UNIVERSITY OF CALIFORNIA AT LOS ANGELES PHYSICAL RECONSTRUCTION AND ORTHOPEDICS 4 4 7 3 9 PHYSICAL RECONSTRUCTION AND ORTHOPEDICS By HARRY EATON STEWART, M.D. CAPTAIN MEDICAL CORPS, U.S. ARMY, DIVISION OF ORTHOPEDICS ; ASSISTANT DIREC- TOR, SECTION OF PHYSIOTHERAPY, SURGEON GENERAl'sOFFICE; INSTRUCTOR IN MEDICAL AND ORTHOPEDIC GYMNASTICS AND MASSAGE, NEW HAVEN NORMAL SCHOOL OF gymnastics; ATTENDING SURGEON, NEW HAVEN ORTHOPEDIC dispensary; FORMERLY INSTRUCTOR IN CORRECTIVE GYMNASTICS, TEACHERS COLLEGE, COLUMBIA UNIVERSITY. Authorized for Publication by the Surgeon General of the U. S. Army 67 ORIGINAL ILLUSTRATIONS AND 2 DIAGRAMS ^ M 1 Ini i 1^ lOEHK 1 NEW YORK PAUL B. HOEBER 1920 3^7'>f Copyright, 1920, Bt PAUL B. HOEBER Published Janvary, 19S0 '*<*<* <. '*ti*i Printed in the United States of Ameriea 7CS' PKEFACE Physical reconstruction is the watchword of the hour and yet the picture brought to mind by this phrase is but a small part of a greater problem, the physical recon- struction of the race. That there is need for such recon- struction among us is evident from any study of the re- jection from service for physical disability which the draft examinations brought forth. We have become a city-dwelling nation, and are subject to the innumerable deleterious influences which follow in the wake of city life and intense industrial competition. The meager begin- nings of playground and physical education appropria- tions and infant welfare movements have as yet in no way compensated the child for his rapid loss of outdoor life and freedom. The physician must be deeply con- cerned with every effort to improve child hygiene. He is specifically concerned with the problem of prevention and cure of remedial physical defects. In this book con- crete directions are given regarding -spinal curvature, congenital defects, rickets and other orthopedic condi- tions. The question of competitive athletics and its rela- tion to health in youth of both boys and girls is considered and certain definite rules for safeguards are laid down. In the reconstruction of the wounded soldier, in which we and our allies are now engaged, much that is new and of great value has been learned. The new orthopedic vi PREFACE principles, appliances, and methods of treatment which have been evolved have been thoroughly tried out under exceptional conditions as regards amount of material, length of observation, and unlimited resources. The application of the successful methods evolved in the treatment of war injuries to the treatment of indus- trial accidents is of the utmost importance to the general surgeon. Physiotherapy and vocational therapy have, by proper application and coordination, achieved such wonderful results that it is inconceivable that they can have other than a very prominent place in the general hospital in the future. Every physician and surgeon should be familiar with the indications for the various types of treatment, and their effects on the local and general condition of the patient, his morale, and his re- turn to his former or new occupation. When one consid- ers that the number of our wounded was approximately two hundred thousand, the importance of the viewpoint just mentioned is seen when we remember that we have in this country about seven hundred thousand industrial accidents yearly. The author's experience in teaching and supervisin.g reconstruction aides in physiotherapy has convinced him that a condensed manual, giving the directions for the various types of treatment as well as the theoretical con- siderations, would be of great assistance to them in the work in which they are now engaged. Since vocational reconstruction is being so largely applied for definite therapeutic indications, it is of the greatest importance that the workers in this corps understand the viewpoint PREFACE vii and treatment given in physiotherapy, which leads up to their work. The theory and treatment of congenital and functional defects other than those following war injuries should be useful to aides who plan to continue the same type of work in civil life. In the teaching of normal-school students of physical education it has also been evident that they need, for their work in orthopedic and medical gynmastics, definite exercise programs for such conditions as faulty posture, spinal curvature, infantile paralysis, flat foot, etc. It has been the author's object to present in condensed form the main principles of orthopedics in the treatment of the defects of childhood, war injuries, and industrial accidents, laying stress upon the treatment by massage, exercise, and other types of physiotherapy. It should, therefore, be of value to the physician, reconstruction aide, physical director, and orthopedic assistant, not only in their better understanding of the work, but in empha- sizing the vital importance of this so long neglected field. The author wishes to acknowledge the valuable aid given him by Miss Helen S. Willard, B.A., his chief Eeconstruction Aide in Physiotherapy, and Captain G. W. Ramaker, Vocational Therapy Officer of the U. S. A. Base Hospital, Camp Meade, Maryland, in the collection of data for this book. H. E. S. New Haven, Conn. Sept. 1, 1919 CONTENTS PART I PHYSICAL RECONSTRUCTION CHAFTBR PAOB I Exercise 1 Relation of Bodily Health to Muscular Health. Nerve Strain of Modem Work. Necessity for Physical Train- ing in Youth. Athletic Problems. Heart Strain. Safeguards for Boys and Girls in Athletics. Proper Exercise for Various Ages. Therapeutic Exercises. Physiology and Pathology of Muscle Tissue. Exercises for Stiff Joints. Setting-up Exercise. II Baking. Hydrotherapy. Electrotherapy . . 27 Physiolo^cal Changes by Baking. Passive Hyperemia, Hydrotherapy Definition, History. Properties of Water. Physiological Effect on the Various Tissues and on Body Temperature. Technique of the Various Baths. Electrotherapy Types of Ciirrent, Uses. Ionic Medica- tion. Alpine Sun Lamp. III Massage 46 Definition. History. Tsrpes of Movement. General Con- siderations. Effect on Different Tissues. Mechanics of the Cardinal Movements. Therapeutic Uses and Con- traindications. Treatment of Limb Stumps. IV Vocational Therapy 7ft Objects Therapeutic, Economic, Occupational Interest, Morale. Co-operation with Physiotherapy, with Federal Board. Types Bedside, Shop, Classroom, Field. Scope Application in General Hospitals, Simple Equip- ment, Relation to Industrial Accidents. X CONTENTS PART II ORTHOPEDICS CHAPTER PAOB V Congenital Defects 91 \^lub Foot Types, Treatment. Hip Dislocation. Hibb's "Table. Rickets Cause, Diagnosis, Treatment. Coxa Vara Pathology, Treatment. Spastic Paralysis Causes, Treatment. VI Infantile Paralysis 97 Pathology. Treatment in Active Stage. After-treatment. Exercises for Paralyzed Arm and Leg. VII The Spine Diseases and Injuries 106 Anatomy. Tuberculosis Diagnosis, Symptoms, Treat- ment. Traumatic Injuries, Strain and Sprain. Sacro- iliac Strapping. Treatment of Bruises. Fractures and Dislocations Diagnosis, Treatment. Penetrating Wounds. VIII Curvature of the Spine HI Kyphosis Tjrpes, Causes, Symptoms, Treatment, Program of Exercises. Lordosis Occurrence, Causes, Sequelae, Program of Exercises. Scoliosis Pathology, Rotation, Occurrence, Classifications, Causes, Treat- ment. Exercise Programs for the Various Types. IX Joint Injuries and Arthritis 135 General Anatomy. Traiunatic Lesions. Strain and Sprain Treatment. Arthritis. Toxic Arthritis. Ar- thritis Deformans, or Rheumatoid Arthritis Diagnosis, Treatment. Acute Rheumatic Arthritis. Tuberculous Arthritis Diagnosis, Treatment. Gonorrheal Ar- thritis Diagnosis, Treatment. Syphilitic Arthritis Diagnosis, Treatment. X Diseases of Bones 146 Periostitis Pathology, Diagnosis, Treatment. Osteitis. OsteomyeUtis Diagnosis, Treatment. Osteomalacia Diagnosis, Treatment. CONTENTS xi CHAPTEB PAGB XI Fractures and Dislocations. The Upper Ex- tremity 152 The Clavicle. Sternoclavicular Dislocations. Fractures. Acromioclavicular Dislocations. The Scapula. Fractures. Shoulder Joint, Surgical Anatomy. Types of Dis- location. Fractures of the Humerus. Anatomica.' Neck. Shaft. Supracondyloid. Epicondyloid. Epitrochlear. Fractures. Involving the Elbow. Types. Olecranon Dislocations of tho Elbow. Types. Myositis Ossificans, Traumatica. Dislocations of the Radial Head. Ankylosis of the Elbow. Fracture of the Head of the Radius. Fractures of the Shaft. Fractures of the Radius and Ulna. The Wrist. CoUes Fracture, Dislocations. The Hand Fractures, Dislocations. XII Fractures and Dislocations (Continued). The Lower Extremity 183 The Pelvis. Types of Fracture. Dislocation of the Sym- physis. Dislocations of the Hip Joint. Fractures of the Femur. Upper End. Shaft. Lower End. Fractures and Dislocations of the Patella. Dislocation of the Knee. Fracture and Dislocation of the Semilunar Cartilages. Rupture of the Crucial Ligament. Fractures of the Upper End of the Tibia and Fibula. Fractures of the Shaft. Lower End. Pott's Fracture. Dislocations of the Ankle. Fractures of the Metatarsus. XIII Foot Strain . y. 205 y The Main Arch. Types of Flat Foot Causes, Diagnosis, Treatment, Strapping, Plates, Exercise, Programs. The Anterior Arch. Metatarsalgia Causes, Diagnosis, Exer- cises. Foot Ailments in the Army. Foot Strain- Literature, Military Viewpoint, Classification, Anatomy, Methods of Examination. Diagnosis and Treatment of Weak Foot. Flaccid Flat Foot. Rigid Foot. Acute and Chronic Foot Strain. Hammer Toe. Corrective Shoe Appliances. Minor Foot Ailments. Synovitis. Blisters. Abrasions. Tissues. Overriding Toes. Corns. Callosi- ties. Warts. Sweating Feet. Chilblains. Trench Foot. Shoe Fitting. Prescriptions. xii CONTENTS CHAFTKR PAOB XIV Braces and Casts 229 Braces for Arch, Club Feet, Knee, Bowleg, Knock Knee. Infantile Leg. Spine. Casta. Care and Preparation of Plaster Technique. Glossart .... 235 Index 237 LIST OF ILLUSTRATIONS no. PAGE 1 Entire Scapula, Except Part of Acromion, Missing . . 5 2 Gain from Complete Disability in Six Weeks of Physio- therapy 5 3 Severe Shrapnel Wound of Left Shoulder with Com- pound Comminuted Fracture of 6th and 7th Ribs . 11 4 Slanting Ladder, Use of Body Weight to Secure Passive Flexion of Stiff Knee Joint 15 5 Suspension Used to Stretch Adhesive Bands in Right Elbow 15 6 Chipping of Humeral Head and Extensive Wound of Shoulder 21 7 Abduction Assisted Largely by Scapular Rotation Well Controlled 21 8 Hyi)erextension Limited by Scar Tissue and Adhesions . 21 9 Muscle Contraction Test for Nerve Injury. Faradic Battery and Generator 25 10 Baking. Electric Light Bath of Knee ..... 26 11 Diathermy. Electrical Heat Penetration for Deep Hyperaemia 26 11a Multiplex Sinusoidal Machine 31 lib High Frequency Machine 31 lie Alpine Sun Lamp, Ultra Violet Ray 32 12 Electro-Motor Points, Upper Extremity 37 13 Electro-Motor Points, Lower Extremity 38 14 Electro-Motor Points, Trunk 41 15 Massage. Effleurage or Stroking of Forearm ... 47 16 Massage. Petrissage or Kneading of Calf .... 47 17 Passive Stretching of a Flexion Contracture at the Elbow 61 18 Massage. Friction Here Used to Loosen Scar Tissue . 51 19 Massage. Tapotement or Hacking of Muscle ... 55 xiii xiv LIST OF ILLUSTRATIONS FIG. PAGE 20 Posterior Half Cast to Prevent Foot Drop .... 55 21 High Explosive Wound of Left Hand 59 22 Loss of 3d and 4th Metacarpals 59 23 Basket-Making 77 24 Telegraphy 77 25 Clay Modeling 78 26 Chair Caning 78 27 Wood Toy Making 78 28 Teaching the Beginnings of Mechanical Principles . . 83 29 Adjustable Foot Appliances 87 30 Musical Knowledge Reapplied to an Instrument the Man's Disability Will Allow Him to Play .... 88 31 Automobile Repair Shop 88 32 Woodworking 88 33 Carriage Which Reduces Friction and Allows on a Smooth Surface a Wide Range of Movement with Slight Effort 95 34 Wire Cockup Splint for Wrist Drop, Light in Weight, and Requires no Bandaging 95 35 Self -Correction for Right Dorsal Left Lumbar Scoliosis . 125 36 Spring Sitting-Position in Right Dorsal Left Lumbar Scoliosis 125 37 Osteomyelitis of Lower End of Tibia and Osteo- Arthritis of Ankle Joint 147 38 External Condyle of Femur Shot Away. Osteomyelitis and Ankylosis 147 39 Cabot Posterior Leg Splint 155 40 Airplane Splint with Elbow Joint 155 41 Abduction Splint for Shoulder 159 42 Humeral Extension Splint 159 43 Comminuted Gunshot Fracture of Glenoid and Humerus at Surgical Neck, with Large Amount of Bone De- struction 163 44 Humeral Neck and Head Fractured, Beginning Bony Union. Shrapnel in the Head 163 45 Extensive Shrapnel Wound of Right Arm with Com- pound Conuninuted Fracture of Humerus . . . 171 LIST OF ILLUSTRATIONS XV FIQ. PAQB 46 Machine-Gun Bullet Through Condyles of the Left Humerus 171 47 Old Infected Gunshot Wound of Upper End of Right Radius and Ulna Involving Elbow Joint .... 171 48 \ Compound Comminuted Fracture, Oblique of Radius 49 J and Transverse of Ulna with Over-Riding of Frag- ments 175 50 Loss of Bone in the 2d and 3d Metacarpals with New Joint Formation 175 51 Loss of Portion of 2d and 3d Metacarpal .... 175 52 Extension Applied to Fracture of Both Bones of the Forearm 179 53 Bradford Frame with Extension Applied to Leg for Fracture of Femur with Shortening 179 54 Caliper Walking Splint 189 55 High Explosive Shell Wound of the Hip, Sustained July 14, 1918 189 56 Fracture of Tibia, Compound Comminuted, with Large Loss of Bone Substance 199 57 Fall fom Horse Causing Fracture Through Head of Astragalus 199 58 Compound Comminuted Fracture of Tibia and Fibula . 199 59 Exercise 11. Walking Forward on Outer Edge . . . 207 60 Exercise III. Rising on Toes, Toeing In .... 207 61 Exercise IV. Walking Forward on Outer Edge, Toeing In 207 62 Exercise V. Ground Gripper Walk 207 63 The Hammock Arch Plate 213 64 The Hammock Arch Applied 213 PHYSICAL RECONSTRUCTION AND ORTHOPEDICS PART I PHYSICAL RECONSTRUCTION Chapter I EXERCISE The health of the body is, in the last analysis, abso- lutely dependent upon the health and tone of the muscular system. The condition of the heart muscle and the non- striated fibers of the blood vessels and gastrointestinal tract, are profoundly influenced by the tone of the skeletal muscles. Many glands are stimulated both directly and indirectly as a result of proper muscular activity. These statements are obvious, almost trite, and yet they are constantly overlooked. The physician often treats first by drugs, then with attention to diet and sleep, and lastly, if at all, by exercise. In modem business and industrial life the premium is placed upon nervous activity and very fine muscular co- ordination. This type of work is exhausting without any corresponding upbuilding of vigor. Physical work in- volving larger groups of muscles, while equally tiring, 2 PHYSICAL EECONSTRUCTION tends to build up both the muscular structure and the general health. Years ago even the skilled artisan used to move about the plant selecting his materials, perform- ing quite varied operations upon them, and perhaps car- ried the finished product to the shipping room. There- fore he was compelled to take a certain amount of general exercise. Modem efficiency has ruled that cheap labor shall bring in these materials, perform the easier opera- tions, and remove the finished product, while the arti- san's entire time is occupied in repeating, hundreds of times daily, some one or two specialized movements, which usually require prolonged, acute attention and delicate coordination. Thus only certain small muscle groups are apt to be used. The same tendency is seen in modem business and professional life, where present appliances make it pos- sible to conduct a whole day's business from the office chair. The many occupations which require standing for hours subject those muscles which maintain the upright posture to strain, rather than exercise. The work of the heart, unassisted by alternating muscular compres- sion and relaxation applied to the veins, is greatly in- creased, and the muscles and ligaments of the foot are subject to a distinct strain. It must be clear, then, since most occupations resemble more or less one or the other of the three types of occupations mentioned, that the average person under modern conditions does not have sufficient exercise for the maintenance of the best effi- ciency. That women, as a class, with the added handicap EXERCISE 3 of dress and social restrictions, take far too little exercise every one will recognize. There is no escape from the tendency of modem life further and further to restrict normal exercise and in- crease the strain of professional and industrial life. I take it to be of the utmost importance that we should see to it that every child and youth be given the oppor- tunity to lay by a surplus in his bank account of health, for these certain and severe strains which modem life makes it impossible for him to avoid. Since we have become a city-dwelling nation, with extremely limited play space, the youth is not so apt to be endowed with a vigorous muscular system at the beginning of his life work as were his father and grandfather. Until we have multiplied our playground, recreational center, and school gymnasium appropriations many times over, wo shall suffer as a nation from this lack of muscular vigor. That every child should have a thorough physical training is recognized by every physician. There are, however, problems closely associated with modem ath- letics which relate to possible overstrain of heart and disturbed blood pressure, which are not universally un- derstood. During my experience in the physical educa- tion of both girls and boys, I was struck with the lack of definite knowledge in the profession of the results of vigorous athletic training on the heart and blood pres- sure. The heart becomes stronger, the cardiovascular ad- justment more perfect, and the blood pressure is not raised, by athletic training. Safeguards that the physi- 4 PHYSICAL RECONSTRUCTION cian should insist "upon in all athletic sports