head exercise his mouth seemed full of thick mucus, but he could not be persuaded to spit it out, and would not allow it to be removed by a handkerchief. July 25 to August 4. — Treatment interrupted. DISEASES OF THE NERVOUS SYSTEM 419 August 10. — Patient's intelligence slowly improving. No vomiting. Appetite normal. Motion every other day. September 13. — I had tried at intervals during the last month to make patient vprite his name, but did not succeed until this day. After very much persuasion on my part he v/rote it, and after being ordered continually for about five minutes to pronounce it, he managed to do so in a whisper. September 15. — After being asked to v/rite " yes" or " no " as to whether he felt better, patient wrote down (in Swedish): "I am better now," signing his name after the answer. He required much less persuasion than on the previous day, and, after being ordered continually for about five minutes, was able in a whisper to repeat what he had written. During the evening of the same day his father asked him to write down why he did not speak. He wrote (in Swedish) : " Of course it is because of the cramp." September 16. — Patient at length understood and carried out the order to spit out into a test tube the thick mucus from his mouth that collected after head exercise. The discharge was foul- smelling, very thick, and yellowish in colour. It did not either this day or at any subsequent date give the cerebro-spinal fluid reaction with Fehling's solution or acetic acid (see p. 186). September 19. — Patient read aloud a paragraph of a news- paper after a good deal of persuasion before and during the performance. Patient finished treatment on September 27, 190'2. Owing to my temporary absence I did not see him until October 6. Examination. — General condition much improved. He could stand and walk straighter. He could look up at the ceiling so that the central line of vision formed an angle of 4.5° with the ground. His expression was more intelligent. He would get up, walk about, and sit down again by himself. No cataleptic symptoms were left. The face was less flushed, the sterno- mastoids not so prominent. Patient sometimes talked in a low voice spontaneously, and generally answered when spoken to. Sensory phenomena. — Patient could feel stimuli, such as a light tap, on hands and feet ; if asked beforehand to say " now " when feeling it, he did so, the interval elapsmg before his doing so varying from one to four seconds. He could feel a pin-prick on the legs, arms, and trunk, but not a light tap. His face contracted 420 ELEMENTS OF KELLGREN'S MANUAL TREATMENT as if from pain during hard nerve frictions on different parts of the body, and on being asked whether the manipulation hurt, he answered " Yes." The pupils were less dilated, and reacted normally to light. Motor functions. — All his muscles were stronger. Patient could walk more quickly ; he walked from his home to the place of treatment in two and a balf hours. He was able to move his head fairly freely. He could sometimes be induced to cut up his own food with a knife and fork. He masticated more quickly, and did not need to be reminded to go on eating. The sterno- mastoids and masseters were less contracted. The tongue could be protruded, although tremulously. Patient shook hands when told to do so. He had of late been writing a few letters, and during this morning, quite spontaneously, wrote a letter of four pages to a friend. The handwriting was quite clear, the sentences quite well framed and with correct punctuation. Reflexes. — Swallowing slightly better. Deftecation : motion every daj'. Other reflexes : — Hight. Left. Plantar reflex ... ... ... ... no . • ., no Kellgren's plantar sign ... ... no ... no Cremasteric reflex ... ... ... no ... ... no Abdominal reflex Epigastric reflex Tendo Achillis jerk Ankle clonus Patellar jerk ... Knee clonus ... ... ... ... no ,, no Adductor jerk ... ... ... no no Gluteal reflex ... ... ... .. no .. . no Tendon jerks in arm ... ... ... no ... . . no Patient's intelligence had improved ; occasionally he laughed. Patient's appetite was better, and he was no longer troubled with vomiting. The pulse, after he had sat still for ten minutes, was 72 per minute. Bulbar Paralysis. Mrs. H., aged .52, came under the manual treatment on March 6, 1899. History of present illness. — About March, 1897, she found that speech was a little difScult. It gradually became more so, and then regurgitation of the food into the nose occurred. No cause could be assigned. Patient had however, become very yes yes yes yes no yes no no exaggerated . mark( DISEASES OF THE NERVOUS SYSTEM 4^1 weak and of low vitality about two and a half years previously in consequence of tlie death of one of the members of her family. Medical aid was not sought for some time, but as the symptoms become progressively worse, speech and swallow- ing becoming more and more difficult, a medical man was con- sulted, who diagnosed bulbar paralysis. This diagnosis was subsequently confirmed by several other medical men. During May, 1898, patient was told that her condition was hopeless, and that no improvement could be expected from any remedy what- soever. From then until March, 1899, she had been trying massage, baths, &c., but all to no purpose ; nothing seemed to effect the slightest amelioration. On March 6 I was called in. Examination. — The condition was well advanced. The face was mask-like and expressionless ; the mouth was half open, and saliva ran from it continually. There was complete facial paralysis on both sides ; the lips could not be moved ; the lower lip hung down. The tongue was nearly paralysed, only slight movements forwards and backwards being possible. Speech was almost impossible ; a few words like " Mamma " could be pronounced with great difhcuity, but otherwise patient could only utter a few disarticulate sounds and grunts. Patient could not swallow the saliva unless very much accumulated in the back of her mouth. Only liquid food (eggs beaten up in milk) had been taken for some months past, patient not daring to try and swallow anything solid or semi-solid. There were no fibrillary tremors of the face, but there were some of the tongue. The general condition of the patient was one of considerable weakness. The arms were more affected than the legs ; any communication the patient had to make was written by her. She was only able to write slowly and with tremors in the arm, so that what she did write could only be read with difficulty. Treatment. (1) Sitting head exercise, PP, including strong vibration over the medulla ; larynx and trachea shaking ; frictions on the facial, superior and inferior laryngeal, lingual, hypoglossal, and glosso- pharyngeal nerves, PP. 422 ELEMENTS OF KELLGREN'S MANUAL TREATMENT (2) Reach grasp standing bead flexion, PK, extension, AR, cervical nerve frictions, PP. (3) Forwards lying back exercise, PP. (4) Sitting arm exercise, PP, AR, &c. (5) Heave grasj) standing chest clapping, PP, side shaking, PP. (6) Half lying leg rolling, PP, flexion, AR, extension, AR ; leg nerve frictions, PP. (7) Half lying stomach exercise, PP. (8) Walk standing double arm circling, breathing, PA. March 22. — Some tremors were felt below the eyes. March 29. — Some movement of the facial muscles had re- turned. Patient could swallow a little better, and the word " Mamma " could be pronounced a little more clearly. April 10. — Some tremors in the soft palate were felt. All the muscles of the face which formerly were quite paralysed were able to move again, although not yet to their normal extent. April 20. — Movement in the soft palate commenced, and was visible. The food no longer regurgitated through the nose. The facial muscles were nearly normal in their movements, and the speech was slightly better. May 23. — The treatment had to be interrupted until July 1. The improvement was still being maintained, although slowly. The soft palate moved better, the voice was better, and tremors had begun in the larynx. The swallowing was a little easier, and the saliva came in far less quantity. The general condition was stronger. July 1. — Patient's condition had declined a little since May 23, and her speech had become worse again. The facial muscles, however, had not lost their tone or any of their power. August 30. — Patient's condition since July 1 had undergone hardly any perceptible change ; if anything a very slight improve- ment had taken place, as the amount of saliva had gradually diminished during the last month. The relatives of the patient did not wish her to continue the treatment, as they thought it could not do her any good. Against my advice, and also that of my colleague. Dr. A. Moller, she went home. I heard during the course of the next six months that a change for the worse had set in, and that after she left my hands the course of the disease was steadily downhill. Patient DISEASES OF THE NERVOUS SYSTEM 423 continued to become worse, and her food liad to be administered by means of a tube ; during May, 1900, she died from involve- ment of the respiratory centres. Disseminated Cerebro-Spinal Sclerosis. K. J., aged "27, occupation tailor, came under the manual treatment on July 1, 1899. History of present illness. — Patient denied syphilis. He said that he had been somewhat nervous all his life, but not to such a degree as to prevent his going through compulsory military service some years previously. He definitely attributed his illness as the result of a fall off a bicycle in May, 1H96 ; in consequence of his machine slipping he was thrown off, and he remembered receiving a severe blow, which caused him great pain in the head and left side, and was followed by loss of consciousness. After a few minutes he regained his senses, but felt very queer. The accident happened quite close to his home, and he walked home the rest of the way (about 100 yards). He felt very shaken and queer for an hour on arriving home, but then felt better again. He did not, however, altogether recover, and found when trying to bicycle again that he was shaky, had dif&cLilty in keeping his balance, and had to ride in the middle of the road ; if he approached the side where the ditch was he had to stop, or would have ridden into it. He likewise found that he had difficulty in walking. He could not walk as quickly as before, neither could he bicycle at more than half his usual speed. His strength gradually left him, and in the left leg pain began to be felt ; this became worse and worse, and he walked with still more difficulty, leaning over to the left side. Early in 1897 he found difficulty in keeping his balance when walking in the dark. Early in 1898 he noticed that his legs began to shake when engaged in any movement requiring exertion, and later on his left arm began to do the same. By August, 1898, these tremors appeared during such ordinary movements as walking, and they had also begun in his right arm and head. About Christmas, 1898, patient began to experience waves of heat passing through his body ; these were specially marked in his toes and hands. After three weeks of this, waves of cold 424 ELEMENTS OF KELLGREN'S MASUAL TREATMENT sensation came on and in time replaced the waves of heat. His general condition steadily became worse, and he said he had an attack of influenza in March, 1899, which made him very much worse in a few days. So far he had been able to do a good deal of work (although nothing very fine), but now he had to stop. Great pain appeared in the legs, and he shook very much when walking or moving his legs. In April, 1899, he sought advice for the first time; ' his medical man recommended electricity, and he was treated daily with it for seven weeks, from the beginning of April to the end of May. This, however, made him still worse. At the end of the time his physician told him that he had spinal cord disease and was in- curable. Patient then went to Dr. Engstrand, (the head medical man in Jonkoping), who diagnosed disseminated cerebro-spinal sclerosis, and told patient that his only chance was to try the manual treatment. Examination. — July 1, 1899 (by Dr. A. ^Nloller and myself). — Patient walked with great difficulty, and was unable to get along without the help of a stick. He kept his feet wide apart, the lines described by his heels being about one and a half to two feet apart, his knees quite straight and his trunk forwards, with his eyes fixed on the ground. He often reached with the other hand (the one not holding the stick) for support from chairs, tables, &c. When walking marked volitional jerks could be seen in his head, both arms, and both legs. His speech was slow, monotonous and syllabic ; his face moved but little when he spoke. Sensory functions. — Patient complained of a general feeling of cold, which occasionally seemed to pass over him in waves. A feeling of cotton wool under his feet had been present since May, 1899. He did not suffer greatly from pain ; when present it was located to a region in the lower limbs corresponding to the ex- ternal cutaneous nerves. There was continual headache. The muscular sense was diminished. Eye symptoms.— Patient complained that objects continually ' The fact that no advice was sought until this date must appear strange to many of my readers. The explanation is, however, that in Sweden in conse- quence of the small population (about 28 per square mile) and the small number of towns, persons living in the country are sometimes distant thirty miles or more from the nearest medical man, and that communication is frequently only by very bad roads. DISEASES OF THE NERVOUS SYSTEM 423 seemed to dance in front of him, then there was a pause after which they danced again. Patient had not anjr great difficulty in reading, although he said that the print danced in front of him. Nystagmus was present. The left eye reacted less to light than the right one. The reaction to accommodation was fairly good. Hearing, taste and smell were nornaal as far as could lie judged. Motor functions. — Reflexes. — Swallowing was normal. Mictur- ition : there was difficulty in starting the stream, and patient sometimes had to tr}' five minutes Ijefore he could get it to start, and at first it came in drops. There was also some difficulty in keeping the mine ; this was first noticed after the electricity treatment. Defascation : there was a motion generally every two days, although occasionally three days elapsed, and there was difficulty in getting it to start. There was no ankle or knee clonus on either side ; patellar, cremasteric and abdominal reflexes were slightly present on the right side. None of these reflexes were present on the left side. Voluntary movements. — The walk has been described. All voluntary movements were accompanied by volitional jerks, which absolutely ceased when the former ceased, and which became intensified during duplicate movements. Patient could eat with a knife and fork until April, but then gave up doing so as, in conse- quence of the volition jerks, he was unable to cut his food and unable to convey it to his mouth. He now ate with a spoon, and could only use his left hand in doing so. He could hardly sew at all with his left hand, as the fingers moved over one another in a rubbing kind of way when he tried ; he could not even hold a needle in his right hand. On being asked to protrude the tongue, he did so with jerks of that organ, and it exhibited fibrillary twitch ings, especially round the edges. Coordination. — The Eomberg symptom was present, the patient swaying for a few seconds first. With the eyes kept open he swayed a good deal, but did not fall. He could not walk in a straight line, but deviated considerably. With his eyes closed he could not Ijring his finger tips together. He wrote with his left hand with difficulty. Patient's memory was not so good as it used to be. He was very thin, weighing -59 kilos, in ordinary clothes. There was a C-shaped scoliosis with the convexity to the right, and the right shoulder was higher than the left. 426 ELEMENTS OF KELLGREN'S MANUAL TREATMENT The sexual power had been weak for a year or more, and since April, 1899, it had been quite lost ; no erection ever took place any- more. Treatment. (1) Eeach grasp step standnig knee Hexion and extension, PA, sacral beating, PP. (2) Stretch grasp standing drawing forwards, PP, vibrations over the bladder, PP. f3) Loin lean stride standing alternate rotation, AR, ringing, PP. (4) Forwards lying back exercise, PP. (5) Stretch side lying running nerve frictions, PP, leg lifting, AE, pressing down, PR. (6) Heave grasp standing chest clappmg, PP, side shaking, PP. (7) Stretch stride standing l_)ending forwards, PA. fn) Stride sit kneeling raising, AE. (9) Standing vertebral column stretching with AR at the patient's head. (10) Half lying stomach exercise, PP. On September 30, 1899, patient left, saynig that he would come back in three days ; he did not, however, do so until December 18, and in consequence no systematic examination was made. Patient, however, told me afterwards that he improved during the time of treatment ; he could walk more easily and did not need to use his stick so much ; he could even walk a few yards without it. He said that the jerks on voluntary movement were less in amount. On December 13 the patient returned to continue the treat- ment. He was in every respect worse than when he left on September 30. Owing to temporary illness on my part I could not make the examination until January, 1900. During that time, however, the treatment was administered by my colleague, Dr. A. Moller. Patient was already better than on December 13. He said that three days after leaving off the manual treatment in September, he began to feel worse, walk worse, &c. ; he got steadily worse until December 13 ; his condition then remained stationary for two days, and then he felt better again. From December 24 to 2Q he received no treatment, and on the 26th DISEASES OF THE NERVOUS SYSTEM 427 he felt that he was again getting worse. Since