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CORNELL
UNIVERSITY
LIBRARY

   

GIFT OF

L. A. Beardsley

 

 

 

 

 

  
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LECTURES

ON

MASSAGE & ELECTRICITY

IN THE

TREATMENT OF DISEASE.

(MASSO-ELECTROTHERAPEUTICS.)

BY

THOMAS STRETCH DOWSE, M.D.,

FELLOW OF THE COLLEGE OF PHYSICIANS OF EDINBURGH ;
FORMERLY PHYSICIAN SUPERINTENDENT OF THE CENTRAL LONDON SICK ASYLUM;
ASSOCIATE MEMBER OF THE NEUROLOGICAL SOCIETY OF NEW YORK, ETC.

flew Pork:

BE, B. TREAT & COMPANY, 5, COOPER UNION.
LONDON: HAMILTON, ADAMS & COMPANY.

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UNIVE key ) y. Price 92.75.
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THESE LECTURES ARE DEDICATED TO
DR. WEIR MITCHELL,
PROFESSOR OF DISEASES OF THE MIND AND NERVOUS SYSTEM
AT THE
PHILADELPHIA POLYCLINIC AND COLLEGE
FOR GRADUATES IN MEDICINE.
WITH EVERY FEELING OF ESTEEM AND REGARD,

BY THE AUTHOR.
PREFACE.

Tue following Lectures on Massage and Electricity
may be found of some interest to those who are desirous
of becoming acquainted with these subjects.

The Author hopes that in their publication his worst
enemies will see no reason to insinuate that they have
been produced from any other than purely professional
motives. He has no connection with advertising Schools
of Massage, Institutes of Massage, Agencies for Massage,
or Homes for Massage. He has endeavoured to deal
with the problems involved in a spirit of scientific
inquiry and research; and he lays no claim to any
special merit or originality, neither has he brought
forward any wonderful cases that he has cured. He
believes and he hopes that the most impartial reader
will see that his chief aim has been, after considerable
practice, to set forth the results of his experience and
labours in a plain, simple, and ungarnished statement
of facts.
vi PREFACE.

Massage and Electricity are very useful agents
in the curative treatment of certain forms of disease,
and it is unfortunate for their advancement as thera-
peutic agents when they are used in an indiscriminate
and casual manner.

He is indebted to Mr. Scuatu, Electrician, of
Wigmore Street, Cavendish Square, London, W., for
numerous woodcuts illustrating the Lectures on

Electricity.

THE AUTHOR

14, Weizecx Srreer,

CavENDISH Square, Lonpon, W.
CONTENTS.

LECTURE

I.

II.

III.

vI.

VII.

VIII.

IX.

XI.

xi.

XIII.

XIV.

XV.

THE PRINCIPLES OF MASSAGE -

THE MODE AND METHOD OF APPLYING MASSAGE

MASSAGE OF THE HEAD AND NECK, AND THE PARTS IN
ASSOCIATION THEREWITH

MASSAGE AND INDUCTION, FARADIC MASSAGE OF THE SKIN
MUSCLE AND NERVE .

MASSAGE OF VENOUS AND LYMPH CIRCULATIONS

THE WEIR-MITCHELL TREATMENT

MASSAGE OF THE CHEST AND ABDOMEN

MASSAGE IN NERVOUS EXHAUSTION AND HYSTERIA
MASSAGE OF THE SPINE AND BACK :
MASSAGE IN JOINT AND BURSAL AFFECTIONS

MASSAGE IN SLEEPLESSNESS, PAIN, DIPSOMANIA, MORPHO-
MANIA AND MELANCHOLIA

MASSAGE IN THE WASTING DISEASES OF CHILDREN, AND IN
THE DISEASES OF SEDENTARY, CHANGING, AND AD-
VANCED LIFE i

ELECTRO- PHYSICS “
ELECTRO-THERAPEUTICS
MOTOR POINTS : :

GENERAL INDEX

PAGES

1—30
31—51

52—67
68—78
79—107
108—126
127—148
149—179
180—222
2238-242
243-—257

258—273

274—289
293—331
3382—364
365—371
3738— 879
LIST OF ILLUSTRATIONS.

Fic, 1.—Illustrates the first position for manipulating the finger me

joints - 37
Fic. 2.—Passive gymnastics of metacarpo-phalangeal joints 38
Fie. 3.—Method for working into palm of hand 38
Fic. 4,—A common mode of petrissaging the muscles of the ball

of the thumb 40
Fic. 5.—Passive gymnastics of wrist joints 40
Fig. 6,—Massage of the wrist joint 41
Fic. 7.—Deep petrissage of the forearm 41
Fic. 8.—Passive gymnastics of the elbow joint 42
Fic. 9.—Light friction rolling: effleurage movements of skin 42
Fic. 10.—Position of hands for light ulnar tapotement 43
Fic. 11.—Position for manipulating the shoulder joint 43
Fie. 12.—Common method of commencing work upon ankle joint

for flexion and extension 44
Fic. 13.—Position for petrissaging the foot and working at the

same time, with the fingers, into the malleoli 45)
Fic. 14.—Position for ordinary knee and hip movements 45
Fig. 15.—Position of extending and stretching sciatic nerve by

flexing the thigh well upon and over the abdomen 46
Fic. 16.—Distribution of the sensory nerves on the head 53
Fig. 17.-The ordinary method of masséeing the head 64
Fic, 18.—Massage of the neck, effleurage, and petrissage 65
Fic. 19.—Massage of the eyeball 66
Fic. 20.—Massage of larynx 67
Fie. 21.—Hysterical contracture of inferior extremities 94
Fic. 22.--Nusbaum’s appliance for writer's cramp 104
Fig. 23.—Passive chest gynmastics for phthisis, kc. 150
Fie. 24,— ” ” ” ” ih
Fic. 25.—Massage of colon, upward and circular movements 152
Fic. 26.—Massage of colon, pressure movements 153
Fie. 27.—Massage of cxcal region, pressure movements 154
Fic. 28.—Are of a circle backwards 209
Fie. 29.—Arc of a circle forwards 210
Fic. 80.—Attitude illegique 211

Fic. 31.—Forward arc of a circle 211
x

Fic.

Fic.
Fic.
Fic.
Fic.
Fie.
Fic.
Fic.
Fic.
Fie.
Fie.
Fic.
Fic.
Fic.
Fig.
Fie.
Fic.
Fic.

Fic:

LIST OF ILLUSTRATIONS.

. 32.—Backward arc of a circle

33.—Digital petrissage for back

34.—Tapotement: vibratory percussion
35.—Tapotement: position of the hands for hacking
36.—Petrissage movements: pressing and kneading
37.—Leclanche’s cell

38.—Voltameter

39.—Pocket galvanometer (Edelmann)
40.—Universal i a

41,— 5 4 5

42,.—Illustrative diagram

43.—Figure for demonstrating the induced current
44.—Faradic battery

45.—Combined battery

46.—Voltolini’s battery

47.—Lewandowski’s electric influence machine
48.— +5 53 5
49,— #3 9 +

s. 50 to 62.—Various electrodes

Plates of Motor Points

PAGE
212

227
228
229
248
295
308
310
311
811
316
319
321
323
825
328
329

- 3830
833 to 336

365 to 371
INTRODUCTION.

Ir is extremely interesting, but in no way astonishing, that the
treatment of certain conditions of disease by massage should
have become so popular within so short a period. Our
continental friends are to be credited with having first made
the attempt to systematize “‘ Movement Cures,” but it cannot
be said at the present time that their knowledge in reference
’ to this subject is in any way superior to our own.

In Germany the treatment of chronic disease by massage is
extremely valued amongst both physicians and surgeons of
known eminence, and with the people it is exceedingly popular.
In our own country it is gradually and surely making way, and
in due course there can be no doubt that it will create and
maintain a position as a curative agent of the very highest
value.

When people say that massage is as old, if not older, than
any other form of treatment, they are wrong. Medical rubbing
and anointing with unguents, and slapping and thumping the
body, were (if we read the history of medicine) common modes
of treatment ; but we claim something more for massage than
this: we say that massage consists of a series of movements
classified and arranged in order to produce certain definite
well-known physiological effects ; and its combination with the
induced electric current passed through the body of the
masseur, adds greatly to its value.

Iam sorry to say that facts are coming to my knowledge
which are detrimental in the highest degree to the best interests
of massage—I refer specially to the growing practice of
masseusés operating upon male patients. This is very wrong
xii INTRODUCTION.

in every way, and should be discountenanced in the most
determined and positive manner by all members of the profes-
sion; it is immoral, disgusting, degrading, and utterly
unjustifiable.

Dr. Graham in his very excellent work, ‘A practical treatise
on Massage,” devotes a considerable amount of space to the
history of massage which is highly interesting—one might
almost say classical, but I have no intention to give more than
a few lines by way of introduction to this part of the subject.
Hippocrates, 380 s.c., said: ‘‘ The physician must be experienced
in many things, but assuredly also in rubbing. For rubbing
can bind a joint that is too loose, and loosen a joint that is too
rigid. And again, rubbing can bind and loosen, can make
flesh and cause parts to waste. Hard rubbing binds; soft
rubbing loosens; much rubbing causes the parts to waste;
moderate rubbing makes them grow.” It is interesting to
know that Hippocrates had some very accurate ideas relative
to rubbing an extremity, although he could not have been
aware of the circulation of blood. He says, ‘‘ that rubbing
upwards in the case of the limbs had a more favourable effect
than rubbing downwards.” The wise and able Emperor
Hadrian, a.p. 76-138, who will be so well remembered as having
built the wall from the Solway Frith to the Tyne, and whose
reign was distinguished by peace and beneficent energy, one
day seeing a veteran soldier rubbing himself against the marble
at the public baths, asked him why he did so. The veteran
answered, ‘“‘I have no slave to rub me.” Whereupon the
Emperor gave him two slaves and sufficient to maintain them.
Another day several old men rubbed themselves against the
wall in the Emperor’s presence, hoping for similar good
fortune, when the shrewd Hadrian, perceiving their object,
directed them to rub one another. Plutarch tells how Cesar
was cured of a general neuralgia by being manipulated daily
by a slave.

In India, as in ancient Greece, it is common for the groom
to rub his horse with his own naked hand, in consequence of
INTRODUCTION. xiii

which it is said the horses have a much finer coat than the
Iinglish horses, which receive so much attention from the
curry-comb and brush.

Ambroise Paré, a.p. 1517-1519, the most renowned surgeon
of the sixteenth century, though not recognised by the faculty
as he was only a barber surgeon, describes three kinds of
friction: (gentle, medium, and vigorous ;) and the effects of each.
In dislocations he recommends that the joint should be moved
about this way and that way, not violently, but in order to
dissolve the effused fluids, and extend the fibres and the liga-
ments, so as to facilitate the reduction.

Hoffman, a.p. 1660-1742, says in his work ‘‘ Medicina
Rationalis Systematica,’’ ‘The human body, like all other
bodies in nature, possesses material forces, by means of which
it effects its movements. All these forces may be reduced to
mechanical and mathematical principles. An imponderable
but material agent, ether, the active moving force, animates all
tissues of the body, and presides over physical phenomena in
every domain in creation.” Mther is the fundamental cause
of all vital motion. We further says, ‘‘Medicine will never
progress until we closely examine the nature of this form of
motion originating in the sentient soul; and until we apply to
medicine the laws of mechanics and hydraulics.” In his writings
“Dissertationes Physico Medice,”’ 1708, the sixth division
of the first volume bears the superscription, ‘‘ Motion the best
means of cure for the body.” And in the first chapter,
On the attainment of long life,” he quotes the saying of Celsus,
“The best of all medicines is none.”

When we consider that Hoffman wrote his celebrated work
at the beginning of the last century, we cannot sufficiently
admire the illumined mind which shews itself throughout his
writings.

The preface to the work cited might have been written by
Skoda himself; and such clearness, moderation, and love of
truth are displayed in it, that it merits a reproduction here.
He says, “He who carefully observes and tests nature’s art of
xiv INTRODUCTION.

healing, is forced to the conclusion that the basis of all health,
life, and disease, is an exceedingly simple one, which never
changes and is never confused. It is a matter of surprise,
therefore, that physicians have invented so many means of
cure to preserve health and to combat disease. Nature main-
tains life by simple processes. A.few contrivances serve her
for the preservation of health, nor are the causes of disease.
many. It is justifiable, therefore, to assume that the remedies
to be used in restoring health should be neither complicated
nor numerous. Indeed, we may not only assume, but I most
positively affirm (and it may be put down to the misfortune or
abuse of therapeutics), that the mass of medicaments and
elixirs found in the works of both ancient and modern
physicians, have had no other purpose than to impede the art of
healing, and to make it uncertain and deceptive. Certainly
the medicines by means of which the physician can support
the efforts of nature, achieve success, cure the sick, and win
honour for himself, are by no means numerous. There are
many things which, though they appear to have little influence
in the healing of disease, or the preservation of health, yet
possess unthought-of power. Of this kind are those six mat-
ters called the natural, namely, air, food, motion and rest,
sleeping and waking. The intelligent application of these
may be of the greatest service in the art of healing
without medicaments. We have an example of their power in
the influence of movement and in the exercise of the limbs.
The influence of exercise is so strone—if we can believe the
testimony of the ancients and of our own experience—that
where disease is to be prevented or cured, it is to be prized
more than the most costly medicaments.”’

There are few physicians in this country at the present time
who study the treatment of disease from the physical or the
mechanical side to the extent that some would have them do.
Dr. Stone elucidates this in his Harveian Oration, delivered at
the Royal College of Physicians, October 18th, 1887, when
speaking of the essentially physical and mechanical character
INTRODUCTION. XV

of Harvey’s great discovery of the circulation of the blood.
His remarks are interesting and are as follows: ‘‘ Now at the
present time, investigation and research are abundantly
carried on in the pathological, physiological, and therapeutical
aspects of medicine, but the physical or mechanical side is
somewhat neglected. For hundreds of ardent questioners of
nature, who are labouring with the microscope, in the biological
and the bacteriological laboratories, those who attack medicine
from its physical side may be counted on the fingers of one
hand. Nor indeed are the written treatises on this subject
abundant, in this country at least. The ‘“‘ Animal Mechanics,”’
of the Rev. Dr. Haughton, of Trinity College, Dublin, is an
exceptional work of great value, which has hardly received the
attention it deserves from the medical profession, but it stands
almost alone as the representative of its class. On the continent,
however, and in America the case is very different. The
admirable ‘‘ Medical Physics,” of Professor Wundt, of Heidelberg,
has been translated from the German into French, with
valuable additions by Dr. Ferdinand Monayer, who regularly
lectures on medical physics at the Lyons Faculty of Medicine,
and affords a storehouse of information of the highest value to
the medical practitioner.

Dr. John C. Draper, Professor of Chemistry and Physics in
the Medical Department of the University of New York, has
also made a valuable contribution to the literature of this
subject in his ‘‘ Text-book of Medical Physics,” published the
year before last. There is, indeed, a small but scanty manual by
Dr. McGregor Robertson, the Muirhead Demonstrator of
Physiology in the University of Glasgow, published in Cassell’s
Student's Series, but it is entirely unfit to compete with the
two exhaustive treatises named before.

As with the bibliography, so with the teaching. With the
exception of a course of lectures which the present speaker has
delivered since 1871 in St. Thomas’ Hospital, I am not aware
of any systematic attempt in London to teach the medical
student the vast mass of physical facts which underlie the
XV1 INTRODUCTION.

daily practice of medicine. This college, however, forms an
honourable exception, for it has on two occasions kindly given
me the opportunity to bring before my brother physicians
some few of what our Harvey terms “‘ Nova vel Noviter inventa”’
—respecting the Physical Basis of Auscultation in the Croonian,
and the Electrical Conditions of the Human Body in the
Lumleian, lectures of a few years back.

It is true that the University of London, in its Preliminary
Scientific Examination for the degree of Bachelor of Medicine,
requires students to satisfy their examiners in physics by means
of a written paper. But this paper is the same as that set to
Bachelors of Science not medical. It is a terrible stumbling
block to the rising medical generation; it bristles with what
the late genial Professor De Morgan, himself a mathematician
of the highest order, delighted to call mathematical conun-
drums; it is set by pure physicists, who know nothing, and
probably care little, for the problems which interest us as
medicalmen. It contributes a large percentage to the slaughter
of innocent aspirants to the higher degrees in medicine, on
which one of their most distinguished graduates, now Censor
of this College, has feelingly and righteously commented. In
the sixteen years during which I have carefully read the papers
there set, I have never once seen a question directly or indirectly
bearing on the physics of medicine.

The fact is that the large, difficult, and somewhat hetero-
geneous branch of knowledge connoted by the word physics is
rapidly splitting into several independent portions. There are
now distinctly molecular, mathematical, industrial, and
physiological physics. Itis the last of these with which we are
concerned. The third or industrial branch has been enormously
developed of late by the technical colleges at Bristol, Manches-
ter, in the City guilds, at Kensington, and elsewhere. The
mathematical branch is well cared for by the two old Univer-
sities of Oxford and Cambridge, but the physiological section
has been hitherto hardly enough recognised by our teaching
bodies. Surely an earnest student should be able somewhere
INTRODUCTION. Xvii

to obtain information as to the natural laws on which the
stethoscope, the microscope, the ophthalmoscope, and the
Sphygmograph are founded, without having to wade through
interminable problems on the C. G. S. system of units, or
vortex theories of matter, or—chimera. of chimeras—the
possibility and advantages of four-dimensional space.

In the year 1825 there lived at Oxford a surgeon, John
Grosvenor, who wrote a book full of interest, entitled ‘An
account of a system of Friction as adopted and pursued with
the greatest success in cases of contracted joints and lame-
ness from various causes.” This late eminent surgeon
was for many years Professor of Surgery at Oxford;
his skill and reputation became so great that he was
soon in possession of all the surgical practice in that
city, and on every side of it within a radius of thirty miles.
No doubt, Mr. Grosvenor was a remarkable man, for he
rendered himself celebrated throughout the kingdom by the
application of friction for the cure of lameness and imperfections
of motion arising from stiff or diseased joints. The cases in
which he found the remedy most serviceable were contractions
of the joints attended with languid circulation and thickening
of the ligaments, and in those cases in which there was too
great secretion of the synovial fluid in joints; in cases of
chorea combined with attention to the system after violent
strains of the joints; in incipient cases of white swelling;
after fractures of the articulating extremities of the joints
when stiffness remains after union; in cases of dislocation
of the joint when the motion is impaired some time after
reduction.

In the year 1812 a gymnastic system was introduced by
Pehr Henric Ling, which is known as the Swedish Gymnastic
Cure, and he was permitted by the Swedish Government to
found a Gymnastic Institution at Stockholm, in the year 1813.
Ling, in a work entitled ‘“Gymnastikens Allmina Grunder,”
declares life to consist of the blending together of three

elements, the dynamic, the chemical, and the mechanical—
i B
XViil INTRODUCTION.

which, through their opposite action, produce variety in vital
phenomena. As soon as one of these elements is deficient or
diseased, a means of cure belonging to the same category
should be chosen, either to restore the balance or the healthy
condition. The means of cure for the mechanical element is
gymnastics. According to the object to be attained, Ling
divides gymnastics into the scholastic, medicinal, and esthetic.
The forms of movement which are to be employed are the
active, the passive, and the compound. In this last consists
the principal peculiarity of Ling’s system. The active move-
ment is performed exclusively by the will of the individual
exercising. In the passive movement, a second person, the
gymnast, conducts the movements of the body of the patient
or pupil, who neither assists nor opposes. In the compound
movements an alternate influence is exerted by both patient
and gymnast, for either the patient performs a movement
to which the gymnast opposes an equal resistance, in such a
manner, however, that he does not completely hinder this
movement, but only renders necessary a greater degree of
power to effect it (compound concentric movement), or the
gymnast conducts the movement of the patient’s limbs, while
the patient opposes a resistance in accordance with his strength
(compound eccentric movement). Gymnast and patient thus
alternately operate, in the first case the patient, and in the
last the gymnast, gaining the ascendancy in turns. A special
direction is, that the movement as well as the resistance
should uniformly commence and subside gradually, so that no
sudden, violent, or tremulous movement from excessive effort
should occur.

In 1870, Dr. N. B. Emerson gave a very interesting account
of the lomi-lomi of the Sandwich Islanders. He describes it as
a luxurious and healthful form of passive motion which the
Hawaiians bestow upon each other.as an act of kindness, and
their crowning act of generous hospitality to a well-behaved
stranger. When footsore and weary in every muscle, so that
no position affords rest, and sleep cannot be obtained, it
INTRODUCTION. xix

relieves the stiffness, lameness, and soreness, and soothes to
sleep, so that unpleasant effects of excessive exercise are not
felt the next day; but in their stead a suppleness of muscle
and ease of joint entirely unwonted. The Hawaiians have an
appreciation of the physiological wants of the wearied system
which Dr. Emerson thinks it would be well for the people
of other civilized nations to imitate. They have various ways
of administering the lomi-lomi. When one is about to receive
it he lies down upon a mat, and is immediately taken in hand
by the person who lomi-lomies, generally an elderly and
experienced man or woman. The process is spoken of as being
neither squeezing, kneading, nor rubbing, but now like one
and now like the other. The Hawaiians are a famous race of
swimmers, and to a foreigner they seem amphibious. When
wrecked, they sometimes swim long distances, and if one of
their number becomes exhausted, they sustain him in the
water and lomi-lomi him at the same time. Dr. Emerson
attributes the superiority in physique of the chiefs over the
people to the fact of their having themselves constantly lomu-
lomied. In recent times, Dr. Weir Mitchell, of Philadelphia,
has brought the Massage System into use, and shown the
great advantages which it possesses in the curative treatment
of disease. He has given very valuable testimony by his
writings concerning Massage in certain cases of anemia
and bed-ridden women, and much evidence of the value
of this remedy is now to be found in the medical journals all
over the world.

I have been lecturing upon and practising massage for
several years, and I venture to think that I have from personal-
experience learned much in reference to this subject. I have
certainly gained information concerning its nature and its
effects which is not to be found in any published work, and
even now I feel that an extended experience is still required to
put it upon a satisfactory and a safe footing as a Therapeutic
agent. Those who have had large experience cannot question
its utility.
LECTURES ON
MASSAGE AND ELECTRICITY.

 

Lecture I.

THE PRINCIPLES OF MASSAGE. .

Mechanical Principles of Massage, Kinetic, Dynamic, and Static—Pregsure
—Motion—Mass—Work and Energy—Potential Energy—Metabolism—Con-
vertibility of Forces—Phenomena, of Life—Transformation of Energy—Trans-
ference of Hnergy—Dissipation of Energy—Laws of Pressure—Nature of
Pressure—Physiological Effects of Massage—Life the sum of Antagonistic
Actions—Huxley on Living Matter—The Human Body an Organism—Deriva-
tion of Energy for the Animal World—The Effects of Massage as a Therapeu-
tic Agent—EHffects of Massage upon a Paralyzed Limb—Conversion of Potential
into Kinetic Energy by Massage—Weir Mitchell—Massage Assimilative Pro-
cesses—Cold and Heat in Nutrition—Body Temperature—Dr. McAlister on
the Nature of Fever—Thermogenesis—Mechanism of Respiration—Stability
of Temperature—Foster on Body Heat—Fick on Muscular Work—The
Muscles as Furnaces of the Body—Dr. Meade Smith and Dr. Sukjanow on
Muscular Fatigue—Dr. Latham on Metabolism in Gout, Rheumatism, and
Diabetes—Sir Dyce Duckworth on Gout as a Neurosis—Action of Vaso-motor
Nerves and Blood Vessels, in Nutrition, Assimilation, and Excretion—Dr.
Latham on Imperfect Metabolism—Circulation of the Blood and Functional
Activity—Physiological Processes subservient to Massage—High Tension, Low
Tension, Variable Tension—Dr. Richardson on Animal or Vital Mechanics—
On the Gaseous Constituents of the Blood in relation to Respiration—Views
of Johannes Miiller, Spallanzani, Levoisier, Lagrange, Sir Humphrey Davy,
Liebig, Regnault, Fernet, Professor Stokes, Matteucci, Claude Bernard and
Paul Bert—Zabludowski On the Effects of Massage on Healthy People—
Schreiber On the Effects of Massage.

ECHANICAL Paincrpizs or Massace.—The principles of
massage movements are in their nature kinetic, dynamic,
and static; and the mechanical movements associated

with the various massage manipulations are formulated in
their kinetical, dynamical, and statical order.

We know that we become conscious of matter whenever we
meet with resistance. Therefore, to anything able to produce
in us this sense of resistance, we apply the term matter.

In Professors Thompson and Tait’s great work on Natural
Philosophy (Part I., Division I., Chap. xi., p. 173), the
following account of matter is given: ‘“‘ We cannot give a
definition of matter which will satisfy the metaphysician ; but
2 PRINCIPLES OF MASSAGE.

the naturalist may be content to know that matter is that
which can be perceived by the senses, or 18 that which can be
acted upon by, or can exert, force.” si

The latter, and indeed the former also of these definitions,
involves the idea of Force, which, in point of fact, is a direct
object of sense, probably of all our senses—and certainly of
the muscular sense.

All that we know about matter relates to the series of
phenomena in which energy is transferred from one portion
of matter.

The process by which stress produces change of motion is
called work; and work, as we know, is the transference of
energy from one body or system to another.

The effecting of changes in matter is working, this being a
process performed against opposing forces. It is in virtue of
its possession of so much energy—a measurable thing—that
any body does work, 7.e., produces changes against force.

Pressure plays an important part, as we shall see, in the
different massage movements. It is unimportant whether the
pressure be applied to mass or to molecule, so that we are
concerned with molar movements, as well as with molecular
motion.

Further, the forces or energy applied must be equal to the
molecular resistance to be overcome. In consequence of this,
we have to deal with motion, mass, and force.

Motion must be considered with regard to change of posi-
tion ; Mass with respect to the quantity of matter ; and Force
relatively to its production of the motion of mass.

Hence the amount of force must be equivalent to the
quantity of mass, and its resisting power. This leads us to
the consideration of Work and Energy.

