Reprinted from the TRANSACTIONS OF THE PHILADELPHIA COUNTY MEDICAL SOCIETY. Vol. ll.—lBBB. THE TREATMENT OV NERVOUS AND MENTAL DISEASE BY SYSTEMATIZED ACTIVE EXERCISES. BY CHARLES K. MILLS, M.D., J’ROFESSOR OF DISEASES OF THE MIND AND NERVOUS SYSTEM IN THE PHILADELPHIA POLYCLINIC; NEUROLOGIST TO THE PHILADELPHIA HOSPITAL ; LECTURER ON MENTAL DISEASES IN THE UNIVERSITY OF PENNSYLVANIA. REPRINTED FROM THE TRANSACTIONS OF THE PHILADELPHIA COUNTY MEDICAL SOCIETY, JANUARY 11, 1888. WM. J. DORTNAN, PRINTER PHILADELPHIA 1888. THE TREATMENT OF NERVOUS AND MENTAL DISEASE BY SYSTEMATIZED ACTIVE EXERCISES. CHARLES K. MILLS, M.D., PROFESSOR OF DISEASES OF THE MIND AND NERVOUS SYSTEM IN THE PHILADELPHIA POLYCLINIC, NEUROLOGIST TO THE PHILADELPHIA HOSPITAL ; LECTURER ON MENTAL DISEASES IN THE UNIVERSITY OF PENNSYLVANIA. [Read January 11, 1888.] Exercises or movements for medical purposes—medical gymnastics, in other words—have been divided and subdivided to an absurd degree by Ling and his followers. Scbreiber gives an example of a German term for what is called the quarternary combination of the standing position, which term contains forty-five letters and nine different words, although it is written in German as a single word. The division, however, into such movements or exercises as passive, dupli- cated active, and active, is rational and useful. Passive movements are performed upon the patient or individual, his will not coming into play except in submitting. In duplicated active movements, both the operator and the individual treated, take part; the first resisting while the second acts, or the reverse. Sometimes these movements are spoken of as semi-active and semi-passive; in the former, the physician or operator resists; in the latter, the subject resists. Move- ments of this class are of the greatest value in some forms of nervous or neuro-muscular disease, but it is not my purpose to discuss them, unless it be incidentally, in this paper; nor do I intend, except per- haps in the same manner, to speak of massage. It is of systematized active exercises, that I will more particularly speak. The expression single active movement indicates that the movement is performed by a single individual without direct assistance, although it may be done under the orders of a physician or master. Exercise of this kind may be performed either with or without appa- ratus, and even when the latter is used it need not necessarily be expensive. While massage and electricity have received a large share of attention from neurologists, they have neglected too much the use 2 MILLS, of medical gymnastics, particularly systematized active exercises. Masseurs and masseuses, good, bad, and indifferent, now abound in our large cities, but good instructors in physical culture, as applied to medical purposes, are not numerous. “Gymnastics,” “exercises,” and “movements,” by some medical writers are used as practically synonymous. Dr. George H. Taylor, however, claims that we should carefully distinguish between gym- nastics and movements, and between calisthenics and movements, and that evil has grown out of confounding these terms. It is probably better in a medical paper to speak with precision of “movements” or “exercises,” designating the particular kind, but “medical gymnastics” covers the whole ground, and the word “gymnastic,” or “gymnastics,” used in a general sense, may be properly employed in medicine. I will not give much space to a discussion of literature, but will refer briefly to a few important publications, including those which I have chiefly consulted in the preparation of this paper. The attention of the profession of this country has been too little attracted to the publications, and the practical work of the brothers, Dr. George H. Taylor and Dr. Charles Fayette Taylor, of New York, who may be regarded as the pioneers in this country of the gymnastic treatment of disease. They deserve great credit for their efforts, not wholly appreciated. As early as 1861 a book was issued on The Theory and Practice of the Movement Care, by Charles Fayette Taylor, M.D., in which is discussed in an interesting and practical way the treatment, by Swedish movements, of curvatures, paralysis, indigestion, constipation, diseases of women, etc. In 1879 appeared a Treatise entitled An Exposition of the Swedish Movement Cure, etc., by George H. Taylor, A.M., M.D. Dr. Benjamin Lee, of Phila- delphia, by his practical labors, and his publications on massage and Swedish movements, has done much to advance the cause of mechano- therapy in America, and stands with the Taylors as a pioneer in this department. Archibald Maclaren’s System of Physical Education, Theoretical and Practical, is an invaluable book, and while not intended for medical purposes should be studied by every physician interested in active exercises as a means of treatment. Blaikie says truly of Maclaren, that he has done more than anyone else now living to point out the benefits resulting from rational physical exercise, and how to attain these benefits. By his individual efforts and his publications, William Blaikie himself has also done a great work for the advance- ment of physical culture. His book published by Harper & Bros., EXERCISES FOR NERVOUS AND MENTAL DISEASES. 3 in 1883, and entitled How to Get Strong, and How to Stay So, has enlisted the interest of thousands, and doubtless has lengthened or saved many a life. In 1886 appeared another little work by Blaikie, in the form of a school text-book: Sound Bodies for Our Boys and Girls. The exercises given in this hook are clear and plain; they are arranged on a natural plan; they are safe, and but little apparatus is required for them—a few dumb-bells, a few wands or sticks, and a horizontal bar, are about all. I have found them to be admirably suited for my purpose in the treatment of some forms of nervous and mental disease. In the Therapeutic Gazette for June and July, 1887, appeared two lectures by Prof. Dujardin-Beaumetz, of Paris, in the first of which he considers the physiological effects obtained from exercise and movements; and in the second, after setting forth the methods of medical gymnastics, he discusses the diseases and conditions in which they are useful. A Manual of Treatment by Massage and Methodical Muscle Exercise, by Joseph Schreiber, M.D., of Austria, translated, with the author’s permission, by Walter Mendelson, M.D., of New York, has appeared within a few months. This book treats the subject of mechano-therapy from various points of view; and in it are found explicit directions in regard to the technique of massage and its effects, and also a discussion of active movements with and without