then, undergoing the treatment all the time, he had progressed steadily'. Examination. — Patient's walk was much worse than in September ; he had great difficulty in walking at all, even with tiie help of a person on one side holding him up, and the use of a stick in the other hand. He was lodging at a house about •200 yards from my own, and to walk that distance took at least ten minutes. In case of windy weather, patient had frequently to stop or he would be blown over, so bad was his ability to balance. He walked with his knees straight and his feet wide apart, hardly lifting his heels at all ; his arms were spread out and caught hold of doors, tables, chairs, &c., to assist his balance, and his whole body exhibited marked volitional jerks in trunk, liiubs, and head. Patient's speech was still slower, more monot- onous and monosyllabic, and the corners of the mouth twitched while he talked. Sensory functions. — -Patient had been subject to severe light- ning pains in his arms and head and lower limbs, specially the latter. He had continual headaches, which were so bad during December before he came to be treated that he could hardly see at all. There was impaired sensation in the feet ; patient con- tinually felt as if he were walking on cotton wool. When receiving forwards lying running nerve frictions he felt as if they were being administered through a blanket which deadened sen- sation. There was a continued feeling of formication in the upper dorsal region and in the pectoral muscles. The mouth and nose felt numb; there was considerable anaesthesia of the fifth nerve; very little sensation was felt on pinching hard the skin of the face. His feet and legs were always cold. There was no sensation in the feet during popliteal nerve frictions, and none in the spine during cervical nerve frictions. There was considerable diminu- tion in the muscular sense. Eye symptoms. — Nystagmus was very well marked, and patient said that objects danced more than they used to. The right eye reacted very little to light, and the left not at all ; the reaction of both to accommodation was not good. Patient could hardly read at all. There was no achromatopsia. Patient's taste was not so good as it used to be ; his hearing and smell were apparently normal. Motor functions — Eefiexes. — Micturition : there was difficulty 428 ELEMENTS OF KELLGREN'S MANUAL TREATMENT in getting the stream to start ; patient often tried eight minutes without success, and then he would stop and^try again later on. When he did succeed, the stream at first only came in drops. He had partial incontinence sometimes ; he always felt it coming on, and then could not hold his water for more than half a minute or so. Defjecation : rectal evacuation took place about every three days, occasionally every four. There was considerable difficulty in getting the motion to start, fifteen minutes having often to be expended in efforts. No ankle or knee clonus, patellar, abdominal, or cremasteric reflexes could be obtained on either side. Voluntary movements. — The volition jerks were much more marked. The gait has been referred to. During ride sitting trunk flexion, PR, extension AR, patient jerked very much indeed ; his head made a series of jerks forwards six inches and backwards three, and his gluteal region was lifted off the couch each time from three to six inches. About half-way through the first part of the exercise patient lost his balance altogether and had to put out his hands to catch hold of the couch to support himself. Patient had to be supported while trying to perform stretch stride standing, bending forwards, PA. Movements involving flexion of the knee-joints could hardly be done at all. An attempt to perform reach grasp toe standing double knee bending, PA, resulted in the patient falling almost at once. During all movements of resistance the whole body jerked very much. Patient used to feed himself with his left hand with a spoon, and had to bend his head forward to get the spoon into his mouth. If he did not the jerks of the left hand were so great that he could not bring his spoon up to his mouth. Even when bending his head forwards the contents of the spoon were often spilt. Patient could not sew at all, and when trying to cut out the scissors wobbled about so that he cut all wrong. He had great difficulty in writing, as he could hardly hold a pen, due to volitional jerks in his fingers. Coordination. — With eyes shut and feet together he would fall at once ; with eyes open and feet together he would sway for a second or so and then fall. Patient was very thin and his joints were very supple. When sitting on the floor with his knee-joints fully extended, patient DISEASES OF THE NERVOUS SYSTEM 429 could bend his body forwards so that bis mouth touched bis knees. His memor}' was worse than during July. His speech has been described. He had slept very badly during November, but since then satisfactorily. There were no volition jerks when trying to go to sleep, though when sitting still the head nodded to and fro continually. The scoliosis was better and the shoulders were of the same height. The pulse while patient was sitting down was 52 per minute. The treatment was about the same as before, with the addition of sitting head exercise, PP, and ride sitting trunk flexion, PP, extension, AR. Progress. — February 13, 1900. — Volition jerks not so marked. Patient walked up a flight of fifteen steps in my house, holding on to the bannister on both sides ; it was difficult for him to do so, but his efforts were successful. He said that he could not have done this two months previously. The walk was better. Sensation was present in the feet during popliteal nerve frictions. March 13. — With feet together and eyes shut patient swayed for a few seconds before falling. The volition jerks were slightly less. Patient was able to sew and cut out a little. April 12. — Patient did not fall at all with his feet together and his eyes shut. There was less difficulty with micturition ; a rectal evacuation had taken place almost daily during the last month. Frictions on the cervical nerves caused some slight sensation down the spine. The volition jerks were consider- ably less. April 20. — Patient had made very great progress during the last three weeks as regards his walk. On April 18 he moved to Huskvarna, and since then he had walked to and from my house once daily, the distance between his house and mine being about two-thirds of a mile. Patient during the time he was under treatment had occasion- ally, every fortnight or so, had a very bad headache, lasting from two to five days. At the conclusion of the headache his improve- ment was quicker for the next few days. Thus he had a rather bad attack just about April 1 before he made the considerable improvement between that date and April 20. May .5. — Patient said that he had not walked as well as to-day for the last fifteen months. 430 ELEMENTS OF KELLGREN'S MANUAL TREATMENT May ].5. — An attempt, for tlie first time, to get patient to perform reach grasp toe standing double knee bending, PA, failed ; he jerked np and down violently two or three times, and then would have fallen if I had not held him up. May 24 to 27. — Bad headache. May 28. — Some fever. May 29. — Patient said that he was able during the morning to stand alternately on each leg while putting on his trousers ; he had not been able to do this since February, 1898. June 8. — Patient's walk continued to improve. His head- aches were less severe ; be could to-day perform reach grasp toe standing double knee bending, PA, although it was very jerky. July 15. — Headaches still better ; patient has not felt as well for over two years. August 10. — Patient's right hand had so far recovered that he was able to use it for sewing purposes to do his tailoring, and while cutting out the scissors did not wobble at all. September 14. — Patellar reflex on left knee had returned to a slight extent. Cervical nerve frictions could be felt down the whole of the spine quite well, and during the exercise stretch half lying double hand and foot nerve frictions, PP, added about two months previously, sensation was felt through the whole of the body. The treatment had gradually changed, and was now as follows : (1) Sitting head exercise, PP. (2) Reach grasp step standing knee flexion and extension, PA, sacral beating, PP. (3) Stretch grasp standing drawing forwards, PP, intercostal nerve frictions and vibrations over the bladder, PP. (4) Head lean arch standing toe raising, breathing, PA. (.5) Forwards lying back exercise, PP. (6) Ride sitting trunk flexion, PR, extension, AR. (7) Heave grasp standing chest beating, PP, side shaking, PP. (8) Stretch half lying double hand and foot nerve frictions, PP. (9) Side lying running nerve frictions, PP, leg lifting, AR, pressing down, PR. (10) Half lying stomach exercise, PP. (11) Stretch stride standing bending forwards, PA. (12) Reach grasp toe standing double knee bending, PA. October 20. — Nystagmus only very slight. Patient could walk when the weather was not windy as quickly as any ordinary DISEASES OF THE NERVOUS SYSTEM 431 person. He did not jerk «o much when performing his gymnastic exercises ; this was specially noticeable as regards bis arms. Two days ago he left off eating with a spoon, and now ate with !i knife and fork. The tongue trembled at the edges, but did not jerk when patient protruded it. November 6. — Objects did not dance in front of patient any more, excepting slightly while reading. There was no nystagmus. December 8. — Slight knee clonus on left side, none on right. Some ankle clonus on both sides. Patellar reflexes : left normal, right not quite so marked. Examination. — December 20, 11)00. — Patient's walk much better ; he walked from his house to mine daily, this taking him fifteen to twenty minutes, the distances being about two-thirds of a mile ; even when it blew hard he could get along fairly well. He preferred walking with the aid of a stick, though the latter was by no means a necessity. When walking he bent his knees and lifted his heels off the ground, and placed his feet fairly well in front of one another, the lines described by his heels being about four inches apart. With the help of a stick he could place his feet when walking so as to describe a contmuous straight line ; he could not, however, do this without a stick. Some slight vohtional jerks were visible in his legs while walking, but none in his arms. Patient's speech was quicker and more lively : he raised and dropped his voice, and generally speaking talked like an ordinary person. Sensorij fiiitctivns. — No lightning pains experienced, but pain was often felt in the ankle-joints, lumbar region, side of abdomen and calves. The headache was much better. For the last three weeks or so great waves of heat had been passing over patient's body, similar to those of 1898, as already mentioned. The feet and legs were now always warm. There was sometimes a feeling of formication in the back of the head and the fingers and heels. The fifth nerve appeared to be normally sensitive. There was no numbness anywhere excepting to a slight extent under the feet, and this was only perceived during nerve frictions on them. The muscular sense was quite good. Sensations in the whole body were felt on receiving stretch half lying double hand and foot nerve frictions, PP, and on receiving cervical nerve frictions, and there was sensation in the feet during sciatic and popliteal nerve frictions. The sensory nerve conductivity in general seemed quite good. 432 ELEME.\TS OF KELLGREN'S MANUAL TREATMENT Eye sjiaptoiuh. — No nystagmus ; patient said that objects did not dance at all in front of him, nor did the lines of a newspaper during reading, unless he was very tired or had a bad headache. The pupils reacted fairly well to accommodation, but little to light. Patient's taste was normal again, but his smell not yet fully restored. Motor functions. — Ketlexes. — Micturition: this was now normal ; there was never anj' symptom of incontinence or reten- tion ; the stream started at once on making the effort. Defse- cation : there was no difficulty in getting the motion started ; there was an evacuation usually every day, occasionally every other day. No epigastric or abdominal reflexes. Kellgren's plantar sign and ankle clonus (four or five jerks) present in equal amount on both sides. Patellar reflex : left, exaggerated, followed by several jerks at knee-joint and ankle-joint ; right, present but not quite to normal amount. Knee clonus : left, one or two jerks felt ; right, there appeared to be the beginning of a jerk. Voluntary movements. — While patient was sitting still, the head did not nod at all ; when he walked quickly it did so very slightly. There were no jerks in the arm when patient held it out at right angles ; the fingers remained almost immovable. During a strong duplicate movement a few volitional jerks took place in the arms. During ride .sitting trunk flexion, PE, extension, AE, about twenty small jerks were given, each one bringing the patient back about half to one inch ; there was no tendency to fall or lose the balance. I'atient could perform stretch stride stand- ing bending forwards, PA, quite well without support. The only movements that caused much jerking were those which entailed contraction of the quadriceps extensor cruris, and the exercise head lean arch standing toe raising, breathing, PA. When patient stretched out his tongue there were no jerks, but fibrillar twitch- ings along the edge. Patient ate with knife and fork quite well. He could sew with his right hand. He could whistle and smack his lips. When speaking his face moved normally. Coordination. — Patient could walk fairly well in partial dark- ness. With eyes shut and feet together he swayed a good deal, but did not fall. With eyes shut and feet at right angles he swayed somewhat. With arms spread out and one foot off the ground he could balance for a second or two without fallmg. Patient said that he felt much stronger. He was still very thin, his weight being 61^ kilos. He had been perspiring very DISEASES OF THE NERVOUS SYSTEM 433 much at night for the last three weeks, ever since he began to experience waves of heat passing over him, as mentioned. His memory had improved during the year. The spine was straight, and no curvature could be seen. The pulse while patient was sitting down was 74 per minute. Erections of the penis often came on ; but he had not yet attempted coitus. Patient continued the treatment under my colleague, Dr. Harry Kellgren. On March 5, 1901, I again saw him. He had continued to improve. The pupils reacted both to light and accommodation, though better to the latter. There were no skin reflexes. Patellar reflex : left, normal ; right, less than normal. Ankle clonus, a very little on both sides. A little knee clonus on the left side. On April 4 Dr. Harry Kellgren wrote to me : " Patient walks better ; can run alone about seven or ten steps. He can do — Eide sitting falling backwards, breathing, PA ; head lean arch standing toe raising, breathing, PA ; stride sit kneeling raising, AR ; lying double leg flexion and extension, PA, perfectly steadily, without assistance and without the jerks which he had before. There are no cutaneous reflexes ; the knee jerks are the same as on December 20, 1900 ; there is no ankle clonus. Pupils react to light and accommodation." Subsequent history. — Treatment interrupted May 7 to June 1, 1901. After that not very much improvement took place; the improvement by January 3, 190'2, can be summed up as follows : No cotton wool feeling under the feet. No volitional jerks in head when walking fast. No knee or ankle clonus. Seminal emissions again taking place ; about once every three weeks. On January 3, 1902, patient, without having said a word previously, left off coming to me for treatment, as he had been persuaded to try some new remedy instead. I have not seen him since that date, and therefore have had no opportunity of making any examination as to his condition. Spinal Apoplexy during Secondary Syphilis, H. S., aged 51 years, male, came under the manual treatment on January 8, 1900. 28 434 ELEMENTS OF KELLGREN'S MANUAL TREATMENT History of ^^rescnt ilhiess. — During November, 1881, patient contracted primary syphilis, which was followed about February, 1882, by secondary symptoms — hoarseness, sore throat, ulcers in the mouth, swollen glands in the neck, condyloma at the anus, &c. During April, 1882, while standing still, patient was suddenly seized with pains in his back and twitchings in his limbs ; in a few minutes he felt his legs giving way, and he was obliged to lie down. In the course of about half an hour complete para- lysis of motion and partial paralysis of sensation ensued in both legs, together with incontinence of both urine and faeces ; there was also a sense of constriction round the abdomen. No medical aid could be obtained until eight days had elapsed, when patient had so far recovered that he could walk a little ; the medical man consulted told him that his spinal cord was affected. A very slow improvement gradually took place during the ensuing two years. After that, however, his condition remained almost unaltered, in spite of his having taken many different kinds of medicine, and having at intervals tried baths, electricity, and massage. Examination. — January 8, 1900. — Patient walked awkwardly, with the aid of a stick, and with his knees somewhat bent ; and he had a foot-drop which caused him to lift his feet high off the ground at each step (" steppage gait"). While walking he looked continually as if he were on the point of falling forwards. Sensori] 2^J>'£»o>ne>ta. — Patient complained of lightning pains in the course of both great sciatic nerves, of more or less continued pain in the front of both lower legs and outer side of both thighs, and of a sensation of constriction round the abdomen. There was cotton wool sensation under both feet. There was partial anaes- thesia of the feet on both plantar and dorsal aspects, and of the front of both lower legs ; in these areas there was delayed con- duction of sensation, sometimes as much as three or four seconds elapsing after the application of a pin prick before the sensation was felt. In the abdomen there was hyperesthesia at the level of the seventh and eighth intercostal nerves, with slight anassthesia and delayed conduction below this area. There was no sensation in the spine during cervical nerve frictions. The eyes reacted slightly to light and not at all to accommoda- tion. Both pupils were very small. Motor phenomena : — Keflexes. — Micturition: there was difti- DISEASES OF THE NERVOUS SYSTEM 435 culty in retaining the urine, and nocturnal incontinence was present. Defecation : There was constipation, often five or six days passing without a motion ; patient often had to strain hard for twenty to thirty minutes before he could get one. Other reflexes were as follows : — Riglit. Left. Epigastric skin reflex slight slight Abdominal skin reflex marked marked Babinsky's sign marked marked Kellgren's plantar sign yes yes Teudo Achillis jerk yes yes Ankle clonus 10-20 jerks 20-30 jerks Patellar reflex exaggerated much exaggerated Knee clonus .. 