The Therapeutic Value of Sys- tematic Passive Respiratory Movements RY HENRY LING TAYLOR, M.D. NEW YORK Reprinted from The Medical Record, May 4, 1889 NEW YORK TROW'S PRINTING AND BOOKBINDING CO. 201-213 East Twelfth Street 1889 The Therapeutic Value of Sys- tematic Passive Respiratory Movements BY HENRY LING TAYLOR, M.D. NKW YOKK Reprinted from The Medical Record, May 4, 1889 NEW YORK TROW’S PRINTING AND BOOKBINDING CO. 201-213 East Twelfth Street 1S89 THE 'THERAPEUTIC VALUE OF SYSTEMATIC PASSIVE RESPIRA TORY MOVEMENTS.1 There is little doubt that the specialization of occupa- tions and pursuits which is such a marked feature of mod- ern civilized life, notably in our cities, has been in some respects a detriment to our physical development. If the hand worker is now less frequently starved outright, he is perhaps more often deprived of sufficient light and whole- some air, and his physical and mental activities restricted to a narrow range. In the commercial and head-working classes excessive competition stimulates, and often neces- sitates, a war of wits, which is usually associated with sed entary habits, and frequently results in starvation of the tissues, in a spindling or dabby physical type, diminished fertility, and stunted asymmetrical offspring. When we come to analyze it, we find that modern city life among all classes, in spite of much superficial variety, is charac- terized by nothing so much as narrowness if not monot- ony, and this is as true of the leisure classes as of any. What can possibly exceed in inadequacy of neuro muscular experience the routine activities of a man or woman of fashion ? Probably nothing; but many of our professional and business men working in narrow grooves, under con- tinuous strain, and innocent of the rudiments of a common- sense hygiene, many of our over-worked women and high- pressure children certainly run a good second. Important regions of the body, as the shoulders, back, and loins, and especially the chest, with the thoracic and abdominal viscera, suffer from our restricted and feeble muscular experiences, with the result of diminished neuro- central tone and general vigor, and it seems to me we 1 Read before the Section on Theory and Practice, of the New York Academy of Medicine, March 19, 1889. 4 frequently have a combination of restriction and irrita- tion, well calculated to produce one-sided and unwhole- some, instead of well-rounded and robust, development of the organism. There are always feeble individuals, ana competition is always hard on the feeble; with increased friction we must get increased detritus. Flat and narrow chests, and diminished respiratory power, with feeble vital energy and small endurance, are the frequent expression in the second generation of im- perfect circulation, assimilation, and innervation, the re- sult of deficient, one-sided, or strained activity in the par- ents. Thus we can conveniently group, for purposes of study and treatment, those conditions resulting from, or dependent on, deficient chest aspiration. The condition of deficient chest power has long attracted the attention of physicians, and many efforts have been made to de- velop chest capacity and to increase respiratory efficiency, by gymnastic exercises, especially of the upper extrem- ities, by voluntary attempts at deep breathing, by modifi- cations of air-pressure, and by other means. All things considered, a prolonged out-of-door life, com- bined with moderately active but varied exercise in the open air, probably furnishes the best remedy for many of the cases we are considering. Systematic gymnastic exercises, as usually given, are far from satisfactory for this special object. They are not adapted to the weak and feeble, and they are open to the objection that while pulse and respiration are consider- ably accelerated, the conditions are not favorable for thorough lung-expansion. In order to pull, push, or lift with the arms, the breath is instinctively held in order to immobilize the thorax, which is the fixed point from which the shoulder muscles work under these conditions. This is a fundamental difficulty, and, as a matter of fact, we notice that boxers, oarsmen, athletes, and porters, who are characterized by great muscular development about the chest, are frequently round-shouldered and of poor endurance. Measurements are easily increased by piling up muscle on the thorax without necessarily in- creasing respiratory capacity. Dr. Stanton Allen tells 5 me that a well-known gymnast in this city, who has a chest expansion of ten inches, and enormous muscular development, blows less on the spirometer than before he developed his muscles, and that the same has been noticed in some of his pupils. Of course, gymnastic exercises will increase chest measurement by overlaying the thorax with