Energy signifies capacity for work, and its possession by the
body, or system of bodies, bestows the capability for activity.
Motion, therefore, including the ordinary molar motions of
translation or rotation, and molar molecular motion of undula-
tion ; heat, electricity, and magnetism, are forms of energy.

To this may be added strain (including compression), ex-
tension, distortion, gravitate separation, as well as chemical
separation, and, possibly, Vital Hnergy.

A careful distinction must be drawn between the energy of
the body not doing work, and the energy of the body that is
doing work ; for, since energy is the possession of the capacity —
cee it is evident that a quiescent body may yet have
_ This latter energy would be of a potential or static kind
implying that no work was done, or space traversed by the
body possessing it. On the other hand, we speak of kinetic
f
lt

PROTOPLASM, THE DEVELOPMENT OF ENERGY. 3

energy, as the energy of the active body, or, in other words,
actual, as distinguished from potential energy.

Potential energy exists in virtue of the force of cohesion or
gravitation. It is this definite and indestructible supply of
potential energy that is the real thing, of whose exertion the
foree is but an indication; it is those potential energies of
nature which are the real element which seems to survive in
association with matter, which gives it its appearance of
substantiality, and which is revealed to us whenever, as we
say, we press against, or force is exerted in relation to, any
particular body, in which case what really takes place is the
transmutation of a certain amount of this potential energy
into kinetic or otherwise. So that it is after all only a revela-
tion of existing potential energy by a transmutation thereof
into kinetic, which takes place when, as we say, a material
body is discovered to the muscular sense.

In passive gymnastic exercises (which form an important
part of my massage system), the patient’s energy is in a poten-
tial or static state, as compared to the energy of the masseur,
which is in an actual or kinetic state. The exchange of matter
and energy peculiar to living beings is known as metabolism,
and consists in the capacity of organisms to assimilate the matter
of their surroundings, and to work it up into their own constitu-
tion, so that it forms for a time an integral part of the living body,
and is the outcome of vital action or vital and physical motion.

Physical science has. now ascertained that the phenomena
with which it deals are only different modes of a common
energy. Heat, light, electricity, magnetism, etc., are but
different modes of motion produced under different conditions,
and they are all, either directly or indirectly, convertible into each
other; and modern investigation tends to resolve chemical
into mechanical problems, that is, into questions of molecular
physics. As we advance from the inorganic to the organic
world, we find that science has not yet been able to trace the
production of vital phenomena to the operation of physical
cor chemical agents; and yet we have strong presumptive
proof that life is transformed physical energy, and that the
energies of the animal frame, muscular, nervous, and s0
on, are resolvable into molecular force. Professor Gardner,
at the meeting of the British Association, at Bath, 1888,
pointed out that in the living substance the most gigantic
changes and evolution of energy appear to be affected by the
action of delicate reagents. With regard to the question of
vital force, he found considerable difficulty in thinking of
protoplasm as a substance. He was of opinion that the
phenomena of life consisted in an infinite arrangement and
rearrangement of an exceedingly complex system of molecules,
4 PRINCIPLES OF MASSAGE.

and that protoplasm would ultimately be found to be the
development of energy and nothing tangible. o

All phenomena, however apparently different, are reducible
into forms of motion, light into heat, heat into chemical energy,
chemical energy into electricity, and so on, so that these are
only various forms of that energy which are convertible into
each other, and each is the exact quantitative equivalent
of that from which it has been converted: amongst the endless
transformations which manifest themselves in the phenomena
of the material world, there is not the faintest quantity of energy
ever abstracted or dissipated, nor the faintest addition to the
grand sum ever made. In every voluntary action, an equally
arbitrary increase, or an equally arbitrary restoration of the
sum of energy takes place.

The whole series of phenomena (metabolic), consists in the
introduction, assimilation, integration, and excitation of matter,
life processes having, in fact, a dynamic basis.

It must be borne in mind that potential energy can be
converted into kinetic, and kinetic into potential.

The transformation of energy is necessarily attended by the
diminution of its availability. Molar energy thus becomes
molecular, and the transference of energy is always accom-
-panied by the dissipation of energy.

Hence it must be clear and evident, even to the uninitiated,
that massage processes, from the merely mechanical point
of view, possess an interest, and are associated with the
accomplishment of some of the highest and most complex
transmutations and transformations of energy. The con-
sideration of this leads us to the true dynamical outcome or
value of such terms as petrissage and tapotement.

The clear interpretation, and intuitive perception, by
practice, of the value of dynamical changes, brought about by,
or associated with, massage processes, are undoubtedly of
much value and significance to the masseur.

Force applied to living matter causes, or tends to cause,
the motion of masses, or, it may be, of molecules, of which
the living mass is composed, assuming the living matter to be
made up of solid, liquids, and gases. We must take into account
the laws of pressure and its area of distribution, as well as its.
intensity upon the organism upon which its influence is exerted.
We must distinguish between the amount of pressure and the-
intensity of pressure. Quantity and intensity of pressure are:
is a to the quantity of heat in, and the temperature of,.
a body.

Pressure applied is transmitted variably, according to the.
resisting power of the tissue to which it is applied,—to its.
vitality,—and to its mass.
MOTION, CONVERTIBLE BUT INDESTRUCTIBLE. 5

Pressure of given quantity deranges molecular integrity,
alters.equilibrium, and so engenders irritability and instability.
Pressure of given intensity produces molecular inertia and
death. This will be found referred to when writing of the
influence of pressure, pinching or petrissage movements, as
applied to the living tissues. According to the nature of the
pressure applied and the resisting power of the tissue operated
upon, so do we get changes in such tissue of molecular
activity and irritability, or molecular derangement and death.

We have seen that motion in all its forms is, as far as we
know, convertible but indestructible, that heat is a mode
of molecular motion, that the phenomena of light, of electricity,
of magnetism, of chemical action, and probably of life itself
are due to different modes of molecular motion.

If a piece of copper and a piece of zinc are placed in dilute
sulphuric acid, the zinc begins to dissolve (chemical action).
Two copper wires attached, one to the end of the piece of
copper out of water, the other to that of the zinc, are found
to be ‘‘ carrying an electric current” (electricity). If the free
ends of the two wires are brought sufficiently near one to the
other a spark leaps from one to the other (light). If the two
wires are joined they are of a higher temperature than they
were before the experiment began (heat). Ifa single connect-
ing wire is wound round a piece of soft iron, the latter is found
to have acquired the property of attracting iron filings
(magnetism). If the two free ends of the separate wires are
applied to a muscle and the nerve connected with the muscle,
of a recently killed frog, the muscle contracts (physiological
action). And if, finally, the two free ends are dipped into
acidulated water, the water is decomposed into hydrogen and
oxygen (chemical action again). This experiment, and in-
numerable others of a similar nature, show that the various
forms of motion are convertible one into the other. Further,
they are numerically convertible, and, with due care in the
conduct of the experiments, it is found that for every grain of
zine dissolved, a definite corresponding quantity of any one of
the other modes of molecular motion is forthcoming. So,
also, when the molar motion of the cannon ball or of a cab-
man’s arms on a winter’s day is converted into the heat of
a target or body there is no actual loss.

Before leaving the subject of mechanics in reference to
massage, I must just call your attention to the consideration
of force in association with mass and weight. We know that
force is that which causes or tends to cause motion. In
merely effleuraging or stroking the surface of the body, or
petrissaging, or kneading and energizing the muscular and
deeper tissues, we are effecting by force molar and molecular
6 PRINCIPLES OF MASSAGE.

motions in the parts, and we have to calculate the amount of
force which is required to overcome the resistance which
the tissues offer according to their condition and according to
their vitality and susceptibility, this clearly becomes a very
important matter for consideration. When a force causes the
motion of a mass, it denotes, and the work accomplished in a
given time is called, power. The masseur working, say at the
arm of his patient, energizes the tissues by the force which he
expends being converted into motion, and the resistance
overcome will be equivalent to the force transmitted. The
work done must be equivalent to the power employed. If the
work be properly effected, there can be no creation and no
destruction, either of matter or motion. It is only the con-
version of motion into another form or phase. We will say,
for instance, a force # cuts against and overcomes a resistance
R, the work done by F must equal the work done by R. If
Fd = Rd d and d represent the respective distances through

which F' and R work, Fd = Rd and = or the distances
moved through by each force are inversely as the forces.
Pressure, as we employ it in petrissage, gives rise to stress and
tension ; for instance, when two forces act and react upon a
body or upon a particle, they are together called a stress.
Their effect upon that which is acted upon isa strain. Stress
and strain are correlated as the active and passive phases of
the same phenomenon or as cause and effect. If the force acting
and the force reacting tend towards each other, the stress
is a pressure ; if they tend away from each other, thé stress is
a tension.

From what I have said concerning the leading principles of
mechanics, kinematic and dynamic, you will, I hope, see that
these are essentially associated with the science of motion
and the science of force, as applied to the operative pro-
cedures of massage, which we know by the terms Effleurage,
Petrissage, Tapotement and Friction.

PuystonocicaL Errecrs or Massace.—I will now call
your attention to points of greater interest, namely, to.
the effects of these mechanical processes by massage
upon the human body, upon the living tissues’ which are
constantly and unceasingly transforming forces, forces of
which we know something, and forces of which we know
nothing. But this cosmic conception of physical and
vital forces bound up in life organization, and the sub-
jective phenomena of existence, involves material for thought
and speculative theories which are within as well as without
our present knowledge of physiology, and all we have to deal
TRANSFORMATION OF POTENTIAL INTO KINETIC ENERGY. 7

with, in fact all that we can deal with here, must be that
which the science of life and disease is constantly imparting
to our observation by means which are well within the grasp
of every practical physician. Life is the sum of antagonistic
actions, and interactions, of internal properties and external
agents, ‘‘ The evolute potential of vitality.” Death is the
dissolution, the catalysis, disintegration and degeneration of
evolute processes brought about by what is termed disease, the
result of the action or influence of chemical irritants upon
tissues more than they can bear. Foster has shown that
there is the most superficial distinction between the normal,
the abnormal, the healthy and the diseased. Huxley, in
writing of living matter, says that ‘it is characterized by its
innate tendency to exhibit a definite series of the morphological
and physiological phenomena, which constitute organization
and life.’” Healthy life is dependent upon correlation of force,
which is demonstrated to the physician’s view as ‘‘ normal
functional activity |!”

Landois and Stirling say, that ‘“‘ The human body is an
organism in which, by the phenomena of oxidation, the complex
nutritive materials of the vegetable kingdom, which are highly
charged with potential energy, are transformed into simple
chemical bodies, whereby the potential energy is transformed
into the equivalent amount of kinetic energy (heat work,
electrical phenomena). All food for the animal kingdom is
obtained, either directly or indirectly, from the vegetable
kingdom, and the three chief representatives of food stuffs,
besides water and inorganic constituents, are fats, carbo-
hydrates and proteids. Plants absorb the kinetic energy of
light from the sun’s rays and transform it into potential
energy, which is accumulated during the growth of the plant
in its tissues, and in the food stuffs produced in them during
their growth. Animals are living beings, which, by oxidation,
decompose or break up the complex grouping of atoms manu-
factured by plants, whereby potential is transformed into
kinetic energy. Thus, there is a constant circulation of matter
and a constant exchange of energy between plants and animals.
All the energy of animals is derived from plants, all the energy
of plants is derived from the sun, thus the sun is the cause,
the original source of all energy in the organism, t.e., of the whole
life.’’ We shall see directly how valuable massage is in bringing
about the oxidation and metabolism of tissue, and the con-
version of potential into kinetic energy, particularly in those
cases of paralysis and nervous exhaustion where oxidation
and respiration of tissue are at their lowest ebb. Massage does
what no other therapeutic agent can do, that is, brings
into activity potential energy, restores the normal to the.
8 PRINCIPLES OF MASSAGE.

abnormal, maintains stable equilibrium of force. For instance,
massage will promote the development and growth of fat.
It also arrests its development and promotes its absorption.
I always illustrate this apparently anomalous fact to my class
in this way :—If a patient is by heredity lean, and he puts on
fat abnormally, massage will bring about its absorption. If,
on the other hand, a patient should by heredity be fat, and
he becomes lean, massage will in him promote the rapid
development of fat: organic disease always excluded.

If any excuse be needed to warrant and to justify my
warmly advocating my system of massage, it is to be found in
the simple fact, that my experience has proved it to be an
agent'of great regenerative power, an agent whose beneficial
influence has not yet been duly appreciated, and an agent
whose curative powers are most: marked in those cases where
other agents have signally failed to bring about a cure.
Unfortunately for the great science of medicine it has no law.
Effects are seen, causes are unknown. The more we study
the simplest laws of nature in reference to functional activity,
the more able shall we be to aid her when those functions are
deranged.

The secret of the success of any remedial agent depends
entirely and absolutely upon the knowledge we possess of its
definite and precise range of action under varying and vari-
able conditions. Nothing but the most careful study of
‘details can ever lead us to a successful issue. /

If we study carefully the effect-of massage upon a paralyzed
limb, say the paralyzed leg of this child suffering from’
ant. polio myelitis, we shall see that several notable changes are
brought about. Some are objective and some are subjective.
We are now considering the local effects only. They are
increased temperature and change of colour from that of
lividity to a bright red. These changes are of course
associated with increased oxidation, increased molecular
activity, and increased sensibility, and metabolism. This
morning I took the temperature of this child’s limb very
carefully at the inner part of the leg (the temperature of the
ward being 64°F.) and I found it was below 70°F. After
ten minutes manual petrissage the temperature of the limb
had risen no less than 17°F. That is to say, the temperature
before massage was under 70° and after massage it was
87° F. We cannot over estimate the value of this increase of
temperature. It indicates, as I have just said, (especially when
associated with a red healthy hue) increased metabolism and
respiration of tissue. The reaction to the galvanic current
before and after massage, in this form of paralysis, is of great
interest. In this little child’s legs that I now exhibit to you
OBJECTS ATTAINABLE BY MASSAGE. 9

we have a common instance of the usual reaction to fara-
dization and to galvanism. In infantile paralysis, during the
acute stage of degeneration, we find an hourly decreasing
response to the faradic current, until in three or four days the
muscles entirely cease to respond. At-this time we find in all
probability that the nerves have ceased to respond to the
galvanic current, but the muscles respond to a less current
than in health (myotatic irritability). When this child first
came under my care, the reaction of degeneration was well
marked, but by massage and galvanism the motor cells of the
grey matter of the anterior horns of the spinal cord have gained
by redevelopment compensatory power, and we now find,
instead of an absence of muscular response to both galvanic
and faradic currents, there is decided activity in both muscles
and nerves to either current, though more to galvanism than
to faradization, But what I am anxious to show is this:
You see I apply the electrodes of Stohrer’s battery to the
limb, and the galvanometer indicates that eleven milliamperes
current strength are required to produce muscular response,
the temperature of the limb being 70°F. I now massage and
I raise the temperature to 95°F, a rise produced by massage
of 25°F. J now apply the electrodes to the limb, and if you
watch the needle of the galvanometer you will see that instead
-of eleven milliamperes only five are required to bring about
muscular response. This is objective evidence of the most
decided kind that massage lessens the resistance and increases
the vitality of the limb.

The primary influence of massage is essentially mechanical,
producing effects which are purely physiological. It matters
not whether the influence is such as can be obtained by
stroking, pinching, hacking, percussion, or vibration.

Our first object is to obtain results by induction through the
nervous system by peripheral nerve agency—superficial
reflexes are always induced by stroking and friction movements.

Our second object is to combat and overcome resistance
(nervous or circulatory) by direct pressure, pinching and
‘kneading.

Our third object is to promote due oxidation and respiration
of tissue by percussion and vibration.

Whatever terms we employ, or whatever divisions we arrange,
they must be looked upon as arbitrary, artificial, and used merely
for the sake of convenience and demonstration. To sum up,
the results of massage are essentially vital, for by them undue
stress, tension, and pressure in the tissues are overcome, the
natural antagonism ‘between constrictor, dilator and trophic
nerves is established, the governing influence of the central
nervous system is stimulated and relieved of inhibitory and
10 PRINCIPLES OF MASSAGE.

fettering influences. Endosmosis and exosmosis have free and.
fair play. Catabolism and anabolism assume a normal level
of correlative stability, and thus we ensure the natural
functional activity of the processes of secretion, excretion,
absorption and assimilation, in fact, healthy nutrition. The
chief condition which regulates the absorption of oxygen is
temperature. I refer to absorption of oxygen by tissue (tissue
respiration) rather than to pulmonary respiration. In_
reference to temperature it must be admitted that blood seems to.
have a greater capacity for absorbing oxygen in cold countries,
but heat (which is one of the first effects of massage) is
absolutely necessary for respiration and oxidation of tissue.

I take a piece of tissue thus between my finger and thumb,
and I petrissage lightly this tissue by rolling and pinching it,
and the first effect which I produce is to increase the tempera-
ture and the activity of the circulation. I convert the potential
energy of the part into kinetic energy with the result that its
vitality is augmented. If I increase the pressure I increase the
sensibility, and if I continue to increase the pressure, which I
can do beyond the point of extreme vitality, I produce a con-
dition below the normal range of vitality, I destroy the
integrity of the vaso-motor nerves, the circulation is interrupted,
possibly destroyed, with the processes and forces of vitality
which are inherent in the tissue. The result is that molecular
disintegration, degeneration and mortification follow. I not
infrequently hear people say that massage is a cruel process,
that they have been made black and blue by the operation ;
this is of course very dreadful to contemplate, for such
massage as this is the very opposite to what skilful massage:
should be, and may be productive of irretrievable harm.

Massage, like every other form of treatment, is doomed to-
discredit, because it will be often applied in those cases to:
which it is ill adapted.

The various processes of massage are of a purely dynamical.
character, but in order to demonstrate the nature of these
processes to you, I must first ask you to allow me briefly to bring
before your notice the physiological changes which are brought:
about by their action, and I hope I shall make it clear to you
(as it has for a long time appeared clear to me) that massage:
has a potentiality of the highest physiological order. Every
practical physician knows perfectly well that the treatment of
so-called functional diseases requires great patience on his own
part, and also on the part of the patient. Many a person
suffering from functional derangement becomes a chronic.
invalid through his impatience and his want of confidence in
the physician or the mode of treatment. Hence he runs.
about from one doctor to another, vainly endeavouring to find
MASSAGE ASSIMILATIVE PROCESSES. 11

an immediate cure for all his woes, and finally, the last state
of that man is worse than the first. If massage is to be
successful as a remedial agent it must not only be dexterously
and skilfully administered, but it must be carried on for a
definite, and, in some cases, for a prolonged period of time.
There can be no doubt that we are greatly indebted to Dr.
Weir Mitchell, of Philadelphia, for having of late years
brought this plan of treatment into practice. I quote his own
words as follows: ‘‘ This form of treatment by massage has
been fruitful in cure, and affords numerous instances of success,
which are in truth living records of the failure of every other
rational and many irrational plans, and comprise a large
number of people who are kept meagre and anemic by constant
dyspepsia in its various forms, or by those defects in assimila-
tive processes, which, while more obscure, are as fertile parents
of similar mischiefs.”’

I will now solicit your attention to what we might call mas-
sage assimilative processes, and I must bring this subject before
you under the heading of metabolism, and give you my
physiological reasons why, in my opinion, massage has a
scientific as well as a physical aspect for our consideration.

We cannot well comprehend the action of any remedial
agent unless we know what are the chemical changes which
take place in nutrition, secretion and disintegration, forces, in
fact, which determine the building up or destruction of tissues,
and the actions and reactions of the atoms and molecules
which enter into their composition. Now these changes and
interchanges, which are constantly active in all healthy tissue,
are known as metabolic changes, and if I am right in my
conclusion that the great object and aim of massage is to
bring about these changes and to raise them to a healthy
standard when they are defective, I must ask you to bear with
me for a short time whilst I endeavour to lay before you some
points of interest in reference to this part of my subject.
The paralyzed limb of the child to which I have before referred,
gives us an opportunity to further consider the great question
of heat in reference to nutrition, to metabolism, and to the
circulation. Cold has a markedly depressant action in nutri-
tion. Heat, on the other hand, is favourable to nutrition,
inasmuch as it is favourable to the due metamorphosis of
tissue. Therefore, energizing muscle by massage induces
metabolism and promotes nutrition. But we must remember
that disorder of the body heat implies disorder of the circula-
tion, of the respiration, of the digestion, of secretion, and of
the nervous and muscular systems. The due maintenance of
the normal temperature of the body under varying conditions
and opposing tendencies is of the utmost importance, and is
12 PRINCIPLES OF MASSAGE.

worthy of serious consideration to all those who are interested
in massage. I may tell you at once that it would be the
height of folly to place a patient under a course of massage
when the circulation was active and the temperature normal,
unless it were for some local defect or localized pam. We
shall therefore be much better able to comprehend the
physiological effects of massage after we have well considered
the sources, nature, and effects of heat in reference to the
human body. In health the stability of temperature is nearly
perfect. Dr. McAlister in the Gulstonian Lectures, “ On the
nature of Fever,’’ delivered at the Royal College of Physicians:
last year, has taught us a great deal concerning the question
of heat, and Iam indebted to these lectures for much infor-
mation upon this subject. (1,) There must be a source in
the body from whence heat is produced (thermogenesis),
(2,) There must be processes by which heat is discharged from
the body (thermolysis). (8,) There must be a mechanism by
which the heat production. and the heat loss are balanced at
the normal height. This is called the thermotaxic mechanism,
and controls in health the thermogenic tonus, which means a
balance between the liberation of thermal energy, on the one
hand, and its repression on the other ; in fact, it regulates the
body temperature and gives it stability, and just as the
governor of a steam engine regulates the speed, it must of
necessity govern and regulate both heat production and
heat loss, and is the highest and most important factor of the
three. We can know more of thermolysis than we can of
thermogenesis by studying the main channels by which heat
passes out of the body, namely the skin and the lungs.
Through the skin there escapes, by evaporation, conduction,
and radiation, more than 80 per cent. of all the heat discharged
from the body, the remaining 20 per cent. escapes through the
breath. The rate of heat loss varies just according to the
vascularity of the skin, and it also of course varies according
to the amplitude of the respirations. A face flushed with wine
feels warm, for it is rapidly discharging heat; a dog whose
skin lets little heat pass through it pants to cool itself. Now,
with reference to the circulation, we are well acquainted with
the fact that the calibre of the arteries is kept constant by the
two kinds of vaso-motor nerves arising in the brain and spinal
cord, and which are called vaso constrictor or motor and vaso
dilator or inhibitory.

With reference to respiration, we find that it also is governed
by a nervous mechanism controlled by centres in the medulla
oblongata and spinal cord, with a two-fold complement of
nerves proceeding to the respiratory muscles, the one motor
and active, the other inhibitory; and we believe that the
OXIDATION IN THE MUSCLES. _ 18

respiratory centre consists of two correlated parts, the one
subserving inspiration and the other subserving expiration.
We thus find that the two channels of heat dissipation are
under the control of double acting nervous mechanisms, each
having a motor and an inhibitory aspect, and from these
postulates we might draw the deduction that the temperature
of the body in health is maintained by the vigilant action of
the sensitive nerve centres, which control the great systemic
functions of circulation and respiration.

When we get an undue or unequal distribution of heat to
different parts of the body, we get from some cause or other a
disorder of the thermotaxic mechanism ; a fluctuation, so to
speak, between thermogenesis and thermolysis, due to
defective metabolism. So much for heat discharge. I must
now refer you to thermogenesis or heat production. The
temperature of the body is merely a function of the difference
between heat income and heat expenditure at any moment.
The stability of temperature (by which I mean the integrity of
the thermotaxic mechanism) is merely a question of tonus or
health. None but the invalid and the physician can say how
variable, and how suddenly and rapidly variable is this state
of thermogenic tonus.

Thermogenesis is necessarily associated with chemical
processes in living tissue, and, as I maintain that the processes
of massage, when curative, are due to their power of inducing
thermogenesis, J must ask you to kindly bear with me whilst
I endeavour to elucidate this subject a little more fully.
What, may I ask, is the tissue wherein thermogenesis is most
active ? In the first place we know that muscle forms about
one half of the substance of the body, and that the mean rate
of oxidation in the muscles is higher than that of the average
of all the tissues, and we are therefore justified in coming to
the conclusion that the muscles are the chief contributors to
the heat of the body. Professor Foster, in his well-known
work on Physiology, says :—‘‘ We may at once affirm that the
heat of the body is generated by the oxidation of the tissues
at large by respiration of tissue. Wherever metabolism of
protoplasm is going on heat is being set free.” . . . . In
growth and in repair, in the deposition of new material, in the
transformation of lifeless pabulum, in the constructive meta-
bolism of the body, heat may be undoubtedly to a certain
extent absorbed and rendered latent, the energy of the con-
struction may be, in part at least, supplied by the heat
present. But all this, and more than this, namely, the heat
present in a potential form in the substances themselves so
built up into the tissue, is lost to the tissue during its
destructive metabolism, so that the whole metabolism, the.
14 PRINCIPLES OF MASSAGE.

whole cycle of changes from the lifeless pabulum through the
living tissue, back to the lifeless products of vital action,
is eminently a source of heat. Fick calculates, from actual
observation, that during severe muscular work the quantity of
exhaled carbonic acid may be five times the normal, showing
that of the total energy derived from the food, one sixth goes
to the work and five sixths to the extra production of heat
that accompanies it. The muscles, then, are looked upon as
the furnaces of the body, and are estimated to contribute in
health four fifths of the body heat. From the investigations of
Dr. Meade Smith and Dr. Sukjanow, (see ‘‘ Du Bois Reymond’s
Archiv,’”’ 1888), concerning the laws which govern the fatigue
of the thermogenic function of a living muscle, we have some
highly interesting conclusions, which I might say are of very
great importance to the student of massage. (Please under-
stand me, I do not mean the medical rubber or the joint
man or the bone setter. I mean the scientific practitioner of
medicine). Let us see what these conclusions are. If a
muscle is stimulated through its nerve, two processes are set
up, one manifested by change of form and the performance of
mechanical work, the other manifested by the increased
development of heat. And each process appears to have its
own laws as regards (1,) The influence of external conditions,
such as intensity of stimulus; (2,) The influence of fatigue
from repeated stimulation; (8,) The influence of general
exhaustion from inanition or other debilitating cause ; (4,) The
influence of the general temperature of the protoplasm of the
muscle; and (5,) The influence of rest and the circulating blood
in restoring lost power. Now, if I wanted a text upon which
to preach a massage sermon, I could not possibly find one
more appropriate than these conclusions of Dr. Meade Smith
and Dr. Sukjanow. Every point seems to me to have a direct
bearing in relation to those cases of nervous exhaustion,
prostration, feebleness, and malassimilation which we know
recover so rapidly under the influence of massage and
appropriate feeding. Then normal metabolism is dependent
upon a balance between the nervous impulses subserving
anabolism or the building up of tissue and the integrity of the
assimilative processes, and catabolicism or the unbuilding,
disintegrating and destructive processes. I must now ask you
to follow me a step further and consider metabolism from its
pathological aspect, taking as types of disease, rheumatism,
gout and diabetes.