5-6 jerks 5-10 jerks Adductor jerk yes yes Crossed adductor jerk yes yes Semimembranosus jerk yes yes Semitendinosus jerk yes yes There was general weakness of all the muscles of the lower limbs ; this was especially marked in the anterior tibial muscles, patient being unable to flex his foot to a right angle, and in the abductors of the thighs patient being almost unable when in side lying position to abduct his leg. Patient could not correctly locate the position of his feet. With feet together and eyes shut, also with heels together but feet at right angles and eyes shut, patient fell at once. Patient could not walk in a straight line. He was quite unable to stand on one leg, even when balancing himself with his arms. He suffered from occasional attacks of prolonged twitching and spasms in his legs. Sensation and motion in the arms were unaffected. Sexual functions. — Since the onset of his illness patient had never had an erection or nocturnal seminal emission. There was atrophy of both testicles, this being especially marked in the case of the left one, which was hardly three-quarters of an inch in its long diameter. Testicular sensation was lost. A certain amount of chronic bronchitis had been present ever since the onset of the disease. The lower intercostal spaces were indrawn on inspiration. Treatment. The exercises were changed a little from time to time, but the following is a general specification : — 436 ELEMENTS OF KELLGREN'S MANUAL TREATMENT (1) lleach grasp step standing knee flexion and extension, PA, sacral beating, PP. (2) Stretch grasp standing drawing forwards, PP, frictions on the abdominal intercostal nerves, and shaking over the bladder, PP. (3) Ride sitting trunk flexion, PP, extension, AE. (4) Forwards lying back exercise, PP, leg flexion, PR, raising, AE. (5) Heave grasp standing chest clapping, PP, side shaking, PP. (6) Stretch stride standing bending forwards, PA. (7) Sit lying knee extension and flexion, PP, extension, AE, flexion, PR. (8) Side lying leg lifting, AE, pressing down, PR, leg nerve frictions and side length hacking, PP. (9) Loin lean stride standing alternate rotation, AR, ringing, PP. (10) Head lean arch standing toe raising, breathing, PA. (11) Half lying stomach exercise, prostate gland frictions, PP. Progress. — March 19. — Patient stronger, ^specially in the abductors of the thighs ; he walked more easily. With feet together and eyes shnt he swayed a good deal, but did not fall. There was less difficulty in retaining the urine. There was no nocturnal incontinence, although patient was obliged to get up two or three times every night to pass water. Rectal evacuation took place every second or third day. May 8. — Sensation and conductivity were normal over the front of the lower leg and dorsum of foot, and there was very little sensation of cotton wool under the feet. The Romberg symptom was almost gone ; patient swayed but little more than a normal subject. He was able to-day, for the first time for eighteen years, to stand alternately on each leg while putting on his trousers. July 7. — Patient steadily gaining strength. Cervical nerve frictions felt down the spine as far as the sacrum. Fewer light- ning pains. September 8, 1900. — Treatment finished. Examination. — Patient's walk better, although still, but to a less extent, exhibiting the peculiarities mentioned on p. 434. Sensor !i phenomena. — Fewer lightning pains, and less pain in DISEASES OF THE NERVOUS SYSTEM 437 the feet and lower legs. No ausesthesia or delayed conduction anywhere. Sensation of constriction round the abdomen not .so pronounced ; less hyperaesthesia in the area of the seventh and eighth intercostal nerves. Patient able to locate the position of his feet. No Romberg symptom (see below). The right eye reacted fairly well to light, but the left eye hardly at all. Both eyes reacted slightly to accommodation. When doing so the left pupil dilated somewhat irregularly. Both pupils were larger than when patient first came to me. Motor phenomena. — Reflexes. — Micturition: this was normal, except for a slight difficulty in retaining the urine. Defaecation : a motion took place every day or every other day, and little straining was needed in order to effect it. The other reflexes were as follows : — Epigastric sliiu reflex Abdominal skin reflex Babinsky's sign Kellgren's plantar sign Tendo Achillis jerk Ankle clonus ... Patellar reflex Knee clonus Adductor jerk ... Crossed adductor jerk Semimembranosus jerk Semitendinosus jerk ... The anterior tibial muscles and abductors of thighs were stronger. Patient could walk in a straight line. With his arms in stretch position he could balance himself on one leg for eight seconds, and he could even do so for two or three seconds with his eyes shut. There had been lio attacks of twitchings or spasm for the last three months. Sexual functions. — These showed very little improvement. No nocturnal emissions occurred ; occasionally a slight amount of erection took place. The chronic bronchitis had almost completely disappeared. Infantile Paralysis. In twelve out of fifteen cases of this disease in the chronic stage I found that there was distinct tenderness or even pain Right. Left. slight slight yes yes yes yes no no no no 5-10 jerks 10-20 jerks normal exaggerated . 1 or 2 jerks ... 1 or 2 jerks yes yes no no yes yes yes yes 43S ELEMENTS OF KELLGREN'S MANUAL TREATMENT during frictions over the kidneys from behind or over the renal plexus in front ; and almost always there was a greater tender- ness over the kidney on that side where the paralysis was greater. Case 1. G. L., male, aged 15^ years, came under the manual treat- ment on October 3, 1899. History of present illness. — During October, 1888, patient was one day attacked with shivering and fever, and about a day later complete loss of motion in both legs resulted, sensation, however, being unimpaired. After three weeks the right leg gradually recovered and became quite well, but the left one made scarcely any progress. No medical aid had ever been sought. Examination. — Patient was a small-sized subject. He walked with two crutches, using only his right leg ; his left leg hung limp and loose, and was two inches shorter than the other. The muscles of the whole left leg, from the gluteal region to the toes, were very much atrophied, as were also the muscles of the left side of the back from the ninth dorsal vertebra downwards. Voluntary movements of left leg. — Hip-joint : flexion, very weak ; extension, hardly any ; abduction, none ; adduction, slight; external rotation, none; internal rotation, none. Knee-joint: flexion, very slight; extension, none, the quad- riceps femoris for two inches above the knee-joint was a mere fibrous band. Ankle-joint : flexion, a trace ; extension, a trace. The abdominal and spinal muscles were very weak. There were no reflexes in the left leg. Sensation was quite good in the paralysed area. There was considerable tenderness over the bladder and left kidney. Treatment. (1) Sitting head exercise, PP. (2) Half lying left leg rolling, PP. muscle-kneading, PP, nerve frictions, PP. (3) Half lying left leg flexion and extension, PA. (4) Half lying left foot rolling, PP, flexion and extension, PA. DISEASES OF THE NERVOUS SYSTEM 439 (5) Forwards lying back exercise, PP. (6) Sitting trunk extension and flexion, PA. (7) Sit lying left knee extension and flexion, PP, extension, PA, flexion, PK. (8) Eeach grasp toe standing double knee bending, PA. (9) Reach grasp step standing left knee flexion and extension, PA, left sciatic nerve frictions, PP. (10) Stretch stride standing bending forwards, PA. (11) Half lying stomach exercise, PP. In the above prescription PA could not always be strictly adhered to, and in most cases the movements had at first to be given with assistance, in some even PP. Progress. — October 6. — In sit lying position patient could swing his leg to and fro a little, the maximum distance through which the swinging took place being two inches. He said that his back was stronger. October 8. — Patient's foot could be actively flexed and ex- tended, the toes passing through about one and a half inches of space (maximum). October 2-5. — Patient's leg was stronger than before; the atrophy as a whole was less. The quadriceps was larger, and much thicker over the lower third of the femur. October 31. — Patient could use his quadriceps to such an extent that he could maintain his lower leg, when in sit lying position, so that the heel was about three inches from the perpen- dicular. November 2. — Patient said that his back was still stronger. November 13. — Patient's calf muscles had developed propor- tionately more than his anterior tibial muscles. He could per- form foot extension, AR, although it was impossible to perform flexion with even very slight resistance. November 17.— Patient no longer needed support during exercise (6) for the extension, but required a little for the flexion. November 22. — Patient performed exercise (6) without assistance. December 20. — Treatment finished for the time being. Patient stronger. Treatment resumed on February 1-5, 1900. Condition: Patient was stronger in his back than when he left ; his leg ,had also improved slightly. The quadriceps femoris had in- 440 ELEMENTS OF KELLGREN'S MANUAL TREATMENT creased in size. Patient could resist while extension at the ankle was carried out ; could also manage half lying leg flexion, PA, extension, PA ; exercise (6) could be accomphsbed without assistance. March 20. — Patient could overcome a little resistance during foot flexion, AE, and could resist more during foot extension, PK. April ] 3 to 16. — No treatment. April 17. — Left foot slowly getting stronger. April 23. — Treatment suspended until May 7. May 7. — Treatment resumed. Prescription changed to the following : — (1) Sitting head exercise, PP. (2) Lying left leg flexion, AR, extension, PR ; flexion, PR, extension, AR. (3) Half lying left foot rolling, PP, flexion and extension, PA. (4) Half lying left leg rolling, PP, flexion and extension, PA. (.5) Half lying left leg rotation externally and internally, PA. (6) Forwards lying back exercise, PP. (7) Sitting trunk extension and flexion, PA ; sit lying left knee extension and flexion, PP, extension, AR^ flexion, PR. (8) Ride sitting trunk flexion, PR, extension, AR. (9) Reach grasp step standing left knee flexion and extension, PA, left sciatic nerve frictions, PP. (10) Reach grasp toe standing double knee bending, PA. (11) Crook half lying double knee abduction and adduction, PA. (12) Half lying stomach exercise, PP. If possible resistance was always oflered during the PA exercises, in order to increase their effect. May 23. — Flexors of thigh stronger. Gluteal muscles and abductors, however, still very weak. .June 2. — Flexors of thigh still improving ; gluteal muscles also improving. June 6. — Anterior tibial muscles improving considerably. July 10. — Not much improvement during the last month, excepting in the gluteus maximus. September 2-5. — Patient finished treatment. Examination. — Patient could now hobble along a little with- out any support. The muscles of the left leg as a whole were larger in bulk. Voluntary movements of left leg. — Hip-joint : flexion, good ; DISEASES OF THE NERVOUS SYSTEM 441 extension, fair; abduction, weak; adduction, good; external rota- tion, weak ; internal rotation, very little. Knee-joint : flexion, patient could flex it to an anf^le of 45° with the couch when in forwards lying position, and could offer resistance during knee extension, PR ; extension, patient could extend it through an angle of 45° when in sit lying position, and offer resistance during knee flexion, PR. Ankle-joint : flexion, patient could flex the foot to a right angle with lower leg; extension, very good. The abdominal and spinal muscles were stronger. There were no reflexes in the left leg. There was no tenderness over the bladder, but still some over the left kidney. Although this case was not by any means cured, it yet shows what can be effected even where a condition of almost total paralysis has existed for eleven years. Case 2. H. S., female, aged '20, came under the manual treatment on May 28, 1900. History of present illness. — During November, 1898, patient caught a cold ; two days later, after a feverish night, she found that she had lost the power of movement in both lower limbs, although sensation in them was intact. She recovered some use of them, however, and after a week could just manage to walk along with assistance. She was then taken to the hos- pital in Jonkciping, where the diagnosis of poliomyelitis anterior acuta was recorded, and the patient was given electricity daily for eleven months. According to patient's account, a good deal of improvement resulted in the left leg, but very little in the right. During November, 1899, she left the hospital, and since then her condition had remained stationary. Examination. — May 28, 1900. — Patient walked very slowlj' and with difliculty ; her feet were kept apart, they dragged on the ground, and with each step her body leant very much over to the other side. Patient said that she could not walk 300 yards without resting, and even walking 100 yards tired her very much. She complained of repeated attacks of cramp in the muscles of the feet and legs in general ; these often came on every two hours day and night ; she had to get out of bed and walk about, the 44:: ELEMENTS OF KELLGREN'S MANUAL TREATMENT pain being otherwise unbearable. I could not find any cause for these cramps. Voluntary movements. — The muscles of both limbs were flabby. Hip-joint : Flexion, right leg, not good ; left leg, not good. Patient could not lift either foot off the ground unless she leant very much to the opposite side. Extension, right, weak; she could not accomplish the second part of forwards lying leg flexion, PP, raising, PA ; left, rather weak ; she could just manage the second part of the exercise just mentioned. Abduction, right, hardly any ; in side lying position she could just lift her foot off the other leg ; left, fair ; in the position just mentioned she could raise her leg to form an angle of 20° with the horizontal. Adduction, right, good ; left, good. External rotation, right, weak ; left, weak; in half lying position patient lay naturally with her heels apart and her toes touching. Internal rotation, right, good; left, good. Knee-joint: Flexion, right, not good; left, quite good. Exten- sion, right, not good ; she could not in sit lying position extend her knee-joint fully ; left, quite good. Ankle and tarsal-joints : Flexion, right, fair; left, quite good. Extension, right, very weak ; even the slightest resistance pre- vented her executing this movement ; left, fair. Eversion, right, none ; the foot was kept inverted ; left, fair. Inversion, right, quite good ; left, quite good. The abdominal and spinal muscles were also weak. Patient could not perform sitting trunk extension and flexion, PA, with- out a good deal of help, and had to be supported durmg stretch stride standing bending forwards, PA, or would have fallen. There were no reflexes in either leg. No rectal or bladder disturbances were present. Treatment. (1) Eeach grasp step standing knee flexion and extension, PA, sciatic nerve frictions, PP. (2) Eide sitting trunk flexion, PE, extension, AE. . (3) Eide sitting double arm abduction, AE, adduction, PE ; arm nerve frictions, PP. (4) Stretch stride standing bending forwards, PA. DISEASES OF THE NERVOUS SYSTEM 443 (5) Forwards Ij'ing back exercise, PP ; leg flexion, PP, raising, AR. (6) Sitting trunk extension and flexion, PA ; sit lying knee extension and flexion, PP, extension, AR, flexion, PE. (7) Standing vertebral column stretching, AR at patient's head. (8) Half lying leg rolling, PP, flexion, PA, extension, AR. (9) Half lying double foot rolling, PP, flexion, AR, extension, PR ; foot eversion, AR, inversion, PR. (10) Half lying stomach exercise, PP. (11) Side lying leg lifting, AR, pressing down, PR ; leg nerve frictions, PP. Progress. — May '29. — No cramp during the night. May 30. — Patient said that she walked a little better. June 1 to 7. — No cramp. June 10. — A good deal of cramp. June 11. — Cramp disappeared and did not return again. June 15. — Patient walked one and a half miles, to accomplish which took her about two hours. Extension of both ankle-joints better. June 20. — Abduction at hip-joints better. July 7. — Extension of both ankle-joints better, that of the left very good. July 20. — Patient walked one and a half miles, partly uphill, in one and a half hours ; she then walked the same distance home in one hour. August 1.5. — Abduction of left leg very good. Eversion of left foot very good, that of right foot somewhat better. August 20. — Patient walked one and a half miles, over the same course as on July 20, in one hour ; she then walked home in fifty minutes. September 15. — Treatment suspended for fourteen days ; patient felt so strong that she took a situation as nurse-maid. October 1. — Patient returned to treatment ; from this day onwards she daily walked to and from her place of residence to my house in order to get treatment, distance nearly one mile ; at present this took half an hour each way. October 22. — Patient only took twenty minutes to walk to my house. November 5. — Patient walked with a slight waddling gait ; 444 ELEMENTS OF KELLGREN'S MANUAL TREATMENT the eversion of the right foot was not restored yet, hut the move- inents of the left leg were ahiiost noriiuil. There was a sHght patellar reflex on the left side. December 20.