apparatus. The treatment of many nervous diseases is discussed. The book is a valuable practical treatise, and its publication will do much to advance mechano-therapy in this country; but one of my chief reasons for referring to it is because it contains an extensive chronological bibliography, which can be consulted by those interested. I am engaged in the preparation of a book on the Gymnastic Treatment of Nervous and Mental Diseases, in which will be con- sidered both general and local methods of exercise, and the combina- tion of such methods with other forms of treatment, as, for instance, with massage, electricity, hydrotherapy, and medicines. One of my chief purposes this evening is to call attention to general systematized active exercise. I will also speak of a few special or local exercises designed for particular organs or parts. In a large number of nervous and mental cases, the improvement of general nutrition is the one thing needed to bring about relief or cure, and one of the most effective aids to this end is general, systematized active exercise. The methods chiefly adopted by me are (1) the exercises of Blaikie, with or without dumb-bells, and with the horizontal and MILLS, parallel bars, or substitutes for them; and (2) exercises with pulley- weight apparatus. I need only refer you to Mr. Blaikie’s1 best known book for a description of some of the simplest forms of apparatus; to the uses which can be made of the jambs of a door and a couple of pitchfork handles, and for the sketch of a pair of pulley-weights of excellent pattern designed by Dr. Sargent. A. J. Beach & Co., of Philadelphia, the well-known dealers in sporting and gymnastic goods, have constructed a form of pulley- weight apparatus, which is very complete, compact, and convenient. “ The Home Exerciser” of C. L. Dowd, of New York, is also con- venient and useful, and has been strongly endorsed by Mr. Blaikie for its compactness, strength, lightness, etc. The apparatus of Reach and Dowd consists of an arrangement of ropes, pulleys, and weights, ingeniously put together so as to occupy but little room, and yet to allow' the performance of many movements. “The Home Gymnasium” of John E. Ruebsam, of Washington, D.C., is well adapted to the office of a physician, or to hospitals and colleges. For a long time I have had this apparatus in use. It occupies more room than the apparatus of Reach or Dowd, but, on the other hand, it is in some respects more complete, having, for instance, combined with it a lounge for massage purposes, and a strong horizontal bar. An apparatus of this kind or one similar should be in every hospital which has not a complete gymnasium. Elastic straps are sometimes used for gymnastic purposes. Accord- ing to Dujardin-Beaurnetz, Pichery was the originator of this system, which he has styled “opposition gymnastics.” Elastic cords with handles attached are firmly fastened in convenient places. By making tractions in different directions, they will bring out almost any mus- cular action. They can be adapted to the leg or foot movements, as well as to the upper extremities. Some objections, however, apply to them which are not applicable to the pulley-weight apparatus, or to the use of dumb-bells, bar-bells, etc. The force used cannot be thoroughly controlled and regulated. Blaikie,2 in describing and criticising one of the forms of parlor-rowing apparatus, has pointed out their defects and shortcomings better than can be done by myself. In spite of their defects, however, he considers them excellent con- trivances, if used intelligently. Movement apparatus run by steam has been largely resorted to in 1 How to Get Strong, etc. 2 Op. [cit., p. 101. 5 EXERCISES FOR NERVOUS AND MENTAL DISEASES. some countries, particularly in Sweden, where the method was invented and introduced by Zander. In this country, it has been used in a few institutions, as at the Surgical Institute, formerly located at Broad and Arch Streets, in Philadelphia, where I have observed its workings. The system has a field of usefulness; it has also certain disadvantages, and needs the most careful supervision, but under the strictest supervision it may be used with great benefit. To some extent, semi-active and semi-passive or duplicated active movements may be carried out by this machinery, and it can be made to cover the whole range of passive exercises. The same cautions and contraindications are to be borne in mind in using the exercises either with or without apparatus: probably the dangers of overdoing are to some extent greater with than without apparatus. In the prolonged treatment of patients, some advantages accrue from the use, conjointly or alternately, of exercises with and without apparatus. The interest of variety is added, and the oppor- tunities for the adaptation of movements to special cases and condi- tions are more numerous. Most of the firms which sell pulley-weight apparatus send with them printed instructions and illustrations; but I must enter a word of caution against the employment of such apparatus by invalids without special medical supervision. Much harm has come to individuals, as well as to the subject of medical gymnastics, by the use of exercises without specific directions. To a considerable extent, I have personally directed the exercise- treatment of my patients in private practice, and in the nervous wards and the insane department of the Philadelphia Hospital. Dr. A. H. P. Leuf, instructor in physical culture in the University of Pennsyl- vania, and Dr. 0. H. Beckman and Dr. Mary Willits, assistants in the department of the mind and nervous system in the Philadelphia Polyclinic, have, under my instructions, successfully treated patients for me. Mr. Clinton A. Dodge, of Philadelphia, is an able and experienced instructor and expert in gymnastics. During the present year he has treated for me, with marked success in most cases, patients suifering from neurasthenia, hysteria, habit chorea, neuritis, lateral spinal cur- vature, melancholia, etc. Mr. Dodge has also had under his charge the patients of other physicians, and, by their permission, he has given me some of the results of his work. The director of these exercises should be thoroughly well fitted for his work. He should not only understand the Avork, but he should combine discretion with enthusiasm in pursuing it. If not a 6 MILLS, physician, or if a physician without special experience in such work, the treatment should be carefully supervised by some one more com- petent. The treatment should be carefully individualized. The instructor or director should not undertake too much in one day; and he will soon tire and do badly with his patients if he cannot