in both boys and girls are, first, preliminary medical examination; second, constant trained supervision; third, play only when in perfect health. I want to emphasize the fact that the delicate child can be built up, and should be encour- aged to exercise when carefully watched; that the heart is a muscle, and as such can be increased in both size and strength when carefully kept from strain. The physician's advice is often sought by parents in regard to the proper amount of physical training that should be taken by the normal child. Such advice can hardly be given without a knowledge of the circumstances surrounding the exercise, which may have a marked effect upon the benefits derived. The number and length of the periods per week, their time relation to meals and fa- tigue, temperature, ventilation, apparatus used, and the way the schedule is graded, all are important. Nearly every normal boy goes in for athletics. His enthusiasm, and that of the coach who must produce a winning team, make it very easy to overstep the limits of safety. We must remember that the boy, as a rule, id carrying a heavy burden of growth, development, study, and extra-curriculum activity. It must be constantly kept in mind that the growth of the heart and larger blood vessels is from one to two years behind the rest of the body, during adolescence. For this reason heart strain is more common than gen- erally realized. Such games as basketball, football, and hockey should be broken up by frequent rest periods. I believe no secondary-school boy should run farther than fe* o J H . H \. .' ^ EXERCISE 7 the 220-yard dash. Cross-country running and distance runs should be reserved for college days. The marathon, or even modified marathon run, is fraught with the grav- est danger to heart and kidneys, as shown by the work of W. L. Savage of New York. No boy should be allowed to participate in more than one major sport at one time, and intervals between train- irig'seasons are desirable. Many breakdowns occur from indulging in athletics when suffering from slight illness, such as tonsillitis, or attempting to return to sport too soon after the cardiac muscle has been impaired by the toxins of disease. The recent rapid growth of girls' athletics has brought us face to face with the same problems in regard to heart strain or overindulgence that we have found in athletic training for boys. My experimental study, * * The Effect on the Heart Rate and Blood Pressure of Vigorous Ath- letics in Girls,*' American Physical Education Review, 1914, showed that even such violent sports as basketball and track athletics were extremely beneficial when prop- erly safeguarded. In regard to girls' athletics, the work of Dr. Clelia D. Mosher of Stanford University, and others, has modified greatly our ideas in regard to the proper relation between exercise and menstruation. It seems to be the unanimous belief that we may safely be much more liberal in our exercise allowance at that time; that marching tactics, calisthenics, and club swinging have a distinctly benefi- cial effect in lessening pain and disability. This is un- doubtedly the result of a redistribution of the circulation \ 8 PHYSICAL RECONSTRUCTION and improved mental attitude. In fact, it is emphasized that the psychical attitude is of great importance, and that the girl should be discouraged from thinking of this perfectly normal function in terms of illness. Among col- lege women Dr. Mosher and others have succeeded in lessening the pain and disability to a very marked degree by exercise and treatment, the fundamental part of such a program being deep abdominal breathing with jin- creased use of the diaphragm by training. This may be done with the patient lying supine and her effort directed toward raising and lowering, to as great an extent as possible, a moderately heavy book placed upon the abdo- men. The more violent types of athletics, including jump- ing and running, should be interdicted for at least three days and longer, when necessary, in any individual case. I am convinced that we are only at the beginning of our knowledge of the possibilities of woman's physical devel- opment. Already in such a sport as track athletics, in spite of their very recent development and meager oppor- tunities, girls are making records in the different events, which range from two-thirds to three-quarters of those records made by our Olympic champion athletes. Those invaluable traits of character, loyalty, unselfishness, self- control, and the team-work ideal, are developed by ath- letics as in no other way. I have not seen, in my ex- perience, the slightest tendency for athletics, developed by coaches with the proper ideals, to make girls in any way less womanly. The sudden secession from regular exercise, which usually comes at the end of school and college life, is EXERCISE 9 something which should not he allowed to occur. From the vigorous games of youth the transition should he made through the gymnasium, volley ball, and tennis to such sports as hiking and golf, which can be followed throughout life. This principle should be applied to both sexes. In general, it is well for the physician to keep in mind that, after a great deal of painstaking study, physi- cal educators, as a rule, have come to the following con- clusions: 1. That exercises of speed, those exercises in which a certain distance is covered in the shortest time, are not suited in their severe forms except to persons in good condition from eighteen to thirty-five. 2. That exercises of strength, which require all of one's energy to perform for instance, weight throwing, weight lifting, and apparatus work are suited to the ages of twenty to thirty-five. 3. That exercises of endurance, which con- stitute many and rhythmical repetitions of easy move- ments, such as distance running, walking, bicycle riding, etc., are suited to any age up to fifty (they are self- limited in childhood), the only exception being the period of accelerated growth, as regards games and distance running, before mentioned. 4. That exercises of skill such as golf, archery, quoits, etc., are suitable through all one's active life, and are invaluable, especially after fifty. Many games, such as tennis, may partake of several or all of these types, and in advising in regard to them one should be guided by the other general principles already outlined. I have appended a simple drill of ''setting-up exer- 10 PHYSICAL RECONSTRUCTION cises" which will make for general development, and a set of exercises on the chest weights, which may be used in the same way, but which is mainly intended to exercise fully both actively and passively each possible joint. These chest-weight movements will greatly assist in the return of function after the disability following fracture, dislocation, or arthritis. Therapeutic Exercise. Turning from the value of ex- ercise, as a means of upbuilding and retaining general health, to exercise as a purely therapeutic measure, there are several things to be considered. In the treatment of patients by exercise much more enters into the problem than the conditions relating to the involved group or groups of muscles. The inheritance of the patient, the environment in which he has been and that in which he must remain during the treatment, and the special eifect of his stage of development must all be carefully con- sidered. The importance of the last fact has been too often overlooked. For example, as E. H. Arnold of New Haven has emphasized, in the giving of corrective exer- cises to children during accelerated growth, more harm than good is often done by overload of work or by the superimposing of a strenuous exercise regime on the al- ready too severe strain of growth, development, and school life, which the child is carrying. Furthermore, we must expect a far different reaction to exercise treat- ment on the part of a patient who has left the ''elastic age" of youth and entered the "connective tissue age(' of middle and late life. It is also the physiological and not the chronological age which it is essential to keep in Fig. 3. Severe Shrapnel Wound of Left Shoulder with Compound Com- minuted Fracture of 6th and 7th Ribs. X-Ray shows entire body of scapula missing, glenoid, coracoid and acromion processes intact. Piercing fracture of ribs. Movements at shoulder limited to 40 of flexion and 20 of abduction. After four weeks of massage and exercise active flexion to 80, abduction to 50. EXEKGISE 13 mind, as has been pointed out by C. W. Crampton of Battle Creek. We have found in the New Haven Ortho- pedic Dispensary many cases of children who had to be taken from home surroundings for the simple purpose of supplying them for a sufficient period of time with adequate nourishment before the special treatment out- lined could be expected to achieve the desired result. There are four main types of exercise used: (a) that done entirely by the operator (passive) ; (b) that done by the patient assisted in varying degrees by the opera- tor (assistive) ; (c) that done wholly by the patient (active) ; (d) that done by the patient opposed by the operator ^weights, friction, or the opposing group of muscles (resistive). The muscular contraction in the last type has been further divided into three varieties, ac- cording to the direction of the movement of the muscle 's insertion in relation to its origin. For instance, in the contraction of the biceps when opposed by the action of the triceps (self -resistive exercise), the former may slowly overcome the pull of the latter and its origin and insertion be brought nearer together concentric contrac- tion; or the power of both may be equal, so that the distance between the origin and insertion remains un- changed static contraction; or the pull of the triceps may be greater, bringing further apart the points of ori- gin and insertion eccentric contraction. As we proceed in the development of the muscular sys- tem certain changes in structure take place. With in- creased bulk and tone developed by exercise there is a tendency for the entire body of the muscle to shorten, 14 PHYSICAL KEGONSTRUCTION bringing its points of origin and insertion nearer to- gether. We make use of this property of well-developed muscle to shorten in the treatment of many orthopedic conditions for instance, in a round-shouldered child we exercise particularly the muscles of the upper back, there- by retracting the shoulders. It might here be noted, as will be emphasized later, that disuse, such as would fol- low the application of a shoulder brace in this same group, has ultimately the opposite effect, namely, to stretch out and weaken the affected muscles and to in- crease the slump. This shortening of the stronger mus- cles is also seen where there is a lack of balance in the power between two muscles or muscle groups having an- tagonistic function as, for instance, following partial paralysis. The less affected tends to shorten at the ex- pense of the more affected muscle or muscle groups. Muscles, then, are elastic, and will shorten when given the opportunity. If this condition remains long enough, real structural shortening ensues. For example, the wearing of high heels for many years has a marked tendency to produce structural shortening of the calf muscle. This tendency to contraction is undoubtedly due to the property of muscle called tone, or tonus. Muscle tone is the result of a slight constant contraction of many of the fibers of any healthy muscle. Tone is increased in vigorous bodily health and well-developed muscle and in response to mental stimulus. It is de- creased during mental depression, bodily weakness, and sleep, and practically lost under complete anesthesia or other complete loss of consciousness. EXERCISE 17 Fatigue is a sluggish or subnormal response of a mus- cle to its stimulus. This may be due to either a weak- ening of the stimulus itself following injury or weakness of the neurone, or to a deadening of the sensitivity of the end-plate of the nerve in the muscle cell by the accumu- lation of fatigue products. The first fatigue products are stimulants to muscular activity, and this accounts for the fact that a muscle works better after a few con- tractions than at first. That is why we "warm up" a muscle before severe exertion. The early onset of fatigue must be carefully watched whenever the muscle is subnormal. In regard to general fatigue the point is often overlooked that it is cumulative in its effect. This means that a little more work done by a fatigued muscular system calls for the expenditure of a tremendous amount of nervous energy. Remedial gymnastic programs for the various ortho- pedic conditions infantile paralysis, kyphosis, lordosis, scoliosis, flat feet, etc., are fully given in the sections where each is discussed. CHEST WEIGI^T EXERCISES. The position assumed for active flexion gives passive extension, and vice versa. Unless otherwise stated, the use of the shoulder height weights is indicated. 1. Wrist. A. Flexion. Patient stands with back of hand toward weights, arms extended downward and flexes. (Passive extension.) 18 PHYSICAL EECONSTRUCTION B. Extension. Patient stands with palm of hand toward weights, arms ex- tended downward and extends. (Passive flexion.) 2. Elbow. A. Flexion. 1. Patient stands facing weights, arms extended forward. Flex, extend. 2. Overhead weights. Arms extended upward, hands en- cased in gloves and bound to handles if necessary. Flex, extend. B. Extension. 1. Patient stands with back to weights, elbow flexed shoul- der high and rope over shoulder. Extend, flex. 2. Overhead weights. With arms at side, let weights flex elbow. Extend, flex. C. Pronation. Patient stands affected side toward weights, elbow flexed, and fixed at side by other hand or by operator. Lower forearm across body and return. D. Supination. Patient stands unaffected side toward weights, elbow flexed and fixed at side by other hand or by operator. Draw forearm up and sideward and return. 3. Shoulder. A. Flexion. 1. Floor or shoulder weights. a. Patient stands facing weights, arms extended for- ward, supinated or pronated. Lower arms and raise. 5. Patient lying supine, head toward weights, arms extended upward. Lower arms fore downward to sides and raise. 2. Overhead weights. Arms extended upward, lower fore downward and raise. EXERCISE 19 B. Extension. 1. Floor or shoulder weights. CL Patient stands with back to weights, arms extended downward. Raise arms forward and return. h. Patient lies supine, feet toward weights. Raise arms fore upward and return. C. Abduction. 1. Patient stands unaffected side toward weights, affected arm across body. a. Abduction in a lateral plane, elbow flexed. Ex- tend elbow. Keep at shoulder level. Return. h. Carry straight arm forward and sideward at shoul- der level. Return. 2. Floor weights. Patienl lies supine, feet to weights. Raise arm side- ward, return. D. Adduction. 1. Patient stands, affected side toward weights, arm ex- tended, shoulder level. Carry arm forward across chest, keeping straight or flexing elbow, then ad- ducting shoulder. Return. 2. Floor weights. Patient lies supine, head to weights, arm extended upward. Lower sideward, raise. 3. Overhead weights. a. From extended arm. Lower and raise. (1) Carry arm obliquely fore downward. (2) Carry arm side downward. (3) Carry arm obliquely back downward. Combination of adduction and abduction. Raise arm sideward to shoulder level, carry forward and return, carry backward and return. 20 PHYSICAL RECONSTRUCTION 4. Trunk. Resistance to forward, backward, and lateral bending of the trunk is obtained by fixing the handle of the weights at given points in relation to the trunk. The higher the weight is fixed, the greater the resistance given. The weight may be fixed on abdomen, chest, head, or arms extended over the head. 5. Thigh. Foot bound to handle by special slipper or loop at- tached to shoe. A. Flexion. 1. Floor attachment. a. Patient supine, feet toward weights, knee flexed or straight. Flex, extend. h. Patient lying on side, feet toward weights, knee flexed or straight. Flex, extend. c. Patient standing, back to machine. Flex, extend. B. Extension. 1. Floor attachment. a. Patient supine, head toward weights, knee flexed or straight. Extend, flex. h. Patient lying on side, head toward weights, knee flexed or straight. Extend, flex. c. Patient standing, facing weights. Extend, flex. C. Abduction. 1. Floor attachment. Patient stands or lies supine, unaffected side toward weights. Abduct, return. D. Adduction. 1. Floor attachment. Patient stands or lies supine, affected side toward weights. Adduct, return. E. Rotation. 1. Floor attachment. Patient lies prone, knee flexed, side toward weights. (a. Unaffected side for inward rotation, h. Af- Fig. 6. Chipping of Humeral Head and Extensive Wound of Shoulder. No active motion at first. Flexion after five weeks of massage and exercises. Fig. 7. Abduction Assisted Largely by Scapular Rotation well Con- trolled. Fig. 8. Hyperextension Limited by Scar Tissue and Adhesions. EXERCISE 23 fected side for outward.) Rotate by swinging foot sideward. 6. Knee. Foot bound to handle. A. Flexion. 1. Floor attachment. a. Patient stands facing weights. Flex, extend. b. Patient lies prone, feet toward weights. Flex, ex- tend. B. Extension. 1. Floor attachment. a. Patient stands back to weights, knee flexed. Ex- tend, flex. b. Patient lies prone, head toward weights, knee flexed. Extend, flex. Setting-up Exercises. 1. a. Arms to thrust raise, thrust forward, return, lower. b. Arms to thrust raise, thrust sideward, return, lower. c. Arms to thrust raise, thrust upward, return, lower. 2. Hands on hips. a. Heels raise, lower. b. Toes raise, lower. c. Heels raise, knees deep bend, knees straighten, heels lower. 3. Hands on hips. a. Trunk sideward right bend, raise, bend sideward left, raise. b. Trunk sideward right turn, return, turn sideward left, return. c. Trunk lower forward, raise, bend backward, raise. 