— Treatment finished. Examination. — Patient walked very much better ; she came from her house to mine in fifteen minutes. She only leant her body a little over to one side while walking. There was still a tendency for the feet to be dragged as she walked. Voluntary movements of right leg. — The muscles of the right leg were still flabby, but the left leg appeared to be quite strong, the only weakness being in abduction of the hip-joint and ever- sion of the foot. Hip-joint: Flexion, normal; extension, normal; abduction, good ; patient could abduct her leg to an angle of "20° in side lying position; adduction, normal; rotation, external, not good; internal, good. Knee-joint: Flexion, normal ; extension, normal. Ankle and tarsal-joints : Flexion, good ; extension, fair ; ever- sion, fair ; inversion, normal. The abdominal and spinal muscles were much stronger. Patient could perform sitting trunk extension and flexion, PA, quite well without help. There was a patellar reflex on the left side, but none on the right. Facial Paralysis of Peripheral Origin. G. A., male, age 7, came under the manual treatment on August 12, 1898. Historij of present ilbtess. — Patient had been running about very much on August 10 ; while in a great state of perspiration he took a bath in the lake close by. During the morning of August 11 his mother noticed that "his face was crooked." On August 12 it was still crooked, and he could not move the right side. Examination. — August 12. — There was complete paralysis of the right side of the face, which was smooth ; there was lachry- mation of the right eye, which remained open. There was no voluntary movement in the right half of the face, neither in the frontal part of the occipito-frontalis muscle, nor cheek, nor in the lower part of the face or lips. The mouth, when patient smiled, DISEASES OF THE NERVOUS SYSTEM 445 was drawn to the left side. The food collected in the right cheek during eating. Speech was not impaired. Taste and hearing were normal. Treatment. — Frictions on the facial nerve and its branches. Patient was urged to try and move his face voluntarily. Some general movements were added. Progress. — The first sign of movement came on August 20 ; patient could smile a little on his right side. The occipito- frontalis could be wrinkled by August 22. The face was normal by September 10, with the e.Kception that the right eye could not close properly. Treatment was suspended until October 6, when it was resumed by Dr. A. Moller, who cured the remaining eye weakness in three weeks. October, 1902. — The face was quite normal. Post-Diphtheritic Paralysis. (From notes taken by Dr. A. Moller and myself.) M. G., female, aged 13, came under the manual treatment on October 16, 1899. History of present illness. — When 8 months of age patient had scarlet fever and diphtheria, with convulsions. Soon after that the paralytic symptoms were first noticed. Many medical men were consulted, who all said that the condition was one of post- diphtheritic paralysis ; but none of their prescriptions seemed to have any effect. The condition remained almost unchanged during the next eleven years. Examination. — The appearance was one of continually half laughing, and the expression was somewhat vacant. The mouth could only be opened about half way. The speech was nasal, although the palate was fairly moveable. There was great difficulty in moving the tongue, as the frenum Imguse was much contracted. The tongue could only be protruded as far as the lower margui of the lower front teeth. Patient could not hft the tongue voluntarily. Salivation was very great in amount and continually running out of the side of the mouth. Patient could not pronounce 1, t, d, and n at all ; her speech was on the whole very thick and at times almost unintelligible. Swallowing was impaired. There was also partial paralysis of 446 ELEMENTS OF KELLGREN'S MANUAL TREATMENT the right upper extremity ; the supinators and extensors of the forearm were very weak, and patient could not oppose her thumb. Frictions on the brachial plexus in the axilla, ulnar nerve, &c., caused sensation only at the point of application, and even that was diminished. Treatment. The special exercises were : — ■ (1) Sitting head exercise and throat exercise ; and trigeminal, facial, lingual, and hypoglossal nerve frictions, PP. Patient had to practise daily protruding the tongue, saying the letters she had special difficulty in pronouncing, trying to breathe without letting the air escape by the nose, &c., in short, trying to do what paralysis had hitherto prevented. (2) Reach grasp standing head flexion, PE, extension, AR, cervical nerve frictions, PP. (3) Sitting right arm exercise, including supination, AE, pronation, PR; hand extension, AE, flexion, PE ; thumb adduc- tion, AE, abduction, PE, kc. (4) Stretch grasp standing drawing forwards, PP, kidney frictions, PP. Some general movements for the constitution were also pre- scribed. Progress. — November 15. — Less salivation ; swallowing easier. The tip of the tongue could be placed against the upper front teeth. L, t, d and n could be pronounced fairly well ; speech was much clearer. Supination better ; patient able to open doors needing supination to perform the turning of the handle ; she could not do so before on the same door. Extension of the lingers better. The thumb could be opposed to the tip of the little finger. December 8. — Improvement mantained. Patient compelled to discontinue the treatment for the time being. February 1-5, 1900. — Treatment resumed. Speech had slightly improved during absence, and the extensors of the forearm were stronger. March 15. — -Treatment again interrupted. The muscles of the forearm had continued to progress during the last month. April 3. — Treatment resumed. Frictions on the brachia DISEASES OF THE NERVOUS SYSTEM 447 plexus, even when not given strongly, caused sensation in the finger tips. April 14. — Treatment finished. Patient's general condition better. Saliva hardly ever ran from the mouth any more ; speech was fairly clear and intelligible, and t and d could be pronounced fairly well. Patient had begun to learn to write with her right hand ; both supination and extension of the forearm were very good, and household work could be done with both hands. The total duration of treatment was about three months and one week. I firmly believe that further improvement, little if at all short of complete cure, would have resulted had patient been able to receive the treatment uninterruptedly from the beginning and to continue it for another few months. Unfortunately this was impossible. Neuralgia and Neuritis. I have in several instances produced immediate and per- manent relief in quite fresh cases of supraorbital, ulnar, and occipital nerve neuralgia, which came to me within twenty-four hours of the first manifestations of the symptoms. The treat- ment was, locally, vibrations or frictions over the affected nerves. Case 1. — -Supraorbital Neuralgia. (From notes taken by Dr. A. Mciller and myself.) Mr. S., engineer, aged 22, came under the manual treatment on February 24, 1900. History of present illness. — On February 14 patient caught a cold, and severe constant pain set in in the right side of the fore- head; this became worse and worse. On February .17 the other side of the forehead was similarly affected. On February 19 patient consulted a medical man who prescribed antipyrin and rest at home for a week. On February 24, as patient's condition had been getting still worse. Dr. A. Moller and I were called in. Patient complained of severe pain in the forehead, which was intensified by a light friction on the supraorbital nerves. There was more pain in the nerve of. the left side. Treatment was 44S ELEMENTS OF KELLGREN'S MANUAL TREATMENT at once administered, consisting of vibrations over the nerves specified and a few general movements. Patient felt much better after it, and there was much less pain. On February 25 patient vs^alked to my house (distance one mile). He stated that one bad relapse of the pain had occurred during the night, lasting twenty minutes ; otherwise he had felt better. There was now no pain in the right supraorbital nerve, although in the left supraorbital nerve some remained ; the latter, however, disappeared entirely during" the treatment (which was in all essentials the same as before). February 26. — Very slight pain in the nerve of the left side. Treatment for the last time. July 20, 1900. — No relapse of any kind whatever had taken place. Case 2. — Sciatica. H. L., male, occupation metal polisher in a factory, aged 30, came under the manual treatment on August 19, 1902. History of present illness. — About nine weeks ago patient began to feel a continued boring pain in his right thigh and gluteal region; although at first slight this pain increased in intensity, and after about a fortnight was so bad that he could not sit without great inconvenience. He was by this time unable to bend forwards so as to pick up anything off the ground. His condition became worse, and on July 2-5 he was obliged to cease work at the factory. On August 15 he consulted Dr. Eric Hellberg, of Jonkoping, who recommended him for the manual treatment. No internal remedies were prescribed. Examination. — Patient walked with a slight limp. He com- plained of continued severe boring pain in the gluteal region and back of the thigh, occasionally extending down the back of the lower leg. He could sleep fairly well in spite of the pain. Occasionally there were acute exacerbations of the pain even when standing still, and the pain was aggravated by sitting down. Any movement that stretched the painful parts greatly increased the pain ; patient could for example in stretch stride standing position hardly bend the trunk forwards. There was great atrophy of the gluteal muscles and of the thigh muscles pos- teriorly, also to a less extent of the muscles of the calf. There DISEASES OF THE NERVOUS SYSTEM 449 was great tenderness to pressure over the course of the superior ghiteal, inferior gluteal, great sciatic and internal popliteal nerves, and to a less extent over the posterior tibial, internal plantar, and external popliteal nerves. Trcatinent. A great deal of attention has lately been directed to the muscular atrophy so constantly found in cases of sciatica even if of comparatively quite recent standing, and massage of the atrophic parts has been strongly recommended by many authors. This procedure, no doubt, in the course of time cures some cases, but I consider that this is due chiefly to the manipulation reach- ing the affected nerve, and not to the stimulation of the muscles. It must be borne in mind that in bad cases of sciatica a primary neuritis has to be dealt with, and that the atrophy of the muscles is secondary to it. The manual treatment is directed towards the real seat of the disease, i.e., the great sciatic nerve itself. Local treatment is administered, consisting of vibrations, and as soon as possible frictions, on the nerve itself, and movements of the leg to pro- mote the circulation of the blood and lymph. Movements are also prescribed that alternately stretch and relax the affected nerve. General constitutional exercises are added in order to raise the vital activity of the body as a whole. The following was the prescription in the case which is being described : — (1) Reach grasp step standing right knee flexion and extension, PA, given with vibrations on the gluteal and great sciatic nerves, PP. (2) Forwards l3'ing back exercise, PP ; right leg flexion, PP, raising, AE. (3) Stretch stride standing bending forwards, PA. (4) Stretch half lying running nerve frictions, PP, kidney frictions, PP. (.5) Ride sitting trunk flexion, PR, extension, AR. (6) Lying right leg flexion, PR, extension, AR. (7) Half lying right leg rolling, PP, flexion, PA, extension, AR. (8) Stride sit kneeling raising, AR. 29 450 ELEMENTS OF KELLGREN'S MANUAL TREATMENT (9) Half l3'iiig stomach exercise, PP, followed by vibrations ou the affected nerves, PP. In exercises (1) and (9), frictions were substituted for vibrations at the earliest opportunity, as soon as the pain had sufficiently diminished. Progress. — September 80. — Treatment finished. Owing to mj^ temporary absence I did not see patient until October 5, 1902. Examination. — Patient much better. No pain in the gluteal or great sciatic nerve or its ramifications on standing still or on sitting down. After walking a good deal a little pain sometimes felt. Patient able to execute stretch stride standing bending for- wards, PA, until his finger-tips touched the ground ; a little pain caused meanwhile. Atrophy of muscles considerably less. No tenderness to pressure over the superior and inferior gluteal nerves ; some still remaining over the great sciatic nerve in its upper part. Patient returned to his work at the factory on September 27, 1902. Further history unknown. Case 3. — Sciatica. (Treated by Dr. A. Moller and myself.) K. K., male, aged 40, whose occupation was that of attending to a screw-making machine, which necessitated his standing all day, came under the manual treatment on August 29, 1898. History of present illness. — About September, 1897, patient began to suffer from pain in his right thigh posteriorly in the region of the great sciatic nerve ; the pain became steadily worse, and about Christmas began to disturb his sleep. It now also appeared in the back of the lower leg, became continuous, and was of a gnawing character. By the end of March, 1898, it was so bad that he was obliged to stop work. He tried a two month's treatment of Ling's medical gymnastics, but this had no effect ; he then underwent a bath and massage cure for five weeks, which made him somewhat better ; on coming home he tried to work again. The sciatica, however, at once got worse, and in a fortnight was as bad as before ; patient was obliged once more to cease work. Examination. — Patient looked pale and thin. He said that he DISEASES OF THE NERVOUS SYSTEM 451 slept veiy little indeed, the pain in his leg being so bad. He walked with a slight limp, and complained of constant severe gnawing pain in the back of the right thigh and lower leg in the area of the great sciatic, internal popliteal, and posterior tibial nerves. This was greatly aggravated by movement, even by flexion forwards of the head, which caused the pain to be felt also in the region of the internal plantar nerve. From stretch stride standing position, flexion forward of the trunk could not be executed through more than an angle of about 10°, on account of the great pain induced. There was great tenderness to pressure along the whole of the right great sciatic nerve and its prolonga- tion down to the internal plantar nerve, the tenderness in the latter, however, not being so marked as in the former. There was considerable atrophy of the whole of the muscles of the right thigh and lower leg, the difference between the maximum circumferences of these parts being about an inch less than the corresponding ones on the left side. The treatment was on the lines already indicated. Progress. — After the first week improvement set in and patient could sleep better. From the eighth day onwards the pain became less severe, and patient could perform the move- ments that stretched his affected nerves with increasing facilitj'. By the end of September he could execute stretch stride standing bending forwards, PA, so far that at the conclusion of the flexion his finger-tips touched the ground. By the middle of October the pain had quite disappeared, and there was no appreciable difference in the circumference of the thigh and lower leg of the right and left legs respectively. Patient continued treat- ment until October 30, when he was quite cured. I saw patient again during August, 1902. He said that after standing very much his right leg felt more tired than his left ; otherwise there was nothing abnormal to be recorded, and he had never had the slightest return of the pain. Mental Overwork. Miss H., schoolmistress, aged 32, of a nervous temperament, came under the manual treatment on April 24, 1900. History of i^resent illness. — Patient had for some months past had a great deal of brain work to do, and for three weeks past she 453 ELEMENTS OF KELLGREN'S MANUAL TREATMENT had felt day by day progressively weaker. On April 21 during the morning and afternoon she had about ten distinct attacks of a peculiar nature ; she suddenly had amaurosis and felt as if she were being lifted up and thrown down on the ground. A few seconds later vision returned, and she was surprised to find that she was still standing up. Great heat and heaviness in the head accompanied these attacks, and was present to a minor degree during the intervals ; between the attacks she had considerable difficulty in walking, as her legs felt shak}'. Palpitation came on every now and then. On April 22, having slept very badly, patient woke up feeling very weak, and with a commencing sensation of sickness. As it was Sunday, she did not need to go to school, and became a little better during the day as she was able to keep quiet. On April 23 she went to school again, and just managed to get through her work. The sensation of sick- ness was worse. Her appetite remained good, however, during the whole time, and she usually felt better after eating. On April 24 she again went to school, but felt so bad that she had to lie down on a sofa in the teachers' room soon after arriving, and later on was compelled to go home. Examination. — April 24. — Patient complained of weakness, headache, feeling of heat ni the head, and unpleasant sensations in the epigastrium. She stated that she was totally unable to read, and the very idea of doing so was almost unendurable. Patient was thinner than when I saw her fourteen days previ- ously, and looked somewhat anajmic. The head was very hot to the touch, specially in the occipital region. There had been palpitation at intervals during the day. Treatment. (1) Sitting head exercise, PP. (2) Forwards lying back exercise, PP. (3) Ride sittmg trunk flexion, PR, extension, AR. (4) Ride sitting double arm abduction, AR, adduction, PR ; arm nerve frictions, PP. (5) Ride sitting alternate rotation, AR ; ringing, PP, added later on. (6) Stretch stride standing bending forwards, PA. (7) Half lying leg rolling, PP, flexion, PA, extension, AR. DISEASES OF THE NERVOUS SYSTEM 453 (8) Sitting trunk extension and liexion, PA. (9) Half lying stomach exercise, PP. Progress. — After the first treatment patient felt better ; she slept very well during the ensuing night. April 25. — Patient still quite unable to attempt reading. After treatment she was rather giddy all the evening (time of treat- ment was 5 p.m.) until 11 p.m., when she retired to bed and slept well. April 30.