become interested. Usually I combine respiratory exercises with the muscular move- ments. “On the two powers, muscular and respiratory,” say Mac- laren, “depends the ability to perform all bodily exercises.” Inherent nervous force has also something to do with the capacity to perform bodily exercise. Of course, in any method of gymnastics, respiration must to some extent be exercised. Breathing becomes accelerated, and even painful, under continuous active exercise. In speaking of respiratory gymnastics in this connection, however, I refer to special efforts of breathing—by taking deep, full breaths through the nose and mouth; by forced expiration, as well as inspiration; by counting with a loud voice while holding the breath, etc. It is not my purpose to refer in this paper to the use of pneumatic chambers or other forms of pneumatic apparatus. It is interesting to recall that the most ancient of books in which gymnastics is discussed, the Chinese treatise Cong-Fou, the Art of Man, speaks particularly of the importance of respiratory gymnastics. Dally and others, in the present century, have maintained that respira- tion is the pivot of every gymnastic exercise, and systems of respiratory gymnastics have been invented (Dujardin-Beauraetz). Want of respiratory power is certainly either at the root, or is an essential constituent of many morbid nervous conditions. It is remark- able how much individuals differ with reference to their respiratory power, even when of apparently the same muscular ability. The development of the lungs, chest walls, diaphragm,' abdominal walls, and other parts; the greater aeration of the blood which is conveyed to weak spinal or encephalic centres; the greater control which the patients obtain over all nervous and muscular effort through these respiratory exercises, make them of decided value in cases in which active movements are applicable. On the other hand, it is quite possi- ble that some harm may result from the incautious use of forced respi- ration. Carried on too long, both as far as giving lessons is concerned, and as far as the weeks and months during which the exercises are continued, it is even conceivable that the air-cells may be unduly strained. Great care should be taken with those who are very weak EXERCISES FOR NERVOUS AND MENTAL DISEASES. 7 generally or in a particular part, especially in the lungs or abdominal region. The treatment should begin with the simplest forms of exercise, and these should he constantly increased and elaborated, as the patients gain in skill and strength. It is wonderful how little some patients can do in this direction. A grasshopper in gymnastics is a burden to them. _ Five minutes or even less, is sometimes all the time that can be safely taken at first, and five minutes of actual exercise must some- times be distributed over half an hour. In most cases the time should never be allowed to exceed twenty to thirty minutes. Often it is im- portant to give resting spells during the process of treatment. Some patients, ambitious to excel or fearing to appear weak, will certainly overdo. Individual peculiarities should be carefully studied. In the majority of cases of nervous and mental diseases in which systematized active exercises are indicated, the danger will be greater of overdoing than of doing too little. It is an important practical matter to have the air of the room in which the exercises are performed as pure as possible. The room should he well ventilated. It is not necessary, particularly in the case of the nervous and weak, that the room should be without fire, indeed, it is sometimes better that there should be some warmth, but fresh air should be admitted to the room. Carrying out strictly hygiene in various directions will very much assist in getting good results with the exercises. When possible, it is well for the patient soon after finishing the exercises to take a sponge- bath, with tepid or cold water, according to individual vigor. Good food, regulated exercise in the open air, and plenty of sleep are, of course, important. To illustrate clearly what is meant by simple respiratory exercises in connection with systematized muscular movements, I will quote for you from Blaikie.’s smaller work two of his very plain directions. I will also quote from the lectures of Dujardin-Beaumetz, one of Daily’s movements. “Directions.—1. Stand four feet apart in the aisles, with arms folded behind you, and with one foot about eight inches in front of the other. 2. Now draw the head back and tip it as far down behind as you can. 3. Hold the chin up high. 4. Eest there a moment, then stand up straight again. 5. Repeat this exercise six times. “ Caution.—Breathe deep, full breaths all the time; indeed, always, when exercising, breathe slowly, and as large breaths as you can.” 1. Take a dumb-bell in your right hand and hold it up high over your head. 2. Stand with the chin up high all the time. 3. Breathe a full, deep, slow 8 MILLS, breath. 4. Now slowly lower the dumb-bell, not down to your right shoulder, but across, above your head, and down over your left shoulder, as low as you can, till it touches your shoulder, letting your body tip over to the left. 2. Hold it there till you slowly count ten. 6. Now bring it back overhead again. Then do the same with the dumb-bell in your left hand. 7. Do this five times with each hand. Repeat this five times each day the first week, and twelve times daily after that right along. One of Daily’s respiratory exercises is as follows: he places the patient in a vertical attitude with the back against a wall, then, both arms being extended horizontally in front, the patient forcibly and slowly separates the fingers while he bends the thorax forward; he remains in this position thirty seconds, makes a deep nasal inspiration, and resumes the initial position, then makes a deep expiration, and repeats this exercise six times in succession. Dujardin-Beaumetz, in reference to these exercises of Dally, remarks that another and simpler exercise will render much service in develop- ing respiratory capacity, viz.: to make the patient count with a loud voice as long as he can without losing breath. Before commencing to count he should make a deep nasal inspiration. Among the diseases of the nervous system referred to by Dujardin- Beaumetz as calling for gymnastic treatment, are muscular atrophies, deformities, chorea, hysteria; ataxic, nervous, and neurasthenic per- sons ; the victims of mental overwork and sedentary life, and idiocy. He also discusses the uric acid diathesis, gout, and diabetes, for which neurologists are often consulted. O This paper is not founded simply upon theoretical considerations