4. a-. Arms forward raise, carry sideward, carry forward, lower. b. Arms sideward raise, carry forward, carry sideward, lower. 24 PHYSICAL RECONSTRUCTION e. Arms forward raise, carry upward, lower forward, lower downward. d. Arms sideward raise, carry upward, lower sideward, lower downward. 5. Hands on hips. a. Raise right knee, lower. &. Raise left knee, lower. c. Raise right knee, extend leg forward, bend knee, lower. d. Raise left knee, extend leg forward, bend knee, lower. 6. Jump to stride stand, arms raise sideward. b. Trunk bending, alternating right and left. h. Trunk turning, alternating right and left, c. Hands behind head. Trunk bending alternately forward and backward. 7. Stationary running on toes with high knee raising. Fig. 10. Baking. Electric Light Bath of Knee. Fia. 11. Diathermy. Electrical Heat Penetration for Deep Hyper^bmia. Chapter II BAKING HYDROTHERAPY ELECTRO- THERAPY . BAKING The result of the treatment of a part of the body by superheated dry air is to cause a local dilatation of the skin and subcutaneous capillaries, thereby thinning their cell, walls and increasing the intercellular spaces. A greatly increased amount of blood serum with its con- tained food is thus permitted to pass out and supply the tissue cells. This, and the increased removal of waste brought about by the accompanying stimulation of the lymphatic circulation, are the two essential factors in shortening the period of tissue repair. The common means employed to obtain this result are : First, electric lights with reflectors, such as the thermo- light; second, the adjustable local electric light bath (Burdick) ; third, Kellogg 's thermophore; fourth, the electric light body cabinet ; and fifth, the various types of ovens heated by gas and alcohol, some of which are quite inexpensive. For the application of heat to the deeper tissues, machines for electric heat penetration are used. The average length of treatment is twenty minutes. In baking, the part must be well wrapped in a dry towel. 27 28 PHYSICAL RECONSTRUCTION Watch for scars or anesthetic areas. The heat is given at 250 to 400 degrees. Passive Hyperemia. This method of increasing local blood supply by means of the constriction band placed proximally to the part, tight enough to shut off the venous return but not to impede the arterial inflow, is usually re- ferred to as the Bier treatment. This method should precede the other types of treatment indicated on the part and its duration should not exceed ten minutes. It is a valuable method of obtaining passive hyperemia, especially in selected cases where means of procuring ac- tive hyperemia are not available. HYDKOTHEEAPY Definition. Hydrotherapy is the application of water to the surface of or within the body for the relief of diseased condition. History. The therapeutic value of this agent was known to the Egyptians, Chinese, Greeks, Romans and Arabs. Modem use of water for curative purposes be- gan in the sixteenth century in Italy, France and Eng- land, as shown in the writings of Lanzani, Barra, Wesley, CuUen and Floyer. In the United States Rush, Lockette, Bell and others have added to our knowledge of this form of treatment. Among modem writers none have contributed more than Kellogg of Battle Creek. At the present time the use of hydrotherapy is being greatly extended and its value more largely recognized. While our larger sanitaria and hospitals have expensive HYDROTHERAPY ELECTROTHERAPY 29 equipments, it is possible to obtain most of the funda- mental benefits from the various forms of treatment with very simple apparatus. Properties. The physical properties of water are all made use of in our treatment. Its different forms solid, liquid and gas all have their places. Added value is de- rived from the ability of the water to hold certain salts and minerals in solution. Varying degrees of the tem- perature of the water used, and the force and amount in which it is applied, each affect the result of the treat- ment. Effect. The main desired result is obtained through the thermal and mechanical effect of the application of water on the sensory nerve endings in the skin. Re- flexly, changes are brought about in the circulation and nervous system. Circulation, (a) Distribution of the blood. The appli- cation of hot water brings about a local hyperemia. Cold water induces vasomotor contraction in the skin and dilatation in the deeper tissues, followed later by cuta- neous dilatation. (b) Composition of the blood. A redistribution of the blood cells shows a marked increase in the red blood cell count in the circulation. (c) Changes in blood pressure. By increasing the skin elimination of toxins and blood vessel dilatation, we are able to reduce high blood pressure. Hot and tepid baths are used. The stimulating effect of cold baths will im- prove capillary tone and raise the pressure when below normal. 30 PHYSICAL RECONSTRUCTION Respiration. A tonic bath will induce deep breathing and raise the general body tone. Nervous SysteWr. (a) Stimulation of the nervous sys- tem is secured by the various tonic baths. Vigorous rub- bing and massage are helps in securing this result. Often a hot bath will act as a stimulant. (b) Sedative effect on the nervous system is obtained by a long continued tepid bath. Muscular System. The removal of local and the les- sening of systemic fatigue is possible by means of the tonic bath. Skin. The direct effect of water applied to the skin is that of a mechanical irritant. This action may be in- creased by the use of salt, etc. The circulatory effect has been described. The removal of waste matter is best ac- complished by warm water. Cold water stimulates, closes the pores and protects against cold. Body Temperature. Cold water is now used freely to lower body temperature in typhoid, heat stroke, etc. It may safely be repeated several times daily if neces- sary. It is a good general rule preceding every bath to heat the body. Methods in common use are the blanket pack, electric cabinet, electric cradle, or exercise. Electric Cradle or Cabinet Bath. In using the cradle (which is a frame wired with lights fitting over the pa- tient in bed) or the cabinet (lined with lights in which the patient sits) cover the head with ice cap or cold wet towel. Take the temperature often and discontinue the treatment when the temperature has reached 100 degrees or the patient perspires freely. Indications All forms Fig. 11a. Multiplex Sinusoidal Machine. Fig. lib. High Fpequency Machine. Fig. 11c. Alpine Sun Lamp, Ultra Violet Ray. HYDROTHERAPY ELECTROTHERAPY 33 of intoxication, gout, nephritis and the relief of internal congestion. Wet Pack. Wrap the patient in a wet sheet and then several blankets. Be careful not to have the surfaces of the body touching. Cold packs stimulate, warm ones soothe. Treatment should average about an hour or to desired physiological effect, and be followed by rest. Evaporation Pack. This type of tonic treatment is given for fifteen or twenty minutes. Cover patient with wet sheet and one loose blanket. It may be given locally as a compress, or as a body pack. It is well to use a head compress also. Neptune Girdle. Two sizes of binder 15" by 60'' and 18" by 72" will serve. Wrap the patient's abdomen in the wet linen binder and cover with dry flannel one slight- ly larger, being careful to exclude the air. Indications Nervousness, insomnia, nausea and digestive dis- turbances. Abdominal Coil. Put on the linen binder, then the coil, then flannel binder. Run water through coil 120 degrees for 15 minutes; remain the rest of the hour. Local compresses are used to relieve hyperemia. Simple Tonic Bath. Sponge bath; apply water with slight friction with hand or cloth. Half Bath. Tub half full of water at 85 degrees lower to 70 degrees or 65 degrees. Pour water over the patient and rub with the hand; sit three to five minutes, then apply the cooler water. Drip Sheet. Stand in a tub of hot water. Hold the sheet so that one-third is in one hand and two-thirds in 34 PHYSICAL RECONSTRUCTION the other. Dip in water; lift out and wrap around pa- tient' and pour on more water duration three to five minutes. Sitz Bath. Sit in sitz bath, place feet in bath tub. Apply water 80 degrees to 60 degrees. Keep rubbing the skin, the patient rubbing the thighs and the operator rub- bing the shoulders and back. For bladder disturbances, pelvic congestion. Use hot water for spasms, colic or chronic intestinal conditions. The body surface should be flushed with heat, followed by a cold shower to get a good reaction or the patient put to bed with the room at an even tempera- ture till the vessels regain their equilibrium. For con- ditions following shell shock, irritable heart, hallucina- tions, fearful dreams, and neurasthenia, the bath at 94 degrees is kept up for an hour or more. Douche. Treatment begins with water 90 degrees, ris- ing to 115 degrees and ending with 60 degrees. Continue for two minutes. Scottish Douche. Two jets, one 100 degrees, the other 60 degrees, applied alternately by a lateral sweep of the nozzle up and down the spine. Whirl Bath. For sensitive stumps or masses of scar tissue, treatment by whirling water at 95-110 degrees, mixed or unmixed with air, leads to a very marked reduc- tion of sensitiveness and to active hyperemia, and is an invaluable means of the preparation of the part for massage or exercise. HYDROTHERAPY ELECTROTHERAPY 35 ELECTEOTHEBAPY This important type of treatment is being rapidly de- veloped and the scope of its usefulness greatly enlarged. It is essential that the student of electrotherapeutics have the elemental facts outlined for him in the simplest pos- sible form. The therapeutic effects of electricity are to produce surface or deep hyperemia; to induce muscular contrac- tion, either by changes in the chemical reaction within the muscle or through its nerve supply; to soften scar tissue ; to hasten the healing of open wounds ; to soothe nerve irritation and to cause the direct absorption of drugs by ionization. Electricity is produced by chemical action, induction or friction, all of which types are used in the treatment of patients. The type of current produced by chemical action is generated in the galvanic cell as typified by the standard Daniell cell, which generates an electro-motive force of one volt. The simplest form of this cell is a quart jar two-thirds full of sulphuric acid, in which is placed a plate of zinc, the negative pole or cathode, and a plate of carbon, the positive pole or anode. If a wire is placed between the upper extremities the current will flow from the positive to the negative pole. In the solution there is a transfer of electricity from the zinc to the carbon. During this process bubbles of hydrogen form around the carbon. This is called polarization and may be great enough to block the current, in which case the carbon 36 PHYSICAL RECONSTRUCTION should be removed and cleaned. In the dry cell a solid substance replaces the sulphuric acid, but the action is practically the same. Electric force may be either nega- tive or positive in quality. Like types repel and unlike types attract each other. The definition of a few electrical terms is here in order. 1. Volt. That unit of electro-motive force generated by the standard Daniell cell. 2. Ohm. The unit of resistance to the current offered by one thousand feet of one-tenth inch copper wire. 3. Ampere. The unit of quantity of current which the force of one volt will drive through one ohm in one sec- ond. McKenzie, Strong and others illustrate the meaning of these terms by the comparison of electricity to water power. If one water container is placed above another, the force exerted by the water in the upper container in seeliing the level of the lower is directly proportionate to the difference in height, and is comparable to the reaction between the positive and negative poles. The difference in height represents potential energy and this force cor- responds to the voltage of an electric current. The amount of water allowed to flow from the upper to the lower container corresponds to the amperage of an elec- tric current. Upon the size of the pipe used depends the amount and force of the stream of water. If a small pipe is used the resistance (number of ohms) is increased, the force of the flow (voltage) is high but the quantity of water (amperage) is small. On the other hand, if a HYDROTHERAPY ELECTROTHERAPY 39 large pipe is used the resistance is decreased and the force is lessened but the quantity of flow is increased. In electrotherapy the type of current commonly used has relatively high voltage but very low amperage, which, for convenience, is measured in milliamperes. Galvanism. The ordinary galvanic battery consists of a cabinet containing a series of cells joined to a switch- board with binding poles, to which are attached the cords and electrodes for applying the current to the patient. There are also appliances for measuring, interrupting or increasing the current. The galvanic is a continuous current flowing steadily from positive to negative. It is used for the following physiological effects : stimulation, sedation, nutrition and chemical changes. Quite different effects are produced by the positive and negative poles. There are two simple tests for differentiating the poles. If the ends of the cords are placed on blue litmus paper the positive pole, because of its attraction of acids, will turn the paper pink. If the cords are dipped into salt solution bubbles will collect around the negative pole, which attracts alka- lines. Where the anode or positive pole is used, circula- tion, muscular contraction and nervous irritability are re- duced. At the point of application of the cathode there is greater muscular contraction, stimulation of circula- tion and increased nervous irritability. Having selected the proper electrodes for the desired effect, they should be applied smoothly and firmly to unabraded skin. It must be remembered that the electrodes should be cov- ered with smooth felt or gauze thoroughly saturated in 40 PHYSICAL RECONSTRUCTION warm salt solution and should be proportionate in size to the part treated. Burns are most likely to occur at the cathode and this point should be most carefully watched. The current should always be applied and decreased slow- ly. This type of current is also applied by local bath with one pole in the water, the other on the spine. Ionization. Ionization is the induction of drugs into the tissues by electrolysis. These substances in solution may be driven in by the galvanic current. The ions of zinc, copper and lithium, being electro-positive, should be placed on the anode, by which they are repelled. The ions of chlorine, potassium and iodine are electro-nega- tive and are repelled by the cathode. "Weak solutions of two or three per cent are usually employed. Interrupted Galvanic Current. The constant current has no effect on muscular contraction, but when it is sud- denly shut off and again applied at both this break and make of the current a contraction is produced. The stronger contraction occurs when the current is made at the cathode. A device called a metronome, attached to the instrument, produces this effect. A smoother type of galvanic current is the sinusoidal galvanic, a current which flows evenly on the positive and negative side alternately. It has a deeper effect on mus- cular nutrition. Faradic Current. The faradic is an induced alternat- ing current, produced by charging one coil, the primary, which then becomes an electro-magnet and when brought into contact with a secondary coil charges it also. By variation in the size of wire or the number of windings HYDROTHERAPY ELECTROTHERAPY 43 on the secondary coil, the voltage of the current may be increased or * ' stepped up. ' ' This current may be made and broken by the withdrawal and reinsertion of one of the coils by hand, or may be rapidly done by mechanical interruption. The faradic gives a harsher stimulus than the galvanic and acts directly through the nerves, producing a defi- nite muscular contraction similar to that of a normal muscle. For that reason one electrode should be placed on a main nerve trunk proximately to the muscle to be stimulated and the other should be placed on the electro- motor point. The difference in polarily is slight, there- fore differentiation is unnecessary. The close similarity of this current to the normal nerve impulse makes it par- ticularly valuable in keeping muscles in good tone when normal exercise is impossible. Most machines for the therapeutic work combine the galvanic and faradic sinusoidal currents and they should therefore be used selectively. Sinusoidal Current. The sinusoidal current is also in- duced and is therefore similar to the faradic, save that it passes in a wave from zero to the highest force on the positive side and then back through zero to the highest force on the negative side and then flows back from nega- tive to positive. This surging effect produces complete muscular contraction, but is somewhat more gradual and therefore more pleasant than the harsh stimulus of the faradic. Bigh Frequency. This is an induced current oscillat- ing from one-half to five million alternations a second, 44 PHYSICAL EECONSTRUCTION with high voltage and low amperage. The different types d'Arsonval, Oudin and Tesla are all used. To obtain the current a resonator, coil (solenoid), adjustable spark- gap and Leyden jar condensers are used. Application to the patient is made by means of vacuum electrodes or plates. Marked changes in metabolism are produced with little discomfort on the part of the pa- tient. Diathermy. Another common use for this type of cur- rent is the driving of heat deep into the tissues by means of two pliable, flat metal electrodes applied on opposite sides of the part to be treated. These electrodes should be smoothed out and then shaped carefully to the part and held firmly in place. The resistance by the body increases the heat which in turn produces marked deep hyperemia. In this way we are able to drive heat deep into the tissue, as in the joint cavity, and to prepare a part for massage or exercise treatments. Static Electricity. This current is produced by the friction of revolving glass plates, charging brushes. Holtz and Wimshurst machines have been varied for special uses. The high tension obtained requires insulation. The types of current are Morton wave for general tonic, simple current for insomnia and ''breeze,*' sedative effect on pain. Sun Lamp. By means of the quartz lens light can be split into its component parts and all but a desired wave length excluded. The ultra-violet or actinic rays may HYDROTHERAPY ELECTROTHERAPY 45 thus be used alone for the chemical effect. These rays have a marked bactericidal and healing action. The patient's body, with the exception of the part to be treated, should be carefully covered. Operators much exposed should wear smoked glasses. An average ex- posure is three minutes at a distance of eighteen inches. Very satisfactory results have been obtained in the quickened healing of open wounds by this means in a number of our base hospitals where these lamps are in use. Chapteb III MASSAGE Definition. Massage is the scientific manipulation of the soft parts of the living body for purposes of health. It is a mechanical interference with and modification of the physiological function of the different tissues. History. Throughout the animal kingdom we find many instances of one animal massaging another or itself by rubbing, licking or biting the affected part. Among mankind it was known to the Chinese at least three thousand years B.C., and was used somewhat by the Egyptians and Greeks and by the Romans in their baths. Among the Greeks, ^sculapius and his followers, the Asclepiades, in their school of medicine on the Islands of Kos and Knidus, were the first to systematize massage. With the other arts and sciences it was submerged dur- ing the dark^ages to reappear on the teaching of Pare, Ling and Metzger in modem history. It was first used extensively in this country by Dr. S. Weir Mitchell about 1877. Types of Movements. There are four cardinal move- ments used: 1. Eflfleurage or stroking. 