— Steady improvement daily since April 26. Patient still felt very weak, but her head was a good deal better. May 1. — Patient had slept badly. Condition otherwise about the same. May 2. — Patient felt ver}' well ; the school class came to her house and received an hour's instruction. May 3. — Patient very well. No class to teach during the day, as the work was done by others. May 4. ^Patient drove to school and gave an hour's instruc- tion. She walked home (distance fifteen minutes' walk). May 5. — Patient walked half way to school, and drove the other half. She gave one hour's instruction and then walked home. May 6 (Sunday). — Treatment. Patient almost well. Palpita- tion during the evening. Ma}' 7. — Patient walked to school and back, and taught for four hours. Her head remained quite well, biTt was easily fatigued. May 8. — Patient rather tired after the efforts of the previous day. Head as on May 7. Occipital region much less hot than on April 24. May 9. — Condition about the same. Four hours teaching at school. May 10. — Patient slept excellently during the night ; walked to school quite easily ; felt very well and did her four hours' work with ease. She was tired in her head during the afternoon ; this disappeared after treatment. May 11 and 12. — Treatment both days. Patient was able to teach as usual on both days. On 12th (Saturday) she felt tired, but revived during the afternoon. May 13. — No treatment. Very tired all day. May 14. — Diarrhcea early in the morning and once again at 454 ELEMKXTS OF KELLGREN'S MAM UAL TREATMENT night ; after it patient felt better than on any occasion since her ilhiess. May 16, 17, 18, 21, 23. — Patient very well indeed during all this week. Treatment once daily. May 25, 28.— Treatment. May 29. — School finished for the term. June 1, 2. — Treatment. Patient very well indeed. June 5, 6, 8, 9, 11, 12, 14, 1.5.— Treatment. Patient very well indeed. June 15. — Treatment finished. Patient normal. Sequelae of Influenza. Case 1. (From notes taken by Dr. A. Moller and myself). Miss T., aged 23, schoolmistress, came under the manual treatment on October 13, 1899. History of present illness. — Patient had influenza in February, 1899, and ever since then, when teaching, had had violent neu- ralgic attacks either in the supraorbital or lateral frontal regions, with headache all over the head, and much pain in her eyes. These attacks generally came on after she had been working about half an hour, and lasted sometimes all day, i.e., from 9 a.m. to 5 p.m., at which hour school finished ; sometimes they lasted all the evening as well. Patient's general condition had become weakened and nervous. Examination. — The supraorbital and great occipital nerves were very tender to the touch. The head felt hot. Patient was very sensitive over the whole body wherever I touched her. Treatment. — The special movements prescribed were : — (1) Sitting head exercise, with vibrations over the affected nerves and the eyeballs, PP. (2) Keach grasp standing head flexion, PE, extension, AR, cervical nerve frictions, PP. (3) Forwards lying back exercise, PP. (4) Stretch grasp standing drawing forwards, PP, kidney frictions, PP. Besides these, some other general movements were added. Patient could not leave off her teaching, and continued it daily as usual. DISEASES OF THE NERVOUS SYSTEM 455 Prof/ress. — October '25. — Neuralgia less intense. October 26. — Only one neuralgic attack, lasting half an hour. November 2. — No neuralgic attack at all during the previous day. Headache better. November 9. — Hardly any headache during the last week. November 11. — Patient considered herself practically cured. No headache. August, 1900. — After very hard work a slight pain was occasionally felt in the supraorbital region ; otherwise patient had kept quite well since the treatment was finished. Case "2. (From Notes taken by Dr. A. Moller and myself.) J., aged 39, coachman, came under the manual treatment on November 19, 1899. History of present illness. — Patient drank a good deal. During March, 1899, he had an attack of influenza, and got up too soon. Since then he had continually suffered pains in his head and body generally; these pains were not always in the same place, but moved about. He sometimes had attacks of giddiness and buzzing sounds in his head. There was general nervousness and weakness. Patient was shaky on his legs. His appetite had remained fairly good, but both taste and smell had become deficient. His condition had existed almost unchanged since getting up after influenza, in spite of various remedies pre- scribed. Nothing particular could be elicited on examination, except that the back of the head was hot to the touch. Tj-eafincnt. (1) Sitting head exercise, including ear vibration, PP. (2) Eeach grasp standing head flexion, PB, extension, AK, cervical nerve frictions, PP. (3) Heave grasp standing chest clapping, PP, side shaking, PP. (4) Forwards lying back exercise, PP. (5) Half lying double foot rolling, PP, flexion and extension, AE. 456 ELEMENTS OF KELLGREN'S MANUAL TREATMENT (6) Stretch grasp standing drawing forwards, PP, kidney frictions, PP. (7) Stretch stride standing bending forwards, PA. (8) Half lying double leg rolling, PP, flexion, PA, extension, AE. (9) Half lying stomach exercise, PP, spleen frictions, PP. Progress. — November 20. — Patient easier in his head. November 28. — Patient still easier in his head. December 2. — No pains in body ; some buzzing sounds in head ; patient otherwise felt quite well. December 16. — Smell and taste restored ; patient very nearly normal. Treatment interrupted until January 4, 1900. January 4, 1900. — Patient returned to treatment, as the pains in his body had recommenced. February 7. — Occasionally feeling of giddiness (perhaps due to the alcohol taken). Patient otherwise normal. Treatment finished. June, 1902. — Patient keeping quite well. Chronic Headache.' Mrs. C, aged 88, came under treatment on November 1, 1900. History of present illness. — Ever since the age of 15 she had suffered from continual headache, with only occasionally a few days intermission. The usual course of the headache was as follows : On waking up there was not much. After getting up a slight amelioration sometimes occurred ; then usually an acute attack came on ; in about two minutes violent pains were felt in the back of the head ; these spread up to the vault of the skull and settled there as well. Then the temples and eyes became affected. Usually patient was so bad that she could not even read. During the afternoon the pains subsided somewhat ; but during the evening they often became worse again. Patient continually suffered from cold legs and feet, and slept badly. Movement and exertion usually aggravated the condition; mental worry nearly always did so. At meal times there was, if anything, a slight improvement. ' A great deal has of late been made of the supposed fact that chronic neuralgic headache can be caused by myositis of the neck muscles ; massage of these muscles has been recommended, and good results appear to be obtained thereby. To my mind the muscular affection is secondary to a primary nerve irritation, and much quicker results can be obtained by nerve vibrations. DISEASES OF THE NERI'OUS SYSTEM 457 Treafment. (1) Sitting head exercise, PP. (2) Eeach grasp standing head flexion, PR, extension, AR, frictions on the second cervical nerves, PP. (3) Ride sitting double arm abduction, AR, adduction, PR, arm nerve frictions, PP. (4) Half lying double foot rolling, PP, flexion and extension, AR. (5) Forwards l3'ing back exercise, PP. (6) Stretch half lying double arm rolling, PP, bending and stretching, AR. (7) Sit lying knee extension and flexion, PP, extension, AR, flexion, PR. (8) Pleave grasp standing chest clapping, PP, side shaking, PP. (9) Half lying leg rolling, PP, flexion, PP, extension, AR. (10) Half lying stomach exercise, PP. Progress. — November 8. — Headache had been gradually dimin- ishing during the week. None at all during this day. November 14.— No return of the headache until this evening. November 15. — No headache. November 16. — A little headache, as patient had worked very hard during the previous evening. November 17. — No headache. November 28. — No headache since November 17. Feet and legs now always warm. Patient said that she felt very well. Treatment finished. July, 1902. — No return of the headache. Epileptic Seizure while Bathing. A., factory worker, aged 3-5, came under the manual treat- ment on July 19, 1900. History of present illness. — Patient had sufl'ered from chronic rheumatism for a year. Two months ago he was operated on for htemorrhoids, and since then had not felt very well. On July 19, 1900, he went to bathe. Suddenly he felt a kind of cramp in his feet, and he remembered feeling it passing up his legs and abdomen. He felt he was falling and screamed for help. After 458 ELEMENTS OF KELLGREN'S MANUAL TREATMENT that he remeinhered nothing moru. The friends of the patient told me that they saw him fail back into the water and dis- appear entirely from view, and about five minutes elapsed before they were able to get him out. When at last they did he was in a state of opisthotonic rigidity. They tried to perform arti- ficial respiration. Dr. Harry Kellgren and I were sent for and arrived at .5.45 p.m., fifteen minutes after the accident. Examination. — Patient profoundly unconscious, markedly cyanotic, eyes closed. Breathing laboured and stertorous ; con- tinued spasmodic movements of the head, which was turned to the left side. Every now and then the eyes opened and I saw that both pupils were widely dilated. Occasionally spasmodic movements of the lower limbs took place, and at fairly regular intervals of a few seconds patient screamed aloud, his cry some- what resembling that heard in cases of tubercular meningitis. The pulse was imperceptible. We immediately performed artificial respiration, together with cervical and other nerve frictions ; the breathing became less laboured, but the movements of the legs increased and spasmodic movements of the ami commenced. The spasmodic movements of the head were now such that the head was-turned alternately to both sides, not only to the left as before. I now noticed when patient opened his eyes that the left pupil was larger than the right. At 6.45 p.m. patient was still profoundly unconscious, the spasmodic movements and screaming continuing. We took him to a house close by and placed him sitting up. Every few seconds patient rose on his feet with a scream and assumed a position of opisthotonic rigidity ; this would last a second or two and then he would collapse into the chair again. A wrist-drop in the right hand was noticeable for the first time. The treatment was now chiefly stimulatory nerve frictions. 7.30 p.m. Wrist-drop disappeared, patient somewhat quieter ; pulse very weak, so rapid that it could not be counted, and very irregular. Patient was driven in a carriage to his house, and on the way he every now and then, after a preliminary scream, assumed a position of opisthotonic rigidity, or sat up for a few seconds, collapsing again as before. 8 p.m. Patient arrived home and we set him in an armchair. The spasms of the body and extremities were getting less, except- DISEASES OF THE NERVOUS SYSTEM 459 ing m the head ; and there was less screaming. Patient was still quite unconscious. Treatment was now chiefly directed to draw- ing blood away from the head. 9 p.m. Faint gleams of returning consciousness. 10 p.m. Patient fairly quiet ; but cardiac action feeble and irregular. 11 p.m. Patient quite quiet. Heart's action very weak, 136 per minute, irregular and intermittent. Respiration still some- what laboured ; many bubbling sounds in the chest plainly audible at a considerable distance (even ten feet away in the room adjoining). The treatment since 9.30 p.m. had been chiefly heart vibration and shaking. It was necessary to main- tain treatment over the heart continuously ; as soon as it was stopped the heart became very irregular, and the treatment had to be resumed at once. From 9.30 p.m. to 1 a.m. the heart could not be left alone for more than five minutes, without giving signs of speedy failure. July 20. — 12 midnight. Heart treatment was gradually given to a less and less amount from now onwards. Pulse 126, more regular. 12.1-5 a.m. Pulse 120, still very weak. 1 a.m. Pulse 116, weak, more regular. Patient opened his eyes when his name was called very loudly. 2 a.m. Patient tried to speak once or twice. Pulse 108 ; heart treatment only administered every few minutes for a minute or two. Patient, who had been sitting in an armchair till now, was put to bed. 2.30 a.m. Patient had turned over in bed twice by himself. Heart treatment only very occasionally. 3 a.m. Patient recognised his wife. Pulse 100, regular. 3.30 a.m. Patient suddenly vomited a large amount of coffee- coloured liquid, after which he recovered consciousness. He remembered nothing since he fell down into the water, and wondered why I was in attendance. 4.4.5 a.m. Patient quite rational again. Pulse 85, strong, regular. I ceased treating patient and went home. During the afternoon I saw patient again. He was weak and sore in the places where we had given him the nerve frictions, but otherwise was fairly well. I executed some movements for the lungs and heart. 46o ELEMENTS OF KELLGREN'S MANUAL TREATMENT July 21. — Appetite normal. Patient went for a short walk. Treatment at home once. July 22. — Treatment at home once. Patient felt very well ; better than before the seizure. July 23. — Patient walked to my house and back (distance about one mile each way). Some rheumatic pain was present in the left toe and shoulder. Treatment henceforth once daily, consisting of : — Movements of joints, such as : — (1) Half lying double arm rolling, PP, bending and stretch- ing, AE. (2) Half lying double leg rolling, PP, flexion, PA, extension, AE. (3) Half lying double foot rolling, PP, flexion, AE, extension, AE. Also respiratory movements, stomach exercise, PP, kidney treatment, PP, head exercise, PP, &c. Progress. — The pains in the toe and shoulder disappeared after a few days, and after appearing in other joints for a few days more finally vanished. On July 23 patient returned to his work at Huskvarna factory. August 23. — Patient felt very well indeed, much better than for years past. He had had no rheumatic pains at all during the last ten days. He had during the time under treatment got rid of a slight chronic catarrh of the lungs, from which he had suffered all his life. Treatment finished. August, 1902. — Patient still keeping very well. A case of "Gunshot Injury to the Musculo-Spinal Nerve," treated by Henrik Kellgren, has been described by Owen in the Lancet for November 18, 1876, pp. 709, 710. In the same journal for December 3, 1876, p. 806, is found a letter from Sir W. H. Broadbent, stating that he saw the case before and after treatment, and certifying to the speedy recovery that took place. CHAPTER IX. DISEASES OF THE LOCOMOTOR SYSTEM. Chronic Rheamatism. Case 1. Mr. K. N., builder, aged 40, came under the manual treatment on November 9, 1900. Historij of present illness. — Patient thought that he first began to suffer from rheumatic pains about five years previously ; he could not ascribe any particular cause. Since that time he had been sufi'ering from pains and stiffness, particularly in the shoulders, back and hip-joints, but also in the arms. There was difticulty and pain on movement at first, although a good deal of movement relieved the condition for the time being. He had never been very bad, and had never had to stop in bed. The rheumatic symptoms were absent during the warm months in the summer time, but always returned during September or October, and remained until the following summer. Patient had never consulted any medical man about his rheumatism, and had never taken any internal or external remedies. For the week preceding November 8 patient had been suffering from rheumatic pains in his left hip and right shoulder. On November 8 he became very hot over some work, and while walking home thought he caught cold. The pains mentioned became much worse in the course of the night ; he slept very badly, perspired a good deal and thought he had some fever. The next morning, November 9, he had pains in his back, both arms, and both