and a study of literature. For several years I have to some extent used systematized active exercises, either with or without apparatus, and during a year past I have had a considerable number of patients on this treatment. My objects, in addition to recording experience, are to call general attention to a too much neglected method of treat- ment, and to make certain practical suggestions which naturally grow out of a study of the subject. It will be impossible to give details of cases without dragging the paper to a wearisome length. When pre- paring this paper I was able to put my hands on forty-four such cases, not including those under treatment at the Philadelphia Hospital. Of these cases, twenty-five were treated by the general active exercises, some with and some without pulley-weight apparatus; the other nine- teen by some local method for a special purpose. The patients treated by the general exercises included cases of idiocy, insanity, asthma, EXERCISES FOR NERVOUS AND MENTAL DISEASES. 9 minor chorea, habit chorea, hysteria, general nervousness, neuras- thenia, nervous palpitations, lithaemia, cerebral syphilis, diabetes, cur- vatures, ataxias, and paralyses; those treated by special more or less local methods included cases of hemiplegia or monoplegia, infantile paralysis, lead paralysis, rheumatic neuritis, muscular atrophy, aphonia, and writer’s or telegrapher’s disease. For the feeble-minded, for the insane, and even for criminals, sys- tematized active exercises can be used with great advantage. Those in O O charge of institutions for the idiotic and feeble-minded in France have in particular given much attention to gymnastics. It is only neces- sary to recall such names as Esquirol, Bourneville, and Pichery. At the Pennsylvania Training School for Feeble-minded, at Elwyn, in charge of Dr. I. N. Kerlin, I have frequently, and with great interest and pleasure, witnessed the performances of the gymnastic classes. As many as eight separate classes are instructed at one time by as many teachers; and at intervals general exhibitions are given. The classes are graded from those pupils who can perform only the simplest move- ments, up to those capable of elaborate and somewhat difficult exer- cises. At Barre, Massachusetts, a gymnasium has been erected, and the children are thoroughly drilled and taught. The same is true of some other institutions for the idiotic and feeble-minded in this country. Much could be said, if time permitted, about the beneficial effects of regulated physical culture in idiocy. For the improvement of the general nutrition of a class of unfortunates, usually deficient in this respect, as well as for their training and development, both mental and physical, systematic exercises are of the utmost value. In some of the grades of idiocy attention should be paid to individualizing the treatment by exercise. To a certain extent gymnastics can be used for diagnostic and prognostic purposes in idiocy, observation of those attempting systematized exercises determining the possibilities as to general improvement. So far as I know, very little has been done with systematized movements in hospitals and asylums for the insane, although I believe insanity affords a great field for such treatment. In the first place, such exercises will do much toward improving the frequently dete- riorated physical condition of the insane; secondly, they afford a method of calling out and improving the impaired mental faculties; and, thirdly, they constitute another valuable means of supplying to the insane that which all alienists now agree is most important to them—occupation. 10 MILLS, “One of the great improvements that has taken place in modern asylum management,” says Clouston,1 “has been that rational physiological outlets are provided for the morbid muscular energy in cases of chronic mania. They are neither confined in their rooms, nor within, ‘airing courts/ enclosed by high walls. They are made to wheel barrows, and dig on farms. They are encouraged to dance, and are well fed. Most of them eat enormously, and if they have not enough to eat they fall off, get worse in their mental state and in their habits. Many of them can be got to expend their energy in hard, regulated work, and are the very best workers on the farms and in the laundries of the asylums. They are not all, of course, furiously maniacal. Some of them simply have a slight morbid excess and exaltation of the brain convolutions, shown by restlessness, want of affection, and want of self-control, but are not incoherent. If they are kept at work, the most objectionable and Repulsive parts of the older asylum life are avoided in a great measure, and the refractory wards, with their noise and danger, are not needed. The scenes with patients, attendants holding them down, and removing them into the seclusion of their own rooms, are few. No doubt there are risks run in the present system to patients and guardians, but I believe the risks are much less in reality than under the old system, for the patients are not so irritable, not so revengeful, and not so dangerous, generally.” By means of systematized exercises the insane can be provided with an additional “ rational physiological outlet ” for their morbid muscular energy, on the one hand, and, on the other, with a rational physio- logical method of calling them out of their muscular and general torpor. A few weeks since, in the Insane Department of the Philadelphia Hospital, I started a class in systematized active exercises, selecting •eight women suffering from melancholia, and putting in with them to give zest to the treatment two other cases not mentally depressed. Sufficient time has not yet elapsed to determine how much in a curative way can be accomplished by such treatment, kut already the experi- ment has proved to me an instructive one. I found that even these patients, plunged into the profoundest depression, could, by sufficient persistence, be aroused to the performance of some movements; others did moderately ■well; some very well. The difficulty of fixing the attention of these patients, and yet the possibility of doing it by suf- ficient effort has been clearly shown. The class has made much improvement in facility and rapidity. Small classes should be formed in large insane asylums, and the treatment given a thorough trial. An instructive case of mental disease, greatly benefited by sys- tematized active exercises, is that of a young man who at the age of twenty-one broke down mentally, as the result of too great output 1 Clinical Lectures on Mental Diseases, p. 158. EXERCISES FOR NERVOUS AND MENTAL DISEASES. 