muscles, and probably in most instances, if judi- ciously used, real chest expansion will follow from the in- creased demand; but there will always be the objection I have named in using it in sick people, or primarily for chest expansion. I believe that it may produce chest contraction if injudiciously employed. Voluntary deep and measured breathing can without doubt accomplish something, but its application is much restricted by its irksomeness and the fatigue it produces. Let anyone take forty or fifty successive full inspirations, and he will find it very tedious and very tiring work. I can conceive that the respiratory efforts which ac- company the inhalation of gases, now systematically prac- tised for various purposes, may have some value as a respiratory exercise. Is it not possible that certain much advertised nostrums may be kept alive by the fact that the method of administration involves an imperfect res- piratory exercise ? Is there, then, any method by which we can expand the chest freely and regularly, for considerable periods, with- out undue fatigue to the patient; any way to automati- cally stimulate this automatic function ? Among the exercises based on the Ling system, which my father used on beginning practice in 1856, and which will be found figured and described in his book,1 is one where the patient is seated, while the operator, standing on the bench behind him, lifts up the shoulders with the hands under the axilla;; one of his knees sup- ports the patient’s back, which is arched backward to pro- duce full inspiration. In another movement the operator, standing as before, grasps the patient’s hands and pulls the arms upward and backward against his resistance, after which the patient pulls down the hands of the 1 Theory and Practice of the Movement Cure. i860. 6 operator until they lie in front of the chest;1 this was also given as a purely passive movement, like Sylvester’s artificial respiration. These and similar movements were very much used for many years in his practice to increase chest expansion and as a general tonic. Very soon Dr. Taylor began to substitute for the hand of the operator, in many of the active movements, a graduated mechanical Fig. 1. resistance, and about 1872 he devised apparatus by which the most important passive movements were given by steam power, among them the passive respiratory move- ment I have mentioned. This apparatus, called the “ res- pirator ” (Fig. i),2 has been in constant daily use since then, and has proved itself a most valuable therapeutic aid, far exceeding the old hand-method in efficiency. VVe use two respirators, one giving thirteen and the other sixteen full respiratory movements a minute, and the strength of the pull can be exactly regulated. The movement is a purely passive one, except that the handles of the apparatus are grasped by the patient. The patient is seated on a re- clining couch, the main levers, bearing the handles, pull 1 Op. cit., pp. 216, 217, ed. 1864. 9 The illustrations were not finished in time for insertion in The Record. 7 the arms of the patient strongly upward and backward, while the chest is arched by the simultaneous backward movement of the upper part of the back of the couch (Fig. 2). The main levers are, for most purposes, so adjusted as to slightly raise the patient from his seat at the limit of motion, after which they move downward and forward, allowing the arms to drop by the sides, and the upper part of the back of the couch swings forward on its hinges, to favor expiration. The exercise is given for from ten to thirty minutes at a time, or with the more rapid machine, from one hundred and sixty to four hundred and eighty full regular inspirations and expirations at a visit. The respirations of the patient coincide automatically with the movement of the machine. l’he actuating mechanism of the respirator consists of two eccentrics symmetrically placed on a counter-shaft; these operate two cranks, to which the long L levers car- Kir.. 2. 8 rying the handles are pivoted in such a manner that the pivots can be shifted on the crank and lever, and the ex- tent of the stroke increased or diminished at will. The eccentrics also operate the levers which give motion to the adjustable back of the couch. The machine is stopped by shifting the belt to a loose pulley. Theoretically we should expect, as physiological ef- fects from the use of such a passive exercise, increased oxygenation of the blood and elimination of respiratory waste; increased thoracic capacity and power; better venous return on account of increased thoracic aspira- tion, and a decided effect on the higher nerve-centres, from improved nutrition and circulation, as well as from direct impression on the centres. I am indebted to Miss Aimee Raymond for a series of careful observations on the