hips, especially the left. The left hip was so painful as to prevent him walking. Patient drove from his house to mine, distance two-thirds of a mile. Examination. — Patient walked with the help of two sticks and tried to use his left hip as little as possible. He complained of great pain in that joint, also in the spinal muscles and both shoulder-joints. Pressure over the hip-joint, a blow on the foot with patient lying down and his knee-joints extended, and any 462 ELEMENTS OF KELLGREN'S MANUAL TREATMENT attempted movement of tlie affected joints greatly increased the pain. There was no fever ; the pulse while patient was lying down was 88 per minute. Treatment. Vibrations followed by passive flexions, extensions, &c., at the affected joints. A great amount of traction was necessary, or the patient would not have endured the exercises because of the pain ; the movements had to be executed through a very small radius at first, and their extent gradually increased. In this way, after about ten minutes or so, I could administer passive leg roll- ing with very little pain to the patient. I also executed move- ments at the other joints of the body, stomach exercise and kidney frictions, PP, forwards lying back exercise, PP. Progress. — After the first treatment patient was so much benefited that he could walk home. November 10. — General condition better. No pain except in left hip. Treatment as before ; patient better after it. November 11. — No treatment. November 12. — No pain in left hip or anywhere else. Treat- ment. November 15. — Treatment finished. No rheumatic pains anywhere. During the evening of the 15th, patient worked out in the open air in cold weather, and became wet through with perspira- tion. No bad effects resulted, however. March, 1902. — No return whatever of the pains. Case 2. E. A., male, aged 35, came under the manual treatment on August 18, 1902. History of j] resent illness. — Patient had for years past, every now and then had rheumatic pains in his legs and arms, although until the present attack never so badly as to prevent his working. Patient had never taken any internal or external remedies for these pains. About July 15 he was caught in the rain, and during the same evening felt pain and stiffness in his lumbar region, aggravated during flexion forwards of the trunk. Kheu- matic pains in the arms and legs, which had been present to a slight extent all the previous week, became intensified. After a DISEASES OF THE LOCOMOTOR SYSTEM 463 lew days there was considerable difficulty in walking, and sleep was disturbed by the pains at night. His condition remained about the same until August 15, when he was attacked by shiver- ing and perspiration, and his rheumatic pains were much worse. He felt very ill and had to cease work ; he went home and stopped m bed all day, also during the following day. On August 18 he had so far recovered that he could walk to my villa for treat- ment, although this caused him a good deal of pain. Examination. — Patient walked with a limp in his right leg. Great tenderness to pressure over the right gluteal region round about the great trochanter, along the outer side of the thigh, and in both lumbar regions. Pain and stiffness on movement of the right leg, especially during excentric extension and during flexion forwards of the trunk. Patient also complained of some pain in the arms and left leg, although no specially tender spots could be determined. Temperature 99 '2°. Treatment. — Kneading of the affected parts, movements at joints to exercise them, forwards lying back exercise, stomach exercise, and kidney frictions. . Progress.— On August -I'l patient was so much better that he resumed work. On August 23 all the pain, stiffness and tender- ness had entirely disappeared, and patient said that he felt quite well and strong. Treatment finished. September 14. — No return of the pains. It will be observed that in both the foregoing cases neither of the patients had ever tried any remedies for their rheumatism previous to their coming under the manual treatment. To this fact I attribute the rapid result. My experience has gone to show that the more previous medicinal treatment rheumatic cases have had the harder they are to cure by the manual treatment. Per- sonally, I should hold out more prospect of cure to a long-stand- ing case of rheumatism that had never received any treatment than to a similar case of shorter duration which had undergone a good deal of medication. Case 3. — Lumbago. In fresh cases of luinbago, in which spasmodic contraction of muscles seems to play an important part,' relief can sometimes ' Cf. Georgii, " Kiuetic Jottiugs," 1880, p. 175. 464 ELEMENTS OF KELLGREN'S MANUAL TREATMENT be produced at once by vibrations, followed by frictions on the affected muscles. In old cases, however, where the condition appears to be more an inflammatory process of the whole or part of the erector spinse, the treatuient is as follows : — (1) Manipulations such as vibrations, frictions, hackings, beat- ings over the affected muscles. (2) Exercises during which the affected muscles are alter- nately passively elongated and shortened. (3) Exercises during which the patient has to put the affected muscles into excentric and concentric contraction. (4) Exercises to stimulate the nerves to the affected muscles. (5) Exercises to benefit the constitution as a whole. S., aged 27, employed in the iron founding department in the factory at Huskvarna, came under the manual treatment on May 29, 1900. History of present illness. — He said that he first began to feel stiff in his back about a year previously ; about six months later this began to cause him serious inconvenience. A medical man he consulted diagnosed rheumatism and gave him powders. These did not help him at all, and he got worse and worse. Early in May he ceased work for a few days, but the rest did him no good ; after this he tried again to work, but was com- pelled to stop after a few days. Another medical man who was consulted diagnosed lumbago, and recommended gymnastic treatment. Exaininatio)!. — The spinal muscles on both sides from the sacrum up to the sixth dorsal vertebra were very hard and resis- tant and painful on manipulation ; even slight flexion of the trunk forwards or sideways caused the patient much pain, as did any other movements involving active contraction or stretch- ing in the muscles referred to. Treatment. (1) Kide sitting trunk flexion, PK, extension, AR. (2) Stretch stride standing bending forwards, PA. (3) Leg lean stride standing trunk flexion, PR, extension, AE. (4) Side lying leg lifting, AH, pressing down, PR. (-5) Lying double leg flexion, AE, extension, PR. DISEASES OF THE LOCOMOTOR SYSTEM 465 (6) Lying leg flexion, PR, extension, AR. (7) Hip lean walk standing lateral flexion, PR, extension, AE. (8) Reach grasp step standing knee flexion and extension, PA, sacral beating, PP. (9) Forwards lying back exercise, PP, with extra frictions over the most painful muscles, PP. (10) Half lying stomach exercise, PP. Progress. — Patient felt better immediately after the first treat- ment, and he continued to improve mitil June 16, when he caught a feverish cold. He was treated at home on June 16, 17, and 18. On June 19 he was able to come to me again, and the only pain he felt was over the left side of the sacrum when the muscles of this region were placed into action. On June 80 he was practically well ; on July 2 he began to do some light work at the factory. He continued the treatment a few days longer to prevent relapse, after which he left me quite cured, and shortly afterwards worked again in the iron founding department. April, 1902. — No return of the symptoms. Case 4. — Lumbago. I., aged 35, worker in Huskvarna factory, came under the mamial treatment on October 3, 1899. History of present illness. — -Patient had been suffering on and off for five years from lumbago, which had been a good deal worse the last six months. Examination. — There was considerable pain during any move- ment entailing flexion of the trunk ; and on trying to get up after sitting still, sharp stabbing pains were felt in the lumbar region. The muscles of the back from the sacrum to about the second dorsal vertebra were hard, resistant, and tender to pressure. The treatment was on the same lines as in the foregoing case, and was administered daily until November 3, 1899, when patient left, being cured, and having no more pain or stiffness of any kind. August, 1900. — Patient said that during the past winter he had occasionally felt slight pain on movements entailing strong flexion forward of the trunk, otherwise he had been quite well ever since the treatment finished. 30 466 ELEMENTS OF KELLGREN'S MANUAL TREATMENT Case 5. — Lumbago. J. O., male, aged 38, came under the manual treatment on February 9, 1901. History of j'^'esent illness. — Patient had been suffering from pains in the lumbar region for about three weeks, brought on, he said, by catching cold. Examination. — There was tenderness over the back on both sides from the sacrum to the tenth dorsal vertebra. There was difficulty in bending the trunk forward, and in any other move- ment involving the lumbar and sacral spinal muscles. Treatment. — Commencing with vibrations on the affected muscles, I increased the strength of the manipulation until they became strong frictions. These at first caused pain, but not afterwards. The patient was then given stretch stride standing bending forwards, PA, with hacking over the lumbar region, after which he said that the pain had entirely disappeared. August, 190'2. — No return of the symptoms. Partial Rupture of the Gastrocnemius Muscle. Lieutenant E. C. F., student at the Central Gymnastic Insti- tute, came under the manual treatment on October 21, 1898. History of present condition. — On October 13, 1898, after having finished an hour's pedagogical gymnastics, patient was seized with sudden pain in the right calf. The pain increased in amount, and the day after the seizure patient noticed that there was considerable swelling over the middle of the calf, and that the part was discoloured, being dark blue. He was able to walk a little, though with much difficulty and pain, and came to the cliuique at the Institute. Examination. — The middle third of the calf was deeply dis- coloured from extravasated blood, and there was considerable swelling. There was great tenderness along the inner border of the gastrocnemius and soleus in the middle third of the calf, and the affected part was hotter than normal. Passive extension of these muscles caused pain. Prof. Murray, who was consulted, diagnosed ruptura musculi in the right calf. Treatment and progress. — The patient did not come under my DISEASES OF THE LOCOMOTOR SYSTEM 467 care at once, but was treated by massage, fat being first duly rubbed on the part manipulated. This was continued daily from October 14 to 20 inclusive, with very little or no benefit. On October 21 I treated the case for the first time. I chiefly administered vibrations over the part, nerve frictions on the internal popliteal nerve, and running vibrations and frictions given centripetally. On October 22 patient was much better, and had but little difficulty in walking. No treatment was administered on October 28. On October 24 the pain had almost completely disappeared, and patient fenced for an hour with only slight inconvenience. The next day he practicall}^ felt no pain. I continued treating him, however, until October 81, on which day the last of the extravasation and discolouration dis- appeared. April, 1899. — Calf muscles quite normal. Chronic Synovitis, &c. (From notes taken by Dr. A. Moller and myself.) B. J., male, aged 25, came under the manual treatment on February 14, 1900, suffering from chronic synovitis in the right knee, chronic pains in the abdomen, chronic laryngitis, headache and general depression. History of present condition. — About two years previously his right knee had begun to be stiff and to hurt him ; it got better after some time, but then worse again. He went on alternately getting better and worse, and then became steadily worse for three months before he came to me. At intervals, when his state was at its worst, he was unable to stand on his right leg with the left foot lifted off the ground, and much pain was caused on walking. For about fourteen months he had suffered almost constantly from pains in his epigastric and left hypochondriac regions, and the slightest touch over these parts often hurt him very much ; sometimes he could hardly bear having his clothes on. At Easter, 1899, he consulted a medical man, who diag- nosed gastric catarrh and prescribed Carlsbad water and castor oil. Patient felt somewhat better during the period he took these remedies, which was one month ; but as soon as he left off he was just as bad again. Often when the pain in his abdomen was very 468 ELEMENTS OF KELLGREN'S MANUAL TREATMENT bad, relief was to some extent obtained by getting a friend to give him a kind of abdominal massage Every now and then the patient became very depressed and could not be cheered up. A chronic laryngitis had been present for some years ; it had been rather worse during the last few months. Examinatio)i. — Patient could not stand on the right leg and lift up the left one without considerable pain in the right knee ; he walked in a somewhat limping way, hurrying over the time he had to support himself with his right leg. He could not flex the affected knee further than a right angle without very much pain, and even flexing it so far hurt him. There was a very tender spot just internal to the right patella. The muscles of the abdomen were contracted and hard, especially in the subcostal triangle, where there was great tenderness to touch. Treatment. {!) Eeach grasp step standing knee flexion and extension, PA, right knee-joint vibration and kneading, sacral beating, PP. (2) Stretch grasp standing drawing forwards, PP, shaking of the pit of the stomach, PP. (3) Sitting trunk extension and flexion, PA ; sit lying right knee extension and flexion, PP, extension, AE, flexion, PE. (4) Stretch lean toe standing double knee bending, PA. (.5) Heave grasp standing chest clapping, side shaking, PP. (6) Stretch grasp toe standing hanging, breathing, PA. (7) Forwards lying back exercise, PP, right leg flexion, PP, raising, AE. (8) Stride sit kneeling raising, AE. (9) Half lying double leg rolling, PP, flexion, PA, extension, AE, right knee-joint kneading, PP. (10) Half lying stomach exercise, PP. (11) Sitting head and throat exercises, P.P. Progress — March 14. — Patient said that his leg was much better ; during ordinary movements there was hardly any pain ; sharp pain only came on with extreme flexion. The tenderness over the spot internal to the patella was much less. Patient, how- ever, very soon became tired in the aflected knee when walking. DISEASES OF THE LOCOMOTOR SYSTEM 469 The pains in tlae abdomen had disappeared; patient said that his digestion had not been in such good order as now for some years. The abdominal muscles were less tense, and there was but little tenderness in the epigastrium. Patient no longer suffered from headaches. The laryngitis was better. April 7. — The right knee had continued to improve, and became less tired on exertion. April 14. — The only abnormal sj'inptom in the right knee was a feeling of fatigue, which, however, only came on after a con- siderable amount of walking Patient said that his digestion was splendid. He was free from headaches; the depression had left him, and he was continually in a cheerful state of mmd. The laryngitis was slightly better. Treatment finished. July 18, 1900. — Patient was still feeling very well, although still liable to slight stiffness in the right knee after much walking. July, 1902. — Condition of knee unchanged. Abscess in the Antrum of Highmore. Mrs. A., aged 48, came under the manual treatment on April '21, 1900. Historij of present condition. — Patient noticed on April 12, 1900, that her nose felt stuffy on the right side, and that, on getting up, a quantity of bad-smelling yellowish matter came out of her nostril ; each subsequent morning a great deal of dis- charge came, as patient, in consequence of weak cardiac action, always slept on her right side. Leaning her head over to the left side usually induced a discharge, or if already in progress it was increased in amount. Examination. — Patient complained of continued pain in the right supramaxillary region, and discharge from the nose. On Hexing the head laterally to the left, some thick yellowish bad- smelling pus appeared from the nostril. The right cheek was red and tender to touch, and there was pain on slight percussion. Treatment. — The special treatment for the antral abscess was as follows : — Sitting right superior maxillary vibration with the patient's head flexed to the left ; vibrations on the root of the nose ; right trigeminal nerve frictions ; right facial nerve frictions. 