11 of mental energy, and physical exertion in business. He became depressed, and soon developed delusions of suspicion, believing that people were watching and following him. In a few weeks, under rest, the depression disappeared; he again attempted business, but became excited, and then developed ambitious delusions. He was admitted to an asylum for the insane, and in three months came out, apparently well. In brief, his subsequent history for eight years was that every year, late in the spring or early in the summer, he had a period of excitement, followed by one of depression, each lasting about three months. About three years ago, he began the use of systematized active exercises, after the method of Blaikie and others. He has since persevered with them, at the same time paying attention to diet, sleep, and general hygiene. On a few occasions he has had touches of elation, lasting only a day or two, but he has been able, owing to his increased physical and mental strength, to resist with success the be- ginnings of such attacks, and he has been entirely without the regular periods of depression and elevation for nearly three years. An experiment made at the New York State Reformatory, at Elmira, lias been frequently referred to of late by the medical and general press. An experimental class in physical culture was formed of twelve men, who for a period ranging from one to two years, had made no appreciable progress in their school work, and who seemed incapable of prolonged mental effort, yet could not, strictly speaking, be considered mentally unsound, or representatives of a class known as feeble-minded; with the object of ascertaining, if possible, if physical culture, as comprised in frequent baths, and massage, and daily calisthenics under the care of a competent instructor, would not result at least in the partial awakening and stimulation of dormant mental power. Increased mental activity rather than muscular development was to be the gauge of success or failure of the experi- ment. Dr. H. D. Wey,1 physician to the Reformatory, in reporting upon the results of the experiment, says that to those who were thrown in daily contact with the men, a mental awakening was apparent. They became interested in their studies, and strove to appear to the best advantage in the schoolroom. Their advancement in their studies ■was not steadily onward, but rather intermittently progressive. It will be interesting to note in the future, as Dr. Wey remarks, whether the good results are permanent; but whether they are or not, 1 Annual Report of the Now York State Penitentiary, at Elmira, for the year ending September 30, 1886. 12 MILLS, the step is one in the right direction, and is to be commended to penologists everywhere. Systematized active exercises serve a good purpose in some of the various disorders designated as asthma. One case of this kind, a young lady, despondent, weak, dyspeptic, hysterical, with feeble heart, and subject to attacks of asthmatic breathing, improved with great strides in a few weeks under general active exercises. She began treatment with half-pound dumb-bells, and at first could stand only five minutes’ work. The exercises were increased, until half an hour was reached, and dumb-bells weighing four pounds were used. In the treatment of chorea, or rather choreas, systematized active ex- ercises are valuable. Special forms of gymnastics have been employed for this affection to some extent, particularly in France and Germany. Napoleon Laisne,1 a French professor of gymnastics, and evidently an earnest and enthusiastic worker in his chosen field, under the direc- tions of Dr. Blache and other physicians of Paris, has used gymnas- tics largely both for chorea and other convulsive disorders. In 1865 he published a book in which his methods are set forth. Both Schreiber and Dujardin-Beaumetz refer to his labors and successes. His method in mild cases, as described by Schreiber, is to place the child before him, steadying it between his knees, and then take its hands in his, and perform rhythmic movements with each arm, keeping time by counting, or, better still, singing, out loudly—“one,” “two,” “three,” etc. The child, at the same time, is also urged to try and keep time with the movements, and not to make them irregularly. “ Care must be taken in the beginning to prevent, as much as possible, the coincidence of involuntary movements with the rhythmic ones. When the arms have been exercised, similar movements are undertaken with the legs. From time to time, a pause for rest is made, during which the limb must be held firmly enough to prevent the occurrence of involuntary motions. The child is then laid on its back upon an inclined ladder, the feet being held by an assistant; then grasping a rung above its head, it holds on in that position as long as it is able. This is to be repeated several times, and to be followed by a short rest. Afterward, the shoulders, back, and legs are rubbed and gently kneaded.” Lengthy details of treatment will be found in Schreiber’s Manual. Two cases of minor chorea improved under medicinal treatment up to a certain point, and then would advance no further. General exer- 1 Applications de la Gymnastique H la guerison de quelques Maladies. -Paris, 1865. EXERCISES FOR NERVOUS AND MENTAL DISEASES. 13 cises with light dumb-bells were ordered, and in both cases the prog- ress to complete recovery was rapid. In the treatment of habit chorea, these exercises have a peculiar value. This, whether in children or adults, is an annoying and dis- tressing disorder, and commonly intractable. By habit chorea is meant an abnormal movement or series of movements, voluntary or partially involuntary, and repeated at frequent intervals. Mitchell1 records two interesting cases, and recommends for treatment careful and good diet, light gymnastics, no school, gentle aperients, and full doses of arsenic, particularly the hypodermic injection of arsenic in the form of Fowler’s solution. I refer to this treatment, as he includes light gymnastics among the measures recommended. Among my nervous patients I have had a goodly number of cases of habit chorea. Nearly thirteen years ago I reported the case of a girl, fifteen years old, who had peculiar movements of her right ear, after a time associated with twitchings of her nostrils and upper lip, and the limbs of the right side. Another patient, under excitement, made a movement of extension and semi-rotation with one arm, some- times accompanying it with twitching of the facial muscles. Facial grimaces constitute, as is well known, one of the most common forms of habit chorea. I have now under my charge a case of habit chorea which is being treated successfully by systematized active