I suppose there is no man living who has applied the science
of Chemistry with greater skill and dexterity than Dr.
Latham, of Cambridge, to formulate an assumptive basis upon
which to connate the series of changes associated with the
MASSAGE IN DIABETES. 15

chemical metabolism of tissue in such diseases as gout, rheu-
matism, and diabetes. Dr. Latham, in his original and, I
might say remarkable Croonian lectures, which he delivered
at the Royal College of Physicians, in 1886, “‘ On some points
in the Pathology of Rheumatism, Gout, and Diabetes,” says
that he classed these three diseases together because they
seem to possess a certain relationship with each other. Not
infrequently transient diabetes appears as the harbinger of a
gouty attack, and, on the other hand, gouty, rheumatic or
neuralgic pains are very common accompaniments of diabetes.
In all we have changes (differing however in character), show-
ing themselves in the blood, the result of abnormal metabolism
either in the muscular or glandular tissue. But, as Dr.
Latham acknowledges, we know nothing of the proximate
elements which make up living tissue, nor what are the
chemical changes which take place as it performs its function,
nor the alteration in the arrangement of its molecules as it
passes from an active to an effete state. So that many of
Dr. Latham’s chemical groupings, as he candidly admits,
must be in a measure pure hypothesis; but, whether they be
hypothetical or not, the practical outcome is of vast chemical,
physiological, and pathological importance, and although
not proven to-day, will, I venture to think, as science
advances, be removed from the realm of hypothesis to that of
physical fact.

Do not think, if you please, that [am leading you away from
scientific massage. On the contrary, I am endeavouring to
claim your attention to these changes going on in the tissues
of the body, simply and merely to show you that where these
changes are defective, we can, by massage and appropriate
dietary, very often bring about a normal condition of things, a
stability, and, in fact, a tonus which is alone compatible with a
state of health. I think the day is not far distant whe nyou
will find this form of treatment an absolute cure for diabetes.
In several cases where I have prevailed upon patients to try it
for six weeks with appropriate diet, every trace of sugar has
disappeared, and the urine has resumed its normal specific
gravity. And if gout is (as Sir Dyce Duckworth maintains)
a primary neurosis due to some instability of the trophic
nervous system, having its origin in the medulla oblongata,
there can be no doubt whatever that diabetes takes its origin
from a similar source. I do not think that we need go to the
medulla oblongata for every form of defective metabolism ;
vaso-motor centres are distributed throughout the whole
spinal axis, and I believe they are excited reflexly by massage
processes. Of course it is only reasonable to conclude that
the dominating and controlling centre is in the medulla
16 PRINCIPLES OF MASSAGE.

oblongata, which is really a complex composite centre con-
sisting of a number of closely aggregated centres, each of
which presides over a particular vascular area. Now, what
does Dr. Latham say about this? I really must give you his
own words because they are so entirely in accordance with
physiological and clinical experience.

* Some of the nerve cells or some portions of this dominat-
‘ing centre in the medulla oblongata may be more readily
exhausted by the continued stimulation of an irritant circulat-
ing in the blood than the others, and after the development
of the irritant (uric acid) in the system, it will of course
produce exhaustion just in these particular cells, and in the
subsidiary ganglia in connection with them, and so lead to
the dilatation in the vascular area directly under their con-
trol. The other unaffected cells in the dominating centre in
the medulla oblongata, and the subsidiary ganglia in con-
nection with them, possessing a healthy tone, will be stimulated
to action in the normal manner, and contraction will take place
in the vascular areas connected with them. This action itself
would have the effect of driving more blood to the paralyzed
vascular area, and intensifying the symptoms there. But
with continued stimulation of these healthy centres exhaustion
will sooner or later be induced. These points of nerve
physiology are of great interest, as showing and explaining
how pathological conditions may and do arise from defective
nervous action, giving rise to exhaustion and defective
correlation. The most powerful vaso-motor nerves are
those which act upon the blood vessels of peripheral parts,
while those that act upon central parts are less active.
In addition to contraction of the vessels, caused by impulses
affecting the blood supply, there are impulses affecting
directly the activity of the protoplasm, so that the construc-
tive metabolism (about the joints, for instance) is stimulated,
whilst the blood supply and destructive metabolism are
lessened, and so there is increased development or growth
about the part.”

I cannot leave the question of metabolism without once
again drawing your attention to the important part which the
dominant vaso-motor centre in the medulla oblongata plays
in the great processes of nutrition, assimilation, and excre-
tion : processes which we believe to be so essentially influenced
by massage. We have, I think, clearly proved that metabolism
is both constructive with vascular dilatation, and destructive
with vascular contraction ; that it is governed by two sets of
nerve fibres, in like manner to those which govern the blood
vessels, respiration, and the movements of the heart, and that
they enable, as far as possible, the two great processes of
IMPERFECT METABOLISM AND GOUT. 17

waste and repair to be maintained in a given ratio, subserving
definite tissue metamorphosis which is compatible with health
and a vital tonus, and which is the secret of success in the
massage processes. We cannot consider the processes of
digestion and assimilation without noticing the important
part which this dominant vaso-motor nerve centre takes in
the metabolic function of the liver. The duty of the liver
is to secrete bile from the blood which contains the products
of digestion, and the nature and quality of the blood will
depend upon the kind of food which has been taken, and we
are led also to believe that the quality of the bile must in a
measure be similarly influenced, so that according to the con-
stitution of the portal blood must be the integrity or otherwise
of the metabolic function of the liver, which, moreover, is
dependent upon the absorption and transformation of certain
constituents of the blood by the hepatic cells, controlled of
course by the secreting nerve fibres in connection with these
cells—(entirely independent of the nervous mechanism con-
trolling the vascular supply). If there be defective correlation
between the vascular dilatation on the one hand, and the
hepatic function of the liver cell on the other, there will be
imperfect metabolism, giving rise, as we know, to sugar as in
diabetes, and to uric acid as in gout; for I think we must
admit that there are various nerve filaments responding to
various kinds of stimuli, some regulating the transformation of
saccharine products, the other the nitrogenous elements con-
veyed to the cells by the portal circulation.

Dr. Latham says that ‘‘ Imperfect metabolism results if too
much nitrogenous material is introduced into the portal vein
from the alimentary canal; the portion then which is least.
readily acted upon (namely, the glycocine) will not be trans-
formed, and so the formation of uric acid is promoted. We
see the same thing constantly, even when the liver is in a
healthy and normal condition ; if it has too much work thrown
upon it, that is, if more nitrogenous material is introduced
into the portal vein than can be transformed in the gland;
and so an occasional indulgence at the table is very generally
succeeded by an appearance of urates in the urine. If the
liver cells are already. exhausted by long continued over-
stimulation, with how much greater difficulty will the perfect
metabolism of nitrogenous food be effected.’’ The uric acid
will then be formed in excess, and if not eliminated will cir-
culate as a poison in the blood, acting as an irritant upon
some portion of the nervous system, according to the sensitive-
ness of the nervous spot or centre in the nervous mechanism,
giving rise to gout, diabetes, rheumatism, dyspepsia, cardiac
irregularity, megrim, etc. ;
18 PRINCIPLES OF MASSAGE.

“In gout,” I again quote from Dr. Latham, “‘as we have
stated, the uric acid is the result of modified innervation of
the liver or exhaustion of the hepatic cells, and so there is
non-transformation of the glycocine and the consequent
formation of uric acid. In rheumatism, the glycocine results
from changes in the vascular area, and in the metabolism of
the muscles, and along with its formation there is also the
formation of lactic acid by hydration, a

Both from the Cyanaleohol, CH,. CH, a

And the Cyanalcohol, CH,. CH {ond

The nutrition of the joint is modified by the uric acid, but the
nutrition is further modified by the presence of the lactic acid,
producing dilatation of the arterioles, more particularly of those
in the cutaneous area. In this manner,” says Dr. Latham,
‘“‘T venture to suggest, are the characteristic changes about the
joints in acute rheumatism developed.”

All this, and a great deal more upon kindred lines of thought,
is brought forward in avery able manner by Dr. Latham in
his Croonian lectures, which bristle with original hypotheses
and deductions concerning the nervous origin and chemical
changes occurring in gout, rheumatism, and diabetes; and if
this chemical theory of the formation of uric acid by changes in
the tissues, ‘‘ by the conjugation of residues of glycocine with
residues of urea,’’ is to supersede the physical theory of the
formation of gouty tophi as mere depositions of insoluble
material, then we shall the more readily understand and
comprehend the basis upon which the massage processes in
gouty states are attended with such eminently satisfactory
results.

The circulation of the blood is so essentially connected
with the vitality of the part, with its metabolism, its heat,
and its sensibility, that its importance in the réle of the
organism must be apparent and self-evident. A regularly
sustained and ample supply of blood is absolutely necessary
to functional activity, no matter whether it be of the nervous
system, the glandular system, or the muscular system.

In the brain, for instance, functional activity and efficiency
are entirely dependent upon a due supply of nutrient material
and of oxygen carried to it by the capillary circulation.

The circulation, if one may judge of it by the pulse alone,
either by digital manipulation or by the sphygmograph, is the
most varying and variable of all functions. This can be
easily conceived if we look upon the circulation as the servant
and not the master; and physiologically it is tissue activity
which conditions the blood, and not the blood supply which con-
ARTERIAL TENSION, HIGH AND LOW. 19

ditions the tissue changes. The heart being the centre of the
circulation, determines its force, strength and regularity, all
surroundings being equal, especially the elasticity of the great
vessels, and the resiliency and due resistancy of the capillaries,
arterioles, and ultimate tissue elements; but beyond these
conditions we have, holding magisterial sway, the influence
of the pneumogastric and sympathetic nerves (the sympathetic
being the motor nerve keeping the cardiac ganglia in a con-
stant state of activity, and the pneumogastric controlling or
inhibiting its action).

But I wish to confine my remarks to the circulation, pure and
‘simple, always bearing in mind that I never desire to enter more
fully into the realms of physiology than is necessary to show how
physiological processes of the highest order are subservient to
‘massage. It would be impossible, however, to consider the
physiology of the circulation in reference to massage, if we did
not remember the omnipotency of the nervous centres and how
the minutest of the minute capillary vessels are en rapport with
its governing nerves. It is only through nerve agency that we
can account for “‘ circulation vagaries,” and particularly that
condition known as the paroxysmal palpitation of the heart,
when the pulse rate will vary from 200 to 300 in the minute,
without any actual traceable change in the structure of the
heart or the vessels. What is this but neurasthenia? Any-
how, the cardo-inhibitory centre in the medulla oblongata
must be involved in these conditions, and for the time being is
in a neurasthenic state. Again, the circulation may be
exceedingly slow and the pulse infrequent—only 40 to the
minute, or, on the other hand, it may give rise to an inter-
mittent and irregular pulse, both conditions being quite
compatible with health, and even vigour, up to a fairly
average age.

There are two states of the circulation to which I must
draw attention, and they are high tension and low tension.
But before considering these, it is well that this question
should be asked and answered, namely: Can we tell from the
nature of the pulse whether massage treatment will be
beneficial? Ibelieve wecan. Let us consider very practically
and briefly these states of tension.

Now, high tension in an artery is significant either of a.
great deal, or, on the other hand, it may be neurosal, or it
may be hereditary, or it may be temporary and transitory,
and mean very little. It may be of blood origin as in gout,
kidney disease, chronic poisoning, and other conditions of the
blood irritating the vaso-inhibitory nerves, producing by its
influence upon the brain, medulla, and spinal cord, clonic
or tonic convulsions, or positive muscular rigidity, just as it
20 PRINCIPLES OF MASSAGE.

affects the higher, the median, or the lower nervous centres. By
increased arterial tension, heightening internal blood pressure,
an increased flow of cerebro-spinal fluid is induced by the:
power which is thus exercised upon the choroid plexuses.

Whatever the cause may be, the tension itself is due to an
obstruction to the normal blood flow, between the minute.
capillaries and veins. This means, of course, resistance.
throughout the whole of the arterial and venous circulations ;
and although this resistance is at first peripheral, it eventually
becomes central, and finally expends itself upon the heart.
So long as this resistance is of low degree, nothing comes of
it, the heart demands more nerve influence and it gets it, but.
this cannot go on for ever. Tension begets tension, resistance:
increases, function is deranged, then impaired, and finally,
arrested. Heart hypertrophy, dilatation, and dropsies are the
sequence. Is this, then, a condition of the circulation which
may be beneficially influenced by massage? I answer most:
unhesitatingly in the affirmative. The pulse characteristics.
of arterial tension are well known, but it must not be for--
gotten that tension is a matter of degree, therefore we have
dissimilarity of tension, varying, but co-equal with resistance ;
so that there may be considerable arterio-capillary tension
before we can readily distinguish that solid cord-like condition
of the pulse, which is usually looked upon as its chief
characteristic. ‘ Cardiographic tracings, judging from my
own experience, are better then sphygmographic tracings in
determining initial arterio-capillary tension. Low arterial.
tension is perhaps of more interest to the masseur than high
arterial tension, so we must for a moment inquire into the:
nature of the former and compare it with the latter; the
comparison is definite and may be stated in a few words,
namely: In high arterial tension resistance is indefinitely
increased ; in low arterial tension resistance is if anything
diminished. In the former, the capillaries and arterioles are:
contracted and their calibre narrowed, so that the blood flow
is impeded. In the latter, the capillaries and arterioles are:
relaxed, allowing the blood to flow with freedom, the heart is.
necessarily weak in action, the pulse will be short and
weak also, so weak in fact, that it is at times scarcely per--
ceptible. Low arterial tension reaches its maximum or
minimum, whichever way you like to put it, just preceding
the act of fainting, and just preceding the convulsions of°
epilepsy. It denotes feebleness and want of energy, defective:
metabolism, defective secretion and excretion, nutrition and
assimilation, and general impairment of function, not of one-
part of the body, but of all parts of the body: the brain and
nervous system more particularly being under its depressing and.
RESPIRATION OF TISSUE. 21

enervating influence. There is another condition of the circula-
tion to which I need refer, and that is a condition of variable
arterial tension of purely nervous origin, and localized in its
nature, its character, and its influence. It is often reflex, and
may be due to a higher nerve centre acting upon a lower, or vice
versa, and is frequently associated with general and inherent
or even hereditary instability of the nervous system as a whole.
It may be looked upon as a rule as mere functional derange-
ment, yet I have frequently met with it in the very primary
stage of aortic insufficiency, therefore care must be taken to
make a correct diagnosis as to the precise state of the heart
under such circumstances. In massage, all the deep processes
should be carried on in the direction of the flow of the
venous blood and the lymph. Dr. Richardson, in one of a
series of very interesting lectures, which he gave at the
Society of Arts, ‘On Animal or Vital Mechanics,” designates
the veins as the true rivers of life. He says, ‘‘ The circulation
of blood in its primary movement begins in the veins, in a
venous current which does not depend in the first instance on
the stroke of the heart; but which has its origin in the
digestive tract, and which supplies the heart as from a vast
surface of absorption with fluid, from food and drink, and
from the lymph formed in the drainage surface of the body.”

The two circulations which most concern the masseur,
are the venous and the lymphatic; but these will be dealt
with fully in a subsequent lecture. (See Lecture VI.)

For many years I have held the opinion that the value of
massage depended upon its influence in promoting respiration
of tissue; but since I heard the admirable address by Prof.
McKendrick, delivered in Glasgow at the meeting of the
Brit. Med. Association last year, ‘‘ On the Gaseous Constituents
of the Blood in relation to Respiration,” I am more than ever
convinced that my opinion is a right one; and here I might
tell you that Iam strongly of the belief that respiration of
tissue is essential to the life activity of all function. We
will now see what respiration of tissue means. You will remem-
ber my reference to the effect upon a piece of tissue by
petrissaging it. I increased both temperature and circulation
in the part so acted upon, in fact I brought about or rather I
stimulated respiration of tissue. And again I submit that I
brought about by massage, respiration of tissue in the limb
of the paralyzed child. Iam sure you will pardon my weary-
ing you with some .very interesting points relating to this
subject :—‘‘ Respiration may be shortly defined as the function
or group of functions by which an interchange occurs between
the gases formed in the tissues of a living being, and the gases
of the medium in which it lives.” —McKendrick.
22 PRINCIPLES OF MASSAGE.

A century ago, Johannes Miller, Spallanzani, Lavoisier,
Lagrange, and several other celebrated men of that period
who were distinguished in the field of science, held two
theories concerning respiration; the one, that combustion
occurred in the lungs or venous blood furnishing carbonic
acid and aqueous vapour, which were exhaled by the lungs ;.
the other, that there was no such combustion, but that
oxygen was absorbed by the lungs and carried to the tissues,
whilst in these carbonic acid was secreted, absorbed by the
blood, carried to the lungs, and there exhaled. These opinions
gave rise to two theories, namely, the theory of combustion
and the theory of secretion. The combustion theory neces-
sarily held its ground until Sir Humphrey Davy collected, and
proved that oxygen was held: in solution in the blood. At
length the evidence of the existence of gases in the blood
became an accomplished fact and, in like manner, respiration
of tissue and the secretion theory became firmly established.

Dr. McKendrick, in speaking of the diffusion of gases
says :—‘‘In order to appreciate the value of this evidence,
and the method employed (referring to his own investiga-
tions), let me direct your attention to the laws regulating
the diffusion of gases. As a mass of gaseous matter has no
independent form, like that of a solid body, nor a fixed volume
like that of liquid, but consists of an enormous number of
molecules which, in consequence of their mutual repulsions,
endeavour more and more to separate from each other, it is
easy to see that if two masses of gas are brought into contact
they will mix, that is, their molecules will interpenetrate,
until a mixture is formed containing an equal number of
the molecules of each gas. The force by which the mole-
cules repel each other, and by which they exercise pressure
in all directions, is known as the pressure or tension of the gas.
It is evident that the greater the number of gas molecules in
a given space, the greater will be the tension of the gas, and
from this it follows that the tension of a gas is in the inverse
proportion to its volume (this is known as Boyle’s law). Sup-
pose now that two gases are separated by a porous partition ;
the two gases will mix, and the rapidity of the diffusion will
vary according to the specific weight of the gases. Thus light
gases, like hydrogen or coal gas, will diffuse more quickly
than air, or chlorine, or carbonic acid.

It is important also to note the laws regulating the absorp-
tion of gases by fluids. If we allow a little water to come into:
contact with ammonia gas above mercury, the gas is rapidly
absorbed by the water (one volume of water absorbs 730 volumes
NH) all the gas above disappears, and in consequence of this
the pressure of the outer air drives up the mercury in the
PRESSURE AND TENSION IN RESPIRATION. 23

tube. The higher the temperature of the fluid the less gas
it absorbs. At the boiling point of the fluid its absorption
= 0, because at that temperature the fluid itself changes into
gas. The power of absorption of different fluids for the same
gas and the absorptive power of the same fluid for different
gases fluctuate between wide limits. Bunsen defined the co-
efficient of absorption of a fluid for a gas as that number
which represents the volume of gas (reduced to 0° and 760
mm. barometric pressure) which is taken up by one volume of
the fluid. Thus one volume of distilled water takes up the
following volumes :

Temp. Cent. N. oO. COz Air.
0 0:02 0041 1:797 0°025
5 0-018 0-036 15 0:022
15 0:015 0-03 1-002 0-018

37 — 0:02 0°569 =_

By the phrase ‘“ tension of the gas in a fluid” is understood
the partial pressure in millimétres of mercury which the gas
in question has to exercise in the atmosphere, when no diffu-
sion between the gas in the fluid and the gas in the atmosphere
takes place. The terms “ pressure”’ and ‘‘ tension ’’ mean the
same thing in pulmonary respiration. Venous blood, contain-
ing a certain amount of carbonic acid at the temperature of
the blood and under a certain pressure, is brought to the
capillaries, which are distributed on the walls of the air-vesicles
in the lungs. In these air-vesicles, we have an atmosphere at
a certain temperature and subject to a certain pressure.
Setting temperature aside, as it may be assumed to be the
same in the blood and in the air-cells, let us consider the
question of pressure. If the pressure of the carbonic acid in
the blood be greater than that of the carbonic acid in the
air-cells carbonic acid will escape until an equilibrium is
established between the tension of the gas in the blood and
the tension of the gas in the air-cells. Again, if the tension
of the oxygen in the air-cells be greater than that of the
oxygen in the venous blood oxygen will be absorbed until
the tensions become equal. This theory has no doubt the
merit of simplicity, but it will be observed that it depends
entirely on the assumption that the gases are simply dissolved
in the blood. It was pointed out by Liebig that according to
the experiments of Regnault and Reiset, animals used the
same amount of oxygen when breathing an atmosphere com-
posed of that gas alone as when they breathed ordinary air,
and that the vital processes are not much affected by breathing
the atmosphere of high altitudes where the amount of oxygen
taken in is only about two-thirds of that existing at the sea-
level. It was also shown at a much later date, by Ludwig
24 PRINCIPLES OF MASSAGE.

and W. Miiller, that animals breathing in a confined space of
air will use up the whole of the oxygen in the space; and it
is clear that as the oxygen is used up, the partial pressure of
the oxygen remaining must be steadily falling. Liebig urged
the view that the gases were not simply dissolved in the blood,
but existed in a state of loose chemical combination which
could be dissolved by the diminished pressure in the vacuum,
or by the action of other gases. He also pointed out the
necessity of accurately determining the co-efficient of absorp-
tion of blood for the gases, that is, the amount absorbed
under a pressure of 760 mm. of mercury by one volume of
the gas at the temperature of the observation. The next
important observations were those of Fernet, published in
1855 and 1857. He expelled the greater part of the gas of
the. blood (dog) by passing through it a stream of hydrogen
and then submitting it to the action of the air-pump. He
then introduced into the apparatus the gas under a given
pressure, the absorption co-efficient of which he had to
determine. He then estimated the amount of gas absorbed,
under different pressures, and found in the case of oxygen
that the amount absorbed with gradually decreasing incre-
ments of pressure was greater than what would have been thé
case had it been in accordance with Dalton’s law of pressures.
The oxygen was not then simply dissolved in the blood.
Further, Fernet arrived at the conclusion that the greater
portion of the oxygen was in a state of combination. By
similar experiments made with carbonic acid, Fernet deter-
mined that the greater portion of it was in a state of loose
chemical combination, whilst a small amount was simply
dissolved according to the law of pressures. Experiments
with blood serum showed similar results as regards carbonic
acid, with the difference that the co-efficient of absorption for
oxygen was much less than with ordinary blood. He therefore
concluded that nearly the whole of the carbonic acid was
chemically retained in the fluid of the blood, whilst nearly the
whole of the oxygen was combined with the red blood
corpuscles.”

Professor Stokes, by reducing arterial to venous blood, anc
submitting it to spectrum analysis, came to the very impor-.
tant conclusion that ‘‘The colouring matter of blood, like
indigo, is capable of existing in two states of oxidation,
distinguishable by a difference of colour and a fundamental
difference in the action on the spectrum. It may be made to
pass from the more to the less oxidised state by the action of
suitable reducing agents, and recovers its oxygen by absorption
from the air.”

To the colouring matter of the blood Professor Stokes gave
RESPIRATION IN THE MUSCLES. 25

the name of cruorine, and described it in two states of oxidation
as scarlet cruorine and purple cruorine. The name hemo-
globin, given to it by Hoppe-Seyler, is generally employed.
When united with oxygen it is called oxyhemoglobin, and
‘when in the reduced state it is termed reduced hemoglobin, or
simply hemoglobin.

These important researches have given an explanation of the
function of red blood corpuscles as regards respiration. The
hemoglobin of the venous blood in the pulmonary artery
absorbs oxygen, becoming oxyhemoglobin. This is carried to
the tissues, where the oxygen is given up, the oxyhemoglobin
being reduced. Thus the colouring matter of the red blood
corpuscles is constantly engaged in conveying oxygen from the
lungs to the tissues. Probably the union of hemoglobin with
oxygen, and its separation from it, are examples of dissociation,
that is, of a chemical decomposition or synthesis, effected
entirely by physical conditions; but data regarding this
important question are still wanting. If the union of oxygen
with the colouring matter is an example of oxidation, it must
be attended with the evolution of heat.

If we then regard the blood as a respiratory medium, having
gases in solution, we have next to consider what is known of
the breathing of the tissues themselves. Spallanzani was
undoubtedly the first to observe that animals of a compara-
‘tively simple type used oxygen and gave up carbonic acid.
But he went further, and showed that various tissues and
animal fluids, such as the blood, the skin, and portions of
other organs, acted in a similar way. These observations
were made before the beginning of the present century, but
‘they appear to have attracted little or no attention until the re-
searches of George Liebig on the respiration of muscle, published
in 1850. He showed that fresh muscular tissue consumed
oxygen and gave up carbonic acid. In 1856, Matteucci made
an important advance, by observing that muscular contraction
was attended by an increased consumption of oxygen, and an
‘increased elimination of carbonic acid. Since then, Claude
Bernard and Paul Bert, more especially the latter, have made
numerous observations regarding this matter. Paul Bert
found that muscular tissue has the greatest absorptive power.
‘Thus we arrive at the grand conclusion that the living body
is an aggregate of living particles, each of which breathes in
‘the respiratory medium passing from the blood.