4;o ELEMENTS OF KELLGREN'S MANUAL TREATMENT Prof/iess. — April '2o. — Discharge less. Less tenderness over the clieek. April 24. — No pain in cheek whatever. May 28. — Patient had been feeling very vi^ell dnrin<,' the last month ; the discharge, however, had remained almost constant in quantity. On this day it was thinner than usual. June 2. — Discharge still thinner. June 4. — Discharge looked like water. June 5. — No discharge, no tenderness. Nose apparently normal. June 16. — Treatment finished. No discharge or tenderness since the 5th. August, 1902. — No return of discharge. Dislocation of the right Humerus. (From notes by Dr. A. Moller and myself.) S., aged 48, worker in Huskvarna factory, came under the manual treatment on November 15, 1899. History of preaent condition. — Patient had on three previous occasions dislocated his right humerus, i.e., (1) in 1886 ; (2) in 1896, when chloroform was used in order to replace it ; and (3) in November, 1898. The present dislocation occurred at 9 a.m. on November 15. Examination. — 10 a.m. same day. There was dislocation forwards of the right humerus ; the right arm hung limp and useless, there was a depression below the acromion, and the elbow- projected backwards. The head of the humerus could be felt lying under the pectoralis major. There were no signs of swelling. There was very much pain in the region of the joint, and patient was pale and shivering. Treatment. — The dislocation was reduced as follows: — The arm was lifted high up into stretch position ; then, asking the patient to resist as much as possible, I performed adduction of the right arm with traction away from the shoulder, bringing the whole limb somewhat forwards as I went. While doing this Dr. Moller pressed in the head of the bone. The object of this pro- cedure was : first, by traction to bring the head of the humerus over the rent in the capsule ; the exertions of the patient to resist DISEASES OF THE LOCOMOTOR SYSTEM 471 caused the deltoid to act as a fixed point of a lever, one end of which was from that point to my grasp on the forearm, and the other from that point to the head of the humerus. The bringing downwards and forwards of the distal end of the arm caused the head of the humerus to pass upwards and backwards into the capsule again. Immediately after reduction of the dislocation the following movements were administered on the joint : — Vibrations to prevent inflammation : duplicate movements at the shoulder- joint in order to exercise, and thus strengthen, the muscles weakened by the displacement, taking care to avoid those which would cause the head of the humerus to pass downwards, i.e., such movements as the following were given : — Swim sitting right elbow pressing downwards, PR. Sitting right forearm flexion, AR, extension, PR. Sitting right arm traction sideways, PP, followed by the patient trying to draw his arm towards himself, with AR. General constitutional treatment was added. Patient was told to move his arm as much as he liked, taking care only to avoid movements of abduction, and was sent home without any bandage or fixation being applied. Progress. — November 16. — Patient slept very well ; there was only very slight pain in the shoulder, which was not increased during movement. November 18. — Patient could lift his arm to almost the perpendicular {i.e., stretch position). No pain. November 21. — Some extra strengthening exercises were added to the treatment. Patient went back to work and did nine and a half hours of metal polishing. November 28. — Patient had been at work all the week, and said that his arm felt quite well. December 14. — Patient continued treatment until this day. He left with his shoulder-joint quite normal. In addition to this, his digestion was much improved by the stomach exercise which he had received every day. Patient's shoulder remained quite well until March 31, 1900, when on lifting up a weight with his right arm, he redislocated it in the same manner. He immediately came to Dr. Moller and myself, who reduced the dislocation and treated it in the same way as on the first occasion. After treatment hardly any pain. No bandage was used. 472 ELEMENTS OF KELLGREN'S MANUAL TREATMENT April 1. ^Slight pain anteriorly in the front of the shoulder. Active and duplicate movements executed. April 'A. — Treatment for the last time. Patient normal. He returned to work again. March, 190"2. — There had been no further dislocation. Dislocation of left Humerus. E. S., female, aged 8j, came under the manual treatment on July 7, 1902. History ofjjresent condition'. — The day previously patient had been playing about ; while running after another child she fell down on her left arm and hurt herself very much. She screamed with pain, which she located in the left shoulder. She kept her left arm still, and any attempt to move it only caused increase in the pain. Her mother was unable to undress her in consequence and she went to bed with her clothes on. She slept very badly and the following day complained of still more pain. Examination. — I first saw patient at 4 p.m. on July 7. The left arm hung limp ; movements of the shoulder were very painful and limited to a slight amount of abduction. The shoulder was flattened and there was a depression below the acromion. The head of the humerus could be felt anteriorly below the coracoid process, and the humerus hung so that the elbow was more posteriorly than normal, and somewhat away from the trunk. Treatment. — Reduction was effected fairly easily with very little pain by means of abduction to a right angle combined with traction away from the trunk, and then adduction with PE while the head was pressed in. Immediately afterwards the following movements for the shoulder were executed : — (1) Sitting left arm circling, PP. (2) Sitting left shoulder vibration and muscle kneading, PP. (3) Sitting left arm traction sideways, PP, drawing arm towards trunk, AR. (4) Sitting left arm abduction to right angle, PP, adduction, PR. No bandage or fixation was used. Patient left, feeling no pain whatever, and could be seen to swing her left arm backwards and forwards as usual when walking. DISEASES OF THE LOCOMOTOR SYSTEM 473 Progress. — Jul)' 8. — No pain. No swelling. Movements of arm quite free. Abduction through 135°, PA, and the reverse movement, PR, was performed. Jul}' 9. — Patient able to perform abduction through 180°. July 11. — Movements quite normal. No pain or swelling. Shoulder normal. Treatment finished October, 1902. — Shoulder had continued quite normal. CHArTER X. DISEASES OF THE GENITO - URINARY ORGANS AND LABOUR. Sudden Incontinence of the Bladder. G. J., female, aged 1'2, came under the manual treatment on December 2, 1900. History of present illness. — Patient had had cystitis two years previously. During December 1, 1900, sudden incontinence of the urine set in without any apparent cause, and the urine ran incessantly the whole day until patient went to bed, when the incontinence ceased. On trying to sit up, or while performing any movement requiring exertion, the urine flowed again. Patient did not sleep well, and on December 2 the incontinence again came on as before. I was sent for at 11 a.m. Examination. — Nothing objective could be made out, except- ing that patient's urine was discharged involuntarily on trying to sit up in bed, and on exertion. The urine itself was normal. Treatment and progress. — I administered suprapubic vibra- tions, frictions on the umbilicus and sacral nerves, and stomach exercise. At their close patient could sit up and move with- out the urine flowing. She got up, and the incontinence did not return. March, 1902. — No return of the incontinence had taken place. Menorrhagia. A. L., aged 27, domestic servant, came under the manual treatment on May 9, 1902. History of present condition. — -Patient enjoyed good health until 1891, when at the age of 16, menstruation of the thirty- day type commenced, and ever since the third time of its onset it had lasted for nine days, during which the discharge was very profuse. This caused her to become weak and anemic, and she suffered continually from headache, which was very bad indeed DISEASES OF THE GENITO-URINARY ORGANS, &c. 475 during her periods. In spite of various internal remedies (iron, quinine, &c.), the condition liad persisted unchanged. Examination. — Patient looked very anaemic and pale, although she had not the typical chlorotic facies. On examination there was nothing objective beyond tenderness over both ovaries, especially on the left side. Internal examination not made. There was no constipation ; heart and lungs were healthy. The last period of menstruation was from April 30 to May 8. Treatiiicnf. (1) Half lying double foot rolling, PP, flexion and extension, AK. ("2) Stretch stride standing bending forwards, PA. (3) Forwards lying back exercise, PP. (4) Reach grasp stoop fall standing double elbow flexion and extension, PA, shoulder hacking, PP. (5) Sit lying knee extension and flexion, PP, extension, AR, flexion, PR. (6) Ride sitting alternate rotation, AR, ringing, PP. (7) Reach grasp step standing knee flexion and extension, PA, sacral beating, PP. (8) Half lying leg rolling, PP, flexion, PA, extension, AR. (9) Crook half lying double knee abduction, AR, adduction, PR. (10) Half lying stomach exercise, ovary vibrations, PP, sacral nerve frictions, PP. No exercises were omitted during the menstrual periods, as depletion of the pelvic organs was aimed at. Progress. — May 30. — Very little headache since the treatment commenced ; general condition stronger. Menstruation began this day. June 4. — Menstruation ceased after having lasted only six days ; less headache meanwhile than usual. June 30. — No headache at all since June 4. Patient's anaemic look was almost gone, and she said that she felt quite well and strong. Menstruation commenced to-day. July .5. — Menstruation ceased, again having lasted only six days. Very slight headache during the third and fourth days, otherwise none. July 9. — Treatment finished. Patient normal, excepting for a 476 ELEMENTS OF KELLGREN'S MANUAL TREATMENT slight amount of teiideniess ovei' tlie left ovary ; tliat on the rif^ht side had quite disaj^peared. Septemher 16, 190'2. — I heard from patient's mother that menstruation had lasted for only six days on the last two occa- sions. Threatening Mammary Abscess- Mrs. C, aged 28, came under the manual treatment on October 27, 1901. History of present condition. — Patient was delivered of her first child on October 13, 1901 ; the presentation was an E. 0. P. and the labour was normal. On October 17 patient was up and about, and I ceased attending her on October 24. Patient's lactation was normal until October 27, when she slept badly and had much pain and sense of weight in the right mamma. I was sent for in the morning. Examination — The right mamma was indurated, swollen, somewhat red, painful, and extremely tender in three spots, one near the nipple, one in the outer upper quadrant, and one in the outer lower quadrant. She had had several rigors, and said she felt ill. Temperature 102-6°, pulse 129. Treatment.— Vibrations over the mamma, specially the tender spots ; expression of the milk by means of suction vibrations ; frictions on the descending cervical, anterior thoracic, and fourth to sixth intercostal nerves ; constitutional exercises. At the close she felt better, and had much less pain and tenderness. Progress. — October 28. — Morning. Patient had slept fairly well. Some redness and tenderness. Temperature 1016°, pulse 104. Treatment. Afternoon. Temperature 101°, pulse 98. Treatment October 29. — Morning. Only slight tenderness left. Temper- ature 97°, pulse 78. Treatment only once during the day. October 30. — No tenderness. Mammary gland normal. Treatment for the last time (The temperatures were all taken in the mouth). September, 1902. — No return of the symptoms. Labour. Mrs. Q., aged 36, came under the manual treatment on May 11, 1900. DISEASES OF THE GENITO-URWARY ORGANS, &-€. 477 Previous history. — Patient had previously two children, both girls ; the first born on August 8, 1894, the second on April 25, 1897. Both labours were normal, the first lasting about fourteen hours ; the second about seven. Present labour. — Commenced at 5 p.m. on Maj- 11; at 9.4-5 p.m. I was sent for. Patient was standing up and walking about, with pains coming about every five minutes ; she was already in the second stage. Vaginal examination. — Cervix fully dilated, head presentation in the L. 0. A. position. The vertex about one inch from the external opening. The membranes ruptured during the examination. During the pains that now came I executed frictions over the sacral nerves and also in the lumbar region, where the patient complained of pain. These frictions were performed with one hand while the other simultaneously executed vibrations on the coronal suture. Patient liked these manipulations very much, and told me that they not only relieved the pain, but also gave her energy and helped in the expulsion of the foetus. At 10.15 p.m. the labia separated slightly during each pain, and the foetal scalp began to appear. At 10.20 p.m. the head was born ; and one minute later the rest of the foetus. While the child was being attended to, I executed frictions over the uterus. At intervals I also executed sacral nerve and uterine frictions, and stomach exercise. Patient liked the manipulations very much and said they made her feel very comfortable. The placenta was born entire at 11.45 p.m. ; I then executed a few more uterine and sacral nerve frictions ; the uterus was well contracted, and I left patient at 12.10 a.m. on May 12. May 12. — No after pains at all. Treatment twice by sacral nerve and uterine frictions and stomach exercise. May 13. — No after pains. Everything going on favourably. Treatment twice on same lines as before. May 14. — Treatment once as before. May 15. — Patient got up during the morning and was up most of day. Treatment once. May 16. — Patient up and moving about as usual. Treatment for last time. September, 1902. — Patient quite well. 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Concussion of the brain . . . . . . . . . . . . . . . . 39(> Constipation .. .. .. .. .. .. .. 34!l, 350, 351 Convulsive tic . . . . . . . . . . . . . . . . . . 39(> Coordination 33, 03, 82, 203, 393 Coronal suture vibration 169,180,238 Corsets for spinal curvatures . . . . . . . . . . . . . . 333 Coryza . . . . . . . . . . . . . . . . . . . . 186 Crises in locomotor ataxia, treatment of . . . . . . • . . . . 394 Croup 48(.) Cutaneous nerves. See nerves. Cutis anserina . . . . . . . . . . . . . . . . . . 161 Defokmitie.s, general principle for the treatment of . . . . . . 75, 76 Delirium tremens . . . . . . . . . . . . . . . . . . 396 Dementia, syphilitic . . . . . . . . . . . . . . . . 397 Depletion. See depletive and head, depletion of. Depletive exercises .. .. .. .. .. .. .. 31,39 Derivative exercises . . . . . . . . . . . . . . 31, 39 Derived positions . . . . . . . . . . . . . . . . 14, 16-26 Diagnosis by touch . . . . . . . . . . . . . . . . 248 Diagnostic exercises . . . . . . . . . . . . . . 36, 37, 247 Diaphragm, nerves of . . . . . . . . . . . . . . . . 165 Diaphragmatic pleurisy . . . . . . . . . . . . . . 165. 481 ,, spasm .. .. .. .. .. .. .. KiO, "217 ,, suction. See subdiaphragmatic. Diarrhoea . . . . . . . . . . . . . . . . . . . . 353 Dicrotism of pulse .. .. .. .. .. .. .. ..162 Diet for cases of fever . . . . . . . . . . . . . . . . 252 Digestive organs, diseases of . . . . . . . . . . . . • . 334 Dilatation of heart. See heart disease. Diphtheria 291,479,482 paralysis after 293, 396, 445 Diplegia, from cerebral ha?morrhage . . . . . . . . . . 396, 397, 407 „ infantile spastic . . . . . . . . . . . . 396, 403 Dislocation of left humerus . . . . . . . . • ■ • . . . 472 ,, of right humerus . . . . . . . . . ■ • . • • 470 Dispersing vibrations . . . . . . . . . . . . . . • . 140 Disseminated cerebrospinal sclerosis .. .. .. .. 161,221,396,423 Dovible, definition of . . . . . . . . . . . . . . . . 42 Drawing backwards . . . . . . . . . . . . . • • . 122 ,, forwards.. .. .. .. .. .. .. .. ..119 „ sideways .. .. .. .. .. .. .. .. 121 Ductless glands, diseases of . . . . . . . . . . . • . . 387 Duplicate movements, advantages of . . . . . . . . . . . ■ 36 „ ,, definition of . . . . . . . . • . . • 1 1 „ „ physiological effects of . . . . . . . . 27-38 „ „ varieties of . . . . . . . . • • . • 1 1 E.\K disease, middle .. .. .. .. .. ■■ 276,478,481 Ear, shakings and vibrations on . . . . . - . . • • • • 187 Ear exercise . . . . . . . . . . . • ■ ■ ■ • • • 225 Effleurage 210 INDEX OF SUBJECTS 491 Effusions, hackings and beatings over kneadings of . . Einleit ungsniassage Elbow carrying ,, flexion and extension of . , ,. ,, ,, „ muscles performing ,. pressing backwards „ ,, downwards and upwards Electrical stimulation of nerve ,, ,, ,, ,, differences from 1 Electricity in nervous diseases . . Elimination of muscular action . . Elongation of spinal cord Embolism into internal capsule . . Epidemic cerebro-spinal meningitis „ parotitis. See mumps Epididymis, vibrations on Epilepsy Epileptic seizure while bathing . . Epistaxis . . Erysipelas . . Erythema nodosum ,, rheumatic Eversion and inversion of the foot Excentric movements. See duplicate movements Exercise. See movements. ,, arm ,, back ,, ear ,, eye ,, head leg ,, stomach ,, throat Exercises, diagnostic ,, modifications in Exophthalmic goitre Expansion, chest . . See also respiration. Eye exercise ,, vibration Face, movements of Facial paralysis Fainting Falling backwards ,, forwards . . Femoral vein Fever, effect of nerve frictions on cases ,, treatment of Fingers, abduction and adduction of ,, flexion and extension of ,, rolling of Fixation in duplicate movements See elimination. U, 33, 35, 43. PAGE •202, 204 209, 210 . . 212 .. lis 49-50, 200, 201 49-51 .. 118 91 155, 15(i 155, 15C 146, 395 , 30, 350, 393 84 390, 397 298, 479 . . 233 .. 396 .. 457 49, 180 293, 479 309, 479 300, 479 . . 102 . . 225 . . 239 . . 225 . . 224 220-223 . . 226 227-231 . . 223 . 30, 37, 247 240, 241, 242 188. 387 124-130 224 . . 185 .. 217 396, 444 102,213 78 52, 78 58, 59, 64, 108 153, 162 251, 252, 253 93 . . 56, 57 . . 100 37 INDEX OF SUBJECTS PAGE Flexion and extension of ankle-joints .. . . 69-72, 241 „ „ elbow-joint 49-50, 200, 201 •, .. „ „ mechanism of . . . . 49-51 „ fingers 56, 57 „ „ foot . . 69-72, 241 „ „ forearm . . 49-56 „ ., „ head . . . . 72-76 „ „ hip-joint 57-08, 94 „ interphalangeal-joints . . 56, 57 ,, „ „ knee-joint . . 63-69 „ raetacarpo-phalangeal joints 56 ,, „ „ metatarso-phalangeal joints 74, 241 .. „ ,> shoulder-joint 4.5-49 » » » „ „ mechanism of 45 „ „ „ tarsal-joints . . . . 69, 72, 241 ., J, ,, thumb 56 ,, „ „ toes . . 72 „ „ „ trunk . . 70-SS, 200, 201 ,, „ ,, wrist-joint 50 ,, ,, ,, lateral, of head 75 „ trimk . . 84-88 Flying, arm . . 103 Foot, clapping on the soles of . . . . 200 „ flexion and extension of . . . . 69-72, 241 „ inversion and eversion of . . . . 