exercises. The patient, a girl eighteen years old, began to be troubled with spasmodic movements nine years ago. These lasted at first from one to two years, then disappeared for a year to return again, and have since gone and come several times. For the last two years, hoAvever, she has been troubled almost continuously with the move- ments, and has tried various modes of treatment, chiefly medicinal, but without any decided benefit. The chorea consists of a sudden jerking of the head downward and to one side, which may be performed once or several times in succession. Either with or without this twitch or jerk, she frequently also has a snapping movement of both eyes. The chorea was not started by imitation, but it is much influ- enced by any cause of nervous excitement, as fright. Systematized gymnastics, either general or local, constitute a rational treatment for cases of this kind, because by means of such exercises not only is the general nutrition of the patient improved, but the nerve centres are given tone and strength, and good habits of 1 Lecture on Diseases of the Nervous System, Especially in Women, hy S. Weir Mitchell, M.D, Philadelphia Medical Times, March 28,1875. 14 MILLS, movement are made to substitute bad. Such eccentric and abnormal movements are the result of eccentric functioning by nerve centres, or of irregularities in the conveyance of impulses through nerve channels. By again and again causing normal impulses to be conveyed in a normal manner to muscles, in time the choreic habit will be overcome. Such treatment, however, needs to be persisted in for months. The advantage of any treatment which involves specific direction and the adroit calling out of the volition of a patient must be evident to everyone who has had experience with hysteria in its manifold forms. In hysterical paralysis much can be done by laying out a careful plan of treatment by exercises, and gradually leading up to their full per- formance. In referring later to ataxias and palsies, functional and organic, methods to this end will be considered. For the improvement of nutrition, and of what may be termed the general nervous and mental tone of hysterical patients, systematized active exercises fill an important place. Properly used and controlled, they may also prove most beneficial for cases of general nervousness, and also for neuras- thenia. Whatever view may be taken of the much mooted question of neurasthenia, without doubt both respiratory and muscular power, either primary or secondary, are often deficient, and the nerve centres themselves can be strengthened and improved by exercising these two powers. Care should be taken not to force individuals suffering in this way to excessive effort at first. Great are the advantages which result from the sojourn by sea or mountain, from the cure of camp and ship; but the improvement of health obtained by such holiday treatment is often soon lost in whole or in part by the individual going back too completely to old habits of living and working. A resort to systematized active exercises for a few minutes daily will do much toward keeping the good that has been obtained. '• A man,” says Maclaren, “ cannot, in a week or two, eat sufficient food to supply the demands of the appetite for a whole year, neither can he take suf- ficient exercise to keep his body in health throughout the four seasons in a summer’s ramble. These mountain excursions or sea-side sojourns must be in addition to, and involving no curtailment of, the daily walk to and from business, the daily ride to and from somewhere, or the daily employment with or at something ; a something which will in its doing, quicken the pulse and augment the breathing, and, if possible, bring the perspiration to the fore- head.” For those forms of nervous palpitation which are dependent upon a neurasthenic condition associated or not with digestive disorder, EXEECI SE S FOR NERVOUS AND MENTAL DISEASES. 15 systematized active exercises are of great value. The exercise should at first be light, but should be carefully and somewhat rapidly increased. Besides the indoor exercises, after the method of Blaikie, or with the pulley-weight apparatus, the patient should use deep breathing while walking out of doors. A case reported by Dr. Theo- dore Clemens1, of Frankfort-on-th e-Main, is interesting in this con- nection. The patient was a man forty-six years old, who applied for treatment, on account of distress and irregularity of the heart. Clemens decided to make him do the thing he most dreaded, viz., climb up several flights of stairs. The effect was most happy. The patient’s pulse, which had intermitted at every tenth or twelfth beat, wavered only twice, and but slightly, in a hundred beats after he had mounted three flights of stairs twice. He now decided to make similar efforts regularly every day, and in three months he was a well man. For the group of diseases which fall to the lot of both the neurolo- gist and orthopaedist—cases of curvature, deformity, atrophy, etc.— systematized active exercises have long been used by the best authori- ties. I can only refer in this general way to this branch of the sub- ject in the present paper. My more particular object is to call attention to the value of systematized respiratory exercises in setting up or straightening the feeble and stooped, who also frequently are sufferers, in some degree from nervous or mental weakness. If, at the same time, appropriate general hygiene is used, the improvement in such cases is sometimes simply wonderful. I have notes of a number of cases treated by Mr. Dodge and myself to bear witness to the truth of this statement, but time will not permit me to refer to these in detail. A gentleman, whose son had been using systematized active exercises, wrote to Mr. Dodge as follows : “ I have pleasure in assuring you that I think my son has wonderfully improved in health and appearance during the past month, while under your care. Even in two weeks we saw a marked change in him for the better— his stooping shoulders (made so by outgrowth of strength) straightening marvellously.” For gout and lithmmia, to promote excretion and nutrition; for ansemia and spansemia, to assist assimilation and further oxidation ; for headache, sleeplessness, and nervous irritability, to soothe and calm the nervous system; to aid elimination in cases of lead, arsenic, mer- curial, and other metallic or toxic diseases; for diabetes, to favor the skin and increase combustion, systematized active exercises have a 1 Medical and Surgical Reporter, October 22, 1887. 