As the blood, containing oxygen united with the colouring
matter (hemoglobin), passes slowly through the capillaries,
-fluid matter transudes through the walls of the vessels, and
bathes the surrounding tissues. The pressure or tension of
the oxygen in this fluid being greater than the tension of the
26 PRINCIPLES OF MASSAGE.

oxygen in the tissues themselves, in consequence of the oxyger
becoming at once a part of the living protoplasmic substance,
oxygen is set free from the hemoglobin, and is appropriated.
by the living tissues, becoming part of their protoplasm.
Whilst alive, or at all events whilst actively discharging their
functions, as in the contraction of a muscle, or in those
changes we term secretion in a cell, the living protoplasm
undergoes rapid decomposition, leading to the formation of
comparatively simple substances. Amongst these is carbonic
acid. As it has been ascertained that the tension of the.
carbonic acid in the lymph is less than its tension in venous
blood, it is difficult at first sight to account for the absorption
of carbonic acid by venous blood ; but its tension is higher
than that of carbonic acid in arterial blood, and it must be
remembered that the lymph has had the opportunity, both
in the connective tissue and the lymphatic vessels, of modify-
ing its tension by close contact with arterial blood. Strassburg
fixes the tension of the carbonic acid in the tissues as equal to:
“45 mm. of mercury, while that of the venous blood is only
41mm. We may assume that as the carbonic acid is set free:
it is absorbed by the blood, uniting loosely with the carbonates
and phosphates of that fluid, thus converting it from the arterial
into the venous condition. This constitutes respiration of tissue.

Let me ask, can anything be of greater interest to the
masseur than information of this kind concerning oxidation.
and respiration of tissue? The scientific masseur feels that
in his every movement, by every exercise of well-regulated.
pressure, he is assisting to effect and to accomplish life pro-
cesses of the very highest order. :

It is important to notice the enormous absorptive surface:
for oxygen presented by the red blood corpuscles of man.
There are about 5,000,000 red corpuscles in each cubic
millimétre. Each corpuscle has a superficial area of 0-000128
square millimétres. Taking the blood in the body of a man of
average sizeat 4°5 litres, that is 4,500,000 cubic millimétres, the.
number of corpuscles is about 22,500,000,000,000, and this would
give a superficial area of 2,880,000,000 square millimétres, or
2,880 square metres, or about 3,151 square yards—that is to say,
the absorptive area of the blood corpuscles is equal to that of
a square having each side about 56 yards. The hemoglobin
in a red blood corpuscle amounts to about 12 of its weight.
The blood of a man of average size may be taken at 4,536
grammes, or about 10 lbs. Such blood contains about 13°083-
per cent. of hemoglobin, and 4,536 grammes will contain
about 593 grammes of hemoglobin, or about 13 Ib. As
regards the iron, which is supposed to be an essential con—
stituent of hemoglobin, 100 grammes of blood contain.
OXYGEN AND H/EMOGLOBIN IN BLOOD. 27

0°0546 eramme. It follows that the total amount, 4,536
grammes, contains about 2°48 grammes, or nearly 39 grains.
Twenty-five minims of the tinctura ferri perchloridi contain
about one grain of iron, so it will be seen that not many doses
are required to introduce into the body an amount of iron as
large as exists in the whole of the blood.

The question which naturally arises in my mind in consider-
ing the massage movements, in reference to tissue oxidation
is this: Do these physical actions dissociate or help to
dissociate the oxygen from the oxyhemoglobin and present
the oxygen to the tissues in a form mm which they can readily
take it up? I should say that such was unquestionably the
case. Ernst Fleisch! von Marxow believes that this work of
dissociation is naturally produced by the stroke of the heart.
The blood is kept in motion by a series of quick sudden
strokes, because for the taking up of the oxygen by the
tissues and the elimination of carbonic acid by the lungs, it
is not sufficient that the blood should run steadily through
the systemic and pulmonary circulations, and therefore a
sharp hard stroke is given to it immediately before entering
and immediately after leaving the lungs. All the blood in the.
body passes through the heart and lungs in twenty seconds ;
and Pfluger says that in this time one-third of the oxygen
is used up by the tissues.

According to the percussion theory, the stroke of the left
ventricle arterialises the blood, that is, liberates the oxygen
from the hemoglobin, and this arterialised blood is carried to
the tissues. The hemoglobin does not get sufficient time to
recombine with the oxygen, because of the successive strokes
of the heart and the vibrating thrill kept up in the arterial
ramifications. The free oxygen is used up by the tissues in
the capillary circulation to the extent of one-third. After
leaving the capillaries, the two-thirds of oxygen again recom-
bine with the hemoglobin, and in this condition return to
the heart, along with one-third of hemoglobin that has lost
its oxygen. In ordinary circumstances, this one-third would
again obtain oxygen from the alveoli of the lungs; but if all
the oxygen there has been used up, of course it cannot obtain
any oxygen. The blood flows from the lungs to the left
ventricle, when it is again arterialised, and again sent out
through the arteries; but as there is now a large amount of
free hemoglobin present in the capillary circulation, it will
seize hold of a part of the oxygen, and the tissues will obtain
less than the usual supply. With each successive circulation,
the amount of oxygen available for the tissues will become
less and less, until.the tissues receive none, because all the
oxygen set free by each beat of the left ventricle is seized hold
28 PRINCIPLES OF MASSAGE.

of in the capillary circulation by the reduced hemoglobin.
The tissues die from want of oxygen, because there is too
much reduced hemoglobin present, a substance having a
greater affinity for oxygen than the tissues possess, a result
that would probably occur, as in drowning, in the time of six
or eight complete circulations, that is, in three or four minutes.

With these observations concerning the oxidation of tissue,
I have drawn largely from the intensely interesting lecture of
Prof. McKendrick, which I consider—and many others far
more competent than myself to judge of its merits, also con-
sider—is the key note to many grand and important dis-
coveries in the physiology of life, which are at the present
time enshrouded in the realms of mystery. And I think it must
be evident, that if physiology, anatomy, and pathology are so
closely allied that they cannot be separated, we ought not to
exclude physics from consideration when we review the life
processes of living matter, and the mechanical treatment of
degenerated and dying tissue.

Other interesting points relating to the physiology of muscle
and nerve will be noticed in those chapters which are devoted
to the consideration of these structures in reference to Massage.

Some observations made by Zabludowski on the effects of
massage on healthy people, are very interesting and significant.
They were made in November, 1881, upon himself, then thirty
years of age; upon his servant, twenty years of age; and
upon his housekeeper, forty-seven years of age. All three
were living under the same conditions with regard to food,
activity, and dwelling, and for eight days prior to the massage,
examinations were carefully made of their weights, muscular
strength, temperature, pulse, respiration, and urine. Observa-
tions were made during the ten days in which they had
general massage, and also for eight days afterwards. The
muscular strength of all three increased during massage.
The weight of the one who was tolerably corpulent decreased,
as also did that of the slender housekeeper, and, corresponding
to this, there was an increased excretion of urates and phos-
phates. The weight of the one who was but moderately
nourished, increased, and with this there was found a diminu-
tion of urates and an increase of sulphates in the urine.
The massage of the abdomen excited the larger intestine to
powerful peristaltic action and caused regular evacuations.
Oft-repeated observations showed that there was an elevation of
the functions of life in general, and, with the improved frame of
mind there were also easier movements of the body. Appetite
increased and sleep was soft, gentle, and steady. The effects.
of the massage disappeared soonest from the moderately
nourished person, the servant; and they lasted during the’
RESPIRATION OF WEARIED MUSCLES. 29

whole time of observation, for eight days after the
massage, upon the housekeeper, who, though thin and slender,
had lost weight, while upon Zabludowski himself, the moder-
ately corpulent person, the after-effects varied at different.
times.

Zabludowski has also made some interesting experiments,
to learn how fatigued muscles are influenced by massage.
Muscles of uninjured frogs were exhausted by aseries of rhythmic
contractions caused by an induction current. Under massage.
they soon regained their lost vigour, so that the contractions.
were almost equal to the first, whilst a rest for the same
period, without massage, had no effect. These experiments,.
showing the restorative effects of massage upon wearied.
muscles, were more than confirmed in man by the same
investigator. He found that after severe exercise a rest of
fifteen minutes brought about no essential recovery, whilst
after massage, for the same period, the exercise was more
than doubled. One person experimented upon, lifted a weight-
of 1 kilo. (2°2 pounds) 840 times, at intervals of one second,
by extreme flexion of the elbow joint, from a table on which
the fore-arm rested horizontally, and after this he could do
no more. When the arm had been masséed for five minutes,
he lifted the weight more than 1,100 times in the same
manner as before without fatigue. The difference in muscular
sensation was very striking after rest alone from work, in
comparison with that after massage. In this case, the person.
experimented upon was an expert subject for experiment, and
after he had made 600 lifts of 2 kilos. (probably in the same:
manner as that just referred to), there was unvarying stiffness.
during a pause of five minutes for rest ; on the contrary, after
five minutes’ massage the muscles were supple and pliant.

Lastly, Schreiber sums up very practically the physiological.
effects of massage and mechano-therapy as follows; and for
that reason I give you his own words :—

‘1, To cause an increased flow of blood to muscles and soft-
parts, increasing thereby the circulation, and removing.
accumulations of waste tissue whose retention causes various-
disturbance of function.

To strengthen muscle fibres, and by setting up molecular
vibrations to induce changes, not only on the muscle and nerve:
fibres, but perhaps even in the nerve centres themselves.

2. To cause the resorption of exudations, transudations,
and infiltrations, in such organs as are accessible. To effect.
the separation of adhesions in tendon sheaths and in joints,
without recourse to the knife. To remove by grinding away,.
intra-arthritic vegetations.

3. To increase by passive and active exercise of all the
30 PRINCIPLES OF MASSAGE.

muscles, the oxidising powers of the blood, in this way correct-
ing disturbances in its composition and stimulating all the
vegetative processes.

4. To relieve the congestion. of such internal organs as the
brain, lungs, intestines, uterus, kidneys, etc., by increasing
the flow of blood to the muscles.

5. To stimulate directly the sympathetic nervous system,
thus increasing secretion and reflexly the activity of unstriped
muscle fibre, and so relieving various functional derangements. .

6. By systematic exercise (health gymnastics) to educate
morbidly affected muscles, to convert abnormal into normal
actions, and to suppress useless movements.
Lecture II.

THE MODE AND METHOD OF APPLYING MASSAGE.

Schreiber on Massage—Its use by Charcot, Billroth, Benedikt, Eulenberg
Esmarch, and others—Definition of the term Massage—Division into Effleur-
age, Petrissage, Tapotement, and Friction—Instruments for Massage—Nature
of Movements—Effleurage Mode of Application—Petrissage Mode of Applica-
tion—Fothergill on Skill—Tapotement Mode of Application—Rolling and
Hacking—The Masseuse—The Human Hand—Instructions to the Masseur in
reference to Patients, &c.—Wash for the Skin.

,

My Lecrure to-day is more interesting than my previous
one, inasmuch as it is more practical. Let us consider,
if you please, the modes of applying massage, and many
other matters in detail relative to the massage processes, the
masseur, and the patient. I have been reading with great
pleasure a yery interesting book entitled, ‘‘ Manual of Treatment
by Massage,’ by Dr. Schreiber, Proprietor and Director of
the Sanitarium ‘‘Alpenheim” in Aussee, Styria, Austria,
translated by Dr. Walter Mendelson, of New York, and I have
been much struck with the following passage: ‘‘ The time was
when reputable physicians scrupled to busy themselves with
mechanical treatment; or, if they did, hesitated to commit
to paper their ideas on the subject, or to contribute, by clinical
observations, their mite towards spreading this now no longer
new method of cure. That day happily is past, and mechano-
therapy may be said to have received its formal scientific
consecration at the hands of such men as Billroth, Benedikt,
Charcot, Eulenberg, Esmarch, Hervieux, Hiiter, Gradeingo,
Gussenbauer, Nussbaum, Pagenstecher, Piorry, Trousseau,
Winiwarter, and others, and to-day the most eminent
physicians do not for a moment hesitate personally to treat
disease by manipulations. The mechanical treatment of a
patient suffering from sciatica is certainly not more fatiguing
than operating for vesico-vaginal fistula, where the operator
is often constrained to remain from one to two hours in a
most tedious and uncomfortable position. It was formerly
customary to assert, with an affectation of superiority, that it
would hardly be possible for a regular physician to condescend to
use a meang until then only in vogue with quacks and female
‘rubbers.’ But as quacks prescribe all sorts of medicines
too, this objection can scarcely be considered a valid one.
Surely, the writing of a prescription, which is but too apt to
reveal small diagnostic acumen, and even less knowledge of
drugs, does not require more intelligence than the mechanical
treatment of sciatica, which cannot be undertaken without
32 MODE OF APPLYING MASSAGE.

a knowledge of both anatomy and physiology. Prescription-
writing often gets to be a matter of routine, requiring in time.
but little exercise of the intellect. The mechanical treatment.
of writer’s cramp, chorea, or neuralgia, on the other hand,
presents numerous and interesting modifications, all of which
have carefully to be considered, and which constantly present
new incentives to the inventive powers.”

I must say that I am quite in agreement with these remarks.
of Dr. Schreiber. I define the term massage to mean, “ The.
application of sentient living matter to sentient living matter
in multifarious ways.” The terms such as Effleurage,
Petrissage, Tapotement, and Friction (I do not know who
invented these terms), are very useful as a basis or. foundation
for certain well-defined manipulations, and I shall therefore
use them in describing the modes of applying massage; and.
I must repeat that massage, in my practice, is conducted by
the hand, and by the hand only. 1 now show you these three
instruments which have been invented to supersede the human
hand, and nothing could be more ridiculous or contemptible =
First, we have this thing which is called Klemm’s muscle beater ;
secondly, this represents, as you see, an auctioneer’s hammer ;
and third, this instrument is supposed to adapt itself to
roll the muscles. These instruments can be obtained of any of
the instrument makers, but do not use them, I beg of you. If
massage is to be performed in this rough, coarse way, then there
is an end of the whole business so far as I am concerned.

Let me impress upon you one of many very important
points which experience has taught me: namely, to manipulate
quietly, calmly, gently, and purposively.. Never allow your
movements to be performed in a hurried, indifferent kind of
way. Iam quite sure that the best effects are brought about by
almost painless manipulations, and the most troublesome con-
sequences not infrequently result from rough, jumping, jerky,
unmethodical work. You will see directly how my manipula-
tions are performed, and I shall again refer to this matter.

ErrLevrace.—This term is applied to all stroking forms of
movement, light movements, free from pressure, whenever sur-
face is brought into contact with surface. If pressure be
exercised, we then travel over the border line of effleurage and.
enter that of petrissage ; but effleurage and petrissage movements
frequently run one into the other, according as they are
performed with more or less pressure. These stroking move-
ments may be carried on with the tip of one finger, or with
the tips of all the fingers in the followimg manner: With the
tips of the thumbs, so (Fig. 19, p. 66); with the backs of
the hands, or sides of the hands, or with the palms of the
hands (Fig. 17, p. 64); also with light rolling to and fro,
PETRISSAGE. 33

friction movements (Fig. 9) ; and in working lightly over the
fore part of the leg (Fig. 31); light, very slightly percussive
movements with the tips of the fingers running over a part as
in playing a piano, and titillating the part. All such are
decidedly effleurage movements, and I advise you in operating
upon any part of the body to commence with these in order
to excite the superficial reflexes. We consider that effleurage
manipulations are particularly applicable to the head, neck,
and upper extremities. The physiological effects of effleurage
are indirect, and for the most part reflex.

Effleurage movements, then, if you please, are of the most
superficial, light, frictional character. You will often find it
necessary ln commencing or prior to massaging a part, to
raise the temperature by some means; therefore, if it is
necessary, you must effleurage with considerable quickness
and velocity, so increasing the heat of the surface by friction,
and stimulating the cutaneous circulation, and the peripheral
nerves. Again, I frequently run over a part, say the fore arm,
with my finger andthumb, so; it does not amount to pinching,
yet it is very near it, but the effect upon the patient is
pleasant and stimulating.

PerrissacE—Is a very useful word. It means pinchmg,
kneading, and working into the deep structures, by bringing or
rather massing them together. I used at one time to think of
this as by far the most important of all the manipulations, yet
every manipulation has its special work and special value.
I bring my finger and thumb together, so; please to follow my
movements, roll your own fingers and thumbs in the manner
I show you. Now do it lightly, and now exercise pressure.
Take a piece of your own skin and pinch it, just so; you now
experience what the effect of such operation would be upon your
patient. Remember what I told youin my first lecture, do not
pinch too hard or you will destroy the vitality of the part which
you are manipulating. Although the great object of massage
is to bring all parts together by direct pressure, still the
pressure must be diffusively, not absolutely direct, in other
words, the petrissage movement should be rolling in its nature,
slow, and purposive in its action. It is usual, and the practice
is a good one, to work from the extremity towards the centre
of the circulation, in the course of the venous blood and
lymph flow; but in the chest and back we take the course of
the muscles and the ribs. For instance, in massaging this
chest, you see I work from the sternum, from the origin of
the great pectoral muscle towards its insertion ; when I come
to demonstrate upon the back and spine, you will see that my
movements are in the direction of the spinalis and longissimus
dorsi muscles ; but in the extremities you will observe that the

3
34 MODE OF APPLYING MASSAGE.

movements are from insertion to the origin of the muscle.
No little fuss has been made by some authors upon the value
of what is called working up-stairs. I am not quite sure what
this means, but if one is to understand by it that one hand
is to precede the other, as one foot precedes the other in going
up-stairs, then I am quite sure that my own mode of operating
is far superior. I now show you what I mean: you can
operate on yourselves, judge for yourselves, and note the
effects and the perfection of petrissage movements. Take an
extremity for instance. You see you can throw the entire hand
into the parts upon which you are operating, so that for the
moment they are welded together. Do not work with your
thumbs transversely, place them vertically upon the limb
after this manner (Zig. 7), and throw the wrist as well as the
ball of the thumb into the work. Always remember to work
fingers and thumbs, “thumb hand ” and wrist hand, thoroughly
and completely, all together, before abandoning the clutch.
Never remove your hand entirely, but work on with your
hands in contact with the limbs just as I now show you; by so
doing the pressure is equalized—and allow me to tell you this.
is of great important in petrissage movements. Let me show
you how some masseurs petrissage. Their hands jump about
in this manner, sometimes up, sometimes down ; in fact, they
are all over the body before you can say Jack Robinson, and
they think they have done marvellously well because they
are breathless, and either as red as a lobster, or pale as death.

But I have referred to this sort of thing before, andI attach
so much importance to it that I shall possibly speak of it
again and again. Some masseurs draw attention to a
squeezing form of petrissage, but after all it is nothing
more than pinching. If I take the muscles of the ball of this.
thumb thus, between my own thumb and fingers (Fig. 4),
squeezing and rolling them about in this way, I certainly
exercise the parts in a very notable and healthful manner ;
but squeezing and pinching are more or less synonymous
terms, and it is just as well to introduce as few terms as.
possible, for a multiplicity of them is quite unnecessary.
In all petrissage movements, no matter whether they are
performed by the finger and thumb, or by the fingers and thumb,
or by the entire hand, one part is usually a fixed point; for
instance, in working rapidly in this way, you see my thumb.
is the fixed point, and I draw my fingers to my thumb; on
the other hand, you see my fingers are fixed points, and I
draw my thumb towards them. In working with the entire
hand, thus, you see the wrist part of my hand is the fixed
point, towards which the palm of my hand and the phalanges. ~
exert their pressure. Now, please observe my manipulations ”’

 

 
TAPOTEMENT. 35

and you will see exactly what I mean. It will take you some
time to perform manipulations, even of the most simple kind,
with dexterity. You must take every possible opportunity to
practise every kind of movement. It is not so easy to acquire
skill as you might suppose. There are some people born
with capacity to effect certain things by mere intuition; but
genius is not common to all, therefore you must again let me
remind you that you can gain by acquirement, by determina-
tion, and devotion to your work, that skill which leads to
accomplishment and perfection. Persevere then, and you will
succeed. Let me also tell you another thing: when you are
once perfect in massage manipulations, you will have to be
constantly practising if you wish to remain so. It is the
same with all handicraft workers. The skilled surgeon,
pianist, oarsman, billiard player, and so on, will all tell you
how essential practice is to them if they wish to keep in the
front rank.

The late Dr. Fothergill’s words in reference to this matter are
ofthe highest possible value. He says, “‘ The knowledge which
one man acquires by the sweat of his brow after years of patient
toil and painstaking cannot be transferred in its entirety to
another. Individual acquired skill cannot be passed from
brain to brain any more than the juggler, who can keep six
balls in the air, can endow an onlooker with like capacity by
merely showing him how it is done. The muscles, and still
more their representatives in the motor area of the brain
hemisphere, require a long training before this manual skill
can be acquired.’’ I must also remark here that it is next to
impossible to explain to you every form of massage manipula-
tion. You must in a measure think for yourselves ; you must
bring your judgment and your reason to bear upon every
movement, and you will find how necessary it is for you to gauge
your patient’s resisting power. But these are points to which
I shall again refer. I advise you most seriously to practise
upon each other, and do not treat this piece of counsel as a
mere joke, for it is of the greatest importance. You can never
do what is necessary unto others unless you know by experience
what others are capable of doing unto you. I will now draw
your attention to ‘:

Tarotement.—All the movements included under this term
are tapping, vibratory, percussive, succussive, and concussive in
their nature. The proximate effect produced by tapotement is
very different to that produced by petrissage, and these move-
ments are specially applicable to certain parts of the body to
bring about definiteresults where the petrissage movements would
be of little or no avail. I shall show you that petrissage is
particularly useful in massing muscle together in the legs,
36 MODE OF APPLYING MASSAGE.

thighs, and buttocks. On the other hand, tapotement move-
ments are applied particularly to the back, chest, and abdomen
and the trunk of the body. It is shéer nonsense to say you
can squeeze the liver, and empty it of its contents in the
same way that you would squeezea sponge. I will defy any one
to do anything of the sort. You can, as I shall show you in
a future lecture, stimulate this organ into activity by percussion
and succussion.

Then, please understand, the mechanical effect of tapoting
is chiefly to bring about vibration. Of course this is all a
question of degree; Dr. Granville’s perceutor is merely a mode
of tapotement, so is the dentist’s apparatus when the instrument
he is using to stop your tooth is worked by the electro-motor,
and so is the current from this Faradic battery, it certainly
stimulates the parts into states of kinetic or active energy,
more than any other form of massage with which we are
acquainted.

‘The simplest form of tapotement is tapping, which I
exemplify to you in this way, by playing with my fingers over
this patient’s forehead. Now, let me show you one form of
hand for tapotement. Close your hands partially, so, by bring-
ing your two first fingers to rest upon the ball of your thumb.
Do not make a fist of your hand. You will observe that your
hand now forms a cavity. Apply it to the flat palm of your
other hand, and note the effect in sound and feeling. Now,
make a fist of your hand and apply it to the other hand as
before, and note carefully the difference. Again. Make a
saucer of your hand by bringing your fingers close together,
and causing your hand and your fingers together to become con-
cave. ‘These are the two common forms of hand for tapotement.

But the most active is the flagellating hand. Observe my
hand, if you please, see how it drops and swings from the
wrist : work it rapidly in the way I show you. Now, note
the effect upon this back;, remember I have merely brought
the tips of my fingers into contact with the surface ; just see
how it has stimulated the circulation. Now, if you please,
use the dorsal aspect of your fingers in this manner ; let them
fall upon your patient. Now, try the hacking hand, and tapote
rapidly, so, with the ulnar side, that is, by the medium of
your little and ring fingers. (Fig. 10, 30.) These, then,
are different modes of bringing about percussion, and they
are all included under the head of tapotement.

I advise you, when operating in this way, to keep your
arms close to your side and work almost entirely with the
forearms. By this means you can graduate your movements
with greater nicety and delicacy. Your movements must be
rapid. Do not raise the hands more than half an inch from

 
MODE OF APPLYING MASSAGE. 37

the surface of the body, and see you travel over every bit
of ground carefully. With practice you will find that you
can graduate your movements so that they are scarcely per-
ceptible to the patient ; on the contrary, you can, of course,
use much more force than your patient can bear. I shall
speak to you again of these and other forms of massage,
when I call your attention to local massage in subsequent
lectures.

Now, my patient, Mrs. G., will thoroughly bare her right
arm, and I will demonstrate to you by successive stages the
various modes of applying massage to it. You will see that
my first object is to ascertain the exact condition of the limb ;
whether there is anything abnormal about it, either with
regard to the nails or the jomts; whether its general develop-
ment is good or indifferent ; whether the skin is harsh or soft,
dry or moist; whether it sets firmly upon the muscles; or
whether it is relaxed and easily drawn out. I then, you see,
examine the muscles somewhat carefully and mark their
outline, their firmness or their flabbiness, their power of
contraction against resistance, the grip of the hand, the
temperature of the hands and fingers, and the moisture or
dryness of the hand and the conformation of the nails. All
these are points of practical value which will come before us
again. I will ask Miss §. to make careful notes of this
examination, so that after the patient has undergone a course
of treatment, the two conditions can be compared together. I
now take the limb and make a few friction movements over
its general surface, so, and commence my manipulations after
this fashion: I grip the hand and the phalanges firmly with
my own left hand (Fig. 1), and with my right hand I extend
and flex every phalangeal joint.

   

\

Fig. 1illustrates the first position for manipulating the finger
joints of the upper extremity.
Having done this, I flex and extend thoroughly, some half dozen
or even more times, the metacarpo-phalangeal joints (Fig. 2.)
38 MODE OF APPLYING MASSAGE.

After this the intrinsic phalangeal muscles are rolled and
pinched between the finger and thumb. Observe, if you
please, that my finger and thumb roll the tissues. This means
that the tissues move in unison with the pressure applied. I
then work well in between the metacarpal bones.