102 „ rolling of . . 109 Forearm flexion and ex tension {see elbow-joint) - . . 49-50 Friction, pressure . . . . 142 Friction vibrations ..143 „ „ with suction . . ..143 Frictions on abdominal organs. See indi\'idual organs. ,, muscles 194. 195 „ „ nerves. See nerve frictions. „ „ salivary glands . . 196 „ round ulcers ..196 Fronto-nasal running v bration . . 186 Fundamental positions 14 G.iLL-BLADDER, frictions on ,, nerves of ,, shakings on ,, vibrations on Ganglia, iScc sympathetic and nerve. Gastro-intestinal catarrh, acute Gastrocnemius muscle, sprain of General principles in the application of Genital organs, female, nerves of ,, „ ,, treatment for „ ,, male, treatment for Genito-urinary organs, diseases of German measles . . Glands, secretory effects from nerve frictions S'ee disseminated. Intra-abdominal pressure. See abdomen. Internal capsule, embolism into Internal jugular vein Interphalangeal-joints. See fingers and thumb Intertarsal-joints. See tarsal-joints. Intestinal catarrh, acute . . ,, ,, chronic Intestines, effect of stomach exercise on ,, frictions on . . ,, nerves of „ shaking of „ vibration of . . Inversion and eversion of the foot 43 . . 396, 437-444 396, 403 83, 85, 100, 125 . . 479 454, 455 33, 393 88 396, 397 48, 73, 74, 75, 132, 184, 213 346, 480 .. 351 .. 229 .. 232 .. 165 . . 232 .. 232 .. 102 Jaundice . . Jaw, lower, movements of upper, shaking and vibration of . . Joints, effect of duplicate movements on ,, ,, passive movements on . . .. 480 181,216 .. 186 35 39, 40 INDEX OF SUBJECTS 495 Joints, effect of traction on „ kneading of „ shakings of ,, traction of . . „ vibration of See individual joints. Jugular vein, internal Kellgren's crossed plantar sign „ plantar sign Kidneys, effect of stomach exercise on ,, frictions of ,, hackings over ,, nerves of „ shakings of ,, vibrations of See nerves, renal plexus Kneading of abdomen. ,, ,, effusions „ „ joints „ ,, muscles ,, suprapubic Knee abduction and adduction . . linee bending ,, pressing down ,, raising ICnee-joint. flexion and extension of ., rotation of . . ,, synovitis of . . Jvneeling position ,, ,, positions derived from See stomach exercise. L.\BOUR, treatment during ,, case of . . Laryngitis, acute . . „ chronic Larynx, nerves of ,, shaking and vibration of Lateral flexion and extension of the head ,, „ ,, !, trunk ,, sclerosis. See amyotrophic and paraplegia. Leg abduction and adduction ,, carrying „ clapping ,, exercise „ flexion and extension ,, hacking ,, lifting . . ,, pressing downwards. ,, raising. . ,, rolling ,. rotation „ swinging ,, traction ,, vibration PAGE •28 •209, 210 .. 194 28, 114, 194 .. 194 48, 73, 74, 75, 132, 184, 213 151 151 230 232 •201 165 232 232 •209, 210 209, 210 207-209 234 95 60 65 05 03-69 98 467 15 237 476 480 467 159 188 75 84-88 93, 94 01 203 226 68, 94 •201 94 94 02 107 97 61 115 189 496 INDEX OF SUBJECTS phthisis, respiration, thorax. Length hacking . . Levers Lift vibration Lifting, anal canal and anus „ chest Lifting, head „ leg ,, pelvic organs „ rectum Ligaments. See joints. Ling's system ,, ,, literature about Liver, frictions of . . ,, hackings over ,, nerves of . . „ shaking of . . ,, vibration of Locomotor ataxia Locomotor system, diseases of Lowered vitality, effect of nerve frictions on conditions of Lumbago . . Lumbar region, hacking of ,, vertebrae, effect of leg movements on Lungs, catarrh of . . ,, nerves of . . See chest clapping, chest expansion, Lying position ,, ,, positions derived from Lymph and lymphatics, diseases of „ ,, ,, effect of duplicate movements on „ ,, „ „ passive movements at joints ' „ ,, ,, ,, respiration on „ „ ,, ,, traction on . . „ ,, ,, „ vibration and shaking on . Lymphadenitis. See lymphangitis. Lymphangitis Machine gymnastics ,, vibrations Malplacements of uterus . . Mammary gland abscess, threatening . . Mania . . Massage, definition of „ differences from Kellgren's kneadings effects of history and introduction into Sweden varieties of a friction abdominal eruptions for headache for sciatica on nerves Mastoid vibration Maxilla, inferior, movements of . . PAGE .. 200 37 139, 237 .. 233 . . 127 131, 184 94 , 236, 237 .. 233 2, 3, 6, 7 6 232 201 164 232 232 161, 393, 394, 396 461 153 463, 465, 466 201 60 329 164 14 23 382 32 on . . 38, 39 ..125, 126, 127 27 . . 183 ..205,382-387 242, 243 182, 183, 184, 243 236 476 397 210 211 212 210 no, 211.212 210 230 211,212,231 456 449 148 187 181, 216 INDEX OF SUBJECTS Maxilla, superior, shaking and vibration of . . Measles Meatus. See ear. Mechanical stimulation of nerve. See nerve friction, pressing and vi Median nerve paralysis . . Medical gymnastics Medicinal treatment of nervous diseases ,, ,, rheumatism Mediotarsal joint. iSee tarsal joints. Medulla, vibration of Melancholia Meningitis, acute . . ,, epidemic cerebrospinal ,, .syphilitic Menorrhagia Menstruation, disorders of ,, insanity of ,, treatment during Mental overstrain and overwork Metabolism, effect of duplicate movements on ,, ,, passive movements at joints on Metacarpo-phalangeal joints. See fingers and thumb. Metatarso-phalangeal joints. See toes. Metrorrhagia Middle ear disease Military gymnastics Mitral valve disease . . . . . . . . . . . . 359, Modifications in exercises . . . . . . . . 3.5, 43, Motor nerves, effect of duplicate movements on ,, ,, ,, nerve frictions on ,, ,, ., passive movements at joints on „ ,, ,, pressings on ,, ,, ,, traction on ,, ,, ,, vibrations on . . Mo\'ements, gymnastic, classification ,, ,, definitions ,, ,, general directions for performing See active, duplicate, passive, respiratory. Mumps . . -263, 2(55, 276, 278, 282, 283, 284, 285, 286, 287, 289, Muscles, abdominal. See abdominal, beating on blood supply to active and resting efiect of duplicate movements on ,, nerve frictions on ,, passive movements on ,, traction on frictions on hacking over kneading of Muscular sense Musculo-spiral nerve, gunshot injury to Myelitis, spinal PAGE .. 186 260, 203, 478 . . 396 2, 3, 5 . . 395 . . 463 .. 185 . . 397 .. 186 298, 479 396, 414 . . 474 236, 275, 474 . . .397 . . 236 .396, 451 35 39 236, 275 276, 478, 481 . . 2, 5 364, 308, 370 240, 241, 242 323 150 39 155 28 149 10, 11, 41 1(1, 11, 12 43, 44 290, 478, 479 . . 204 28, 29, 30, 31 34, 35 150, 151, 152 38, 39 27 194, 195 .. 202 207-209 33 .. 460 .. 396 Neck bending and stretching Nerve or nerves, abdominal sympathetic 32 164-169,230 40H INDEX OF SUBJECTS Nerve or nerves, auricular, posterior . . auriculo-temporal bladder, sympathetic of brachial plexus bronchi, sympathetic of cervical, anterior branches ,, posterior branches „ sympathetic circumflex coccygeal ,, ganglion (ganglion impar) crural, anterior cutaneous, external (of leg) ,, internal (of leg) „ of foot descending cervical diaphragm, sympathetic of dorsal . . eyeball, of eyelids, of facial fifth {see also separate branches) foot, cutaneous of gall-bladder, sympathetic of ganglion. See individual ganglia and ,, impar genital organs, syinpathetic of glosso-pharyngeal gluteal, inferior ,, superior heart, of hypogastric plexus, inferior hypoglossal ilio-hypogastric ilio-inguinal impar, ganglion infraorbital infratrochlear intercostal, in abdomen ,, thorax interosseous, posterior intestines, sympathetic of kidneys, sympathetic of lachrymal laryngeal, inferior ,, superior lingual . . liver, sympathetic of lumbar . . lungs, sympathetic of masseter, of med'an . . mental . . musculo-cutaneous (of leg) musculo-spiral PAGE . . 157 ..173 165, 168 IfiO, 170, 396 . . 164 160, 161, 162 1, 100, 101, 162,213 . 162 170 . 167 . 166 . 172 . 172 . 174 72, 174 . 163 . 165 64, 165 . 158 . 158 58, 396 . 173 72, 174 . 164 . 166 . 105 . 159 . 171 . 171 59, 164 . 169 . 159 . 166 . 166 . 106 . 158 157, 186 166, 230 162, 103 170 . 165 . 165 . 158 . 159 . 159 . 159 164 64, 165 . 164 . 158 80, 396 . 158 . 172 70, 460 170, INDEX OF SUBJECTS 499 PAGE Nerve or nerves, nasal 157,186 „ „ ,, obturator . . 172 , ,, ,. occipital, great .. 157 , „ „ „ small .. 157 „ „ optic 185, 393, 396 phrenic .. 159 , „ „ plantar, external ..172 „ „ „ internal 151, 171, 180 , „ ,, popliteal, external .. 171 , ,, ,, ,, internal .. 171 , „ „ pylorus, sympathetic of . . 164 , „^ „ radial . . 150,171 , „ „ rectum, of 165, 167 , ,, „ renal plexus 165, 167 , ,, „ sacral . . .. 163 , ,, ,, saphenous, long 151,172 „ „ „ short ..172 „ „ sciatic, great {see sciatica) 58, 171 , „ „ sensory of foot ..172 , ,, „ solar plexus . . 167 „ „ spinal accessory . . 160 , „ ,, splanchnic 10.5, 166 „ „ spleen, sympathetic of . . 165 , ,, „ stomach, sympathetic of . . 164 „ „ submaxillary ganglion ..159 , „ „ subtrapezial plexus . . 160 , „ „ supraorbital ..157, ISO, 447 , „ „ suprascapular ..170 , ., „ supratrochlear 157,186 „ „ tempore -facial ..173 , „ „ thoracic, anterior ..170 , „ „ „ sympathetic . . 164, 165 , „ „ tibial, anterior ..171 „ „ „ posterior 171 , „ „ ulnar 170, 390 , „ „ uterus, sympathetic of .. 105 , „ ,, vagus . . ..159 See sympathetic nerves. Nerve frictions and vibrations, effects uf, direct 149, 150 » » .. „ ., physical . . 144 „ „ „ „ „ reflex 150-154 „ „ „ „ hand and foot . . 180 „ „ „ „ hand to foot . . 175-179 „ „ head to foot . . 175,179 „ „ „ „ history and development . . 144 „ „ „ „ modus operandi 142-144 „ „ „ „ on nerves of arm 170,173 „ ,, „ „ „ ,, cerebro-spinal system as a whole 175-179 „ „ „ „ „ „ head and neck ..157, &c., 173 „ leg ..171, 172,174 „ „ „ „ ,, „ trunk 102-169 „ „ ,, V. nerve pressin gs . . 155 See individual nerves and running. Nerve fiinctionabilitv. effect of nerve frictions on 50U INDEX OF SUBJECTS Nerve pressings Nerve vibrations, effects . . „ ,, history and development ,, „ modus operandi See nerve frictions. Nerves, effect of dviplicate nio\'onients on ,, ,, nerve frictions on „ „ passive movements at joints on ,, ,, pressings on ,, ,, traction ,, ,, .. vibrations on . . ,, motor. See motor nerves. ,, sensory. See sensory nerves. ,, sympatlietic. Sec sympathetic nerves. Sec aho nerve or nerves and nerve frictions. Nervous diseases, electrical and medicinal treatment of ,, ,, functional ,, ,, organic brain and spinal cord „ „ peripheral ,, „ sympathetic . . Neuralgia . . Neurasthenia Neuritis (see sciatica, supraorbital) Nipping vibrations Non-pregnant uterus. See uterus. Nose, shaking and vibration of . . Occipital suction movement Occipito-atlantal joint [see head) Oertel's treatment Ovaries, frictions on ,, vibrations on . . Pancre-\s . . Paraplegia, spastic Paralysis . . iS'ee individual diseases. Paralysis agitans . . Parotid gland. See salivary glands. Parotitis ,. epidemic. See mumps. Parturient uterus, treatment of . . Passive movements, definition . . ., ;,■ at joints, effects . ,, ,, ,, varieties. Pedagogical gymnastics . . Pelvic organs ■ . . See also ovaries, uterus. Pericarditis Peritonitis, acute . . Perspiration, effect of massage on ,, ,. nerve frictions on Petrissage . . Pharynx, shaking and vibration of See also throat exercise. PAGE 144 i48. 155, l.'je, 159 144, 149 144 .. 136 32, 33 149-153 39 144, 155 28 149 . . 395 .. 394 . . 391 .. 394 394, 395 390, 447-451 .. 396 396, 447-451 .. 140 49, 394: 293, 394. .. 186 .. 219 73, 132 358, 359 . . 236 . . 236 230, 232 396, 397 37 73, 105, 230. 396 . . 479 237. 238 13 . . 38-40 13 59, 91), 127, 160, 204 370, 479 165, 230, 341, 480, 482. 483 211,231 150, 162 210,211 187 INDEX OF SUBJECTS 501 Phthisis pulmonum Pit of the stomach, shaking of . . Plantar reflex. See Babinsky. Kellgren. Pleiirisy, acute ,, chronic . . ,, diaphragmatic . . Plexus. See nerve. Pneumonia, acute croupous ,, broncho- Polioinyelitis aaterior acuta PopUteal vein Positions, definition of „ description ,, varieties Post-diphtheritic paralysis Post-partura, treatment of Pregnancy, treatment during Pressing, elbow ,, knee leg ,, on arteries ,, on nerves. ^S'ee nerve pressing. ,, on \'eins Pressure friction . . ,, vibration Principles, general, of treatment Prolapse of uterus Pronation and supination (see radio-uhiar joints) Prostate gland Psychical effect of gymnastic movements Puerperium, treatment during . . Pupils, effect of nerve frictions on Purely active movements. >See acti\'e movements Pylorus, nerves of Pyrexia. See fevei'. Radial flexion Radio-ulnar joints, pronation and supination . . Raising. .See arm, bacli, heel, knee, leg, toe. trunk. ., stride sit kneeling Raynaud's disease Rectum, nerves of ,, lifting Reflex arc, effect of movements at joints on Resisted exercises. Sec duplicate movements. Respiration during gj'mnastic exercises ,, effects of duplicate movements on ,, effects on circulation of blood ,, ,, flow of lymph Respiratory exercises See respiration. Respiratory organs, diseases of . . Rest in bed for cases of fever PAGE .. 150 , 164, 168, 230 . . 192 311,313,318-320,481 321-.333 165, 481 .. 25 1.311 316, 481 481, 483 396 437-444 . 65, 69, 108 10 . . 14-26 14 293, 396, 445 213,238 . . 237 91, US 65 94 .. 213 .. 213 .. 142 .. 137 .. 249 . . 236 . 49-51, 101 . . 233 33, 392 . . 238 . . 153 r^ments I, 51. 54, 56 .. 101 5, 91, 93, 103 .. 215 . . 397 165, 167 .. 233 39 34, 35, 43, 44. 78, 80, 82, 127 124 35 124 125 -130 311 252 502 INDEX OF SUBJECTS Retrobulbar haemorrhage Rheumatic cephalalgia „ erythema „ fever . . ,, pericarditis Rheumatism, chronic „ „ medicinal treatment of Ringing Rolling. See circumduction. Rotation, alternate ,, of the head ,, ,, hip-joint ,, ,, knee-joint „ „ shoulder-joint . . „ „ trunk ,, ,, wri.st-joint Rotatory shaking ,, vibration Running nerve frictions . . ,, nerve vibrations ,, ,, ,, exercises comprising ,, vibrations Sacbal beating Salivary glands, frictions on ,, ,, siiaking and vibration of See mumps. Scarlatina anginosa . . . . 2(W, 2139, 270, '274, ,, gravior „ simplex Schott's treatment Sciatica Scoliosis. See spinal curvature Screw turning Secondary positions Secretory effects produceahle by nerve frictions Sensory nerves, effect of duplicate movements on „ ,. „ nerve frictions on „ „ ,, passive movements at joints „ ,, ,, pressings on . . ,, ,, ,, traction on ,, ,, ., vibrations on . . Sensory-motor circuit Sequelae of influenza Shaking and vibration, effects . . ,, ,, ,, history and development ,, ,, ,, modus operandi „ ,. ,, aroiuid abscesses ,, „ ,, on the abdomen -, ,, ,, ,, anal canal ,, ,, „ „ anus „ ,, ,, ,, appendix „ ., ,. „ arm ,, ,, ,, over the bladder ,, .. ,, on the coronal suture . . PAGE . . 396 479 300, 479 300, 479 370, 479 305 461, 466 .. 463 87 99 . 98 181, 184 97 .. 98 97 99 97 .. 135 .. 139 .. 143 .. 139 173-179 . . 139 . . 203 .. 196 .. 188 , 282 284, 478 27G 288, 478 273, 286, 478 . . 359 396, 448, 450 .. 110 . . 16-26 150, 153 32 149, 152 39 155 28 . . 149 32 454, 455 .. 183 180, 181 133-136 .. 193 .. 192 . . 233 . . 233 . . 232 .. 189 168 169, 233 .169 186, 238 INDEX OF SUBJECTS 503 PAGE Shaking and vibration of the ear 187 , epididymis 233 eyes 185 ,, „ „ , gall-bladder 232 , head 181, 18+ , heart ..190, 191, 192 » » .. inferior maxilla. . 181 „ ,, ,. , intestines 232 „ „ .. , joints 19 1 ,. „ „ , kidneys . . 232 larynx . . 188 ,, ,, ,, , lateral half of body 189 „ „ „ . leg .. ..■ .. 189 ,, „ „ liver 232 »» »» , mastoid . . 187 medulla. . 185 „ „ „ nose 181,186 „ „ ovaries . . 230 pharynx 187 pit of the stomach 192 „ „ prostate gland . . 233 „ , salivary glands. . 1 88 , spermatic cord . . 233 spinal cord 192 „ spleen . . 2.32 »» ,, ,, , , stomach. . 231 »» »» j> , stomach, pit of the 192 , subcostal triangle 192 ,. superior maxilla 180 , testicle . . 233 „ ,, „ , thorax . . 189 „ „ „ , thyroid gland . . 188 „ „ „ , tonsils . . 187,188 trachea . . 188 trunk 189 ulcers 193 , whole of body . . 189 „ „ „ wounds . . 193 See vibration. Shoulder hacking . . 200 Shoulder-joint, abduction and adduction of . . 89-93, 241 mechanism of 89 ,, ,, dislocation of 470, 472 „ ., eighth movement of .53, 118 „ „ flexion and extension of 45-49 >i .. „ „ „ mechanism of . . 45 „ ., rolling of . 103-106 „ ,, rotation of 97 Side length hacking 201 Side shaking 189 Sitting position 14 „ positions derived from 22 Skin secretion 211,231 See perspiration. Soles of the feet, clapping on 203 S04 INDEX OF SUBJECTS PAGE Sommerbrodt's reflex . . . . . . . . . . . . . . . . 33 Spasm of muscles from nerve irritation . . . . . . . . . . 394, 39(i Spastic diplegia . . . . . . . . . . . . . . . . 39c, 403 paraplegia . . . . . . . . . . . . . . 39G, 397 Specific infectious diseases. .SVp individual diseases. Spermatic cord, vibrations and frictions of . . . . . . . . . . 233 Spinal cord, beating over . . . . . . . . . . . . . . 204 „ effect of nerve frictions on . . .. .. .. 149, &c., 161, Ui4 ,. „ trimk movements on .. .. .. 84,85, 100, 122 ,, elongation of . . . . . . . . . . . . . . 84 „ hacking over. See back and shoulder hacking. ,. vibration over .. .. .. .. .. .. ..192 ,, compression of . . . . . . . . . . . . . . 396 ., gunshot wound of .. .. .. .. .. 161,168,396 ,, hsemorrhago and embolism of . . . . . . . . 396, 433 iSee individual diseases. Spinal curvatures . . . . 78, 1 95, 250, 329, 332, 333, 396, 425, 429, 433 Spleen, frictions on . . . . . . . . . . . . . . 232, 358 ,, hackings over . . . . . . . . . . . . . . . . 201 „ nerves of .. .. .. .. .. .. .. .. .. 165 ,, vibration on . . . . . . . . . . . . . . . . 232 Sprain of the gastrocnemius muscle . . . . . . . . . . . . 466 Stammering .. .. .. .. .. .. .. .. ..168 Standing position . . . . . . . . . . . . . . . . . . 14 ., ,, positions derived from .. .. .. .. .. 17 Stationary nerve frictions . . . . . . . . . . . . . . 143 „ „ vibrations .. .. .. .. .. .. ..138 Stimulation, electrical, of nerve. See electrical stimulation. ,, mechanical, of nerve. See mechanical stimulation. Stomach, effect of stomach exercise on . . . . . . . . 229, 230 ,, exercise, comparisou with other methods . . . . . . . . 230 effects of 228 „ „ modus operandi . . . . . . . . . . . . 227 ,. nerves of . . . . . . . . . . . . . . . . 164 „ shaking on . . . . . . . . . . . . . . . . 231 ,, vibration on . . . . . . . . . . . . . . . . 231 Stretching, arm. See arm stretching. „ calf muscle .. .. .. .. .. .. .. .. 215 tnmk 105 ,, vertebral column .. .. .. .. .. .. ..214