2. Petrissage. Pinching or kneading. 46 Fig. 15. Massage. Effleurage or Stroking of Forearm. Fig. 16. Massage, Petrissage or Kneading of Calf. MASSAGE 49 3. Tapotement. Hacking, slapping or vibrating. 4. Frictions. Objects : 1. To increase arterial, venous and lymphatic flow. 2. To improve skin function. 3. To soothe or stimulate the nerves. 4. To eliminate waste products. 5. To break down adhesions. 6. To reduce swollen tissue. 7. To improve nutrition. General Considerations. Since by means of massage we are going to interfere with the physiologic function of tissue, a broad and thorough knowledge of physiology is an absolutely essential basis for scientific work. Not only the way tissues and organs act, but their structure and location must be exactly known; therefore a com- prehensive knowledge of the anatomy, at least of the soft parts of the body, is of extreme importance. The too great neglect of this valuable means of treatment has been to a large extent due to the impression left on both the physician and the public through the ignorant and unscientific use of massage by a large proportion of those claiming to be able to treat by this means. Al- though one of the best contributions to this science was made by the Swedes, many valuable features have since been added to the theory and application of this form of physical therapy. It is a mistake, then, to follow the Swedish, or any other so-called system, to the exclusion of others. 50 PHYSICAL RECONSTRUCTION The proven value of this form of treatment, and the fact that in so many serious conditions its use is indi- cated, make it a worthy branch of the medical science. No person can be truly successful in this work who does not approach it from the standpoint of service and who is unwilling to make the personal sacrifice necessary to gain a well . rounded knowledge of the entire subject. The high type of young women entering the work for the army will undoubtedly elevate the plane of this field of endeavor. Let us hope that in the mind of the general public the athletic ''rubber" and the Turkish bath at- tendant will be hereafter clearly distinguished from the true masseur or masseuse. The close personal contact with the patient makes it imperative that the operator remain constantly mindful of the fact that the feeling of confidence and trust on the part of the patient is an invaluable aid toward success. Dignity, reserve and high moral tone are prerequisites. In an oiBfice practice it is desirable to have a couch or a padded table about three feet high and two feet wide. The best temperature is from 70 to 75. Only the part should be exposed which is being manipulated. Both hands should be trained to equal skill and during a treat- ment are usually kept in contact with the skin. Powder is being increasingly used to lessen skin friction and is in many ways preferable to cocoa butter, cold cream or vaseline. The use of ichthyol or strong liniments to produce counter-irritation is unnecessary. The length of the average treatment depends upon the vigor and concentration of effort, the object desired, and the size MASSAGE 53 of the surface to be covered, and varies from twenty to fifty minutes. Venous Circulation. Venous circulation runs in the same direction as the lymphatic and is modified by the action of the valves scattered throughout the venous sys- tem. Lymphatic Circulation. Its general course is from the extremities toward the heart and is modified by ** stops," individual or groups of glands. Arm. From the tips of the fingers to the axilla, espe- cially on the, flexor side. Gland in the elbow, middle of the arm and chain in the axilla. Leg. Largest vessels on the dorsum of the foot, the back of the leg, popliteal space, inner side of the thigh to the front above. Glands between the tendo Achillis and external malleolus, the lower part of the thigh and the chain of inguinal glands in the groin. Face. The upper vessels center at the root of the nose ; the lower ones go toward the neck. Neck. Down the front of the sterno-mastoid and in front of the edge of the trapezius, where most of the cervical glands are located. Chest. Superficial glands from the inner third of the breast toward the sternum, outer two-thirds toward the axilla. Deep vessels toward the sternum. Abdomen. Generally toward the inguinal glands. Back. Superficial circulation of the upper part to- ward the axilla ; deep circulation toward the spine ; lower back toward the sacral notches. Stroking is always done in the direction of the lym- 54 PHYSICAL RECONSTRUCTION phatio and venous flow, the only exception being to re- move secretions from an open wound. MECHANICS AND PHYSIOLOGICAL EFFECT Effleurage or StroMng. Stroking is done with one or both hands or any part thereof simultaneously, alter- nately or with one only and with varying degrees of force, rapidity and duration, depending upon the part massaged and the purpose in view. The object is to in- fluence the blood and lymphatic circulations. The super- ficial circulation is always affected, the deeper only by added pressure. The direction is always toward the heart with the exception noted above. The skin is mildly stimulated, but this effect is les- sened with the use of lubrication. Sensory nerve endings in the skin are stimulated by stroking and the sum total of the effect depends upon concentration of the nerve endings in the part, the amount of surface covered, and the number of strokes used. Since stimulation depends upon variation, and nerve end- ings soon become dulled to the same type and degree of stimulus, repeated light stroking is in its sum total ef- fect soothing. The circulation may be greatly modified by stroking. No measurable effect can be procured on the arterial flow. Capillaries are dilated by strong stroking and contracted by light stroking. Venous circulation can be markedly im- proved. The stroking should be deep enough to compress the vein, more rapid than the venous circulation, which Fig. 19. Massage. Tapotement or Hacking of Muscle. Fig. 20. (A) Posterior Half Cast to Prevent Foot Drop. (See Fig. 58 for X-Rav.> MASSAGE 57 is not more than five inches a second, and long enongh to extend over the next proximal valve, which would be from six to eight inches. The lymphatic flow will be aided by slow, deep stroking, especially over the lymph glands. The muscle can be directly relieved in fatigue through the removal of waste products by deep stroking. Glands can be stmiulated by the indirect effect of cir- culatory changes in the skin. In such bones as the tibia the periosteal circulation and nutrition can be aided. Several writers have called attention to the different effects produced on muscle tissue by the different types of massage. They consider light stroking to be both soothing and relaxing and therefore indicated in spastic contracture. Others do not massage spastic muscle at all. Petrissage. Pinching, Kneading. This type of mas- sage is used mainly for its effect on muscle tissue. The amount of tissue grasped would then depend upon the part being massaged. Fine pinching is done between the thumb and first finger. Coarser pinching between the thumb and the side of the second phalanx of the first finger, or the thumb opposed by the tips of all the fingers, is good on a flat surface, such as the back ; to this twist- ing may be added for more vigorous effect. The hands may be used effectively close together and alternately, one pinching while the other is re-grasping. On the extremities the hands may be used on opposing sides, completely grasping the various muscle groups. The direction of the pinching should be at right angles 58 PHYSICAL RECONSTRUCTION to the muscle fibers. On the abdominal wall, where we are unable to obtain selective action on the different layers of muscle, it is well to knead in concentric circles. Pinching the muscle fibers brings about a partial con- traction of those having their nerve supply intact. Some orthopedists believe a beneficial or a stimulating effect may follow even where we find that the nerve supply is entirely lacking. It is easier to obtain a partial con- traction of a large number of fibers, or a complete con- traction of a few by this means than by the use of elec- tricity. Since only the stimulated part of the muscle re- acts, we may by this means keep up the tone and health of muscles in the immediate neighborhood of inflamed joints, yet at no time cause an undesired movement of the joint. For this partial effect the different nerve sup- plies and the several heads of the various muscles must be kept in mind. A beginner should early learn to differen- tiate in infantile paralysis the thick, fat and connective tissue layer which so often overlies the muscle and upon which, without due care, the petrissage may be directed from the muscle itself. ^ Tapotement. Hacking, slapping, vibrating. This pro- cedure is aimed at the skin and the muscles. Skin slapping should be done with light, fast, alternate strokes. The wrist should be relaxed, each hand instant- ly rebounding from the skin. Superficial blood vessels and later the deeper vessels are quickly dilated in this manner. Over groups of muscle the strokes are made alternately with the ulnar sides of the hands. Here, too, the wrists Fig. 21. High Explosive Wound of Left Hand. Loss of third and fourth fingers and part of hand. Function good following exercise and massage. (X-ray Fig. 22.) Fig. 22. Loss of 3rd and 4th Metacarpals. MASSAGE 61 should remain relaxed, the hand nearly open, the fingers slightly separated. In this manner the fourth finger strikes the part first, the others following in turn. For harder striking, to relax a knotted muscle, for instance, the hand may be held rigidly extended and the strokes given more heavily, only the ulnar side of the hand and little finger striking the part. Another method is by the use of the partially clenched hand, palm down, striking flat with the second phalanges of the fingers. Vibrating can be done by keeping the finger tip or other parts of the hand in contact with the patient, the wrist relaxed, and performing a shaking motion of the whole arm. The stimulation resulting from this method depends upon the number and force of the strokes and the amount of surface covered. Frictions. Frictions are seldom used except on ad- ventitious tissue in a number of pathological conditions. The breaking up of scars and adhesions forms an im- portant part of its usefulness. We generally approach such tissue by concentric circles starting well out at the periphery. Frictions of the spine are sometimes used to stimulate the nerve roots. This manipulation is also valuable in the reduction of callus. THERAPEUTIC USES AND CONTRAINDICATIONS Skin. Where the skin is dry, harsh and cold, slapping will dilate peripheral capillaries, warm the skin and in- duce perspiration. Oold, clammy, moist skin can be 62 PHYSICAL RECONSTRUCTION aided by frequent light stroking centrally above the part to aid the venous circulation. Glands. Inactivity of the sebaceous glands, followed by the formation of blackheads and pimples, often oc- curs where the skin is normally rather immobile. Mas- sage will improve the circulation, mechanically squeeze out the inspissated secretion and restore normal gland activity. Dandruff is the result of hypersecretion of these glands in the scalp. The oil not being fluid enough, in- stead of supplying the hair it collects in layers around the gland openings and flakes off. The hair not being prop- erly oiled, tends to dry and break off or split. Massage of the scalp will stimulate gland activity and the return of the sebaceum to its normal fluidity. After chronic inflammation of the skin, for instance, as caused by boils or carbuncles, scar tissue may be re- duced. Scars. It must be remembered that scars are com- posed of connective tissues only and contain no sweat or sebaceous glands and no touch, pain, or heat corpuscles and are the result of wounds not healing by first inten- tion. Frictions over and around scars will reduce the amount of tissue in duration and the size of the scar itself. Massage will prevent tissue contraction. Atrophy. This condition is commonly seen after the wearing of casts or on the soles of the feet after pro- longed rest in bed. Massage is extremely useful here in restoring skin function and hardening the soles of the feet preparatory to walking. MASSAGE 63 Contraindications. 1. Hypersensitivity of the touch corpuscles, which may, however, reflect the same state of the mind, contraindicates massage. Parts covered by hair must be well lubricated or shaved. This shav- ing does not stimulate the growth of hair as much as does the repeated irritation caused by the pulling of the mas- sage itself. 2. Pimples or skin infection are not massaged. In case it is necessary to stroke a skin covered with blackheads and pimples, clean thoroughly before and again after the treatment with alcohol or soap and water. CAEDIO-VASCXJLAB SYSTEM The Heart. The heart can at times be stimulated by tapotement directly over its location, or this procedure over the stomach may greatly relieve cardiac embarrass- ment caused by gas formation there. Pericarditis. Here the heart laboring under mechani- cal difficulties which retard its action can be relieved by stroking of the extremities, thus removing some of its normal work. Myocarditis. In the same way a weakened or inflamed heart muscle can be relieved of some of its load. This very obvious fact in therapeutic indications for massage has been almost entirely overlooked by the general pro- fession. Graded muscular exercise should, if possible, be given in conjunction with massage. Endocarditis. This condition can be aided in the same way and, since cardiac dilatation is sometimes due to back 64 PHYSICAL RECONSTRUCTION pressure from the venous system, this mechanical aid should never be withheld. Contraindications. Tapotement and the more vigorous types of massage may often be useless, but gentle strok- ing in the direction of the venous return will always aid a heart working under a handicap. Acute endocarditis and purulent myo- or pericarditis and angina pectoris contraindicate massage. Veins. Dilatation of the veins may be treated by ele- vation and stroking, which may, especially in the veins of the lower leg, prevent them from becoming varicose. Varicose veins cause a great deal of extra work to be thrown on the heart through venous stagnation. Massage by gentle stroking above and below. When the dilata- tion is not marked or any sign of ulceration present, slow, gentle stroking may be done directly over them. Phlebitis. Here the walls thicken, a sign of inflamma- tion in the vein, which may greatly enlarge, become ad- herent to the surrounding tissue or break down and ul- cerate. Later joint contractures may form in the knee or elbow. Elevation and rest should be given in the active stage. Later on gentle frictions and stroking at the sides over the non-inflamed veins and above and below the inflamed part, to aid in removing the swelling, is of value. Contraindications. In varicose veins any pro- cedure except stroking is to be avoided and even this is not done when the walls are thin or ulcers have formed. In phlebitis, during the active stage, or at any time di- rectly over the vein, avoid massage for fear of freeing a thrombus. MASSAGE 65 Lymphatics. Dilated lymph capillaries and spaces may be massaged with stroking and deep pressure centrally, with light friction added over the lymph nodes. Eleva- tion is