  

Fg. 2 illustrates passive gymnastics of the metacarpo-phalangeal joints.

I next deposit the dorsal surface of my patient’s hand in
the palm of my left hand, and place the palm of my right
hand upon that of my patient, and exercise both by percussion
and friction several brisk movements. (Fig. 3.)

 

Fig, 3 illustrates the method for working into the palm of the hand.
MODE OF APPLYING MASSAGE. 39

‘Now I petrissage deeply into the muscles of the palm, pinch-
ing particularly the muscles of the ball of the thumb (Fig. 4.)
and with afew general and rolling movements the operations
upon the hand are completed.

I now direct my attention to the wrist joint. By flexion
and extension as well as lateral movements, I ensure the
perfect freedom of this joint. (Fig. 5.). Let me tell you that
I work up the limb by stages from joint to joint, that is, from
the wrist to the elbow and from the elbow to the shoulder.
I may say that thorough manipulation of the joints, whether
they require it or not, is one of the essential features of my
system; for I hold that so long as a joint remains badly
nourished, so long will it be impossible for the nutrition of
the limb to be improved.

But this is a matter which I shall bring more thoroughly
before you when we have joints especially under our considera-
tion. If you will observe my manipulations, you will now
see that I petrissage deeply all the ligaments and tendons
and other structures in connection and in association with the
wrist joint. (Fig. 6.)

I now commence to operate upon the forearm from the
wrist to the elbow, by making several effleurage and friction
movements with the palms of my hands, and titillating move-
ments upon the skin with my fingers and thumbs, producing
increased vitality of the surface. JI now come to proper
petrissage movements, which are of two kinds: superficial
and deep. These movements must be of a centripetal
character, in the direction of the flow of the lymph and
venous blood. /

The superficial petrissage movements are best performed
by the first and second fingers, with the thumb and with the
ball of the thumb.

In these manipulations, which act upon the skin and the
underlying fat and cellular tissue, the parts are not only
pressed upon and rolled, but they are at the same time
strained and stretched laterally. You will now see how my
deep petrissage movements are performed, and you will readily
understand, if you watch my hands, how they mould them-
selves to the tissues upon which I am operating. Observe, I
flex my patient’s forearm slightly so as to relax the muscles,
and by this means I am able to mass them together.

I wish to draw your attention here to a point of some
importance relative to this procedure. You see I not only
work with my hands and fingers at the same time, but I throw
the carpo-metacarpal parts of my hands and the balls of my
thumbs well into the tissues, in order that I may effect greater
and more uniform pressure. (Jig. 7.)
MODE OF APPLYING MASSAGE.

40

 

Fig. 4 shows a common mode of petrissaging the muscles of the ball of

the thumb.

1 : \ . =
Li Mbinyyy) 7)

 

Wa

A,

 

lini ide

Sa
ny

thie, oF oo ;
i @ Y i i

| Nn
.- i :
Fig. 5. Passive gymnastics of wrist joints,
the wrist is flexed and extended soms twenty or more times.

o

oe

1)

The arm is held firmly whils
MODE OF APPLYING MASSAGE. 41

 

Fig. 6 shows the way the wrist joint is massaged, fingers and thumbs.
working simultaneously.

 

Fig. 7 indicates fairly well deep petrissage of the forearm. The thumbs:
are placed upon the limb vertically, so as to throw the heel of the operator’s
hand into the process Era intl
A2 MODE OF APPLYING MASSAGE.

I now roll the forearm between my hands, and use slight
tapotement and flagellation. The next step you see is to
perform passive extension and flexion of the elbow joint. I
grasp the back of the arm firmly with my left hand, fixing,
in fact, this arm, and so moving the forearm upon the arm.
(Fig. 8.)

 

Fig. 8. Passive gymnastics of the elbow joint,

After flexion and extension have been performed some six
times, I make myself sure that the radio-ulnar joint is free,
by taking the hand of my patient and fixing at the same
time my thumb upon this joint. I then pronate and supinate
the forearm. Then my next procedure is to work well into the
elbow joint in this manner, having, as you see, the joint flexed.
The movements now to be made upon the arm are precisely
simular to those which I have just gone through upon the
forearm; and I finally, if necessary, use rolling and ulnar
tapotement. (Figs. 9, 10.)

 

Fig. 9. Light friction rolling; effleurage movements of skin; deed
petrissage movements can be effected by exerting increased pressure,
MODE OF APPLYING MASSAGE. 13

 

Fig. 10 shows position of the hands for light ulnar tapotement. This form
of tapotement is usually applied to the abdominal muscles.

 

Fig. 11 shows position for manipulating the shoulder joint ; the operator
fixing firmly the clavicle and scapula with one hand, whilst the movements
-of the joint are effected by the other hand.

The last joint +o which I have to call your attention, as
far as the upper extremity is concerned, is the shoulder joint.
44 MODE OF APPLYING MASSAGE.

We shall find that adhesions of a rheumatic character: are
here exceedingly common. :

In order to bring about the different movements of this
joint, it is customary for the operator to place himself behind
the patient and fix the scapula by pressing firmly upon it
and the clavicle. (Fig. 11.)

You must not fail to observe how necessary it is to fix the
scapula, if you wish to make yourself quite sure of the
limitation of movement in the shoulder joint.

I will now, if you please, direct your attention to the lower
limb, but do not commence to massage any other part than the
arm until you have made yourself quite familiar with the
different modes of manipulation. If your patient is not in
bed, you can be seated in a chair, in this manner, with the leg
of your patient resting upon your thigh; (Fig. 12.) but you
will have to be constantly varying your position according
to the part of the leg and foot upon which you are operating.

 

Fig, 12 shows merely the common way of commencing work the:
ankle joint for flexion and extension, pene ae

The movements required for the leg are essentially of the
MODE OF APPLYING MASSAGE. 45

same character as those for the arm; every toe and every toe
joint must be flexed and extended after the manner adopted
for the fingers. Then the muscular and bone interspaces are
petrissaged. (Fig. 18.)

 

Fig. 13 indicates position for petrissaging the foot and working at the same
time with the fingers into the malleoli.

 

 

 

 

Fig. 14 shows position for ordinary knee and hip movements (passive
gymuastics.)

If you follow my movements you will see how admirably
the balls of the thumbs are adapted for working around the
46 MODE OF APPLYING MASSAGE.

malleoli of the ankle joint, and these movements must be
followed by pressing and friction movements into and upon
the plantar structures of the foot. The tendo Achillis must
receive more than an ordinary share of attention, and the
ankle joint be flexed and extended, and the foot inverted and
everted. After this you see, I work at the leg in precisely the
same way that I operated upon the forearm. Another ex-
cellent way to work into the muscles of the calf is to flex the.
leg after this fashion with the patient lyingdown. You can see
now how thoroughly I get hold of every bit of muscular tissue,
working of course from the heel upwards to the popliteal space,

The knee is now thoroughly flexed and extended after the
manner I here show you (Fig. 14.), and the thigh massaged by
deep petrissage movements. The fat and muscles of the thigh
frequently form a thick fleshy mass, so that tapotement in
addition to petrissage movements is required.

You will observe exactly how I hold this leg to put the gluteal
muscles and the sciatic nerve upon the stretch in severe cases
of sciatica (Fig. 15). The thigh is forced over the abdomen to
the opposite side of the body, and kept in this strained posture
for one or two mintues. It is then extended and slightly
abducted also with some force. When I lecture to you upon
joints I shall refer to all these matters in detail.

 

 

 

=

Fig. 15 shows position of extending and stretching sciatic nerve by flexing’
the thigh well upon and over the abdomen, :
THE MASSEUSE. 47

I must now call your attention to some points of interest
and importance relative to the masseuse, time of operating,
length of operation, &c. With reference to the individuality of
the masseur and the masseuse, I must say that some individuals
are utterly unfitted for the office by nature, by education, by
general development and by disposition. Ihave no wish, in fact.
I will not try to lay down a hard and fast line concerning
physical development to the entire exclusion of a large number
of persons who fail to come up to the exact standard, for it.
must be remembered that our patients to be massaged are not.
all of the same type, either mentally, morally or physically.
Young children for instance do not require the same standard of
masseuse that would be required for a fully developed adult.

The standard of individuality for the masseur or masseuse
may be thus defined :

1.—Good physique and good health absolutely essential.

2.—Cleanliness in every particular is of the greatest im-
portance.

3.—An intelligent interest in the patient’s welfare.

4.—Perfect devotion and zeal in carrying out fully and
carefully the duties of the work to the minutest detail, so as to
ensure the confidence of the patient.

5.—Good temper and forbearance are necessary.

6.—Absence of fuss and undue haste.

7.—Intelligence and even refinement are advantageous.

8.—A happy cheerful disposition with vivacity and dexterity,
readiness and ability, not forgetting a pleasant contented face,
complete the standard of individuality.

Let me now draw your attention to the human hand. You
cannot massage unless you are clever with your hands. Of
course, massage is made up of manipulations, therefore you
certainly should know something about the hand. I assure
you, if you do not already know it, that the hand is a study of
the highest physiological, anatomical and pathological signifi-
cance. I was much interested in reading The Bridgewater
Treatises, ‘‘On the Power, Wisdom and Goodness of God as
Manifested in the Creation,” vol. 10. ‘‘ The Hand; Its Mechan-
ism and Vital Endowments as Evincing Design,”’ by Sir Charles
Bell. This learned and gifted surgeon says: ‘‘ The human hand
is so beautifully formed, it has so fine a sensibility, that sensi-
bility governs its motions so constantly, every effort of the will
is answered so instantly, as if the hand itself were the seat of
that will; its actions are so powerful, so free, and yet so
delicate, that it seems to possess a quality instinct in itself,
and there is no thought of its complexity as an instrument, or
of the relations which make it subservient to the mind; we
use it, as we draw our breath, unconsciously, and have lost all
48 MODE OF APPLYING MASSAGE.

recollection of the feeble and ill directed efforts of its first
exercise, by which it has been perfected. _We ought to define
the hand as belonging exclusively to man, corresponding in
sensibility and motion, with that ingenuity which converts the
being who is the weakest in natural defence to the ruler over
animate and inanimate nature.”

You will remember how frequently I endeavour to impress
upon you the value of the thumb in manipulations.

Sir C. Bell, in speaking of the thumb, says, ‘‘ On the length,
strength, free lateral motion and perfect mobility of the thumb,
depends the power of the human hand.” The thumb is called
pollex because of its strength ; and that strength is necessary
to the power of the hand, being equal to that of all the
fingers. Without the fleshy ball of the thumb the power of
the fingers would avail nothing; and accordingly, the large
ball formed by the muscles of the thumb, is the distinguish-
ing characteristic of the human hand, and especially of .that
of an expert workman.* The loss of the thumb almost
amounts to the loss of the hand, and were it to happen in
both hands it would reduce a man to a miserable dependence;
or, as Adoni-bezek said of the threescore and ten kings; the
thumbs of whose. hands and of whose feet he had cut off,
“They gather their meat under my table.’’ The motions of
the fingers do not result merely from the action of the large
muscles which lie on the forearm, these are for the more
powerful efforts; but on the palm of the hand, and between
the metacarpal bones, there are small muscles (lumbricales
and interossei), which perform the finer motions—expanding
the fingers, and moving them in every direction with quickness
and delicacy. The combined strength of all the muscles in
grasping must be very great. Indeed, the power is exhibited
when we see the sailor hanging by a rope and raising his
whole body with one arm. ‘What then must be the pressure
upon the hand. The elastic pad in the foot of the horse and
camel is not a whit more appropriate than the fine elastic
texture of the hand! To add to this purely passive defence
there is a muscle which runs across the palm, and more
especially supports the cushion on the inner or ulnar edge.
It acts powerfully as we grasp; and it is this muscle which,
raising the edge of the palm, hollows it and adapts it to hold
water, forming the cup of Diogenes.

Whilst the cushions on the ends of the fingers defend them
in the powerful actions of the hand, they are also useful in
subservience to the nerves of touch, conferring a power of
receiving impressions which the utmost delicacy of the nerves

* Albinus characterizes the thumb as the lesser hand, the assistant of the
greater—manus parva. majort adjutrix.
THE HUMAN HAND. a 49.

themselves could not bestow. We must not omit to speak of
the hand as an instrument: of expression. Formal disserta-
tions have been written on this; but were we constrained to
seek authorities, we might take the great painters in evidence,
since by the position of the hands, in conformity with the figure,
they have expressed every sentiment. Who, for example, can
deny the eloquence of the hands inthe Magdalens of Guido; their
expression in the cartoons of Raphael; or in the Last Supper,
by Leonardo da Vinci? We see there all that Quintillian says
the hand is capable of expressing. ‘‘ For other parts of the
body”, says he, ‘‘ assist the speaker; but these, I may say,
speak themselves. By them we ask, we promise, we invoke,
we dismiss, we threaten, we intreat, we deprecate, we express
fear, joy, grief, our doubts, our assent, our penitence, we show
moderation, profession, we mark number and time.” The
natural position of the hand is certainly indicative, in a
measure, of the character of the individual. For instance,
the hand of the Venus de Medici is what may be termed the
nervous, sensitive hand; there is the slightly drooping wrist,
the extension of the metacarpo-phalangeal joints, slight
bending of the fingers with the thumb drawn backwards ;
whilst in the Diana of the British Museum, which is the
typification of a strong woman, the hand is free, the wrist
extended, and the fingers and thumb flexed. This condition
of hand is usually considered to be indicative of will, deter-
mination, energy, and power; and it is well known that
persons in whom the thumb is largely developed have energy,
will, and individuality.

These are passing points of interest and are worth remem-
bering.

The perfect hand for massage work should be soft, smooth,
dry, and fleshy, and of good normal, healthy temperature.

The square hand, with powerful thumb adductors, is usually
found most useful; but the following conditions in the nature
of the hand are of unquestionable value, namely: good
muscular power, suppleness, pliability, flexibility, firmness of
grip, and compliancy to yield readily, impressibility, smooth-
ness, fineness, warmth, even delicacy. A damp, cold, clammy
hand is totally unfit for massage manipulations.

You will find that every part of the hand must be made avatl-
able, and there is no position which the hands and fingers can
assume which cannot be adapted to some form of massage.

Whilst considering the masseur, I am anxious to draw your
attention to several points of importance. The first is, that
you keep yourselves in good health, take three good meals a
day, but never take stimulants until your work is over ; then,
provided you are in active work, you will find a pee of
50 MODE OF APPLYING MASSAGE.

stout and a good night’s rest restore your energy, and equip
you for the following day’s work. Avoid working on Sundays,
if you possibly can ; and on this day get fresh air and natural
exercise. Now, please to clearly understand me upon this
point. If you are in active work, you will have to conserve
your energy in every way possible. You cannot, for instance,
walk a mile, even to your patient ; for should you get to your
work flushed, hot, and wearied, you are doing yourself and
your patient an injustice.

And now we will consider our patient from several points
of view. The room should be of comfortable temperature,
say from 62° to 65° F. The couch or bed upon which the
patient is placed should not be too soft or yielding. As little
as possible of the body of the patient should be exposed
at one time. In general massage one hour should lapse
after a meal before the process is commenced, and the process
should extend from thirty to forty minutes, twice a day,
between 11 and 12 in the morning, and 5 and 6 in the
evening ; or between 12 and 1 mid-day, and 8 and 9 at night,

During the séance, I strongly advise you not to talk to your
patient or allow your patient to talk to you. ‘This, which is a
very common practice, mars the good effects of the operation.
No operator can manipulate well and thoroughly, and be
trying at the same time to amuse his patient, of this I am
quite certain. Not only does the masseur or masseuse become
exhausted, but the patient, instead of feeling refreshed by the
manipulations, becomes exhausted also. I know it is a difficult
matter to decline answering the ridiculous questions which
patients will sometimes put to you: relative to how long you
have been at the work, whether you have any very interesting
cases on hand, how many patients you have cured, and so on.
All you have to do, is to tell your patient to be quiet until
the operation is over, or until you have finished the part upon
which you are working. I have heard that the success of
some operators depends more upon the way they use their
conversational powers than the way they manipulate. I do
not believe that success of this kind can be lasting. Then, if
you please, always enjoin silence during the time that you are
manipulating. “Do not talk to your patient, and do not allow
your patient to talk to you.

After the operation is over, it is imperative that the patient
should be made thoroughly warm, and be kept at rest for half
an hour. I want you particularly to remember this question
of warmth after every form of massage, whether local or
general. ‘‘ Always endeavour to maintain the heat which your
energy has generated and created.”’ When it is necessary for
you to perform petrissage, and pinch and knead: the deeper «
INSTRUCTIONS TO THE MASSEUR. 51

‘muscles, where you want to exercise energy and pressure, the

‘skin can be advantageously washed with a spirit and ammonia

lotion. What I commonly use has the following composition,

namely : .

Liq. Ammon. fort. 3ss. | Aquee Aurant. flor. 3j.

Spirit Vini Rect. ad 3viij.

Vaseline and other tar compounds are highly objectionable,

and so are preparations bearing the name of electron.

 
Lecture III.

MASSAGE OF THE HEAD AND NECK, AND THE
PARTS IN ASSOCIATION THEREWITH.

This Lecture treats of the Fifth and other Cranial Nerves—The Sympa-
thetic Ganglia of the Neck—Headache—Megrim—Tic Douloureux—Goitre—
Throat Deainess—Meniére’s Disease—Singing noises in the Head and
Ears, &c.

Berore I attempt to demonstrate to you the manipula-
tions which are common to the head and neck, I must
call. your attention, as I have done before, to the fifth
nerve and its connection with the cervical ganglia of the sym-
pathetic. I donot expect you to remember the anatomy of the
nerve in detail, but perhaps you will follow me attentively
whilst I point out to you the ganglionic connections and a few
other points of importance. Let me tell you at once that
massage of the head and neck is one of the most, if not the
most, valuable therapeutic agent which we have at our com-
mand for the curative treatment of headaches, inveterate
neuralgias, giddiness, singing noises in the ears, Meniére’s
disease, throat deafness and goitre, and I would have you
observe that the continuous galvanic current is unquestionably
of great value when used with it or in addition to it. I shall
bring forward several cases in proof of my assertion, and you
can also see many cases which are now under treatment.

The fifth nerve gives sensation to the entire skin of the head
and face (except in the occipital region and the back and lower
part of the ear, which are supplied by branches of the cervical
plexus and great occipital nerve) and the mucous membrane
of the mouth, with the exception of the posterior pillars of the
fauces and the posterior third of the tongue, which derive
their sensation by means of the glosso-pharyngeal nerves.

In this diagrammatic representation which I now show you
is seen the outlines of the various regions represented as
supplied by the different sensory nerves on the head (fig. 16).

When you have made yourselves acquainted with these
nerves and their anatomical distribution you can then use
these sensory areas as guides to diagnosis, showing which
branch of the nerve is particularly involved, say, for
instance, in diseases like brow ague, auriculo-temporal
neuralgia, infra-orbital neuralgia, toothache, and so on. You
must clearly understand that it is to these different sensory
areas that you will have to direct your attention in performing
the different massage movements of the head, and it is well
THE FIFTH NERVE. 53

that you should know when manipulating what special branches
of the fifth nerve you are operating upon.

 

Fig, 16, Distribution of the Sensory Nerves on the Head.

SO, Area of distribution of the supra-orbital nerve. ST, Supra-trochlear.
IT, Infra-trochlear. I, Lachrymal. N, Ethmoidal. JO, Infra-orbital. B,
Buccinator. SM, Subcutaneous mala. AT, Auriculo-temporal. AM, Great
auricular. OMj, Great occipital. OMi, Lesser occipital. CW, Region of
the central convolutions of the brain, SC, Region of the speech centre
(third left frontal convolution).

I must have you remember for subsequent reference that the
third division of the fifth nerve resembles a spinal nerve in
having both motor and sensory fibres; that the first and
second divisions of this nerve are purely sensory; that the
sensory root of the nerve receives fibres from the grey matter
of the spinal cord as far downwards as the middle of the
cervical region; that the origins of the sensory root anas-
tomose with the motor nuclei of all the nerves arising from the
medulla oblongata with the exception of the abducens. This
fact explains the vast number of reflex relations of the fifth
nerve.

I will now show you the different branches of this nerve,
which are easily seen upon this large diagram which I have
drawn from Landois and Stirling; and if you look at this
skull you can see the point of exit of each division, namely,
the supra-orbital, the infra-orbital, and the mental, dividing
into branches to supply the different sensory areas to which I
have just drawn your attention.
54 MASSAGH OF THE HEAD AND NECK.

I want to interest you a little more deeply in the connections
of this very complex nerve. Let me explain to you the five
ganglionic enlargements, or rather four, because we can ex-
clude the great ganglion of Gasser.

The first ganglion is situated within the orbit, and is called
“ophthalmic,” “lenticular,” or “ciliary.” It gives off the
ciliary nerves to the iris, and the muscle of accommodation of
vision.

The second is called ‘‘ Meckel’s Ganglion,” or ‘“ spheno-
palatine,” and sends branches to the orbit, nose, and soft
palate. It lies in close relation with the superior maxillary
nerve.

The third is called the “ otic ganglion,” and lies upon the
inferior maxillary nerve below the foramen ovale, and sends.
branches to the two tensor muscles, namely, the tensor palati
and the tensor tympani, and is thus physiologically associated
with the acts of hearing and deglutition.

The fourth is called the submaxillary, since it lies above the
‘submaxillary gland.

I do not wish to ‘enter into any detail of the many connec-
tions of these ganglia, but unless you have some general idea
of them you can _ scarcely comprehend how by massaging the
head, and so influencing the sensory peripheral fibres of the
fifth nerve, you are really inducing changes which we believe
are of a nutritional nature in the ganglia themselves and their
various relations. You will see, I hope, that some knowledge
of this kind, no matter how superficial it may be, presents
advantages of considerable importance.

The sensory root of each of the four ganglia is derived from
this fifth nerve, the motor root is derived in three cases out of
four from the seventh cranial nerve, and finally, the sympa-
thetic branch comes from a plexus upon some neighbourmg
blood vessel.

Tam not going to weary you with any further observations
concerning the anatomy of the fifth nerve, but I cannot leave
the subject without drawing your attention to the cervical
ganglia of the sympathetic in the neck, and particularly to the
superior cervical ganglia.

Here you see it is well shown, and observe that it is in
direct connection with the four upper cervical nerves. The
internal carotid artery is seen here. Please note how the
branches from this superior sympathetic cervical ganglion
traverse the surface of this vessel and send connections to
the different ganglia to which I have just drawn your attention.
’ If we stimulate by massage or galvanism the peripheral ends
of the cervical sympathetic we produce a marked effect upon
the blood vessels going to the brain, and either diminish or
VASO-MOTOR NERVES. 55

Increase the calibre, bringing about at the same time dilata-
tion of the pupil.

Remember also that the same effects are induced by massée-
ing the spine between the shoulders as low down as the second
dorsal vertebra, where exists the centrum cilio-spinale in-
ferioris. The connection between this centre and the sympa-
thetic takes place, as Budge and Claude Bernard have shown,
through the communicating branches of the anterior roots of
the spinal nerves; the four upper cervical roots of which are
connected directly with the superior cervical ganglia, as I have
just shown you.

Voisin has stated that besides the connection by means of
these communicating branches, still another exists, certain
filaments of the emerging spinal nerves surround the vertebral
artery, anastomose with the carotid plexus in the cranium,
and so reach the sympathetic root of the ciliary ganglion.
But this is denied and disproved by the experiments of
Eulenburg and Guttman, who state that Voisin’s assertion
can raise no claim to their consideration, especially as it is
quite unsupported by descriptive anatomy.

** According to Claude Bernard the vaso-motor nerves of
the head which influence vascular-thermic effects have their
origin in the spinal cord, but not from the same spot as the
oculo-pupillary branches. Section of the anterior roots of the
two first dorsal nerves gives rise to contraction of the pupil
with flattening of the cornea, narrowing of the palpebral
fissure, retraction of the globe, but no dilatation of the vessels
of the head, and no elevation of the temperature of the head.
Division of the ascending filaments of the thoracic sympathetic
between the second and fourth ribs, on the other hand, produces
only dilatation of the vessels and elevation of the temperature
of the same side, whilst the oculo-pupillary phenomena do not
appear. Bernard, therefore, came to the conclusion that the
centre for the oculo-pupillary and the vascular-thermic filaments
of the cervical sympathetic are at different points in the spinal
cord, and that the latter branches issue from it at the level of
the third and fourth dorsal nerves by means of the communi-
cating branches. Although recent investigations have placed
it beyond doubt that the vaso-motor centrum for most parts
(including the head) is in the medulla oblongata, nevertheless
there may be ganglionic centres for vessel contraction placed in
the periphery, in the walls of the vessels themselves, or in
their immediate neighbourhood.” :

I have called your attention to this point for this and for
other reasons to show you that by massaging and galvanising
the spine you are exerting an influence upon heat and vascular
centres concerned in.the nutrition of parts distant from. the
56 MASSAGE OF THE HEAD AND NECK.

spinal cord itself. Do not forget, if you please, that this lecture
treats of massage of the head, face, eyes, ears, neck and
throat, and that thus far my object has been to direct your
attention to the head and neck, inasmuch as those parts are
acted upon by the fifth nerve and the three cervical ganglia of
the sympathetic, with regard to their sensation, their vascular
and heat supply, and their nutrition. These are of course
points of great interest and importance with which you ought
to be familiar. We have to deal firstly with derangements or
functional changes in the fifth nerve, or to reflex irritations.
Sir J. Paget has reported a case where the hair of the entire scalp
had turned white after a severe attack of neuralgic headache,
and Anstie has reported a case where the hair of the eyebrow
alone became blanched from pain in that region dependent
upon the supra-orbital nerve. Hilton reports a case where the
hair of the temple from the irritation excited on the dental
branches of the fifth nerve through a decayed molar tooth
became suddenly grey, and another where an obstinate form
of ulcer, in the auditory canal, which was very painful and had
withstood all methods of treatment, was cured by the ex-
traction of a decayed tooth in the upper jaw.