16 MILLS, value which cannot be too highly extolled, and one which I have had an opportunity to demonstrate in my own practice. In curable ataxias, as in those which follow diphtheritic or exanthe- matous diseases, and in the hysterical varieties, systematized active movements, the patient at first lying down or sitting, and subsequently standing, have proved of great service in my hands. In Dr. Mitchell’s lectures,1 some valuable advice and interesting details are given with reference to the best method of slowly training by what are really systematized active movements, although not so called by him. The weak and inapt muscles are cautiously brought into use. The patient is first convinced, after she has made an effort which seems extreme, that another forth-putting of will must add to the previous results. The nurse begins to train the patient while in bed, to move the legs one at a time very slowly, but in larger and larger movements, with intervals between of a minute or more. “An order is given to lift the leg; if it be too weak, a finger beneath the ankle aids it, but no attempt must be let to fail utterly ; as she gets on, the orders are to be obeyed more quickly. It is easy to sketch out for one’s self what such a system should be in its details. After it has gone far enough the patient is seated in bed with some support to her spine, and is trained to move the head freely. The next step used with me to be a lesson in walking, but of late I find it better to teach the girl to creep, which is an easy and natural mode of training for the walk. The patient has pads tied over her knees, and, lying flat on her face on the floor, without skirts, has around her a folded sheet. At an order, she tries to rise, helped by a lift of the sheet belt by the nurse. When she is able to do this, and gather her legs and arms so as to make herself a quadruped, she is taught to balance herself, every effort being assisted, when needing help, by the nurse standing above her. The progress to creeping is easy; then comes the lesson of kneeling and pushing a chair; and last, that of standing in a corner or by a chair. In the treatment of ataxic affections, even sometimes when depend- ent upon organic disease of the cerebro-spinal axis, the use of what may be called balancing or acrobatic gymnastics is of some value. Dr. Mortimer Granville, in the Practitioner for 1881, and subsequently in his monograph on “Nerve Vibration and Excitation,” discusses a method for the regeneration of the nerve elements by exercise on the basis of the law of development through function, holding that the ataxic subject is reduced by dissolution to the position of a child just learning to stand or walk. His plan is to direct the patient to stand with his eyes closed in his bath, after pouring a small can of water down his spine, or applying a mustard poultice over the full length of 1 Op. cit. EXERCISES FOR NERVOUS AND MENTAL DISEASES. 17 the spine for ten minutes or a quarter of an hour, to persevere in an attempt to stand for, at first, a quarter of an hour, and, as his state improves, for half an hour every morning. -He is to be furnished with a chair or rail at hand, to which he can cling in case of need, but is instructed to avoid using it except when in danger of falling. The exercise must be continued diligently for weeks before success can be obtained. In patients suffering from multiple neuritis, or some curable forms of myelitis, advantage should be taken of the first signs of motor improvement to begin with active exercises, while the use of electricity and massage is continued. The particular point upon which I desire to insist, is that the attempt to join the will of the patient to the long unused muscles, shall not be deferred a moment longer than is neces- sary. Simple attention to this truth, which ought to be self-evident, would, I think, in many cases have saved patients from weeks or months of uselessness. In the treatment of various forms of paralysis that systematized active movements may be employed with advantage has long been known. Even in paralysis from organic brain disease, a clear method of using gymnastic treatment will be found to serve an excellent pur- pose. Such paralysis is usually the result of hemorrhage, embolism, thrombosis, tumor, abscess, or depressed fracture; less frequently of meningitis or cerebritis, of atrophy or arrested development, and still more rarely of ursemia. Sometimes in cases of sudden lesion, as hemorrhage or embolism, the assault upon the nervous system is so violent, or the destruction is so great, that death results quickly, or the patient is reduced to a state of utter helplessness, for which, prac- tically, nothing can be done. In many cases, however, soon after the attack, or even at a later period, the amount of palsy is dispro- portionate to the cerebral lesion by which it has been initiated. Many cases of monoplegia and hemiplegia illustrate this truth. Little by little some of these patients regain muscular power to such an extent as almost to induce the belief that they will get entirely well; indeed, in some cases of hemorrhage, tumor, traumatism, syphilitic menin- gitis, and uraemia, complete or almost complete recovery does occur. We should, therefore, not disregard entirely the treatment of such patients. The course of treatment usually pursued in these cases, in the main wise, is, at first, to do little more than protect the patient from dis- turbing influences; and after the shock of the attack, and the acute 18 MILLS, inflammation which sometimes accompanies or follows it, have sub- sided—that is, in a few weeks or months—to give absorbents and alteratives, and to apply electricity, and possibly massage, allowing the patient to use the affected limb as he sees fit. More than this, however, should be done; and it is just here that single active exer- cises, after some thorough system, may play a useful part. Every effort consistent with safety, should be made to unite again the paralyzed limb with the volitional centres. Such patients often need to be incited to effort. Two methods of systematized active exercises may be tried for these hemiplegias and monoplegias. One is the method partly of duplicated active, and partly of single active movements, used and described by some of the writers on Swedish movements; as, for instance, by the Taylors. The patient is placed in a recumbent or half-reclining pos- ture, so that he may be able to direct all the cerebral energy at his command toward the paralyzed member, and is then urged to make some simple movement. If he succeeds to ever so slight a degree, he should simply be encouraged to repeat the movement, but he should be carefully guarded against undue or too long prolonged effort. Other simple movements are added from time