helpful. Contraindications. Active inflammation contraindicates all direct massage. Arteries. No disease of the larger arteries is amenable to massage treatment. The compensatory circulation may be improved in obliterating endarteritis. Arterio- sclerosis usually begins in the capillaries and arterioles in the distal extremities, the left leg being often the first point of onset. The X-ray may show this condition. Tor- tuous temporal arteries, arcus senilis, palpation of the radial artery and high blood pressure are other means of determining its presence. A general massage con- tinued for years and well done on the extremities and the veins of the surface will often arrest the progress of this disease and may give partial recovery. The mental attitude of these patients is greatly helped and this is a most desirable and important element in the treatment. Contraindications. Tapotement, when the condition is at all advanced, and in aneurism, should not be used. MUSCULAB SYSTEM Myositis. Muscle soreness follows the insufficient re- moval of fatigue products. Stroke centrally above the muscle to open up the lymph channels and then stroke over the muscle. Knotted muscle, which occurs in athletes, especially track, after severe exertion, is the next stage of the same process, but includes as a rule the tearing of a few fibers 66 PHYSICAL RECONSTRUCTION with some serous exudate into the muscle tissue. Pro- ceed as in muscle soreness just described but the stroking of the muscle itself should be deeper and of greater dura- tion with some friction added. Muscle Bruise. Here, in addition, occurs hemorrhage into the muscle with discoloration. If treated at once, it is dealt with as in knotted muscle. Later the fibrin glues the muscle fibers together and deep frictions must be used to break it up. Work in concentric circles. If neglected for some time the blood clot may become or- ganized and a great deal of exertion must be put into the massage and a longer time given to the treatment. Vig- orous tapotement should be added. Occasionally it may be necessary to make the muscle '* black and blue" again by this means before the organized mass can be broken up and the free play of the bundles restored. Torn Muscle. This is usually associated with severe bruising and is followed by true scar formation within the muscle. This scar must if possible be reduced and broken up in the same manner as for a bruise, but the part should be immobilized between the treatments. The bandaging should start above and below and work to- ward the tear, thus keeping the fibers approximated. It is evident that tight bandaging started directly over the lesion would force the fibers apart and increase the amount of scar formation. ''Charley Horse'* is a subperiosteal hematoma which follows deep bruising that involves the periosteum, tear- ing some of its blood vessels. Frictions and stroking will prevent organization and hasten reabsorption. This is MASSAGE 67 a common football injury of the front of the thigh and its presence is indicated when, with knee raised forward, the patient is unable to extend the leg. Contraindica- tions: Purulent myositis, trichinosis, and muscle wounds should not be massaged. Atrophic Muscle. The commonest condition we deal with here is infantile paralysis. The lesion is primarily in the motor and trophic nerves ; occasionally the sensory are involved. While massage is aimed at aiding nutrition and stimulating any muscle cells and nerve endings that may be alive, we must remember in children how de- pendent we are for growth upon contact stimuli. These are usually lacking, but can to some extent be supplied by massage. Slapping and light tapotement with open fin- gers are useful, and fine pinching, which must penetrate the layer of fat and connective tissue and be directed on the muscle fibers, is of great value. The intrinsic power of all muscle tissue to contract is thus stimulated even in the absence of motor impulses. Contraindications: In the active stage of infantile paralysis no massage should be used, and in advanced atrophy of old age or convales- cence only stroking is indicated. Spastic Muscle. Stimulating massage of the physio- logical opponent is good and on the muscle itself gentle stroking, which is now believed to be relaxing, aids the condition. Some authors, however, call all massage oon- traindicated in spastic muscle. Sarcolemma or Muscle Sheath Inflammation. This structure is often inflamed in places where a large number of muscles lie close together and considerable friction de- 68 PHYSICAL RECONSTRUCTION velops during their overuse, as in the neck, forearm and calf. The ' ' spike soreness ' ' of track men is of this type in the opinion of some writers ; others class it as a neu- ritis. Rest, baking and elevation are invaluable adjuncts to massage stroking. Try to get between the muscles with the tips of the fingers. In chronic cases where there may be organized deposits, use deep friction followed by stroking. Tendon Sheath Inflammation. Tendons themselves sel- dom are inflamed or injured. The sheath acts as a deli- cate insulation within which the tendon moves. This movement requires constant lubrication by a fluid se- creted by cells in the inner layer of the sheath. Overuse will exhaust this fluid and set up an inflammation (teno- synovitis). Overproduction of fluid then takes place, distending the sheath with pressure on adjoining struc- tures. Fibrin may coagulate within the sheath and form a painful, semi-solid swelling. In the vn:ist and ankle the annular ligaments may partially shut off a portion of the tendon sheath and, aided by gravity, hasten coagulation. Occasionally the fluid may enter a joint cavity and float the bones apart with a tendency to sprain and dislocate. Any mechanical interference in the absorption of the ex- cess fluid, unless it be a snugly fitting bandage from the extreme distal part completely over the entire swelling, may be injurious ; hence wrist and ankle supporters often do more harm than good. The tight lacing of high shoes is a common cause or an aggravation of this condition. Treat by heat, rest, removal of constrictions and ef- fleurage, with frictions if any coagulation is present. MASSAGE 69 Contraindications. Wounds and pumlent inflammations should not be massaged. BONES Periostevm. Chronic periostitis may be greatly aided by deep stroking, especially in bones, like the tibia, which are practically subcutaneous. Scar formation following tears may be lessened by friction and stroking. Hemorrhage beneath the periosteum has been de- scribed under diseases of the muscle. Fractures. The large callus that usually follows frac- ture repair may be reduced by frictions. These calluses may include some of the soft parts which must first be liberated. Deep frictions working circularly from the periphery to the center are best. The action of the muscles may be greatly hindered by having to work over such an enlargement. Occasionally there may be great pain and discomfort from this condi- tion. Even a small callus may cause trouble if situated near the joint. Fractures involving joints, which have been so common in the European war, have proven the indispensability of massage treatment to reduce callus and to break up foreign bodies and adhesions. Callus formation interfering with joint movement may be too soft to be disclosed by the X-ray and yet demands atten- tion. Faulty Metabolism. Such conditions as rickets may be greatly aided by massage aimed at the circulation. General body massage is often indicated and improved 70 PHYSICAL RECONSTRUCTION nutrition of the bones leads to increased formation of red blood corpuscles. Contraindications. Immediately after fracture and in acute inflammations, osteitis, os- teomyelitis and periostitis, massage is not used. JOINTS Dislocations. Gentle friction and stroking will aid the healing of the torn ligaments. In certain joints, for ex- ample, the shoulder, there is a tendency for the disloca- tion to recur and here the treatment should be delayed. Sprains. These should be massaged at once in spite of pain. Deep strokes and frictions aid in the removal of extravasated blood and help to prevent its clotting. If the case is not seen until the clot has organized it must be broken up by deep frictions followed by stroking. If this is not done the ligaments heal over the clot, which, when it is finally absorbed, leaves the ligaments elongated and relaxed with a tendency to frequent recurrence. As I have before emphasized, there is no treatment available superior to this, coupled with a support to prevent re- sprain. Synovial membrane is always involved in joint injuries. There is an increased secretion of synovia by means of which nature attempts to float apart the two inflamed surfaces. This results in lateral insecurity of the joint and this is where support is indicated. In the case of the knee a posterior splint, which is commonly used, is not the preferred treatment but a lateral hinged brace, which prevents twisting and lateral strain, but allows normal hinge movement, is indicated. Because of the relatively MASSAGE 71 poor blood supply, such injuries heal rather slowly, but a week should suffice in the ordinary case. When repair is delayed much beyond this time suspicion of the pres- ence of toxins should lead to careful examination of the teeth, gastro-intestinal tract, etc. Baking and counter- irritation are of value. Massage should consist of ef- fleurage above and over the sprain. In the chronic or subacute stage the excess of fluid is absorbed, leaving a gelatinous residue containing fibrin, which tends to coagulate. Hard frictions, getting as deeply inta the joint as possible, are then indicated. If coagulation has taken place, small particles may be broken off and become loose in the joint. In the knee the so-called **rice kernels" are of this type. Here the joint should be fully flexed to open it up and moved several times during the treat- ment to shift the particles under the fingers. The next stage in untreated cases, or in repeated sprain, is a thick- ening of the synovial membrane which may not be ap- parent for two or three weeks. Here, too, the joint be- comes insecure with tendency to subluxation and re- injury. The synovial membrane becomes thick and spongy and rolls between the bones like dough before a rolling-pin and a fold or crease in front or rear may limit joint movement. Normal movement, well protect- ed, still tends toward cure, but as a rule heat and mas- sage must be continued for months before permanent re- covery takes place. Contraindications. Infective in- flammations, toxic inflammations when most acute, and dislocation while unreduced should not be massaged. 72 PHYSICAL RECONSTRUCTION NERVOUS SYSTEM Brain Diseases. The quieting effect of stroking, espe- cially of the back, may be of service in mild states of mental agitation. After a prolonged agitation, sys- tem exhaustion may be lessened by complete massage treatments. The persistent chronic constipation asso- ciated with many of these disorders may be relieved by abdominal massage of the type to be described. "Softening of the brain" resulting from faulty circu- lation in localized areas cannot directly be affected. When it involves motor areas, however, the affected mus- cle should be treated by reeducational gymnastics and "muscle massage." Apoplexy. Downward stroking of the veins of the neck relieves congestion. Treat the paralyzed muscle by "muscle massage." This has not only a distinct local beneficial effect but a pronounced sedative influence upon the patient's mental condition. Contraindications. In acute inflammations of the brain, meningitis and hyper- susceptibility massage should not be used. SPINAL DISEASES Injuries. The spine cannot be directly stimulated be- cause of its location. Infantile Paralysis. Stroking of the back may be beneficial in the subacute stage. Local massage of the affected muscle should not be begun until tenderness has entirely disappeared, but thereafter it must be continued MASSAGE 73 until recovery or for a number of years. Contraindica- tions. The acute stage contraindicates massage. Functional Diseases. Improvement in diagnosis and recent researches are bringing us more and more to the point of view that pure functional neuroses are extremely rare, and that there is usually an organic or functional lesion somewhere. This should be diligently sought and if found removed. Neurasthenia. The nervous and bodily weakness ac- companying this condition is more efficiently treated by regular and complete massage than by almost any other method at our command. Both mentally and physically great benefit is usually obtained. The muscles are kept in good health and tone without the expenditure on the part of the patient of the energy which exercise would require. Later on massage should be supplemented by graded exercise. Hysteria. General massage is indicated here when possible for its general tonic effect. Contraindications. Violent hysteria should not be treated by massage. Peripheral Nerves. Thickening of the nerve sheath following injury can sometimes be relieved by light strok- ing. The nerves are often caught in scars following frac- tures or extensive tissue destruction. They must be loosened up and relieved from the pressure by passive movements, friction and stroking. Neuralgia. This is a symptom, not a disease. Mas- sage may help to remove the cause. It is contraindicated on the affected part. Neuritis. This is commonly a result of some constitu- 74 PHYSICAL RECONSTRUCTION tional poison and the massage is directed toward helping- the body eliminate the causative agent. The muscular atrophy which usually accompanies severe neuritis can be retarded. Contraindications. Massage over the af- fected nerve is contraindicated. ABDOMINAL VISCERA Stomach. Vigorous tapotement directly over the stomach will often assist in the elimination of gas which may, beside causing local distress, be embarrassing the action of the heart. Intestines. Chronic Constipation. This is one of the most common distressing and truly important conditions with which we are concerned. Among the common causes are enteroptosis with stretched mesentery, partially oc- cluding the blood vessels and resulting in atonic muscula- ture. The mechanical stimulation to proper peristalsis is dependent upon the presence of a fairly large bolus within the intestine and then a period of rest. This means regular meals and not the constant nagging of small amounts of contents without rest periods. It also re- quires that we eat a reasonable amount of indigestible residue, largely cellulose, to maintain the required bulk. Lack of normal secretion within the gastro-intestinal tract, adhesions and lack of the formation of regular habits of attempt at evacuation may also be important causes. Long dependence on drugging is unwise. We must first not only eliminate, if possible, the cause but bring to our assistance every factor that will aid in the return of the normal function. Bodily exercise and espe- MASSAGE 75 cially abdominal exercise of the type outlined for lordosis is very eflScacious. By massage we may increase the tone of the abdominal muscles, thereby lessening ptosis, and in most cases we may directly stimulate intestinal mus- cle coats. Deep pressure with the heel of the hand or the fist should begin over the cecum and follow the course of the large intestine. Circular stroking should follow the same course. Deep frictions should be thorough at the hepatic and splenic flexure, where deep stroking from back to front between the lower ribs and the pelvis should be vigorously applied. On the left side the ulnar sur- face of the hand in many cases may follow the sigmoid flexure for quite a distance downward and forward. Liver. Tapotement over the ribs covering the liver, circular frictions over its free edge and gentle depression of the movable ribs will stimulate hepatic activity. Pancreas, kidneys and bladder are not treated by mas- sage. Hernia may be aided indirectly by bettering the nutri- tion of the abdominal wall muscles, especially where a truss is worn. Contraindications. Any abdominal ten- derness, pregnancy, and all acute infectious diseases con- traindicate massage. Scalp. The scalp is often rather tight and its circula- tion somewhat impaired. It can be loosened by finger tip friction with considerable benefit to the circulation and the growth of hair. Limb Stumps. In all its range of usefulness massage gives no more gratifying results than in the preparation of stumps for artificial limbs. In a great number of cases 76 PHYSICAL EECONSTRUCTION at the Walter Eeed Hospital in Washington careful mas- sage has worked wonders. During the war many of the stumps were, under stress of circumstances, operated on in such a way as to make it extremely difficult to prepare them for weight bear- ing. The chief pressure from an artificial limb is lateral, but the soft tissue must be drawn down to form a cushion over the end of the bone. Massage should be begun at the earliest possible moment regardless of whether or not the wound is healed. If effleurage is used great care should be taken to prevent drawing up of the muscles. The stroking should be mostly downward. Vibration and friction are used concentrically from above down- ward, loosening the scar and working to the very edge of the new formed tissue over and around the end of the bone. Where this technique is followed very few of the blue, cold stumps, such as were common earlier in the war, result and the whirl bath for theirrelief is unneces- sary. Simmmry. I would again emphasize the fact that it is necessary to know thoroughly anatomy and physiology and the reaction of the various tissues to strain, injury, under-nourishment, etc. With this knowledge, and a gen- eral idea of the technique of the main movements, the masseur is at liberty to develop his own special technique and method of procedure. One so equipped is in a far better position to perform successful and helpful work than one working merely from the mechanical standpoint, be he ever so efficient in any given system or school of massage. It paEECS tiire pieafaritly Fig. 23. Basket-m.