~The removal of teeth for severe neuralgias of the face and
even for blindness has been known to cure the disease. Ina
paper which I had the honour of reading before the Odonto-
logical Society in the earlier part of this year, I endeavoured
to show the undesirability of extracting teeth in some cases of
neuralgia of the fifth nerve.

I will at once draw your attention to massaging the head
and neck for headaches, and particularly for migraine and
hemicrania. You will, after the description I am about to
give you of these headaches, comprehend why I have been
desirous to make you in a way acquainted with the ganglionic
connections of the fifth nerve. Romberg was the first to
associate hemicrania with painful affections of the brain, dis-
tinguishing it from the various peripheral neuralgias by calling
it “‘neuralgia cerebralis.”” Ido not think from my own ex-
perience that this sharp line of definition between mere hemi-
crania and neuralgias of the fifth nerve can be maintained.
“‘ Functional headaches are neuralgias of the fifth nerve,” and

hemicrania is the most typical example. Whether the disease

is one of the fifth nerve primarily, and of the sympathetic
secondarily, or vice versa, is open to dispute, and I for one
sannot come to the conclusion that it is essentially due to the
sympathetic nerves. The great physiologist, Du Bois-
Raymond, who was a martyr to migraine, inferred that it was
saused by tetanus of the muscular coat of the vessels on the
wffected side of the head, or, in other words, tetanus in the
MASSEEING HEAD AND NuCK FOR NEURALGIAS. 57

region supplied by the cervical part of the sympathetic nerve.
He found that during the attack the temporal artery of the
painful side was hard and cord-like to the touch, while that on
the opposite side was in its normal state. On the affected side
the face was pale and sunken, and the eye small and injected.
‘The pain was increased by everything which raised the blood
pressure in the head (as stooping, coughing, &c.), this increase
being synchronous with the pulse in the temporal artery. To-
wards the end of the attack the ear also became warm and red.
These phenomena, the state of the temporal artery, the
bloodlessness of the face, the sunken appearance of the eye,
show that the muscular coat of the vessels of the affected side
of the head was persistently contracted. On removal of the
cause which produces this condition of tonic spasm, relaxation
follows the over-action of the unstriped muscular fibres, and
the walls of the vessels yield more than usually to the lateral
pressure. This secondary relaxation explains the congestion
of the conjunctiva and the redness and increased temperature
of the ear which occur when the violence of the attack begins
to subside. The vomiting and flashes of light before the eyes
which frequently accompany this form of headache are caused
by sudden changes in the intra-cephalic blood pressure. From
these marked signs which I have just brought before you we
have evidence of the most undisputed kind that the vascular
spasm on the affected side of the head must have its origin
in the sympathetic ganglion or nerve of the same side, or
in the medullary centre of the sympathetic fibres involved,
even as low down in the spinal cord as the cilio-spinal centre,
which, if you remember, I told you was ona level with the
second dorsal spine. If these spines are examined during an
attack of migraine they will be frequently found extremely
painful upon pressure, the pupil on the same side will also
be found dilated, and an elevation of the pulse is frequently
noted, as well as considerable increase in the quantity and
tenacity of the saliva. If you examine this diagram again
you will see that the submaxillary gland receives its fibres
of secretion from the sympathetic, and possibly from the
otic ganglion. Of vascular changes in nearly all and every
form of headache there is in my mind very little doubt,
therefore the conclusion may be admissible that their origin is
in the sympathetic nerves and ganglia. In confirmation of this,
if the eye on the painful side be examined by the ophthalmo-
scope during an attack, the central vessels of the eye are seen
+o be dilated, the veins sometimes being knotted and convoluted,
whilst the vessels on the non-painful side are normal. ;
Eulenberg and Guttman state that there are cases of hemi-
erania which are entirely opposed in character to that of Du
8 MASSAGE OF THE HEAD AND ann.

30is-Raymond’s, that is to say, in which the striking symptoms
we not those of spasms in the vessels, of arterial tetanus in
ihe parts supplied by the cervical sympathetic, but those of
‘elaxation of the vessels, of arterial hyperemia caused by a
oss of energy in the vaso-motor nerves. These are cases that-
me might designate hemicrania neuroparalytica or angio-
yaralytica, as opposed to Du Bois-Raymond’s ‘ sympathico-
ionica,.””

Vaso-motor nerve centres, a8 we have noted, exist in the.
nedulla oblongata, and it is reasonable to conclude that during
in attack of severe headache this important part of the
1ervous system is more or less irritated, which gives rise to
ihe shiverings, coldness and lividity of the extremities, and
suppression of perspiration during the paroxysm. With
cegard to the pain or ache of the head during these attacks,
Du Bois-Raymond has suggested that ‘‘the state of tonic
spasm of the unstriped muscles of the vessels may itself give
‘ise to pain, just as it is felt in striped muscular fibre, in,
xramp of the calf of the leg and in tetanus, or in unstriped
nuscular fibre in the uterus during labour pains, and in the
ntestines during an atiack of colic.’ Probably this pain comes.
rom pressure in the nerves of sensation distributed within the.
nuscular tissue, and thus affords a reasonable explanation for
the :observation that pain is increased along with the blood
oressure. We have every reason to conclude that the nervi
aervorum of Marshall and Horsley and the sensory nerves are
listurbed and excited by changes in the diameter of the.
accompanying and surrounding. blood vessels, especially when
these changes occur with some degree of suddenness. Anomalies
wf the circulation generally, and anemia especially, have long
been recognised as important causes of neuralgia.

I have said more about the nerve physiology of these head-
aches than I otherwise should do, as I earnestly wish to
impress upon you the relationship of the second, fifth, and
ninth cranial nerves with each other and with the sympathetic
ganglia of the neck. Incurable as these headaches are usually
considered, I assure you that within the past three years, since:
[ have given so much attention to the application of massage:
and electricity, my success in the treatment of these affections
has really astonished me.

Now before I show you how to massage and to galvanize:
the head for these headaches, I am anxious to make you.
acquainted with a few other forms of disease where these
modes of treatment are extremely beneficial. The first is
2xophthalmic goitre—Basedow’s disease, Graves’ disease. Let:
me tell you at once that this disease when it occurs in
people over sixty is as a rule incurable and shortens life. On
MASSEEING FOR GRAVES’ DISEASE. 59

the other hand, in young people, the prognosis is hopeful.
We have an exceedingly interesting case now under treat-
ment, where the neck is fast resuming its natural contour.
I cannot do better than recall some of the more prominent:
symptoms and signs of this patient, whom I now show to you,
although the signs presented by her are mere traces of what
they were when she first came under our notice. She is of
fair complexion, twenty-five years of age, and has suffered
from epileptic fits; her intellect seems rather obtuse, and her
temper is variable and irritable. She will tell you that she.
is weakly, easily becomes tired, loses her breath upon exertion,
and suffers from violent palpitation of the heart, especially
upon ascending the stairs. Systolic blowing murmurs can be
heard over the innominate and subclavian vessels; there is.
also increased arterial tension, and the pulse beats are over a.
hundred per minute. The eye-balls are prominent, and the
upper lid insufficient to cover them. When she looks down,
as in reading, you see that a part of the cornea remains.
uncovered. If you observe the neck, which is unusually long,
the lateral lobes of the thyroid gland are seen to be large,
though they are not by any means as large as they were. If
you grasp the gland in this way you will find that it les some-
what deeply in the neck, and in massaging this gland you must
not forget this; you must work deeply into the structures.
with the neck slightly flexed. Of late years it has been
experimentally noted that the thyroid gland forms a very
important link in the chain of nutritional and metabolic
agencies.

It is now generally admitted that this disease is due to some:
functional disturbance in the cervical sympathetic. It is
bilateral, rarely if ever unilateral, so that it differs from
migraine in this respect. But, as in migraine, the oculo-
pupillary fibres of the cervical sympathetic (centrum cilio-
spinale) are in a state of irritation. I refer to this because,
as in other affections supposed to be due to the sympathetic
nerves, we must always remember to use spinal as well as
local massage. ee

T must now, please, call your attention to aural vertigo—
labyrinthine vertigo—Meniére’s disease, which usually depends
on some derangement of the auditory nerve, probably of the
nerve endings in the labyrinth. It is almost invariably
associated with giddiness, sometimes slight, sometimes severe.
Oftentimes there is intellectual confusion, rarely absolute loss
of consciousness; it may be associated with distinct sense of
nausea. Its onset is usually sudden, lasting for a few seconds,
or very much longer. There is usually some defect of hearing,
which is one-sided. Tinnitus is usually present, often it is.
30 ‘MASSAGE OF THE HEAD AND Nuun.

yersistent, distressing and harassing. These strange noises in
he head are of the most varying character, resembling the
lissing of steam as it issues from the kettle, the roaring of
vater as from a waterfall, the shrill whistle of a steam engine,
ihe muffled sound of distant thunder, the jingling of bells.
Perhaps the most common form is the rumbling murmur
xperienced by putting a shell to the ear. These sounds are
of varying intensity ; they may be high-pitched or they may be
ow-pitched. In my experience this disease is more common
n the middle and advanced periods of life. Meniére’s disease
s often associated with a gouty habit of body; sometimes it
»ecurs in persons who are otherwise in good health, but this is
10t usually the case. There are generally indications of
‘unctional nerve troubles and nervous exhaustion. Whatever
nay be the change in the auditory apparatus, such as the
aerves of the ampulle or of the semicircular canals, one of its
sredisposing causes is shock to the nervous centres, or over-
work, worry, or profound and intense anxiety. You may
gerhaps remember the case of a woman forty-seven years of
wge who received very decided benefit from massage and the
sontinuous galvanic current when drugs utterly failed to
relieve her. Her tale was that she had suffered from nervous-
aess since the birth of her last baby six years before, but some
aime previous to this the right eyebrow and lashes became
suddenly quite white. She was partially deaf in the left ear,
and ‘complained of noises in it and the left side of the head
like a distant waterfall; and in the right ear the sounds were
like a railway train coming through a tunnel at full speed.
They were so distressing that she felt as though she were
going out of her mind. They were worse at night when she was
alone, but when engaged in conversation she scarcely heard
bhem at all. Sometimes she suffered from giddiness for weeks,
and had strange sensations and severe headache at the
back of the head. At times the noises quite unnerved her and
prevented her doing her household duties.

I have notes of many similar cases. A gentleman, a solicitor
by profession, consulted me on account of what-he called his
strange attacks. He was an unusually strong man, in active
work, over sixty years of age. He would be seized quite
suddenly with a feeling of giddiness, and down he would go,
unless he had time to take hold of something firmly to support
himself. But what was somewhat peculiar was that if the
attack of giddiness came on whilst he was sitting in the chair
he would glide out of it upon the floor. He also had singing
noises in the ear with some deafness.

A few months ago Dr. Snow, of Bournemouth, sent a lady
to consult me suffering from Meniére’s disease. She was a
x
MENIERE’S DISEASE. : \ 61.

lighly nervous woman, and complained of attacks of giddiness,
severe neuralgic headaches, deafness of the right ear, and
romiting. She had consulted several distinguished aurists,
vho told her that her deafness was of a nervous character,
ind that local treatment would be of no use to relieve her.

I informed her that I could cure her of many of her nervous
symptoms, such as her headache, giddiness and vomiting,
but I could not cure her deafness, and it was very doubtful if
[ could cure the noises in her head. However, after six weeks
of massage and galvanic treatment, all the symptoms left her,
except the deafness, which remained as bad as before. Every
physician knows how difficult these cases are to relieve, not to
say cure. Of course many are due to some chronic change.
caused by gout or syphilis, but the majority are functional, and
are more readily relieved by massage and the continuous.
galvanic current than by any other form of treatment with
which I am acquainted.

I cannot speak from other than a limited personal experience:
of the effects of massage upon the eye-ball itself, but Dr.
Graham: seems to have given considerable attention to this
subject, and as opportunities arise I hope to test its effects.
Cases have been reported of keratitis and corneal ulcers which
have been cured by massage. ‘There are three classes of
visual defects occurring in young people, in which I feel sure
that spinal massage from a physiological standpoint ought to
be productive of great benefit. I refer to (1,) Decrease of the
range of vision, short-sightedness (myopia). (2,) Decrease
of the acuteness of vision (amblyopia). (3,) Decrease of
the endurance of vision (asthenopia). Dr. Liebrich, the con-
sulting ophthalmic surgeon to St. Thomas’ Hospital, was.
known to have very decided views as to the cause of these
conditions in young people, and in the year 1885 he gave two
very interesting lectures, entitled ‘School life in its Influ-
ence on Sight and Figure,” and he has often surprised a parent
with the remark, ‘“ There is really nothing the matter with the
child’s eyes, it is the child’s spine that is at fault.” ;

I certainly believe most thoroughly in the views of this.
celebrated oculist. The centrum cilio-spinale which, as we
have seen, is situated in the spinal cord, on a level with the
first and second dorsal spines, communicates with the sym-
pathetic through the branches of the anterior roots of the spinal
nerves, and so passes along the internal carotid artery to the:
ciliary ganglion, there meeting with the trophic fibres, which
come direct from the Gasserian ganglion. If the constrained
posture which desk-work must inevitably produce does not lead to-
positive spinal curvature it certainly has that tendency, and this,
to my thinking (of course, I may be quite wrong), sets up from.
32 MASSAGE OF THE HEAD ANvy nnn.

indue strain an irritability of the cervical sympathetic leading
io functional defects in the eye, which is not only subjected to
sxonsiderable vascular tension, but also frequently to very
abnormal sight. Of course the ophthalmic and orthopaedic
surgeons are thoroughly acquainted with these anatomical and
ohysiological relationships, but I fail to see in the literature
xf these branches of medicine that amount of attention
paid to these conditions which I think they deserve. The
seulist naturally, possibly wisely and scientifically, has
recourse to glasses, the orthopedic surgeon to some form of
mechanical appliance ; but in my humble opinion massage to
the spine is far to be preferred to either. In my lecture on
lateral curvature I shall again refer to this subject.

Dr. Graham says that Pagenstecher, of Wiesbaden, seems to
have been the first ophthalmic surgeon to use massage upon
the eye-ball after Donders had recommended it, but apparently
independent of this recommendation. In one case that for
twenty years had been subjected to periodical attacks of inflam-
mation of the eyes, presenting an affection of the whole sclera,
with uniform conjunctival and sub-conjunctival injection to a
considerable degree, the conjunctiva of the globe slightly
cedematous, with here and there at the margin of the cornea
small round or oval prominences, not unlike the formations
which are described as cystoid cicatrices. By the use of
massage he succeeded in suppressing the attacks in their
first stages. Immediately after the massage, diminution of
intra-ocular pressure was observed in this as in other cases.
Pagenstecher also used massage in a case of episcleritis, and
in another of parenchymatous keratitis of specific origin. His
method of using massage was by moving the lids, under slight
pressure, in a radial direction from the centre of the cornea as

quickly as possible, and after this by making circular friction .

under slight pressure upon the upper lid around and upon the
region of the sclero-corneal margin. His idea was that massage
might succeed in removing hindrance to the circulation, and
in this he was not disappointed, as it emptied the blood vessels
and lymphatics at the sclero-corneal margin, and thus pro-
moted rapid absorption of exudation around them. He
employed massage once a day from two to four minutes, and
sometimes twice daily when it was well borne; and he often
used a small quantity of yellow precipitate ointment under the
lids, which made them glide more easily over the eyeballs,
besides distributing and dividing the ointment in the finest
possible manner, so that its specific effect would be greatly
developed. The experience of Pagenstecher has been con-
firmed by many oculists, much to their agreeable surprise.
Panas practised massage and found it painless, speedy, and
WRY NECK. : 63

agreeable. In his hands, used together with precipitate
ointment, in chronic affections of the cornea in young people,
it was of great service, and it proved particularly effectual in
eae and scrofulous keratitis and pannus granu-
osus.

Spasms of the facial nerve, when not due to organic disease
and the so-called ‘‘ habit-spasms,’’ are very troublesome con-
ditions, and do not as a rule yield to ordinary forms of treat-
ment. They are often cured by massage to the head, neck,
and spine when used in conjunction with a weak, stabile
voltaic current (uninterrupted), the anode (sponge electrode) over
the seat of spasm. The current, very weak (from six to eight
milliampéres), should be continued for ten or twenty minutes.
The positive current seems to have a soothing influence: the
kathode should be placed at the back of the neck.

The case which I now show you is one of torticollis, com-
monly called wry neck. This patient was sent to me by Dr.
Macpherson Laurie, of Weymouth. You see how the head is
drawn downwards and slightly backwards to the left side, and
how the trunk of the body inclines in the same direction. She
will tell you that at times the body seems to be drawn into
that position.

The spasm is of the tonic kind, very persistent, and frequently
gives her great pain. The cause is not very apparent. The
affections came on about two years ago, and until she com-
menced the massage treatment with the combined voltaic
and faradic currents nothing did her any good. Now, you
see, she has considerable voluntary power, and can raise the
head and maintain it for some time in a nearly erect posture.
If you examine the right sterno-mastoid muscle it feels
rigid, and it is curved and unyielding. I certainly get better
effects from the combined current than I do from either of the
currents applied singly. It seems as though the splenii were
involved in the spasm as well as some of the anterior fibres of
the trapezius, and I can scarcely believe that the rectus and
obliquus escape altogether. It may be of an_ hysterical
nature, but I doubt it.

Facial paralysis, of which you have seen several cases under
treatment, readily yields also to massage and the combined
current, certainly-much more readily than do cases treated by
galvanism alone. ;

Let me call your attention briefly to this case of tic-douloureux
(trigeminal neuralgia). This patient was sent to me by Mr.
Reece. Her history is that the attacks of pain and spasm
came on about seven years ago, and from that time to the
present she has rarely ever been free. 1 wish you to compare
her condition now with what it was when she came under
4 MASSAGE OF THE HEAD AND nwun.

reatment six weeks ago. At that time, if you remember, she
would be seized with violent paroxysms of pain and spasm,
svery three or four minutes. She would hold and rub the right
side of her face and head with a frantic look of the deepest,
wony. Theattack was scarcely over when it would be renewed, ,
he attacks came on during the night and awoke her out of her
leep, so that she got little rest ; they came on during eating
vith intense severity, so that she was nearly starved; they
same on when engaged in her household duties, so that she
was obliged to relinquish them altogether; in fact she was
lriven to a state bordering on distraction. The pain began in
‘he ethmoidal sensory region of the fifth nerve, and then shot
cross to the lachrymal and supra-orbital. She had seven
ieeth drawn at one sitting, but this did not relieve her in the
ilightest degree. Now she has not had an attack for a week;
the sleeps and eats well, and as she truly says, she feels quite
wdifferent being, thanks to the massage and galvanism.

Now let me draw your attention to the manipulations for the

 

Fig. 17 illustrates the ordinary method of ‘masséeing the head, effleurage.
One hand of the operator is carried over the mastoid portion of the temporal
and upwards to the vertex of the head, whilst the other hand is carried over
she opposite frontal eminence, Both hands are so directed that they meet
2ach other at the top of the head..
MODE OF APPLICATION. . 65

head, neck and face. I seat the patient upon this stool and
stand behind it, and work my hands upon opposite sides of
the head (Fig. 17).

First: I place my right hand firmly upon the occiput and
mastoid process of the right temporal bone, whilst my left hand
is placed, thus, upon the temporal bone and external angular
process of the orbit. Both hands you see now traverse the
head to meet each other upon the vertex; my right ascends
upwards over the parietal bone to meet my left hand which is
carried over the superciliary ridge and left frontal eminence
of the frontal bone. These movements must be made firmly,
and if well done the pressure of the one equalizes the pressure
of the other, and so the head is kept vertical upon its balance.
You see I now perform precisely the same movements, but
they are reversed, the left hand is now working in the same
-~way that the right hand was before.

Second: This movement requires a little practice, which I
will show. Place both your hands at the back of the head in the
occipito-mastoid regions respectively precisely after this manner ;
carry them both upwards and forwards on each side over the
temporo-parietal regions, then continue onwards and forwards,
each hand over the supra-orbital ridges and frontal eminences ;
then cross and work from before backwards over the vertex, 80 ;
now recross the hands and carry the movements right and left
hand behind the right and left ramus of the jaw downwards
over the sterno-mastoid muscles into the root of the neck. Do
not remove the hands, but work them up the neck, the heel of
the hand being followed by the fingers; work the fingers well
into the sub-occipital spaces and posterior triangles of the
neck; then commence and repeat the movements as before.
I make these movements more or less firmly from first to last.

 

Fig, 18 gives a diagrammatic representation of a common method of
ae masséeing the neck, effleurage and petrissage.
5
66 MASSAGE OF THE HEAD AND NECK.

I now make them lightly, after this fashion, passing my fingers.
through the hair. Again, I walk over ths in ith i
fingers, thus, the hands and fingers going in reverse directions.
I now leave the head alone and manipulate deeply into each
triangle of the neck. You observe my movements are lateral
and rotatory (Fig. 18). I can thus manipulate the cervical
sympathetic ganglia and the glands and lymphatics, the
vagus, laryngeal and other nerves, and the submaxillary and
thyroid glands.

Third: We place the patient in the horizontal posture with
the face upwards, and you will find that for some purposes this
1g more convenient, especially for manipulating upon the eyes,
and the fifth and facial nerves. The thumbs are better than
the fingers for the eyeball massage.

 

 

 

 

Fig. 19 illustrates the method adopted for effleuraging the upper lid and
the eyeball. Care must be taken to place the thumb exactly in the middle of
the lid and to rotate them bilaterally. Considerable friction and even pressure
can be applied when required.

If a little tact is used this process will neither be irritating

nor painful, but care is required not to touch the eyelashes.
Considerable pressure, slowly and gradually applied, can be

exercised with very good effect. The head is now in the best. —
position for performing soothing,tranquillizing and hypnotizing —

manipulations ; these belong entirely to the effleurage class,
and are performed lightly in the direction of the supra-orbital
nerves, in the same way that we manipulate for brow ague-
and supra-orbital neuralgia. . .

I conclude this lecture by drawing your attention to a
GYMNASTICS OF THE LARYNX. 67

process of manipulation which I style gymnastic massage of
the larynx for throat deafness, which you know is so common.

 

 

 

Fig. 20 illustrates the position of the thumbs at the cricoid end of the
thyroid cartilage for massaging the larynx and effecting laryngeal
gymnastics in throat deafness.

I place my thumbs at the lower border of the thyroid cartilage,
and I then ask my patient to swallow; of course in the act
of swallowing the larynx is raised, my thumbs follow the
larynx as it ascends, and when it can go no higher I fix it in
this position, and I again request my patient to make every
effort to swallow, and by this means the Hustachian tube is
frequently cleared of its contents, and the hearing is greatly
improved.
Lecrure IV.

MASSAGE AND INDUCTION, FARADIC MASSAGE OF
THE SKIN.

The value of Effleurage and other manipulations upon the skin, which we
look upon as a medium of connection of the various sensation processes—
The resisting power of the epidermis in health and disease—The epidermis
as an insulator—The epidermis and peripheral nerves a gauge to the
activity and correlative integrity of the brain centres and reflex acts,

I wave told you that my definition of the term effleurage is
to stroke lightly, to bring surface to surface. Two surfaces
may be brought into superficial contact with considerable
velocity without either experiencing great resistance; never-
theless friction is induced of a kind relative to the mode of
energy expended. Light friction movements are often
productive of more active physiological effects than are
movements of a more definite and decided kind; we measure
the kinetic influence which results according to the impress
which is made, not only upon the peripheral nerves and blood
vessels of the skin, but also upon the brain and spinal centres,
The sensation produced by the impress of a feather upon the
skin differs from that of my finger, and the effect upon the
surface of the brain is of a distinct but different nature.
The impress is synthetic as far as the skin is concerned, but it
is analytic when appreciated by the sensorium; therefore I
would say that the physical energy known as an impression
becomes transformed into vital energy by the brain cells.
It is the brain which converts an impression into a
sensation. The phenomena of sensation is not a simple
phenomena constituted by the mere reaction of a tissue.
in the presence of external excitations, it is the complex
subordinated operation of the nervous activity which re-

quires the participation of a great many organs successively —

brought into play in order to arrive at complete evolution.
We have thus far, you see, built up a sensitive impression,
originated in the peripheral nerves of the skin, and trans-
formed by some psycho-intellectual operation into conscious
sensation. I need scarcely say that conscious sensibility
is manufactured in the grey matter of the brain and is
associated with volitional response, provided correlative
integrity reigns supreme. Unconscious sensibility, on the
other hand, is of the dynamic order, and is associated with
the more complex centres in the medulla oblongata, and gives
rise to reflex and it may be unconscious acts. If, for instance, 1

A
CONSCIOUS AND UNCONSCIOUS IMPRESSIONS. 69

energize by impress through the vibratory movements of
tapotement the skin of your arm, I create a sensibility which
is directly conscious, as well as unconscious: the impress goes
straight to the brain, which converts it into conscious
sensibility, but part of the impression is arrested either in the
spinal cord or the medulla, which gives rise to unconscious
sensibility experienced by the vaso-dilators of the blood vessels,
the effect of which is to produce redness of the skin itself.
Just remember, then, that it is by the terminal expansions of
the nervous system spread out, so to speak, in a fine delicate
network, the recipient of all that comes to impress it, that we
are made sensitive, conscious, and even unconscious creatures,
according to environment. I have not in this lecture to deal
with the brain proper, except in so far as to show you that it is
in direct communication with the skin, but this much I want
to make clear to you for future observation, that in health
those active sensory and sensorial impressions are constantly
passing to the optic thalami and that they radiate from thence
through the white fibres to the cortical grey matter of the
brain. There must be integrity throughout the living chain of
which the skin, nerve, and ganglionic centre are but links.
Force, conduction and resistance must be of a definite and
uniform standard in order that the moral, the mental and the
physical may work together in unison, and I shall prove to
you, and in fact show you by demonstration, that the skin is
an index of the functional activity, not only of the lower,
but of the higher nervous centres, ‘conscious,’ ‘ volitional,’
‘unconscious,’ ‘automatic.’ We all experience the fact that
the higher the level of the nervous centre in direct com-
munication with the skin, the more sensitive the skin becomes,
the more rapidly is the impression received by the brain, and
the less is it diluted in its transit. You must remember this
on applying galvanism ; and I shall shortly call your attention
to these points when speaking of skin reflexes and per-
turbations of sensibility.