to time. If he can do absolutely nothing, the operator should perform on the patient the desired movement, while the latter fixes his attention upon the per- formance and tries to assist. When a little headway has been made systematized active movements should be used in conjunction with electricity, massage, and duplicated active movements in an orderly and thoroughly regulated manner. With light dumb-bells and with the pulley-weight apparatus, all possible movements, and particularly those which are most wanting, should be cautiously encouraged. From a cautious pursuance of such methods I have seen a surprising result in a number of cases supposed to have reached the limit of improvement. Such treatment does good, not only because the original lesion may have been partially removed, but also because by such efforts portions of the brain adjoining the centres destroyed may be made to take on new function; or possibly, in some instances, the other hemisphere of the brain may be called into new activity. To central spinal palsies, as well as to paralysis from brain disease, in a large measure the same truths apply. Another method of gymnastic treatment which I have often em- ployed with benefit in cases of monoplegia and hemiplegia, is to cause the patient, first, to make a movement upon the unaffected side, and EXERCISES FOR NERVOUS AND MENTAL DISEASES. 19 then instantly to perform the same movement with the paralyzed member, following this quickly with an attempt to do the same thing with both limbs. It is surprising the curious results that will be sometimes obtained in this way, if the leg is but little affected, and the patient can stand while these movements are performed by the upper extremities. To exercise the legs, the patient, of course, should be placed in an easy position, and one that will allow the movements to be performed with the greatest convenience. Exercises of this kind probably have some effect in bringing the paralyzed side of the body under control of the uninjured side of the brain through com- missural channels in the spinal cord. For some of the arthritic neuroses, and for rheumatic neuritis, or muscular rheumatism, these exercises are of undoubted value. I have seen three cases of a form of rheumatic neuritis affecting the deltoid and adjoining muscles, in which the progress to complete recovery was much assisted by an early resort to dumb-bell exercises and pulley-weights. Cases of this kind are best treated by using large doses of oil of gaultheria, or sodium salicylate, with hypodermic injections of morphia in the most acute stage; a little later resorting to massage, electricity, or both ; and then to exercises with light dumb- bells or pulley-weights. Here, again, the point I wish to impress is, that such active exercises should not be deferred too long. Hysterical aphonia or apsythria (loss of the power of whispering) can sometimes be treated successfully by a species of respiratory gym- nastics, or a combination of respiratory with vocal and muscular gymnastics. Hr. Mitchell has described a method of bringing back the voice, which is really a form of respiratory gymnastics, a method which I have used several times with success, and less frequently with failure. Speaking of a young woman who had good power over the laryngeal muscles, but could neither speak nor whisper, he concluded that if he could teach her to speak only with a very full chest, he might secure an involuntary success. Asking her to fill her lungs several times, and when very full to keep her mouth wide open, he then had her try to sound the broad a, at the same time breathing out violently. She made a clear, audible sound, and was at once on the high road to cure. Some years ago, with this simple method, I obtained a brilliant success with a young lady who had not spoken even in a whisper for many months. I now combine light dumb-bell and pulley-weight chest exercises with this method. In certain cases the treatment by rest, seclusion, etc., can be suc- cessfully combined with that by systematized exercises. After the 20 EXERCISES FOR NERVOUS AND MENTAL DISEASES. nervous or broken-down patients suitable for the. treatment have pro- gressed to a certain point; after their nutrition has been placed upon a firm basis, respiratory exercises without apparatus, or with very light dumb-bells, can be carefully begun. Five minutes, or perhaps only three minutes, should be taken at first, and the time should be increased with the utmost caution. In a recent neurasthenic case with hystero-epileptic seizures, after the patient had improved under the rest treatment, systematized active exercises were resorted to with the greatest benefit. In those cases of hystero-epilepsy in which the seizures are partially voluntary, or of the induced voluntary kind, the use of such exercises assists the patient in obtaining the control ol herself and her movements which enables her to resist the beginning of the attacks. Dr. C. F. Taylor, in the book to which I have already referred, has hit the secret of the combination of rest and exercise in certain cases. “ The true remedy,” he says, “is rest and exercise. Let the rest.he complete relaxation of all muscular effort—not the entertaining of company, sitting bolt upright, so that the spinal muscles must be constantly acting, or reclining in a ‘graceful’ attitude on a lounge, with book in hand, but a completely sustained position, when all the muscles must cease to act. Then the exercises to follow should be short, varied, and taken with some vigor.” The now generally accepted views with reference to cerebral locali- zation throw some light upon the manner in which systematized active exercises, or other forms of gymnastic treatment, improve or repair the nervous system, and especially the brain. This fact has not been overlooked by authorities in neurology and gymnastics, as by Emil Du Bois-Beymond, Schreiber, Crichton-Brown, and others. In the brain are represented both a differentiation and an integration or solid- arity of function. Centres for speech, for vocalization, for particular movements, for the special senses, for the muscular sense, for organic sensations, for some of the higher faculties, as of attention and inhibi- tion, are now, with reason, claimed to have been isolated. For the localization of some of these, as of speech, motor, and some of the sensory centres, the facts and arguments are practically incontroverti- ble. In the plainest of terms, if brain centres which determine certain movements exist, the performance of these movements must develop and train not only the muscles concerned in these actions, but the cerebral centres with which they are connected.