\ki.ng. Can be begun while the patient is still hediiddtn. and has therapeutic value in hand and wrist injuries. Fig. 24. Telegraphy. Instruction begins at the bedside and is carried on through the shop to fold work. i'lU. 2."). ('lav AIoDKl.lXG. One of the most valuable therapeutic measures for joint mobihty in the fingers and hand. It can be used very early in cases where more complicated work ia impossible. Fia. 26. Chair Caning. A trade of great vocational value with many varied movements of the hand and arm which aid in restoring function. Fig. 27. Wood Toy Making. Ps3rchologically most patients become like children for a time. They are then easily interested m toy making. Later this interest and incentive to work is transferred to other things. Chapteb IV" VOCATIONAL THERAPY This branch of physical reconstruction is growing most rapidly in its breadth of application to war injuries. The problems met and overcome so successfully are those which must in the future be met by the surgeon in civil practice. The work done and the lessons learned will be of the greatest value to the compensation insurance com- panies whose interest in the men crippled in industrial life closely parallels the economic interest of the govern- ment in the soldiers. Insurance companies have of late recognized that treatment of the insured by physiotherapy in many cases is a paying investment, the men being returned to partial or complete eflBciency at a much earlier date than would otherwise have been possible. It is cer- tain that vocational therapy will in the future play an increasing role in the treatment of convalescent em- ployees. The larger manufacturing concerns which take care of their own compensation cases would in like man- ner gain much from a careful consideration of these mod- em methods of treatment, which have proven their effi- ciency in far too large a group of cases to ever be con- sidered fads. The facts are that we have as yet ex- hausted but a small part of the possibilities which these methods of treatment hold forth. 79 80 PHYSICAL RECONSTRUCTION Specifically, the objects of vocational therapy are thera- peutic, economic, occupational and to improve morale. In the early treatment of men in the army the therapeu- tic indications control to a large extent the type and amount, or dosage, of work outlined for a patient. For example, a man with scar tissue contracture or fibrous adhesions in the elbow joint, allowing only limited motion in semi-flexion, may be put at planing in the carpenter shop. This treatment is given the man as far as possible on the prescription of the surgeon, as shown on page 59. Such a prescription is given as soon as the man has suffi- cient strength, motion and muscular control to make some movement possible, this beginning usually having been obtained by the preliminary application of physiotherapy. For some time the man may be treated by the suitable physiotherapy methods together with this simple occu- pational work. With the lessening of his disability the problems of his future value to himself and society are taken up. The patient is either given training in work which he has done before or takes up new work which will bring him reasonable financial return and in which his interest has been already aroused. If his disability is such that he is unable to return to any occupation com- parable to the one in which he was engaged in civil life after the best surgical and vocational expert advice and treatment, he is then trained in some line in which his injury handicaps him little. His degree of disability in its relation to his future earning power is calculated and the difference made up to him. Certain types of vocational training have as their main VOCATIONAL THERAPY 81 object the arousing of the patient from the mental and physical lethargy into which he is so apt to fall. For this purpose basketry or any simple creative work which oc- cupies his time and interest has proven of great value. Study with a teacher of the simple branches of learning is also used to good advantage. Interwoven throughout a man's entire treatment is the inspirational idea. The personality of the teacher is, of course, of prime importance. These men are so often left with the belief that their disability has permanently un- fitted them for their place in society that the time allowed them for introspection may be more destructive to their future efficiency than the wound itself. That these men do not lack courage their glorious record has proven. The problem lies in properly arousing . their grit and stamina, which, during their stay in the hospital, has become gradually inert. The man must be made to real- ize that the noblest of all courage is the conquering of physical handicaps by patient endeavor and that both the instructor and the government realize the quality of man- hood which such a successful fight requires through weeks and months of persistent effort. Too much cannot be said in praise of the splendid corps of aides who are carrying their own discouragements in addition to lifting, to the best of their ability, those of the men whom they serve. Their work will live in the years to come through the increased efficiency with which these men will carry on. For the proper attainment of the man's rehabilitation a close and active cooperation must be obtained between 82 PHYSICAL RECONSTRUCTION the surgical, physiotherapy and occupational depart- ments. It is essential that each understand and appre- ciate the scope of the others. Between the man's voca- tional training and his final status in civil life stands a most important and efficient organization, the Federal Board for Vocational Training. This organization is prepared to give expert advice on the selection of future work. It also aids the man financially to obtain better training even to the extent of paying his tuition in voca- tional training schools or colleges until he has reached the best preparation of which he is capable. This done, the government's debt of honor to the wounded man is met and he is returned to civil life and self-support. Let us hope that never again the old pension system with its paternalism and attendant evils will have a place in the government's care of its veteran soldiers. In such a book as this no detailed description of the methods used in the some two hundred and fifty occupa- tions taught to convalescent soldiers can be undertaken. I will, however, briefly state a few of the most useful methods employed. At the bedsides are taught basketry, clay modeling, wood carving, leather and bead work, making of simple toys and the beginning of the studies of English, mathematics, stenography, telegraphy, etc. In the shops are taught carpentry, photography, automobile repairing, vulcanizing, modem machine shop practice, pattern making and a wide variety* of other trades. In the class rooms stenography and typewriting, wireless and the common branches of language and mathematics are a few of the subjects taken up. This is further de- * ^ ' '^ ^i '^^ - "^9 i #ii *^ 5^ ^^i ft K^ ^Hj 1 /^ . tmJ^L. 1 i ^:l:-^- > 1 '^''' ^^t..^-^ ii 1 ^M ^^^^g 1^. 1 ^^i^^H ^H ^^el"' 'H Phl ,,.,^ ^^. ^ tS^-JiZ^J^^ 1 l^^^^^l ^H iK^''.J isy ' Sri 1 IHHH Fig. 28. Teaching the Beginnings op Mechanical Principles. Toys are here being made from tin cans. VOCATIONAL THERAPY 85 veloped, where possible, by field work in electrical con- struction, surveying and other outdoor occupations. Of special interest to the general hospitals wishing to add vocational training to their equipment is the curative workshop. This is an attempt to combine the simple forms of vocational work requiring only inexpensive equipment and limited space. The therapeutic indication is the leading motive for treatment. In such a workshop we would find clay modeling, which has proven invalu- able in the treatment of stiff fingers and wrist. The scroll saw and various lathe machines with adjustable pedals offer unlimited possibilities for increasing mobility of hip, knee and ankle. A simple kit of tools suffices for mechanical drawing, wood working, shoe making and similar occupations. The talent of an artist is not destroyed nor his means of expression lost when a physical disability interferes with the particular method of drawing, painting, or play- ing which he had formerly used. There are several cases on record for artists following injury of the right hand have quickly learned to work equally well with the left. In the same way musical talent can be utilized. Pro- fessional musicians are used in an advisory capacity to aid men to choose that instrument or mode of musical ex- pression which is not interfered with by his disability. There is another value to this type of treatment which must not be lost sight of and that is the inspirational ef- fect of the music itself. Many a man will spend happy and beneficial hours in the music studio instead of giving 86 PHYSICAL EECONSTRUCTION way to the mental depression and discontent of the in- valid. In the early spring of 1919 there were already over fifty thousand patients in this country under treatment by a corps of something over three thousand aides who are teaching, as before mentioned, between two and three hundred subjects. Vocational therapy will see increasing growth and development, and must necessarily be one of the last to be discontinued when this big chapter of our country's history is closed. I wish again to emphasize that the medical profession owes the same intelligent care to our great industrial army which the government has so efficiently given to its veterans of the Great War. Fig. 30. Musical Knowledge Reapplied to an Instrument the Man's Disability Will Allow Him to Play. Pleasure and higher emotional tone are derived from the production of good music. Fig. 31. Automobile Repair Shop. This is one of the most practical, valuable and popular forms of vocatio therapy. Fig. 32. Wood Working. Gives many possibilities for self expression, arouses the creative interest and exercises almost innumerable muscle groups. VOCATIONAL THERAPY 89 (Orthopedists have found the following simplified form useful in briefly outlining the reconstruction treatment which they con- sidered best suited to the needs of the patient.) EDUCATIONAL SERVICE U. S. Army Base Hospital Camp Meade, Md. MEDICAL OFFICER'S PRESCRIPTION Name Ward 191 . Diagnosis Probable length of stay in hospital weeks. Probable condition after completion of hospital treatment Functional result to be attained. In orthopedic cases check below: .Abduction ..Thumb ..R....L .Adduction ..Finger . Flexion ' . . Wrist .Extension ..Elbow . Pronation . . Shoulder . Supination . . Back . Circumduction . . Toes . . Mid-Tarsus . .Ankle ..Knee ..Hip Remarks 90 PHYSICAL EECONSTRUCTION PRESCRIPTION BLANK. FOR VOCATIONAL THERAPY Please check below the general class to which this man's dis- ability belongs, using double check for major disability and single check for minor. MEDICAL CONDITIONS Cardio-vascular Pulmonary Tuberculosis Fimctional Neurosis Insanity Nephritis (rastro-intestinal Skin Disease Gassed Convalescent Other general medical SUBOICAL CONDITIONS Orthopedic Amputation Eye, Ear, Nose Throat Disease or Wound Nervous System Blindness Deafness Speech Defect Severe Injury to Face or Jaw Venereal Disease or Sequelae Surgical Condition of G.-U. System Venereal Non-Venereal Other surgical conditions Convalescent This man is ready for assignments checked below (please i elude all of which he is capable) : Work in wards: Mental Physical Classroom work not to exceed hours and minutes daily. Shop or farm work .... Hours per day .... Light Heavy Outdoor Indoor To be avoided Medical Officer's Signature (This prescription will be filed in the Surgeon General's Office as a part of the Physical Reconstruction Register.) PART II ORTHOPEDICS Chapter V CONGENITAL DEFECTS Club Foot. As this common condition is much more often congenital than acquired, the congenital type only- will be considered. There are four types. The deformed foot (talipes) may be, 1. Extended and everted, equino valgus. 2. Extended and inverted, equino varus. 3. Flexed and everted, calcaneo valgus. 4. Flexed and in- verted, calcaxeo varus. Simple talipes equinus is dis- cussed under muscle-bound foot. These deformities vary greatly in their resistance to corrective measures. Eesistance in any given case in- creases with age, therefore treatment should be begun as early as possible. In very slight cases manual correc- tion alone may suffice. In the more marked types a se- ries of casts must be used. In the commonest type, equino varus, emphasis must first be placed upon straight- ening the foot, flexion being easily obtained later on if necessary by tenotomy. The series of casts should be as nearly continuous as possible and each should remain on about two weeks. Hip Dislocation. This condition is more common than is generally realized and the difficulty of reading X-ray 91 92 ORTHOPEDICS plates makes it necessary to use the utmost care in diag- nosis. A neglected hip means an undeveloped or shallow acetabulum into which it may be impossible to place the head of the femur later on. It interferes with the devel- opment of the bones and tends to an asymmetrical pelvis. The table devised by Hibbs of New York has been used very successfully in diflScult cases. Care must be taken not to overreduce and create a dislocation in the oppo- site direction, as has often been done. BICKETS Cause. We find rickets most prevalent among negro and Italian children of the first generation. It is caused by a lack of suflBcient lime salts in the bone, primarily because they are not supplied in proper amount in the diet. The prolonged nursing of children to the fifteenth or even eighteenth month is perhaps the commonest cause. The dependence upon macaroni as the staple Italian diet accounts for a good deal of it. Diagnosis. The large, square head with overhanging forehead and delayed closing of the f ontanelles ; enlarged epiphyses of the long bones; the beading of the sternal end of the ribs, so called rachitic rosary ; the prominent, hard abdomen, and a tendency to draw up the legs, are the main early symptoms of the disease. Later on, bow- ing of the legs or knock knees develop. Treatment. Improved hygiene, especially in regard to diet, fruit juices, particularly orange, green vege- tables, fresh milk, eggs, etc., is essential. Massage is a yaluable adjunct of the treatment. Braces are usually CONGENITAL DEFECTS 93 needed and must be faithfully worn. Even in rather se- vere types of bow leg one brace will often suffice. If not it can be changed over or an additional brace made for the other leg. Anterior and very severe lateral bowing often call for surgical interference. A careful study of the epiphyses by the X-ray is very essential in order to determine the optimum time to operate when true bone has just begun to be rapidly deposited. Knock knee as well may call for surgical intervention guided by the same principles. It must be emphasized that permanent injury may be done to the knee joint rather early in neglected cases and that, with each additional degree of deviation from the normal line of weight transmission, a very great amount of additional strain is thrown upon the structures of the knee. Coxa Vara. This is a decrease in the angle between the surgical neck and the shaft of the femur with con- sequent shortening of the affected leg and change in the normal line of weight transmission. Its effect is similar to but not usually as pronounced as that described as resulting from congenital hip dislocations. It calls for a long stilt brace on the affected leg to transmit the weight of the body from the pelvis to the ground, the weight of the leg giving some extension. The shoe on the unaffected side should be built up. Spastic Paralysis. Central motor neurone lesions most often found in prolonged labor or instrumental delivery result in spastic paralysis. The only immediate relief of this condition is decompression, as performed with con- giderable success by Dr. Sharpe of New York, but even 94 ORTHOPEDICS under most favorable conditions a happy result is not certain. The associated retardation of mental develop- ment greatly complicates the problem of neuro-muscular education. Treatment by effleurage and passive stretch- ing should precede exercises for coordination and bal- ance. To bring lasting results these must be extended over a span of years. Every case can be improved and should be a challenge to us to obtain the greatest improve- ment possible, even when complete recovery is hopeless. Fig. 33. Carriage which Reduces Friction axd on a Smooth Surface Allows Wide Range of Movement with Slight Effort. Fig. 34. Wire Cockup Splint for Wrist Drop, Light in Weight, and Re- quires No Bandaging. Chapter VI INFANTILE PARALYSIS In infantile paralysis the lesion is a destructive one of the anterior horn cells of the cord and the lower motor neurones and almost always the resulting paralysis is a flaccid one. The trophic nerves are likewise affected and the part tends to decrease in bulk as well as in power. During the active stage, and while ^ny tenderness per- sists, the patient should be kept immobile. This is best done by means of a cast or splint, but immediately there- after for an extended period of time, daily treatment consisting of massage, exercise, support and sometimes heat, should be instituted. Massage should be mainly fine, deep petrissage for stimulative effect. The operator must be sure that he is getting direct action on the few fibers that may remain alive under the usual thick coat- ing of connective tissue and fat. Exercises. In general, small and often repeated doses bring the best results. Like the burning out of a weak motor, lasting harm may be caused by overdoing. Many devices for counter-weighting the limb have been used, thereby giving the patient the early and stimulating ef- fect of being able to move the limb actively. We have used a small carriage, consisting of a grooved plat- form mounted on casters and with a retaining strap. 