For the moment let me remind you that the skin consists of
three layers of tissue: firstly, the epidermis; secondly, the
chorium or cutis vera, with the papille; and thirdly, behind
this a layer of fat. The influence of massage upon the
skin by effleurage induces sensory, sensorial, and metabolic
effects mainly through the nervous system, so I say, if you
please; that these are induced effects, and so also, in degree,
are the results brought about by tapotement. But petrissage
movements act upon the various structures of the skin by
direct pressure; the sebaceous glands which are frequently
choked by sebum are in this manner relieved of their contents,
and so are the sweat glands, the lymphatics and the blood
70 MASSAGE AND INDUCTION.

vessels. The function of the skin is to eliminate principally
carbonic acid and water, and to promote the exchange of
gases by the absorption of oxygen. This form of cutaneous
respiration is much more considerable in frogs and other
amphibians with a thin, almost moist epidermis, than in
warm-blooded animals; so that the skin is a more important
respiratory organ in these animals than the lungs themselves.
The dog, on the other hand, does not sweat, hence the activity
of the pulmonary respiration. There exists between the skin,
the lungs, and the kidneys, as excretory organs, a functional
sympathetic relationship, through the medulla oblongata. As
venous blood loaded with carbonic acid is the natural stimu-
lant of the respiratory centres, so we may conclude that
earbonic acid is the natural respiratory stimulant of the skin,
and urea and uric acid the natural stimulant of the kidneys.
These waste products, when normal in quantity, produce
through the vaso-motor centres a healthy degree of arterial
tonus ; but when the vaso-motor centre is over stimulated we
find as the result an excess of arterial tonus or morbid or high
tension; and when this exists its influence is felt, not only in

the functional activity of the skin, but in the tissues generally ; °

and it is highly probable that massage exerts a beneficial effect.
by stimulating respiration of the tissues of the skin and thus
relieves the medulla and vaso-motor centres of over-strain.
One thing is clear, namely, that massage can advance as well
as ‘diminish arterial tension. It advances it when deficient
by promoting respiration of tissue; it diminishes it when
in excess by increasing metabolism and the elimination of
carbonic acid.

Let me call your attention to the sweat glands of the skin.
The amount of water given off by the skin is about two pounds
in twenty-four hours (Srrrtine). There are two kinds of per-
Spiration, insensible perspiration and sensible perspiration; the
former is evaporated at once from the skin, the latter collects
in drops upon the surface. I am anxious that you should take
sensible perspiration into consideration ; it presents points of
interest with which you should be familiar.

The influence of nerves upon the secretion of sweat is very
marked. That sensible perspiration is healthful under certain
given conditions is unquestionable, but this is not the case if
it occurs when these conditions do not exist.

The man who sweats profusely, when his fellows under the
same influences do not do so, is more liable to functional and
even degenerative changes than others. ‘As in the secretion
of saliva vaso-motor nerves are usually in action at the same
time as the proper secretory nerves, the vaso-dilator nerves
(sweating with a red congested skin) are most frequently
EPILEPTOID SWEATS. 71

involved. The fact that secretion of sweat does occasionaliy
take place when the skin is pale shows that when the vaso-.
motor nerves are excited so as to constrict the cutaneous blood-
vessels, the sweat-secretory nerve fibres may be active”
(Lanpors and Strruine). It is to the latter class I refer, and I
assure you they are more common than is usually supposed ;
and it is indicative of a want of tone, and a low degree of
vitality of no small importance ; it is always associated with a
form of nervous exhaustion,—understand me, it is essentially
neurotic, and is not unfrequently followed by organic change
in the nerve centres leading to mental disturbance, diabetes,
and albuminuria. There is a form of hyperidrosis, called
by Eulenberg “‘ epileptoid sweats”: I think this form is very
correctly named. A man will suddenly, after walking a few
yards and without any apparently exciting cause, break out
into a profuse perspiration, become pale, hungry and faint,
and lose resisting power, without vaso-motor dilatation or con-
striction ; indeed, it seems as though, for the time, the dilator |
and constrictor fibres were both paralyzed. The normal
secretion of sweat diminishes along with other derangements
of nutrition of the skin in some nervous diseases, and in
degeneration of the motor-ganglia of the anterior horns of the
spinal cord. In some cases the nutrition of the skin is inter-
fered with in a peculiar way, so that it becomes glossy and has
the feeling and appearance of parchment. I call your atten-
tion to these abnormal conditions of the skin in order that you
may the more readily examine and make yourselves acquainted
with the precise nature of every skin with which you may
come in contact. Examine all skins prior to massage as to
their hardness or softness, dryness or moistness, temperature
and colour, fat and elasticity. Elastic fibres of the skin exist
in the chorium and the papilla, and smooth muscular fibres
occur in the chorium in certain situations, on extensor surfaces
(NeumaNN), nipple, areola mamme, prepuce, and in special
abundance in the dartos and the scrotum. The nerves
of the skin form a dense plexus in the superficial layers of the
chorium, branches from which extend into the epidermis.
These nerves form by their termination end ‘“ bulbs”’ “the
touch corpuscles,” which lie essentially in the papille ; they
are most numerous in the palm of the hand and the sole of
the foot, and in the fingers and toes. 2

In the sensory nerve trunks we find fibres which administer
to painful impressions, and fibres which administer to tactile
impressions. The sensations of temperature and pressure are
also reckoned as belonging to the tactile group. ‘Tactile sen-
sations (including pressure and temperature) are only dis-
charged from the coverings of the skin and the orifices of the
12 MASSAGE AND INDUCTION.

body. Tactile sensations are absent from all internal viscera—
pain alone can be discharged from these organs. It is neces-
sary to remember that tactile nerves can only discharge a
tactile impression or sensation of contact, while thermal stimuli
are required to produce a temperature. sensation, and in both
sases the results are only obtained when the appropriate
stimuli are applied to the end organs. Observe, for your
special guidance, that strong stimuli disturb normal tactile
sensations by over-stimulation and result in pain.

Dr. Brown Sequard believes that there are besides the four
listinct kinds of nerve fibres of the higher senses at least,
aleven kinds of nerve fibres in the spinal cord and in the
sranial, spinal and sympathetic nerves. He enumerates these
sleven kinds as follows :

--1.—Conductors of impressions of touch.

2.— ” ” ” of tickling.

3.— ” ” ” of pain.

Aone ” ” ” of temperature. :
5.— of muscular contraction...

6.—Incitor-motor conductors.

7.—Incito-nutritive and secretory conductors.
. 8.—Voluntary motor conductors.

~Involuntary motor conductors.

‘10.—Vaso-motor conductors.
11.—Nutritive and secretory conductors.
We now know that there are many more nerve fibres than
ihese directing and controlling function.

It must be within your experience to find that the tac-
iile sense varies greatly in different individuals. The skin of a
oerson may be under sensitive (partial anesthesia) or insen-
sitive (anesthesia), or over sensitive (hyperesthesia), or sensi-
oility to pain may be absent (analgesia), whilst the sensibility
to touch is present, or sensations may be perverted, hot objects:
feeling cold and cold objects feeling hot ; or sensation may be
retarded and then quite suddenly experienced as extreme pain.
When perception of pain is delayed, that of temperature is
Jelayed in like manner.

You have seen instances of these varying states of sensibility
in some of the patients upon whom you have been operating.
These conditions do not always indicate disease of the central
nervous system ; they are often found in states of nervous ex-
haustion, hysteria, and the like of these, “functional and
nutritional diseases.” We not unfrequently find intense pain
in the upper limbs from the tips of the fingers to the elbow,
and from the toes to the knees, with a subjective sense of
numbness and deficiency of muscular sense, yet tactile im-
pressions are normal. Such conditions are often found in
SKIN REFLEXES. 73

women at the change of life, and they are quickly cured by
massage and the galvano-faradic current, not only applied to
the limbs, but to the spine and to the head. It is often the
case that cramps of the muscles, of the calf of the leg and of
the toes, likewise of the fingers, tingling, burning, and other
abnormal sensations of a distressing character are experienced.

The reflexes of the skin are interesting, and it is well that you
should know something concerning them. They may be absent.
altogether, or they may be excessive and very easily excited.
You have seen the skin of the abdomen drawn into fold-like
prominences when I have passed my finger nail over it. You
are aware that in order to get a perfect reflex act there must
be complete continuity between the afferent sensory or centrip-
etal nerve with its centre (which lies in the spinal cord
between the roots of the sensory and motor nerves), and the
efferent or motor nerve by which the act is brought into opera-
tion. This constitutes the reflex arc. The stimulus so sent to
the spinal cord, may, as I told you just now, travel on to the
vaso-motor centre in the medulla, and from thence it may
become impressed upon the brain and effect a conscious sensa-
tion, and these become identified with a volitional impulse.

These reflexes are named according to the part excited
(pray do not be atall surprised if you get no cutaneous reflex,
it is quite possible for it to be altogether absent), plantar
reflex, gluteal reflex, cremaster reflex, abdominal reflex, epi-
gastric reflex, lumbar, dorsal, scapular, and‘so on. Of course
the reflexes of the eye are of the highest importance ; contrac-
tion of the pupil to light, accommodation, dilatation on stimu-
lating the skin of the neck, ete.

I must now draw your attention to the epidermis or scarf
skin, as it is called, and I think we shall find that the con-
sideration of this structure is of interest to us from several
points of view. It consists of many layers of epithelial cells
united to each other by cement substance ; it varies in thickness
in different parts of the body, notably the soles of the feet,
where in parts it is quite horny. The superficial layers
—stratum corneum—consist of several layers of dry horny
non-nucleated squames, devoid both of nerves and blood-vessels ;
the minor part of the epidermis which lies upon the true vas-
cular sensitive chorium consist of many layers of nucleated
protoplasmic epithelial cells, amongst which are sometimes
found granular leucocytes or wandering cells, so that we see
as we pass from without to within the epidermis there is a
gradual approach to a highly-organised tissue. If the skin be
dry the epidermis becomes an insulator, but its power of resis-
tance is not complete ; occasionally, however, we find the skin
of the back with thick layers of desquamating epithelium, dry
"4 MASSAGE AND INDUCTION.

ind scurfy, resisting an ordinary galvanic current which
vould be painful if applied to the cheek or to the inner part of
he thigh.

We take advantage of this resisting power of the epidermis
nthe employment of what I call Faradic Massage. You are
ising this form of massage daily, so it seems scarcely needful
osay anything about it. However, I will draw your attention
o one or two points, as the success of this mode of treatment
lepends to a great extent upon the manner in which it is
mployed. We use the faradic or induced current, and the
ffect is to produce an agreeable impress of a decidedly stimu-
ating nature on the peripheral nerves of the skin. You may
ise the voltaic or continuous current just in the same way
vith the deep petrissage movements upon muscle, but. I do not
ee any special advantage in this. The faradic current has
irst to overcome the resistance of your own body before it
neets with the body of your patient; the current can in this
nanner be applied to any part of your patient’s body, and I
renerally use it for the back and the head and neck. I may,
vhen applying it to the head, throw in a moiety of the galvanic
urrent, which certainly in some cases seems to be beneficial.
use the flat metal electrodes covered with chamois leather ; it
loes not matter which pole is applied to your patient. The
‘onducting power of the electrodes must be made complete by
Higistening them with the smallest amount of water, just
ufficient in fact to make them damp; and remember we have
o. study resistance rather than conduction. The epidermis of
rour patient and that of your own hands must be as dry as
Bible. One electrode should be placed over the sternum of

e patient, the other at your own neck just within the collar,
o that your hands are left free for any movements you wish to
rerform. You may fasten one electrode to your arm if you
ike instead of placing it at the back of your neck, but I prefer,
nd always adopt, the latter method. It does not matter upon
vhat part of the body you are operating, your movements must

ie as light as possible; they may be made with any part of.

he hand, but as arule you will find the back of it answers
etter than the palm or the tips of the fingers. The current
hould never be conducted with sufficient force to produce
auscular spasm either in yourself or your patient, and the
reat point to which you must attend is to maintain resistance
nd lessen the conducting power of the electrodes and the
pidermis. —

If the electrodes are too wet, or the skin of your patient or
our oe hand moist, you will quite fail to produce the effect
esired.

In order to demonstrate the relative resistance of the epi-
SKIN RESISTANCE INDICATIVE OF MENTAL TORPIDITY. 75

dermis as compared with the true skin make a scratch through
the epidermis of your hand, and you will find a weak electric
current produce such a painful impression that you will be
unable to bear it, although when applied to the epidermis itself
it is scarcely perceptible.

Thus far we are convinced that the conducting power of the
epidermis is limited ; that impressions which are called tactile
would be really painful if this were not the case, so that the
difference between tactile sensibility, common sensibility,
thermic sensibility, and painful sensation is merely a question
of conduction and resistance to impressions on the part of the
epidermis.

Let us pass now from the resisting power of the epidermis
to the consideration of another form of resistance which is
common to a class of cases apart from hysteria. You have
‘seen many such here under treatment. The patients are
usually depressed, melancholic, and suffer from nervous
exhaustion. They are also remarkably insensible to the
faradic and galvanic currents, and this insensibility seems to
be in proportion to the obtuseness of their mental powers ;
but it is interesting to note that as their mental condition
improves so their sensibility to Faradism gradually returns to
its normal state. Here we certainly have resistance in the
nerves or nervous centres, or most probably in both, or it

- might be in the brain itself alone.

I have often noticed that this torpidity of intellectual
power is associated with increased physical resistance to the
faradic current and to the general sensibility of the skin. Of
course in locomotor-ataxy and general paralysis of the insane
this is a marked feature; but I am alluding now to cases where
in most instances the patients are told that there is nothing at
all the matter with them, and although we see that physical
resistance is increased, we invariably find that moral resistance
(will resistance) is below the normal standard.

We know that in the domain of intellectual activity proper
‘sensitive impressions are of the utmost importance; but tactile
impressions are specially destined to provoke reactions in the
intellectual sphere, and these sensitive impressions we have
already dealt with; they are not only associated with touch,
contact and pressure of bodies, but they give us the idea of
temperature and of the activity of our muscles.

These impressions unquestionably play a very important
part in the cerebral activity (or otherwise) of a man’s individ-
uality. ‘‘ We all know,” says Dr. Luys, in his work on the
Brain and its Functions, “‘ how fine, delicate, and sensitive is
the skin of women in general, and particularly of those who
live in idleness and do no manual work; how their sensitive
6 oe MASSAGE AND INDUCTION.

ervous plexuses are in a manner exposed naked to exciting
gencies of all sorts; and how, from this very fact, this tactile.
asnsibility, incessantly awake, and incessantly in vibration,
eeps their mind continually informed of a thousand sensations.
aat escape us men, and of tactile subtleties of which we have.
o notion. Thus in idle women of society, and men with a
ne skin, mental aptitudes are developed and maintained in
re direct ratio of the perfectionment and delicacy of sensibility
f the skin. The perfection of touch becomes in a manner a.
xeond sight, which enables the mind to feel and see fine
etails which escape the generality of men, and constitutes a.
uality of the first order, moral tact, that touch of the soul
‘oucher de Vdme), as it has been called, which is the
haracteristic of organizations with a delicate and impression-
ble skin, whose sensoriwm, like a tender cord, is always ready
) vibrate at the contact of the slightest impressions.
Inversely, compare the thick skin of the man of toil, accus-
yred.to handle coarse tools and lift heavy burdens, and in
‘thom the sensitive pleasures are removed from the bodies.
iey touch by a thick layer of epithelial callosities, and see if,
fter an examination of his intellectual and moral sensibility,
ou;are understood when you endeavour to evoke in him
yme sparks of those delicacies of sentiment that so clearly
haracterize the mental condition of individuals with a fine.
cn. On this point experience has long ago pronounced. .
idgment, and we all know that we must speak to everyone in
1e language he can comprehend, and that to endeavour to:
waken in the mind of a man of coarse skin a notion of the
slicacies of a refined sentiment is to speak to a deaf man of
1e deliciousness of harmony, and to a blind man of the
eauties of colours.

To the facts we have already cited respecting the pathogenic.
ifluence exercised by certain anesthesias upon the genealogy
f certain forms of delirium, we should add as a complement
1e following observations reported by Dr. Auzony, which
early show what a curious influence sensitive impressions.
iay have upon psycho-intellectual phenomena in general.
he case was that of a young man, clever and rational, who-
iddenly became undisciplined and rebellious to the utmost:
stent, and gave himself up to the worst tendencies, even to-
1e compromising of the peace and honour of his family.
xamination showed that he was completely anesthetic.
‘uring his stay in the asylum he successively experienced
sveral intermittent phases of anesthesia, of which the.
opearance manifestly coincided with the return of his worst-
istincts. When sensibility reappeared in the skin, moral.
spositions contrary to the preceding were observed to. return.

!
INSENSITIVE STATES OF THE ‘SKIN. 77

in him, together with a very clear consciousness of his
situation.”

Some years ago I met with a case in which a young lady,
aged about twenty-three, stated that she was totally uncon-
scious of sensations of any kind. In all her life she had never
experienced pain, ‘‘ had never had a headache.”’ Heat or cold,
sunshine or fog, were all the same to her; nothing seemed to
affect either her health or her spirits ; she was uniformly calm,
easy-going, imperturbable. She was married about a year after
I first knew her, and to a lady friend whom she had known
intimately in their days of school-girlhood, and who met her
six or seven years afterwards, she said that her peculiarity had
in no way changed. She was still insensible to pain, and
during her three pregnancies had suffered nothing, even the
critical periods of labour having been passed through without
any physical distress. She was highly educated, musical, and
pleasant in society; the only abnormality that her friend
detected in her was her extreme coldness of manner in her
own home to her husband and children; to the latter especially
she was harsh and unreasonably exacting, and appeared totally
devoid of the faintest rudiments of natural affection. _

A case is known to me at the present time in which a young
man, aged twenty-one, exhibits entire insensibility to the
sensation of pain. He is quite willing at any time to demon-
strate this to his friends on their expressing incredulity on the
subject, performing for their entertainment a variety of un-
natural feats, such, for instance, as running a darning needle
through a finger or thumb, in at one side and out at the other,
or pinning his hands to a table by means of four stout needles
driven through the thin part of the flesh extending between
the fingers and the fingers and thumb. About two years ago
he underwent an extremely severe operation on one of his eyes,
refusing to be placed under chloroform, and taking a conscious
interest in the movements of the surgeons throughout the
whole operation. I may mention that a very strong galvanic
current produces but little impression upon him. He is a
young man of peculiar temperaments, given to the exhibition

.of fits of violent anger and passion on quite inadequate provo-
cation, which are succeeded by great sullenness and silence
for several hours. Hesometimes shows destructive tendencies,
and will wantonly smash and spoil articles of value, although
remonstrated with by his friends on the subject and begged
to desist.

We now, I hope, know something about the skin and-
epidermis ; the latter undoubtedly forms a valuable protective
covering to the body. It is a bad conductor of heat, and thus
acts as one of the factors regulating the radiation of heat.
8 MASSAGE AND INDUCTION.

t resists the action of electricity, and the solid, easily
iovable cutis affords a good protection against external
aechanical injuries; while the dry, inpermeable, horny
pidermis, devoid of nerves and blood vessels, affords a further
afeguard against the absorption of poisons, and at the samé
ime it is capable of resisting, to a certain degree, thermal and
hemical actions.

By way of conclusion I should like to say a word or two
9 you about the absorptive power of the skin and the use of
pplications to it, either during or after massage.

Some deny that the skin has any power to absorb. This is

mistake. Mercury is readily absorbed and taken into the
ystem through this medium. You know some skins are very:
ourse and naturally greasy, and where this is so I recommend
he part to be well washed with a solution of eau de cologne.
ndiammonia. I maintain that no form of unguent, fat or
aseline should be used during the massage process, with two
xceptions, namely, to the abdomen and to the joints. After
aassage it is well in many cases to anoint these parts with
ome unctuous material, becauseit causes the heat and increased
etivity to be maintained.
LEcTuRE V.
MUSCLE AND NERVE.

Physiological relationship of nerve and muscle—Disturbance of nerve.
function leading to motor, trophic, sensory, and sense derangements in
muscle—The value of massage in central nervous affections, muscular
atrophy, locomotor-ataxy, paraplegic ataxy, polio-myelitis, pseudo-hyper-
trophic paralysis; also in occupation cramps of muscle, rheumatic and
gouty inflammation of nerves, cervico-brachial neuralgia, lumbago, sciatica,
multiple neuritis, alcoholic and diabetic paralysis, chorea, etc.

You will remember in my former lectures I told you that all
movements in the body were the result of muscular action,
excepting ciliary and ameboid movement: That the especial
property of muscle was its power to contract when
acted upon by certain forms of energy or stimuli, the
natural stimulus being sent to it from the nervous
centres, the nerve being the rheophore or medium of
conduction: That the integrity of voluntary muscular
movement was dependent upon the integrity of the nerve cells
in the kinesic area of the cortex of the brain on the opposite
side to the muscles which were being stimulated, and to the
integrity of the nerves as conducting agents, rather than to the
integrity of the muscles themselves: That the nerve cells in the
motor area of the hemispheres had a small sensory equivalent
when compared to their large motor equivalent: That the axis
cylinder of most nerve fibres is continuous in one direction with
the process of a nerve cell, and may be looked upon as a pro-
longed process of the cell showing its stages of exaltation and
depression, and also its functional and nutritional defects:
That muscular sense and tactile sensibility were likewise
located in the kinesthetic area: That there were two prime
levels for the liberation of energy, the one volitional, situated in
the grey matter of the cortex, the other automatic, and
situated in the bulbo-spinal axis: That the centres of the
lower level had an existence of their own, but that these
centres were subordinate to the centres of the higher level :
That muscular tone was dependent upon the vitality of the
nervous centre and its connection with the muscles: That
the conducting power of the nerve was inversely to the
resistance that the stimulus had to overcome in its transit:
That pain, spasm, and cramp in muscles were due to over
excitability on the part of the nerve cell, or to defective resist-
ance on the part of the nerve or muscle producing undue tension
and pressure in the muscular fibrille: That the generation and
transit of a stimulus was equivalent to the work which it had
10 MUSCLE AND NERVE.

o perform: That the stimulus travelled in a regular and
hythmical manner: That a nerve fibre enters each muscular
ibre, and where it enters it forms an eminence, the ‘‘ motorial
md plate’: That muscular tissue had an “independent
xcitability,’”’ which was inherent in certain constituents of the
arcous substance, so that a muscle may be made to contract
lirectly by a stimulus acting upon itself, as well as indirectly
vy an impulse sent to it through its motor nerve: That the
legree of contraction of a muscle depended upon the
itrength of the stimulus, the contractile power of the
nuscle after a time becoming exhausted, even though the
timulus continue of the same strength: That the direct
is well as indirect stimulation of a muscle is productive
f%phenomena with which we ought to be acquainted in
jecting a muscle to the galvanic or faradic currents.
‘referred in my first lecture to the metabolism of
nuscle and to the oxidation and respiration of tissue,
und if I remember rightly I also told you that these
changes were always increased by muscular contraction. Let
ne now show you the effect of electric stimulation of a
nuscle and of its nerve, in health and in disease, and from
vhat I have just told you Iam quite sure you will follow my
xperiments with some amount of knowledge and interest.
- In this patient I have a case of atrophy of the deltoid
nuscle. If you compare the right shoulder with the left you
‘annot fail to observe a very marked and striking difference.
You see the left shoulder is rounded, and of natural contour,
wd if you place your band upon it you will feel a well
leveloped and firm deltoid; this condition is absent on the
ight side: instead of rotundity and uniformity we have
latness and irregularity. You see the acromion process of the
capula projecting, of a somewhat square outline, and you can
jush your fingers well upon its under surface; the muscle
eels like a flat band. I now tell the patient to raise the left
wm, which he does with perfect freedom; but observe how vain
nd ineffectual are his efforts to raise the right arm. There is
ome apparent power, but this is only apparent, for the
hhoulder and scapula are raised by the trapezius. If you press
irmly upon the scapula and clavicle, in this manner, there is
vidently no power whatever to abduct the arm. If you feel the
xm you will find considerable wasting of the biceps and triceps
nuscles, but this is in a measure due to disuse, rather than
rom the primary cause which has brought about this change in
he deltoid. I believe the change to be of central origin, anterior
\olio-myelitis of the lower cervical portion of the spinal cord; it
‘ame on with acute symptoms—fever, high temperature, great
vain, and some delirium ; these have passed away, the storm
ACTION OF ELECTRIC CURRENTS UPON MUSCLE AND NERVE. 81

has calmed down, and we are going to investigate the wreck
to see what remains of timber, spars, and rigging. It seems
to me that this is an excellent opportunity to demonstrate to
you the effects of the induced and continuous electric or
galvanic currents upon nerve and muscle, ina healthy and
in a diseased state.

I have told you that muscle can be excited by stimuli
independently of nerve; but in the living subject where we
find muscle and nerve in conjoint union and in a healthy
condition, the stimulus applied to muscle will be direct, in as
far as the muscle is concerned, but will act directly
upon the nerve, the nerve being the excitable and exciting
agent. If the continuity of the nerve fibres be destroyed or
deranged, the conduction of the impulse is either interrupted
or destroyed.

There is an important practical deduction to be drawn from
this fact. Strong stimulation causes fatigue in a healthy
nerve. .Too strong stimulation of a fatigued or diseased
nerve may utterly and irreparably destroy its conducting
power, no matter whether the stimulus be mechanical or
electrical.

An electrical current acts most powerfully upon a nerve at
the moment when itis applied and at the moment when it ceases.

If a constant current be applied to a motor nerve the
greatest effect is produced when the current is closed (closing
shock) and when it is opened (opening shock), if it be applied
as a stimulus to a sensory nerve the effect is most marked at
the moment of breaking the current.

We will, if you please, operate upon the healthy deltoid
muscle, first with the faradic current, and then with the
continuous current; note the reaction, and compare it with the
same muscle of the opposite side.