pulse, respiration, and tem- perature of several patients who were taking the respirator about half an hour daily. In four patients, all the sub- jects of lateral curvature of the spine, the number of ob- servations was eight to thirteen each. To study the varying results, I took the averages, which I append, dis- regarding fractions, in the following table : Table I. Average Pulse before. Pulse after. Temper ature before. Temper- ature after. Respira- tion before. Respira- tion after. Miss M , aged sixteen ; respira- tor one-half hour. 13 days. 92 90 98.1 98-3 24 24 Miss B , aged seventeen; respi- r a t o r one-half hour. 11 days. 94 92 98.7 98.8 27 25 Miss W , aged eighteen; respira- tor one-half hour. 13 days. 8S 87 98.2 98.8 18 18 Miss L , aged fourteen; respira- tor twenty min- utes. 8 days.. 88 90 979 98.0 20 19 From this it is seen that in the two with the slower pulse an increase of about two beats was noted, while in the two with the more rapid pulse a decrease of the same 9 amount followed the use of the respirator. In two the respirations remained at the same rate after the exercise, and in two they were slightly diminished in frequency. In every one of the four the average temperature under the tongue was found slightly increased after the exercise —the general average being 98.2 before exercising and 98.4 after—due, as I take it, to increased oxidation. We notice, clinically, that the circulation improves. The cerebral centres are soothed and the patient fre- quently becomes drowsy under the repeated effortless stimulation of the centres, for we must not forget that we have here a direct means of stimulating certain cen- tres. After the exercise the patient usually feels invigo rated, and the chest feels fuller and more expanded. If there has been mental or physical overwork the patient Teels refreshed, from the more perfect oxygenation of the blood, and the exercise of neuro muscular arcs habitually neglected, while at the same time the overworked areas are at rest. After a course of the respirator we usually find im- proved color and circulation, often improved appetite and digestion where these are at fault, and usually some increase in weight when the patient is thin. In nervous patients, better sleep and better co-ordinated neuro-cere- bral action often follow. The effect on the chest expansion is usually quite marked after a few weeks, sometimes after one or two. The respirator has been most frequently given, not so much for its special effect in developing chest expansion as for its effect on the circulation, and as a general and special tonic. But during the last five or six years I have made, from time to time, a considerable number of careful chest measurements. I have taken fourteen cases without selection, except that cases of well devel- oped lateral curvature of the spine are not included (Ta- ble II.), and find that the measurements, after a month or two of the respirator—usually six times a week for from twenty minutes to half an hour a day—has produced an average gain of just about one inch in the chest meas- urement on full inspiration. 10 No. X in Age. Date. Chest, inches. Date. Chest, inches. Number of months. Gain, inches. I . M. 14 Oct. 11, 1883 .... 27X~3°34 Nov. 13, 1883 ... 2734-3i34 I X 2 . M. l6 Oct. 11, 1883 27/4-31•• Nov. 13, 1883 ... 2734-3134 I X 3- M. 15 Feb. 18, 1884 3°%-34 • • March 21, 1884.. 3°X~34% X 4-. M. IS Jan. 23, 1884 3°X-3234 March 21, 1884.. 31-34 2 i34 S-. M. 19 May 26, 1884 . .. 33%-3 6X July 9, 1884 35-37X • • i34 I 6.. F. 35 Dec. 1, 1884 28-2934 • • Feb. 16, 1885.... 2834-3°34 234 I 7-- M. IS Oct. 4, 1886 3i34~3234 Nov. 2, 1886 3i34-33>4 I i34 8.. M. l6 Jan. 5, 1887 31^-33-• Jan. 17, 1887 ... 3234-34-- X I 9-- F. 8 Sept. 9, 1887 .... 2oJs-22>£ Oct. 23, 1887 22-24.••• iX iX IO. . F. II Sept. 21, 1887 ... 24)4-26)6 Nov. 12, 1887... 25-27 134 I II.. F. 9 ()ct. 1, 1887 24-25% • • Nov. 12, 1887... 2334-2534 iX 34 12. . F. 7 Feb. 5, 1887 2334-24 • • April 7, 1887 2434-2634 2 2X J3- ■ M. l6 April 19, 1888 3°X-32.- May 30, 1888 ... 3134-3234 1% X 74.. M. 18 April 4, 1888. . .. 3134-33 ■ May 3, 1888 32-33% • • I % Table II. The patient often continues to gain in chest measure for a considerable time, even when the visits are much less frequent, but the rate of increase is not so rapid after the first two or three months. When the exercise is dis- continued frequently some of the gain is lost, but a good deal is retained. In all of the fourteen unselected cases there was some gain at the end of the short period given. Whatever the amount of gain in chest capacity, there is nearly always marked improvement in health. A lady, aged thirty-five, not included in the table, who was taking the respirator for its tonic action, told me that the waists which had always fitted her had become so much too small