97 98 ORTHOPEDICS This is easily made, and by overcoming to a large degree the friction of even a smooth table surface, will allow great amplitude of active movement very early in the treatment. Let us consider as a typical case a paralyzed arm in which the adductor muscle group is partially affected, the abductors of the arm, especially the deltoid, the trapezius and the supraspinatus have regained their strength but slightly, the flexors and extensors of the elbow have very little power remaining, and the muscles of the forearm and hand are practically powerless. The following three programs of exercise, preceded by the application of massage and heat, are suggested as giving, when used in rotation, a variety, which is of value in retaining the patient's interest. PROGRAM I The patient sitting, affected side toward table, hand strapped on carriage. 1. "Wide sweep of arm forward and backward. 2. Flexion and extension of the elbow to the side. 3. Wide sweep of arm with one or more attempts to stop and start again at definite points. 4. Small hand circles, elbow free, done a few times in each direction. 5. Flexion and extension of the elbow, fixed. 6. Patient leaning far forward, wide sweeps of the arm., (The plane of the movement of the arm in relation to the body is thus changed from horizontal to vertical and valuable help is given in stretching the adductors.) 7. Forearm fixed, abduction and adduction of the wrist. INFANTILE PARALYSIS 99 8. Hand turned, ulnar side down, flexion and extension of the wrist. 9, Patient prone on the table, wide sweep of the arm from iide to side overhead. (On a narrow table use as wide a move- ment as possible directly above the head.) PBOGBAM n. FREE EXERCISES Patient supine on the table. These exercises may be done by the affected arm only, by both together or alternately. Greater variety of neuro-muscular training may be secured by these different combinations. 1. Raise arm fore upward, carry above head and return. 2. Place hand on hip and return. 3. Carry arm sideward up to head and return. 4. Carry arm across body to opposite side of waist and return. 5. Snap hand to shoulder and return, aided by lifting elbow sideward if necessary. 6. Carry arm sideward, flex elbow, bringing hand to axilla, straighten sideward and return, 7. Flex elbow, bringing hand to opposite shoulder and return. 8. Supinate and pronate the forearm. (In this position this may be a shoulder exercise.) 9. Flex elbow to right angle, supported if necessary and pronate. (This position eliminates shoulder assistance.) 10. Flex elbow, hand on neck to shorten leverage, extend shoulder upward and return several times, return hand to side. PROGRAM m. RESISTIVE EXERCISES Fingers. 1. A well-fitting kid glove with small rings at the finger tips, to which are attached very light weights by means of strings, and used for flexion of fingers singly or together with the hand supine, the strings running over a wrist roller 100 ORTHOPEDICS or a row of spools. Pronate the hand for finger extension in similar manner. 2. Finger flexion machine finger tread-mill. Wrist. 1. Wrist roller. 2. Supination and pronation machine. 3. Abduction and adduction machine (McKenzie). With overhead chest weights. Elbow. 1. With hand encased in glove, if necessary, and at- tached to overhead pulley handle, flex elbow. 2. With arm at side allow weights to flex elbow as far as the control of the patient will allow, and extend downward. Shoulder. 1. From extended arm, carry arm obliquely fore downward. 2. From extended arm, carry arm side downward. 3. From extended arm, carry arm obliquely back downward. 4. Arm raised sideward at shoulder level, carry forward and return, carry backward and return. Without Chest Weights. Patient seated in chair, back to operator. Operator places hands on tips of shoulders while patient (1) pulls the shoulder forward, (2) lifts it up, (3) pushes it backward. Most of the above exercises can be worked out with the shoulder or low chest weight, especially with the patient lying supine, head toward the weights. The overhead pulley, however, gives the additional advantage of passive stretching of the stronger, and frequently shortened, adductor groups. The other, and still more common, result of infantile paralysis is a partially paralyzed leg. We will take as our basis a leg in which all the muscles of the thigh have a fair amount of power present, the extensors of the foot are considerably weak- ened, and the flexors are almost powerless. INFANTILE PARALYSIS 101 PROGRAM I Patient lying supine. 1. a. Operator grasps the fore part of the foot with one hand, the heel with the other and passively flexes the toes and the fore part of the foot. b. With the right hand grasping the fore part of the foot, the thumb on the ball, the left hand grasping behind the heel, the operator vigorously flexes the foot with an attempt at stretch- ing the gastrocnemius and the calf muscles and, if necessary, slightly assists the extension. "With the left hand working in the opposite direction, he overcomes the patient's movement at the hip, because, in attempting to extend the foot, the patient will press down with the whole leg, and vice versa. 2. The operator, supporting under the knee with the right hand, and the left under the ankle, is able to give any needed amount of assistance to the extension of the leg. 3. Grasping behind the ankle and giving support over the knee, if necessary, he assists the flexion of the hip with straight leg. 4. From the same starting position abduction and adduction are given, the operator carrying the weight of the leg. 5. Deep flexion of the thigh is done with the same assistance. 6. The carriage is placed under the ankle for active abduc- tion and adduction. Patient lying on affected side. 1. a. Place the affected ankle on carriage, knee fixed, for active flexion and extension. b. With knee bending, flex the thigh acutely. Patient lying prone. 1. The knee is flexed at right angles and held by operator or patient for rotation of the thigh. 2. Flexion and extension of the knee. 102 ORTHOPEDICS 3. Overextension of the thigh by backward and upward pull of the operator. 4. Knee flexed, circling of the foot both ways, which is a combination of 1 and 2. There are various tread mills and extension weight machines, which are of value. Machines for flexion, ex- tension and circumduction of the ankle all have their place, if available. It is taken for granted that the operator will vary and adjust his exercises exactly in relation to the strength of each group of the patient's muscles, follow- ing the general rule that the movements often have to be entirely passive at first, with a slowly increasing amount of assistance by the patient, and final develop- ment into active or even resistive movement. Again I would caution against too much work. An average of four to eight repetitions of each exercise in the program selected are sufficient for each treatment. Support, especially a brace in the case of the leg, is almost always essential and when needed should be worn constantly. The deformities we fear, overextension of the knee and drop foot, are generally the result of the neglect of this needed support. Parents often need the truth driven home to them that it is the brace which car- ries the child, when to them it appears that the child is lugging around a heavy extra weight. A late compli- cation, coming from two to four or even six years after the disease, is scoliosis, and this must be watched for from time to time. Indeed, Doctors Hibbs, Farrell and INFANTILE PARALYSIS . 103 Humphries, from their work in the New York Orthopedic Hospital, have come to the conclusion that infantile paral- ysis is the most common single factor in the causation of scoliosis. Late sequelae in unfavorable or neglected cases may demand tenotomy or muscle transplantation, but these operative procedures are not as early resorted to as heretofore. They should only follow several years of patient endeavor to secure the fullest results that may be hoped for from exercise, and, if done, must in turn be followed by reeducation. Recent rather brilliant re- sults in apparently hopeless cases have been achieved by baking for a considerable time in moderate tempera- ture. One must avoid allowing the monotony of the work to get one into a rut and to make one overlook the in- dividual problem incident to each case. Nothing in our field of work brings richer reward than patient, intelli- gent work with this distressing condition. Drop Wrist. This is another common type of paraly- sis, which may follow fractures of the humerus, or lead poisoning. It is the paralysis of the extensors of the wrist and exercises as outlined above are applicable. Splinting in extension must be maintained constantly. NEBVE INJUBIES IN WAB Injuries to the peripheral nerves are very common in modem warfare because of the extensive lacerations of the soft tissue caused by many types of projectiles. In fact the high velocity bullet at mid-range and gas shells are about the only missiles that do not make this kind of wound. * * The Orthopedic Treatment of Gunshot In 104 ORTHOPEDICS juries,'* by Leo Mayer, covers this field in a very satis- factory manner. Neurological examinations were made at the Field or Evacuation Hospital when possible and splints supplied if the injuries were extensive. It is important to re- member that all wounds of the soft parts are now splinted where practicable. I will attempt only briefly to out- line the diagnosis and treatment of injuries of the most common type. Upper Extremity. 1. Brachial plexus injuries are oc- casioned by axillary or supraclavicular wounds. 2. Cir- cumflex. The teres minor and deltoid are affected, so that full abduction of the arm is impossible. 3. Mus- culocutaneous. Weakness of elbow flexion without areas of anesthesia occur. 4. Musculospiral. This very com- mon injury makes it impossible to extend the wrist or thumb and the proximal phalanges of the fingers are also affected. The distal phalanges can be extended, supina- tion and the action of the triceps are weak, and small areas of anesthesia may be present on the base of the thumb. 5. Median. Flexion of the fingers and thumb is absent and there is anesthesia over the first two fingers and the outer half of the third. To test paralysis of pronation have the elbow fixed. 6. Ulnar. Fourth and fifth finger flexion is weak and there is inability to spread the fingers to the normal extent. The fifth finger and the inner side of the fourth is anesthetic. Lower Extremity. 1. Sciatic. There is weakness of knee flexors and complete paralysis of the foot with nearly total anesthesia. 2. External popliteal. Dorsal INFANTILE PARALYSIS 105 flexion and eversion are absent and the dorsum of the foot and toes is anesthetic. 3. Internal popliteal. Plan- tar flexion is weak or absent with anesthesia of the sole of the foot. 4. Musculocutaneous. Foot eversion is weak and there is anesthesia over dorsum of foot. 5. Anterior tibial. Dorsal flexion is absent with anesthesia of the big toe and part of the second toe. 6. Posterior tibial. Adduction is weakened and toe flexion is absent. Treatment. Early treatment by splinting in such a way as to relax the fibers of the affected muscles is essen- tial. This general rule may be accepted in the case of ulnar nerve injury because of the danger of contracture, hence the fingers should be kept straight. Attempt to bring the severed ends of the nerve into as close approxi- mation as possible. Plaster, leather or metal may be used for splinting. In injury to the musculospiral nerve keep the hand extended. It is well to abduct the thumb also. The proximal phalanges of the fingers must be kept extended by the cockup splint. Chapter VII THE SPINE DISEASES AND INJURIES Anatomy. The spine is a flexible column made up of a series of block-like bones, the vertebrae. There are thirty-three in the entire column, seven neck or cervical, twelve dorsal or thoracic, five lower back or lumbar five fused together for the sacrum and four fused to form the coccyx. In general, the vertebrsB consist of two essential portions, the heavy solid body in the front and the neural arch formed by the two pedicles and two laminae, with their processes, two transverse, four articu- lar and one spinous. The bone structure is more dense in the neural arch than in the body. The bodies, with their intervertebral, cartilaginous pads are able to rotate slightly, one upon the other in what more or less closely approximates the horizontal plane. The articular processes, however, are placed in an oblique plane, the superior backward and upward, the inferior forward and downward in direction. With the spine erect these articulations act as a check to rotation between the bodies. The anterior common ligament, binding the front of the bodies together, is not nearly as strong as the combined interspinous and supraspinous ligaments. There is a great difference in the mobility of the various parts of the spine. We find the most mo- 106 THE SPINE DISEASES AND INJURIES 107 bility between atlas and axis; flexion forward is least in the dorsal, then cervical, most in lumbar; extension backward, the same ; rotation is most in the cervical. Tvhercvlosis of the Spine. ("Pott's disease.") The spine is one of the most common regions at which the tubercle bacillus attacks the bony skeleton. One or more vertebrae may be involved either as a primary or a sec- ondary focus of infection. The bodies of the vertebrae are usually the parts first invaded. Points of lowered resistance caused by trauma are often affected or such a trauma may bring to light a slowly developing and here- tofore unsuspected infection and cause its rapid spread. The "cancellous nature of the bones permit early destruc- tion with crushing in wherever the infection is exten- sive. The collapse of the body of one or more vertebrae makes more prominent the spinous process and forms on the back the distinctive angular deformity known as a gibbus. Complete paraplegia from pressure on the cord may occur. Spinal caries is more frequently found from the fourth to the fifteenth year. Symptoms. Knowledge of tuberculosis in the patient or his family should make us use extreme care to rule out this condition in the presence of any obscure symp- toms pointing to the back. Usually they are pain, pro- tective spasm with resulting rigidity, angular deformity and the general signs of a chronic infection, although in early stages this may.not be present. Rigidity alone is a symptom of great significance and sometimes a suflB- cient basis for a positive diagnosis. The X-ray should al- ways be used and will often confirm the diagnosis. It 108 ORTHOPEDICS is of the utmost importance to differentiate this condi- tion from scoliosis and kyphosis since the treatment for tuberculons spine by exercise would do certain injury. I have seen them exist together, with the postural defects the more obvious. Treatment. Pott's disease demands the same consti- tutional treatment as tuberculous manifestations else- where in the body. The local treatment consists in fixa- tion and extension by means of cast, brace, stretcher frame, or by the operative establishment of immobility, secured by a bone graft from the tibia implanted into the split spinous processes and extending one or two vertebrae above and below the lesion as devised by Albee of New York. Another successful method is that of Hibbs, consisting in a partial resection and fusion of the laminae. This operation has the advantage of mak- ing but one incision and eliminates the slight promi- nence of the bone graft. Where the lesion is in the cervical section an extension of the brace or cast which will lift up the head is necessary. For example, the Taylor brace with head support (jury mast) is often used. Grafts which prevent collapse have been suo- cessfuly planted into the sacrum. A complication which necessitates special attention is abscess formation. They commonly follow the course of the psoas muscle, and point in the inner side of the thigh, but are subject to a wide variation and may point in almost any direction from the seat of the lesion. Aspiration under aseptio precautions is sometimes advisable. Sinuses already formed should be injected with Beck's bismuth paste. THE SPINE DISEASES AND INJURIES 109 They should be carefully dressed to prevent mixed in- fection and will usually clear up when proper measures are instituted at the seat of the original lesion. TRAUMATIC INJURIES Strain and Sprain. Prolonged carrying of heavy weights when the patient is not in proper condition may lead to back strain. An example of this is the heavy marching order on the part of the recruit not yet thor- oughly hardened. Weight lifting in the stooping posture is the common cause of lower back strains. Sudden twisting or falls upon the back or the awkward landing after jumping, may lead to quite severe sprains of any of the various ligaments. Treatment by means of heat, massage, rest, and sup- port is indicated. In sacro-iliac sprain the following strapping will be found most serviceable: The patient lying prone, the surgeon fixes the strap, which should be the full width of the roller, 3 to 5 inches in front of the anterior superior spine on the further side of the patient. The patient then rolls slowly away from the surgeon, who applies the strap tightly obliquely upward, ending just below the twelfth rib of the opposite