after a month of the exercise that she was no longer able to put them on, though she had not gained in weight. It should be remembered in considering these results that they were all obtained in delicate, or even sick people, with particularly deficient chest capacity. Chest measurements are subject to many inaccuracies, but we can, I believe, get useful information from re- peated observations. This exercise is particularly useful in cases of flat, narrow, shallow, weak, and inelastic chests, whether due to faulty development, phthisical predisposition, old pleuritic exudations, round shoulders, or other causes; but, valu- 11 able as it is in such cases, I believe that still greater benefit is derived from passive respiratory movements systemati- cally employed in the actual physiological and clinical effect of the exercise, irrespective of its expansive power on the thorax. Lateral curvature of the spine always diminishes res- piratory capacity, and for this and other reasons I pre- scribe this exercise for such cases in connection with other treatment. Lateral curvature is one of the most difficult things to treat in orthopedic practice, and I do not claim to be always able to secure brilliant results; but I have noticed that whatever be the effect I am able to produce on the curvature, my patients almost invariably improve in health and vigor. The exercise is indicated in anaemia and in convalescence from exhausting disease. Another class of cases in which its use is followed by par- ticularly gratifying results is that of the functional neu- rotics, ranging from anaemic, delicate, and overworked persons—women especially—of flabby fibre and feeble respiratory power, through the victims of backache, head- ache, the neuralgic, dyspeptic, and semi-uterine type, up to the well-developed neurasthenics and hysterics, even including the bed-ridden neurotics. This is a large and heterogeneous class of invalids, many of them very great sufferers, who should command our best skill and sym- pathy. In no class of cases is routine treatment of any kind less applicable. Each case must be treated and guided on its own merits after the closest analysis and dis- crimination of the conditions and indications, fn nearly all, however, we need to improve the quality of the blood and the general health, and to regulate nerve-centre action. The respirator is one of the means at our command to fulfil these indications. For we have here (and this is only one of many exercises, but perhaps on the whole the most important) a means of directly affecting the nerve- centres as well as the circulation. We may begin with special exercises in bed, if need be, and after a time are able to add the passive respiratory and other passive move- ments in the exercise-room. This idea is perhaps the most fruitful of any in connection with the application of 12 the respirator, but I have not time to develop it here. I refer those interested to a paper on “ The Hygiene of Reflex Action,” published last March in the Journal of Nervous and Mental Disease. I wish to call attention to the circumstance that the action of the respiratory and similar passive movements for the trunk and extremities have this in common with the use of massage, electricity, and hydro-therapeutics—all valuable when used for specific indications—that they act directly on the nerve-centres by peripheral stimulation. But I emphasize a marked differ- ence in the kind of stimulation. The respiratory and similar movements are not a simple shock or stimulus, or shower of stimuli, to the centres, but train and educate them in coherent associated movements by a series of changes in position and muscular tension of the arms, trunk, and thorax, and modify their tone and action by a series of impressions on the centres which react to changes in the respired air and circulating blood. Each has its appropriate indications and inherent limitations ; I simply note a difference. There is an equally radical and im- portant difference in the general effect produced by such exercises, and by gymnastics, which consists in the almost total absence from the former of voluntary or violent effort and consequent fatigue, rendering them applicable to the very weak and delicate. Here, too, each has its appropriate field. The application of systematic, passive respiratory move- ments to the treatment of some forms of organic heart disease, and to certain diathetic vices and faults of elim- ination where it might seem indicated, remains to be studied ; but we have in them a tested means of— 1. Expanding and strengthening the chest, and invig- orating the respiratory function. 2. Oxygenating the blood. 3. Equalizing and toning the circulation. 4. Regulating and co-ordinating nerve-centre action. 5. Improving general vigor. 201 West Fifty-fourth Street.