side. The procedure is then repeated in the reverse direction, the two, broad, snugly fitting straps crossing over the sacrum. They may be reinforced by a short vertical strap of the same width over the sacrum and one or two lumbar vertebrae. Most corsets or belts which fasten in front aggravate the con- no ORTHOPEDICS dition because their pull tends to open the saoro-iliao joints. Bruises. Bruises of the muscles and ligaments along the spine show, beside the swelling and discoloration which may be present, a localized tenderness on one side of the spine. The spinous processes should not be tender in this injury. Fractures and Dislocations. Spinal fractures are rare. Cervical Region. This region, because of its mobility, is prone to dislocations, but fractures do occur. Slight lesions only need treatment, as a fatal outcome is almost certain in severe injury. Dislocation of the atlas an- teriorly on the axis is sometimes seen. Slight displace- ment, if associated with fracture of the odontoid process, may not be fatal. In this lesion the short spine of the ,axis may be palpated. The head is bent forward. Slight lateral dislocation at this joint, or between the other Lordosis, exercises, 120, 121 Massage, contraindications, 63 indications, 54 technique, 54-62 types, 46 Mechanotherapy, 131 Median nerve, 104 Metatarsalgia, 216 Mirror, use in exercise, 114 Movements, passive, assistive, aetire, resistive, 13 Muscle atrophy, 103, 104 balance, 14 contracture, 14 degeneration, 177 electrical stimulation, 39 fatigue, 17 massage, 57 tonus, 14 Musculocutaneous, 104 Musculospiral, 104 Nauheim exercises, 10 Nerve injuries, central, 93 peripheral, 103, 104 scarg, adherent to, 105 Occupational therapy, 79 Osteitis, 149 Osteogenesis, 150 Osteomalacia, 150 Pain, massage, guide, 49 passive movement, guide, 13 scars, 62 Paralysis, flaccid, 97, 103 infantile, 97 spastic, 93 traumatic, 104 Passive movements, 13 Peronei, transplantation of, 103 Petrissage, 57 Phalanges, dislocation, 178, 204 fractures, 178, 204 Physiotherapy, 27 Plaster of paris, application, 232, 233 preparation, 233 Popliteal nerve, paralysis of, 104 Pott's disease, 107 Prescriptions, foot ailments, 228 Pulley weights, exercises, 17-24 Badiant heat, 27 Reconstruction, 10 Ee-education, 97 muscle, 10 physical, 17, 222 vocational, 79 Bheumatism, 140 Eickets, 92 Sacroiliac lesions, 112 strapping, 112 Scar tissue, contractures, 62 massage, 61 pain in, 62 stretching of, 13 Scoliosis, braces, 129 diagnosis, 127 exercise programs, 130 prognosis, 130 types, 123 Septic wounds, Carrel-Dakin, 150 massage, 57 violet ray, 44 Shoe, fitting, 227 modifications of for foot deform- ities, 224 Shoulder, ankylosis, position for, 165 dislocations, 157 exercises for deformities, 18 fractures about, 162 Sinusoidal current, 43 Spine, arthritis, 140 braces, 232 casts, 232 dislocations, 110 fractures, 110 kyphosis, 113 lordosis, 119 torticollis, 110 tuberculosis of, 107 Splints {See also Braces), caliper, 192, 231 humeral extension, 166 Jones' cockup, 105 240 INDEX Splints, Thomas leg, 231 wire cockup, 103 Sprains, diagnosis, 137 treatment, 138 Static electricity, 44 Strapping, back, 112 flat foot, 211 metatarsalgia, 216 sprains, 138 Stumps, massage of, 75 preparation for prothesis, 76 Sun lamp, 44 Synovitis, treatment of, 69, 224 Tapotement, contraindications, 58 technique, 61 Tarsus, injuries to, 203 treatment of, 203 Tendons, massage of, 68 tenoplasty, 222 tenosynovitis, 69 tenotomy, 222 transplantation, 103 Thermolight, 27 Thermaphore, 27 Thomas heel, 224 Thomas splint, arm, 161 leg, 231 Tibial nerve, paralysis of, anterior, 105 posterior, 105 Trench foot, 226 Tuberculosis {See Arthritis and Bone), 142, 151 Ulnar nerve, paralysi* of, 104 Varicose veins, massage of, 64 Vertebrae (See Spine), 106 Vibration, manual, 61 mechanical, 61 Vocational reconstruction, 106 Volkmann's contracture, 177 Whirlpool bath, 34 Whitman arch plate, 215 Wrist, drop, 103 exercises for, 103 injuries, 177 treatment, 177 Paul B. Hoeber, 67-71 East 69th Street, New York HOEBER'S MEDICAL MONOGRAPHS MEDICAL MONOGRAPHS Published by PAUL B. HOEBER 67'69'7i East 59th St., New York This catalogue comprises only our own publications. It will be noticed that particular care has been exercised in the selec- tion of Monographs of timely interest. We are always glad to consider the publication of new and original medical works. Correspondence with authors is in- vited. Owing to the constant changes in manufacturing costs, prices in this catalogue are subject to change without notice. ADAM: Asthma and Its Radical Treatment. By James Adam, m.a., m.d., f.r.c.p.s. Hamilton. Dispensary Aural Sur- geon, Glasgow Royal Infirmary. 8vo. Qoth, viii+184 pages, Illust net $1.75 ADLER: Compendium of Histo-Pathological Technic. By Emma H. Adler. Formerly Technician Pathological Labora- tory, Presbyterian Hospital, New York. 12mo. Cloth net $125 ADLER: Primary Malignant Growths of the Lungs and Bronchi. By I. Adler, a.m., m.d.. 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Cloth, 94 pages, 45 Illust net $3.50 ELLIOT: Sclero-Comeal Trephining in the Operative Treatment of Glaucoma. By Robert Henry Elliot, m.d., b.s. Lond., d.sc. Edin., f.r.c.s. Eng. Lieut. Colonel i.m.s. 2d Edition. 8vo. Cloth, 135 pages, 33 Illust net $3.00 EMERY: Immunity and Specific Therapy. By Wm. D'Este Emery, m.d., b.sc. Lond. Clinical Pathologist to King's Col- lege Hospital and Pathologist to the Children's Hospital. Adopted by the U. S. Army. 8vo. Cloth, 448 pages, with 2 Illust net $3.50 EMERY: Tumors, Their Nature and Causation. By Wm. D'Este Emery, m.d., b.sc, Lond. Director of Laboratories, King's College Hospital, Captain r.a.m.c (T. F.). 12mo. Cloth, 146 pages net $1.75 FAILLA, JANEWAY AND BARRINGER: Radium Ther- apy in Cancer at the Memorial Hospital. (See Janeway, Barringer and Failla.) FISHBERG: The Internal Secretions. (See Gley.) 6 HOEBER'S MEDICAL MOHOGRAPHS FRIESNER AND BRAUN: CerebeUar Abscess; Its Eti- ology, Pathology, Diagnosis and Treatment. By Isidore Fries- NER, M.D., F.A.C.S., Adjunct Professor of Otology and Assistant Aural Surgeon, Manhattan Eye, Ear and Throat Hospital and Post-Graduate Medical School, and Alfred Braun, m.d., f.a.c.s., Assistant Aural Surgeon, Manhattan Eye, Ear and Throat Hospital, Adjunct Professor of Laryngology, New York Poly- clinic Hospital and Medical School and Adjunct Otologist, Mt. Sinai Hospital. 8vo. Cloth, 186 pages, 10 pi., 16 Illust net $3.00 GERSTER: Recollections of a New York Surgeon. By Arpad G. Gerster, m.d. 8vo. Cloth, 347 pages, 18 Illust net $3.50 GHON: The Primary Lung Focus of Tuberculosis in Chil- dren. By Anton Ghon, m.d., English Translation by D. Barty King, M.A., M.D. Edin., M.C.R.P. Large 8vo. Cloth, 196 pages, 72 Illust., 2 pi net $3.75 GILES : Anatomy and Physiology of the Female Generative * Organs and of Preg^nancy. By jArthur E. Giles, m.d., B.sc. Lond., M.R.C.P. Lond. ; f.r.c.s. Ed. Gynecologist to the Prince of Wales General Hospital. Large 8vo. 24 pages, with Mannikin net $2.00 GLEY: The Internal Secretions. By K Gley, m.d. Mem- ber of the Academy of Medicine of Paris, Professor of Physiology in the College of France, etc. Authorized Trans- lation. Translated and Edited by Maurice Fishberg, m.d. 8vo. Cloth 241 pages net $2.50 GREEFF: Guide to the Microscopic Examination of the Eye. By Professor R. Greeff. Director of the University Ophthalmic Clinique in the Royal Charity Hospital, Berlin. With the co-operation of Professor Stock and Professor Win- tersteiner. Translated from the third German Edition by Hugh Walker, m.d., m.b., cm. Large 8vo. Qoth, 86 pages, Illust net $2.00 GREEN, ED RIDGE-: The Hunterian Lectures on Colour Vision and Colour Blindness. (See Edridge-Green.) HARRIS: Lectures on Medical Electricity to Nurses. An Illustrated Manual by J. Delpratt Harris, m.d., m.r.c.s. 12mo. Cloth, 88 pages, Illust net $1.00 HELLMAN: Amnesia and Analgesia in Parturition ^Twi- light Sleep. By Alfred M. 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Cloth, 418 pages, Illust net $4.00 KERLEY: What Every Mother Should Know About Her Infants and Young Children. By Charles Gilmore Kerley, M.D. Professor of Diseases of Children, N. Y. Polyclinic Med- ical School and Hospital. 8vo. Paper, 107 pages net 35c KETTLE: The Pathology of Tumors. By E. H. Kettle, M.D., B.S., Assistant Pathologist, St. Mary's Hospital, and As- sistant Lecturer on Pathology, St. Mary's Hospital. 8vo. Goth, 242 pages, 126 Illust net $3.00 LAMBERT: A Terminology of Disease. To facilitate the Classification of Histories in Hospitals. By Adrian V. G. Lambert, m.d., Associate Professor of Surgery, Columbia Uni- versity ; Director Surgical Research Service, Presbyterian Hos- pital, N. Y. 12mo. Cloth, 176 pages net $225 8 HOEBEKS MEDICAL MONOGRAPHS LEWERS: A Practical Textbook of the Diseases of Women. By Arthur H. N. Lewers, m.d. Lend. Senior Obstetric Physician, London Hospital. With 258 Illustrations, 13 Colored Plates, 5 Plates in Black and White. 7th Edition. 8vo. Cloth, xii+S40 pages net $4.00 LEWIS: Clinical Disorders of the Heart Beat. A Hand- book for Practitioners and Students. By Thomas Lewis, M.D., D.sc, F.R.c.p. Assistant Physician and Lecturer in Car- diac Pathology, University College Hospital Medical School. 4th Edition. 8vo. Cloth, 120 pages, 54 Illust net $2.50 LEWIS: Lectures on the Heart, Comprising the Herter Lectures (Baltimore), a Harvey Lecture (New York), and an Address to the Faculty of Aledicine at McGill University (Montreal). By Thomas Lewis. 124 pages, with 83 Illust net $2.50 LEWIS: Clinical Electrocardiography. By Thomas Lewis. 8vo. Qoth, 2nd Edition, 120 pages, with charts net $2.50 LEWIS: The Mechanism of the Heart Beat. With Special Reference to Its Clinical Pathology. By Thomas Lewis. Large 8vo. Qoth, 295 pages, 227 Illust. New Edition in prep- aration. LEWIS: The Soldier's Heart and the Effort Syndrome. By Thomas Lewis. 8vo. Cloth, 156 pages net $2.50 McCLURE: A Handbook of Fevers. By J. Campbell Mc- Clure, m.d., Glasgow. Physician to Out-Patients, The French Hospital, and Physician to the Margaret Street Hospital for Consumption and Diseases of the Chest, London. 8vo. Cloth, 470 pages, with charts net $3.50 McCRUDDEN: The Chemistry, Physiology and Pathol- ogy of Uric Acid, and the Physiologically Important Purin Bodies. With a Discussion of the Metabolism in Gout. By Francis H. McCrudden. 12mo. Paper, 318 pages net $2,00 McKISACK: Systematic Case Taking. A Practical Guide to the Examination and Recording of Medical Cases. By Henry Lawrence McKisack, m.d., m.r.c.p. Lond. 12mo. Cloth, 166 pages net $1.75 MACKENZIE: Symptoms and Their Interpretation, By James Mackenzie, m.d., ll.d. Aber. and Edin. Third Edition. 8vo. Cloth, Illust. xxii+318 pages net $4.00 MACKENZIE: The Action of Muscles. By Willlam Colin Mackenzie, m.d., f.r.c.s., f.r.s. (Edin.) 8vo. Cloth, 267 pages, 99 Illust. New Edition in preparation. HOEBER'S MEDICAL MOHOGRAPHS 9 MACMICHAEL: The Gold-Headed Cane. By William Macmichael. Reprinted from the 2nd Edition. With a Pref- ace by Sir William Osier and an Introduction by Dr. Fran- cis R. Packard. Printed from large Scotch type on a special heavy-weight paper, 5J4 by 7^ inches, bound in blue Italian handmade paper, with parchment back, gilt top, square back, and gold stamping on back and side net $3.00 MAGILL: Notes on Galvanism and Faradism. By E. M. Magill, M.B., B.S. Lond., r.c.s.i. (Hons.) 2nd Edition. 12mo. Cloth, xvi+224 pages, 67 Illust net $2.00 MANUAL: See United States Army X-Ray Manual. MARTINDALE and WESTCOTT: ."Salvarsan" "606" Dioxy-Diatnino-Arsenobenzol), Its Chemistry, Pharmacy and Therapeutics. By W. Harrison Martindale, ph.d. Mar- burg, F.C.S., and W. Wynn Wescott, m.b. 8vo. Cloth, xvi+76 pages net $1.50 MINETT: Diagnosis of Bacteria and Blood Parasites. By E. P. MiNETT, M.D., D.P.H., D.T.M. and H., M.R.C.S., L.R.C.P. 12mo. Cloth, viii+80 pages tiet $1.00 MITCHELL: Memoranda on Army General Hospital Ad- ministration. By Various Authors. Edited by Peter Mit- chell, M.D. Aberd., Lieut.-Colonel R.A.M.C. (T. F.), Officer Commanding No. 43 General Hospital. 8vo. Qoth, v+109 pages, Illust. with vii pi net $2.25 MOTT: Nature and Nurture in Mental Development. By F. W. MoTT, M.D., F.R.S., F.R.C.P. Pathologist to the London County Asylums. 12mo. Cloth, 151 pages, with diagrams net $1.75 MUNSON: Hygiene of Communicable Diseases. By Lieut. Francis M. Munson, U. S. N., Retired. Lecturer on Hygiene and Instructor in Military Surgery, School of Medicine, Georgetown University; Late Brigade Surgeon, 2d Provisional Brigade, U. S. Marines. Published with the approval of the Bureau of Medicine and Surgery of the Navy Department, and by permission of the Secretary of the Navy. 12mo. Flexible cloth, 800 pages, Illust In Press MURRELL: What to Do in Cases of Poisoning. By Wil- liam Murrell, M.D., F.R.C.P. Senior Physician to the West- minster Hospital. 11th Edition. 16mo. Cloth, 283 pages ttet $1.00 NEUROLOGICAL BULLETIN. Qinical Studies of Nerv- ous and Mental Diseases in the Neurological Department of Columbia University. Edited by Frederick Tilney, m.d., ph.d. ; Associate Editor, Louis Casamajor, m.d.; Editorial Board; S. P. Goodhart, m.d., F. M. Hallock, m.d., Randal Hoyt, m.d., C. A. McKendree, m.d., Michael Osnato, m.d., Oliver S. Strong, PH.D., I. S. Wechsler, m.d. Published monthly. Vol. I, 1918, $3.00; Vol. II, 1919. Yearly subscription net $5.00 lo HOEBER'S MEDICAL MONOGRAPHS OLIVER: Lead Poisoning: From the Industrial, Medical and Social Point of View. Lectures Delivered at Royal In- stitute of Public Health. By Sir Thomas Oliver, m.a., m.d., F.R.C.P. 12mo. Cloth, 294 pages net $2.25 OLIVER: Studies in Blood Pressure, Physiological and Clinical. By George Oliver, m.d., Lond., f.r.c.p. Edited by W. A. Halliburton, m.d., f.r.s. 8vo. Cloth, xxiv, 240 pages, Illust net $3.00 OSLER: Two Essays. By Sir William Osler, m.d., Regius Professor of Medicine at Oxford. Vol 1. A Way of Life. An Address to Yale Students, Sunday Evening, April 20th, 1913. 16mo. Cloth, 61 pages net 75c Vol. 2. Man's Redemption of Man. A Lay Sermon, Mc- Ewan Hall, Edinburgh, Sunday, July 2d, 1910. 16mo. Cloth, 63 pages net 75c OSLER ANNIVERSARY VOLUME: See Contributions to Medical and Biological Research. OSNATO: Aphasia and Associated Speech Problems. By Michael Osnato, m.d., Associate in Neurology, Columbia University ; Consulting Physician Manhattan State Hospital and Central Islip State Hospital ; Assistant Chief of Clinic, Vanderbilt Clinic, Department of Neurology. 12mo. Cloth, 200 pages, Illust net $2.50 OTT: Fever, Its Thermotaxis and Metabolism. By Isaac Ott, a.m., m.b. 12mo. Cloth, 168 pages, Illust net $1.50 OWEN: The Legislative and Administrative History of the Medical Department of the United States Army Dur- ing the Revolutionary Period (1776-85). By Col. William O. Owen, U. S. A., Curator Army Medical Museum, Wash- ington, D. C. 12mo. Cloth, 226 pages, Illust PAGET: For and Against Experiments on Animals. Evi- dence before the Royal Commission of Vivisection. By Stephen Paget, f.r.c.s. With an Introduction by The Right Hon. The Earl of Cromer. 8vo. Cloth, xii+344 pages, Illust net $1.75 PATON: Education in War and Peace. By Stewart Paton, M.D., Lecturer in Neurobiology, Princeton University, Lecturer Psychiatry, Columbia University. 12mo. Boards, 125 pages In Press PEGLER: Map Scheme of the Sensory Distribution of the Fifth Nerve (Trigeminus) with Its Ganglia and Con- nections. By L. Hemington Pegler, m.d., m.r.c.s. Senior Surgeon, Metropolitan Ear, Nose and Throat Hospital, etc. Folded in Cloth Binder net $10.00 HOEBEKS MEDICAL MONOGRAPHS n PICKERILL: The Prevention of Dental Caries and Oral Sepsis. By H. P. Pickeriix, m.d., ch.b.m.d.s., l.d.s., Professor of Dentistry and Director of the Dental School in the Univer- sity of Otago. Second Edition, 1919. 8vo. Cloth, xvi+374 pages, Illust net $5.00 RAWLING: Landmarks and Surface Markings of the Hu- man Body. By L. Bathe Rawling, m.b., b.c, f.r.c.s. 5th Edition. 8vo. Cloth, 31 pi., xii+96 pages of text net $2.50 RITCHIE: Auricular Flutter. By William Thomas Ritchie, M.D., F.R.C.P.E., F.R.s.E. Physician to the Royal Infirmary. Large 8vo. Qoth, 156 pages, 21 pi. 107 Illust net $3.50 ROCKWELL: Rambling Recollections. An autobiography by A. D. Rockwell, m.d. Svo. Cloth, 332 pages, 7 Illust net $4.00 RUTHERFORD: The Ileo-Caecal Valve. By A. H. Ru- therford, m.d. Edin. Svo. 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Being an Abridged Edition of "Health and Disease in Relation to Marriage and the Married State." By Prof. H. Senator and Dr. S. Kaminer. Trans, from the German by J. Dulberg, M.D. Svo. Qoth, 452 pages net $2.50 SLOAN: Electro-Therapy in Gr3mecology. By Samuel Sloan, m.d., f.r.f.p.s.g.. Consulting Physician to the Glasgow Royal Maternity and Women's Hospital, etc. Svo. Qoth, 320 pages, 39 Illust net $4.00 12 HOEBER'S MEDICAL MONOGRAPHS SMITH: Studies in the Anatomy and Sxorgery af the Nose and Ear. By Adam E. Smith, m.d., Past Chief Medical and Sanitary Officer, Nile Reservoir Works, Assuan, Egypt; Past Instructor in Operative Surgery, College of Fliysicians and Surgeons, and Past Attending Surgeon, German Hospital, O.P.D., New York. Large 8vo. Cloth, 168 pages, 45 pi tvet $4.00 SMITH : Some Common Remedies, and Their Use in Prac- tice. By Eustace Smith, m.d. 12mo. Cloth, viii+112 pages net $125 SQUIER and BUGBEE: Manual of Cystoscopy. By J. Bentley Squier, m.d. 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Cloth, xi+140 pages, Illust net $1.75 Complete catalogue and descriptive circulars sent on request. 4473 9 I UNIVERSITY OF CALIFORNIA LIBRARY Los Angeles This book is DUE on the last date stamped below. DEC 1 * I960 OEC 2 7 196-J DtSCK JUN 9 1981 Form L9-37m-3.'57 (C5424s4 ) 444 UN. ' .-ITY of CALIFORNIA AT RM Stewart - -n?0^ Phyoieal re coii S81i struction and orthopediea , Hay 6 I95I4 rvE llll.iiiiliii illiii lliii liiliiilliiiiiiiilllilllllllllll 3 1158 00690 8643 <