I now place this flat electrode (anode from the faradic bat-
tery) upon the vertebra between the shoulders, and this
carbon-covered electrode (kathode) upon the healthy deltoid
muscle ; you see the arm is raised by the stimulus so applied.
I now make and break the current by moving the hammer
with my finger; you will observe that no shock is felt on
making the current, but only on breaking it, when a single
contraction occurs. When the hammer vibrates rapidly, as it
does now (about fifty times a second), the muscle remains con-
tracted during the whole time of the flow. I now place the
earbon-covered electrode upon the diseased or wasted deltoid
muscle, and I get no shock, no muscular contraction. Let me
increase the strength of the current. I now, you see, get some
muscular contraction, though it is very slight, so little in fact
that I might say faradic excitability in this muscle is nee oe
82 MASSAGE AND INDUCTION.

let us see what will be the effect upon each muscle by the appli-
cation of the continuous or galvanic current. I place the
galvanometer in circuit, and use a current of eight milliampéres,
which I apply to the healthy muscles by means of my carbon
electrode as before. If you look at this battery you see I have
here what is called a current reverser, and by this means I can
alter the polarity of the current without removing the electrode.
You see now the current is broken, there is in fact disconnection
between the battery and the rheophores. Please follow my
movements carefully, and note the effect produced upon the
‘muscle, according as I make the negative current or break it;
the first is called kathodic closure, and is represented by the
letters KC; the second is called kathodic opening, and is repre-
» sented by the letters KO. Now I know perfectly well that this
» deltoid muscle will contract, for whenever I make the circuit,
» which I now do, the contraction of the muscle follows. This
is called kathodic closwre contraction (KCC). I now break this
_ negative current, and observe the muscle; there is a slight
< contraction, but it is very slight compared to the make. This
:, contraction is known as the kathodic opening contraction (KOC).
. So far, then, we have been dealing with the active negative or
& kathodic current. I will reverse the current and make it posi-
tive or anodic instead of negative or kathodic. Now, if you
please, I will make and break this current as I did the negative
E current. Watch the muscle whilst I make sharply the anodic
current; you see contraction follows, but not such a decided
- contraction as followed the kathodic make, but far greater than
' the kathodic break. This is called the anodic make or
# anodic closure contraction, represented by the letters ACC.
I now break or open the anodic or positive current, and the
muscular contraction so produced is called the anodic opening
F’ contraction (AOC).

’ These points with regard to muscular contraction upon
making or breaking the positive (anodic) or negative (kathodic)
currents are exceedingly interesting, and they admit of many
modifications which I cannot enter into now, but which I might
say are due to the strength of the current employed, and to the
power and nature of the resistance which it has to overcome
(conduction and diffusion).

As a rule muscular contraction is increased every time the
strength of the current necessary to obtain that contraction is
increased. For instance, kathode closure contraction (KCC)
-will be strong when obtained with the strength of current
necessary to excite an anodal closure contraction (ACC) or
anodal opening contraction (AOC), and very strong when com-
pared with that which is required to excite a kathodal opening
contraction (KOC).
ELECTRIC REACTION. 83

I must now, if you please, draw your attention to the un-
healthy or wasted deltoid muscle (so far we have been dealing
only with the healthy muscle). It really is a question if we
have any healthy muscular or nerve fibre here to deal with,
and from the absence of marked response to the faradic
current at different points, the conclusion is that the nerve has
undergone degeneration similar to the muscle itself. However,
we can in a measure solve the problem.

Bear in mind that muscle and nerve when diseased lose
their power of reacting to electrical stimuli in the same manner
that normal tissues do, so that we cannot hope to get the same
reaction in this wasted muscle, or even an approach to it, that
we got in the healthy muscle; anything like tonic or tetanic
contraction is completely out of the question. Let me tabulate
the reactions of the healthy deltoid muscle to the galvanic cur-

rent, so as to make the matter clear to you:
ACC; ,
i, KCC; a, { AGG} 8, Koc.

Now, if you please, let us see what the reaction to the
galvanic current of this muscle is. Our mode of operation
shall be precisely as before, but instead of using eight milliam-
pere current strength we will use fifteen, because I feel sure
that the stage of irritability has passed.

I now place the kathode upon the muscle. You see there is
no immediate response upon making closure, but after waiting
some ten or fifteen seconds, you may perceive four or five
rapid feeble contractions. I now reverse the current, from
kathode to anode, making closure as before, and you see pretty
well the same result; after a pause there are four or five feeble
contractions, and the contractions to the breaking currents,
both kathodic and anodic, are very doubtful.

Let us tabulate them, and compare the table with the
former one:

1, {AG Baa i 2, AOC; 3, KOC, scarcely appreciable.
Here we have, then, a good example of what is called the reaction
of degeneration. Faradic excitability very greatly diminished,
and galvanic excitability below normal. The prognosis is not
particularly hopeful, or was not before the days of scientific
massage; we will wait for a week, have the muscle massaged
well daily, and again test the reaction to both currents. I
shall call your attention to a somewhat similar case to this
and to others which have come under my treatment during the
past two years, and which have been treated by massage and
galvanism. .

Let me tell you at once, if you please, that massage is
‘endowed with wonderful power, not only in arresting muscular,
84 MASSAGE AND INDUCTION.

atrophic and nerve degenerative changes, but it possesses an
ability unique which no other agent does possess, in restoring
the nutrition and regenerating the growth of nerve and mus-
cular fibre; and when I tell you that cases of progressive
muscular atrophy which have been given up as hopeless have
been cured by massage, under my own daily observation, I am
quite sure you will agree with me that it should receive a definite
place as a therapeutic agent of the utmost value.

I should like to say afew words to you relative to the patho-
logical changes in this nerve and muscle which we have just
been testing electrically, and I do so with the more interest
because I feel certain that there is a stage in these degener-
ative changes of nerve and muscle which, if fully recognised

. and treated by massage, would completely revolutionize pre-

vailing views concerning the more or less incurability of these

. conditions.

We conclude that the circumflex nerve supplying the deltoid.

. muscle, which springs from the posterior cord of the brachial

plexus, that is from the sixth and seventh cervical roots, has
undergone degeneration in consequence of its nutrition being
impaired, owing to atrophic change in the motor cell or
corpuscle of the anterior horn of the grey matter of the
spinal cord, from which it takes its origin and receives its
motor stimuli; and we also have every reason to believe
that the degeneration and wasting of the muscular fibres are

due to defect in the nutritional or trophic nerve fibres which

oe
&

« accompany the motor fibres of the nerve. Thus the degenera-
- tion in the nerve is called ‘secondary.’ The inflammatory .

- action which originated in the grey matter of the spinal cord

may be rapidly transmitted throughout the whole of the nerve
to its intra-muscular nerve endings, and even to the fibrille of
the muscle; the changes which occur in the nerve are an over-
growth in its cellular elements, its nuclei and protoplasm,
whereby the nerve becomes segmented, and its conducting
power either partially or completely destroyed. It ceases to be
excitable, either totally or in part; infact its function is gone,
and it does not respond, as we have seen, to the faradic current ;
but according to the degree of loss of function so is its response
to the continuous galvanic current. When the nerve fibres are
in an active process of degeneration the nerve is in a state of
irritative over-sensibility, and it responds to a weaker current
even than it does in health, but the contractions are of the
most clonic kind and soon cease altogether. Now, if, as I have
told you, the trophic or nutritive nerves going to the muscles
follow the course and are in association with the motor nerve
fibres, it is evident that degeneration in the nerves must be
followed by degeneration and change in the nutrition of the
MUSCULAR PARALYSIS. ~ 85

muscles. This is the case. The first change is functional
atrophy, the second is molecular atrophy. The fibres become
granular, reduced in width, and lose to a certain extent their
striated outline, whilst the connective tissue is so increased that
a condition allied to cirrhosis results. I am anxious just merely
to touch upon this subject of change in nerve and muscle (de-
generation) because what I want particularly to point out to you
is this, that disintegration of a nerve and muscle may go on
either rapidly or slowly to a considerable extent, and yet by
massage, and I maintain by massage alone, regeneration can
be effectually established. According to Ranvier regenera-
tion is brought about by the growth of new axis cylinders from
the central end of the nerve which become finally covered with
myelin. If the nerve cannot be restored it is contrary to reason
to hope that the muscle can be repaired. Our first knowledge
of recovery of the nerve will be some increase in size and move-
ment in the muscle, then, following this, we shall have a degree
of response to the faradic current and to the kathodal closure
of the continuous current. You may think that I have, perhaps,
gone beyond my bounds in bringing this subject before you, but
I have given you a glance at one form of muscular atrophy from
organic disease, because there are degenerative and regenerative
changes in association with it having clinical features of special
interest ; and I cannot leave the subject of muscular atrophy
without again calling attention to other forms which concern
us more particularly from the massage point of view. Of
late years many forms of paralysis of muscle have been shown
to be due to degenerative and inflammatory changes in
the nerves and in their peripheral endings, without any
corresponding change in the spinal cord, and it is well that
these should receive some consideration from us, because
it is this class of muscular atrophy which of all others is
the most likely to be cured by massage manipulation, and even
if we feel sure that we cannot cure these conditions, it is by no
means certain that we cannot arrest their downward course by
massage. Therefore, if you please, I will take these forms of
paralysis and muscular atrophy in the following order—

Muscular Atrophy, chronic.

Muscular 55 idiopathic.

Muscular 3 pseudo-hypertrophic (?)
Paralysis < Muscular re from disease.

Muscular » from over-use.

Muscular - from joint affections.

Muscular 5 from multiple neuritis.

“ Alcoholic,” “lead,” ‘‘diphtheritic,”’ ‘‘ diabetic,” and “ hysteri-
cal paralysis.”
86 MASSAGE AND INDUCTION.

My remarks concerning these various conditions must
necessarily be very brief, and I would rather merely name them
to you than give you, as I am compelled to do, a very imperfect
description of them, did they not present signs of different in-
terpretation. In all kinds of muscular atrophy, no matter
whether of central, peripheral or intrinsic origin, defect of nutri-
tion isfrequently a primary and important factor ; and although
we are unable to treat in a direct manner an inflammatory
change in a nerve centre, yet, seeing that the periphery of a
nerve is the direct continuation of that centre, we are fairly
and reasonably permitted to arrive at the conclusion that we
can indirectly influence that centre, with regard to its blood and
nutritional supply, through its periphery, by those manipulation
and galvanic processes with which we are now familiar. Nine

tenths of the spinal diseases with which we are acquainted

«have a peripheral origin. A blast of cold air over a given area
of skin will, in one case, inhibit the vaso-constrictors and pro-

‘duce dilatation of vessels asin erysipelas ; but, in another case,
the impress upon the skin is not necessarily potential, it travels
along the nerve to its centre, and produces the same effect in
that centre which it otherwise produced in the skin. This isa
subject of great interest, and one concerning which I could say
a great deal, but I must without further remark bring the
muscular paralysis under your. notice.

First, with regard to chronic muscular atrophy, let me tell
you at once that this disease when fairly established has
been looked upon as incurable; it is called progressive
because its onward march, though slow, leads to a serious and

in fact fatal issue. You may as well massage and galvanize |

a bone deprived of its periosteum as massage and galvanize a
“patient with progressive muscular atrophy after the disease has
arrived ata certain stage. Butit never should arrive at this
stage ; loss of function and of power to perform certain definite
movements are the first indications which we have of this fear-
fulandintractablemalady. Massageandavery weak continuous
current and passive automatic exercise at this period will check
its onward progress and arrestits fatal issue. It may originate in
the bulbo-spinal system, in the pyramidal tracts, or in the eord
alone at any level, or it may originate in the lower cells of the
kinesthetic area of the cerebral cortex, the fibres from which
take a definite course through the internal capsule to the
pyramidal tract, and thence to the antero-lateral columns of
the cord, giving rise to amyo-trophic sclerosis. This latter
form of muscular atrophy is more common in women, the
former is more common in men. Hysteria, as you know, is
much more frequent in women than in men, and I wish you to
remember that you may have signs simulating lateral sclerosis
MUSCULAR ATROPHY. 87

in hysteria which are really due to some functional derange-
iene in the cells of the lower level of the cortical area of the
rain.

The form of protopathic muscular atrophy which we are
now considering generally commences in the arms or in
the shoulder, or it may be in the muscles of the hand,
particularly inthe muscles of the eminence of the thumb.
(The photograph I now show you is that of a young girl
aged fourteen, a hospital patient. You can see almost
complete atrophy of the muscles of the ball of the thumb; she
was under galvanic treatment at several hospitals, and galvanism
alone did not arrest the disease. I have not seen her for some
time, but when she left, after three months’ treatment by mas-
sage and static electricity, a very marked improvement had
taken place, so, if not cured, I think we might say that the on-
ward progress of thedisease has been arrested by massage when
other means had failed). Depressions are soon seen between
the metacarpal bones on the back of the hand, and then the
flexors of the arm become involved, the flexors usually before
the extensors; and Imay say that this is almost peculiar to this
form of paralysis, for, asa rule, the extensors of the forearm give
way before the flexors. I need scarcely tell you how the
various muscles follow suit, or how parts become distorted,
owing to the paralysis of certain groups of muscles over other
groups, but I must just refer you to the sensory symptoms which
are insignificant when compared to the motorial derangements,
though these, such as they are, often give the patient a great
sense of distress. I remember a man some years ago at the
Central London Sick Asylum with almost complete atrophy of
the muscles of the upper extremities and the shoulders, who
complained sadly of aching, wearisome, rheumatic-sort of pains
in these members and in the spine, where rubbings always
relieved him immensely. I regret to say that I knew nothing
of massage in those days as I know it now, and I can well re-
member going round the wards at that time with my hypodermic
solution of strychnine and my galvanic battery, but, alas ! Icould
neither cure nor relieve these unfortunate sufferers. Had I then
known how to practise massage with and without galvanism as
I donow, I am quite sure, and I speak with all sincerity, the
case would have been very different.

Iam not going to take up your time with any remarks
concerning idiopathic muscular atrophy, suffice it to say
that it is a rare affection, unassociated with disease of the
spine, that it frequently begins by wasting of the muscles
of one side of the face, never of the ball of the thumb,
hand or forearm. The flexors of the arm and of the leg
are always weakened and atrophied before the extensors ;
88 MASSAGE AND INDUCTION.

whilst the glutei stand out with remarkable prominence, firm
and hard. I have a gentleman patient, aged twenty-five, suffer-
ing from this peculiar affection ; he has consulted the leading
members of the medical profession, not only in this country, but
upon the continent; hitherto the disease has been steadily
advancing, but he has promised to place himself under my
care for massage treatment, so I hope we shall have an oppor-
tunity of testing its merits.
The next form of muscular paralysis is what is called
spseudo-hypertrophic. It is congenital in its origin and nature
and is consequently associated with childhood; I have, however,
seen several cases in early manhood. It rarely affects girls; I
. have had nine cases under my care, all boys. The condition
“~when once seen and observed can never be mistaken ; if you
“have any doubt about the diagnosis, lay the child upon his
‘-back and tell him to rise. The calves and the buttocks are
“yemarkably hard and firm. As the disease advances so the
muscles atrophy, and all kinds of deformity are the result. Dr.
Gowers, in his work on the spinal cord and nerves, has given
an original, completeand diagrammaticaccount of this affection
to which Imustrefer you. Up to the present I regret that I have
“not (since my massage experience) had any of these cases that
F could put well under treatment, but I am very anxious to
have some, for I believe massage manipulations are likély to
be .effective, provided they are adopted early enough in the
course of the disease. ;
- Let me now call your attention to muscles wasted and atonic
_from disuse. This condition is one of atrophy, but it differs
“very materially from those forms of atrophy which we have
just merely referred to, because there is really no organic
“change in the muscles or in the nerves; still the muscles are
weak and almost powerless from defective nutrition, and in
these cases massage will soon restore them to their normal
state. Your services will often be required to effect this object.
After a fractured limb has been incarcerated in splints or plaster
of Paris for a month orsix weeks you will find it (in some people
more than in others) wasted and withered. Take for instance
a case of Colle’s fracture of the forearm, where it has been
necessary to adjust a pistol splint with some exactness and care
for a given period of time to prevent deformity arising, the
joints are dry, the skin is shrivelled, the muscles are flabby, -
and the extremity is stiff, the circulation has been impeded, the
digital and wrist movements are almost impossible, and when
attempted are accompanied with great pain. The surgeon has
done his work, the bone is united, but the part is practically
useless. You have here an excellent opportunity of restoring ,
the limb to its healthy condition in as many days as it would —

iat
MUSCULAR ATROPHY. 89

otherwise take weeks if left alone. Again, the orthopedic
surgeon will often require your services. It is the practice
after the division of tendons to adjust some form of steel ap-
paratus to keep the foot in position. The muscles after the
tendons are divided have a special tendency to waste more than
they had before the operation. Now massage is imperatively
demanded in such cases as these ; I have often told you that 1]
should give these patients a great deal more massage and much
less steel. There is sucha condition as muscular atrophy from
over-use, but this is not common. It is probably caused by
strain of an undue kind upon the nerve, and we know also that
some athletes who are men of pluck rather than power, good
for a spurt rather than for distance, are not unfrequently the
subjects of muscular atrophy and general paralysis of the
insane. Just as a man can break down mentally from
mental over-work and utterly destroy a fine intellect, so in like
manner can he break down physically from over physical work
with resulting physical change in muscle and nerve.

I shall speak of muscular atrophy in association with joint
affections when I am lecturing upon joints. (See Lecture XI).

I have an opportunity this morning to show you three forms
of muscular paralysis of the forearms, each presenting different
features, and all three are rapidly improving by massage and
electricity. We will compare these three cases and consider
the different signs and symptoms which each form presents to
us. I will take the least complex first. This man, aged thirty-
nine, is suffering from lead palsy. He is a painter, and you can
see the lead line of a bluish black colour along the alveolar
margin of the gums. Only the right hand and forearm are
absolutely paralysed, but the grasp with the left hand is quite
as feeble as with the right. The hand drops from the wrist,
and he is unable to extend the fingers. There is no defect in
sensation, neither is there any pain. Please remember these
two points, for I wish my observations to be accurate, though
they must of necessity be very brief.

This man, aged twenty-three, who had well marked secondary
symmetrical atrophy of the upper extremities, is also a painter ;
but if you look at the gums you will find no trace of lead, and I
really doubt if lead had anything to do with it. About four
months before I saw him he began to suffer from muscular
pains of the forearms and shoulders, what he called ‘‘ rheumatic
pains”; in a short time both arms became weak, and he was
unable to raise them without difficulty, the hands then became
weak, he could not lift a weight from the ground, neither could
he co-ordinate the movements of the forefinger and thumb to
write or to button his coat. The paralysis increased until the
arms and the hands were almost useless. When I saw him on
0 MASSAGE AND INDUCTION.

he 12th October, 1887, the muscular wasting of the arms
vas perfectly symmetrical; the deltoids were flattened and
ukmost powerless, so that he raised the arms by jerking up the
thoulders ; when he attempted to grasp he did so by fixing the
shoulders and throwing the heel of his hand into the part ; the
ingers were scarcely at all under his will; the muscles of the
yalls of the thumbs were greatly atrophied ; when told to extend
‘he hand it was only partially raised at the wrist ; the terminal
dhalanx of the thumb was flexed, the proximal phalanx was
lrawn outwards ; the forefinger and the little finger were par-
ilally extended, but the two middle fingers were flexed and
dowerless (this pseudo claw-like hand is characteristic) ; the
muscles of the forearm were wasted; he had been galvanised
vy the family medical man, but the arms became more power-
ess. We commenced in October to treat the muscles by mas-
sage and galvanism, and from that time I may say the disease
was arrested. At the present time he is all but cured. The
itrophied muscles are now well developed, in fact every single
ind combined muscular movement is almost completely under
us will, and he is following the occupation of a clerk. Who can
loubt the influence of massage in restoring muscular power
ifter such an instance as this? It is, however, only one of a
aumber of which I have records.

You see this man as he is now with power restored him, but
aad you seen him (which I wish you had) when I first did so
ihe contrast would have been implanted upon your memories
‘or life. He is a sharp, bright, intellectual fellow, and felt duly
ind thankfully the influence which the treatment was having
ipon him, the more especially as he had been told that there
vas little chance of his recovery.

It was very interesting and almost amusingto see the delight
with which he hailed the advent of some movement which mas-
sage had called back into existence. -He would say “‘ Look, sir,
( could not do that a week ago, it would have been impossible!”
The movements of single muscles were the first to return, the
sircumflex nerves (after the median) gave evidence of return to
iormal activity by the restoration of the deltoid muscles, then
followed the flexors of the wrist, and after these the extensors.
The last to regain their normal power were the muscles-of the
ihumb, the thenar muscles in particular. The reaction of de-
yeneration test was marked so far as all the nerves of the
brachial flexors were concerned, but particularly the nerves
of the posterior cord (circumflex and musculo-spiral) ; the
sranches of this nerve were the first involved and the last to
yet well. It was a great day for him when he could button his
waistcoat and hold a pen. In this case, as in the other, there
was no loss of sensation and no severe pain.
MULTIPLE NEURITIS. 91

I now show you another case (the patient is a female, aged
twenty-seven), where the objective signs are very similar to the
last, but the subjective symptoms are very different and distinc-
tive. It is a case of ‘‘ multiple neuritis.” You observe in the
two former cases there was no defect of sensation and no pain,
the motor area of the nerves being alone involved. Here we
have an inflammation of the trunks and peripheral ends of
the spinal nerves involving both their functions of sensation
as well as motion, so that we not only find motion interfered
with but sensation also. This woman, about six months ago,
awoke in the morning with numbness, tingling, and burning
pains in the fingers and hands; these were soon followed by
defective power, so that when she was sweeping the floor the
brush would, as she called it, fly out of her hands; the left
hand was affected a week or so before the right; toward the
after part of the day, and especially when the hands get warm,
she has fairly good use in them. She will tell you that she
suffers very much from cramps, with burning pains in the
muscles of the calves of the legs and the toes; these come on
particularly at night and in the early morning. Sometimes
her feet feel as though they were on fire, although to the
touch they are very cold. We have here, then, a case of
symmetrical multiple neuritis, and the chief signs are defect
of power in the arms and in those muscles supplied by the
musculo-spiral nerve; defect of the anterior muscles of the
legs, only slight compared to the defect in the arms; inability
to extend the wrist and the fingers; some wasting of thenar
muscles and extensor muscles of the forearms, accompanied
with loss of sensation, more marked upon the extensor surfaces
of both arms, hands, and legs and feet; there is also great
pain experienced when too great pressure is made along the
course of the nerves, as well as subjective pains to which I have
referred ; and if you look at the face you will observe that the
mouth is slightly elongated, giving the countenance a smiling
aspect. I have no doubt that both facial nerves are symmetri-
cally affected here, though this, by the way, is not common.
She has now been under massage and electric treatment for
more than two months, the painful sensations and cramps
have disappeared, the nerves when pressed upon are scarcely
at all tender, and muscular movement has decidedly improved.
Therefore, let me advise you once more of the fact, that for
multiple neuritis you have an excellent remedy in massage
and galvanism.

I had an exceedingly interesting case, which upon more
than one occasion rapidly yielded to treatment by massage
and galvanism. I find that I have headed it in my note-
book, Diabetes, Neuritis of Arms, Dystrophy of Muscle and
92 MASSAGE AND INDUCTION.

Skin, Neuralgia. The subject was an elderly lady, sixty-four
years of age, with pronounced diabetes and fondness for
alcoholic drinks, who consulted me for this and for want of power,
and general weakness in the arms. She remarked, I have no
thirst when at rest, but the slightest movement brings on a feeling
of exhaustion and intense thirst. At times she would have
feverish attacks and become utterly prostrate with all her
diabetic symptoms more pronounced. All the nerves of the
arms and forearms—the musculo-spiral more particularly—to
their periphery would become exceedingly tender upon pressure,
accompanied with shooting pains; and in the course of a fort-
night the palms of the hands would peel like a person
recovering from scarlet fever, the dorsal surfaces of the
hands become brown, and finally the skin would have the
appearance of white parchment. As the feverish attack
passed off in the course of a few weeks, nutrition reasserted
itself, and the skin resumed its natural aspect.

There was marked tenderness along the course of the spine,
and subjective symptoms too numerous to mention. Massage
not only restored power to her muscles, but promoted nutrition

snerally, and decreased the amount of sugar in the urine.

‘I have now to call your attention to a form of paralysis
where massage and galvanism is pre-eminently the essential
mode of treatment. I shall deal with hysteria in a future
lecture, so that at the present time I refer only to those
functional and inhibitory processes of the nervous centres
resulting in defective will power over voluntary muscular action
and voluntary control.

This is an extremely wide, interesting, and important sub-
ject, and one, by the way, which is ill understood by many.
It is unfortunately too true that many cases of hysterical

ensory and motor derangements in the muscular system have
been looked upon as due to organic disease, and what is still
more serious, organic changes have been considered as due to
hysteria; and this is in a measure excusable, because organic
changes in the nervous system may be masked by hysterical
manifestations. I have even seen cases of right hemiplegia in
men, with complete aphasia, where emotion was most profound,
and directly they were spoken to they would laugh or ery much
as a highly hysterical woman would do. Therefore we have
to guard against what may be an error of diagnosis; for in
the one case our massage and electric treatment is curative,
in the other case it is absolutely useless. I must, however,
leal briefly with this subject, for to treat it exhaustively
would take me completely away from the true object of my
remarks. A common form of hysterical paralysis is that
which often occurs in young women, “ Hysterical loss of
HYSTERICAL PARALYSIS. 938

phonation.” They can only speak in a whisper, although it
may be they can sing well. They try very hard to speak, but
the effort of will meets with no response. Faradization to
the palate and vocal cords and massage (laryngeal gymnas-
tics) is an infallible cure.

Hysterical or functional paralysis of the limbs may take
the form of hemiplegia and paraplegia, the latter is much the
more frequent. I need scarcely say that this affection is much
more common in women than in men. That men suffer from
hysterical paralysis is an undisputed fact. Hysterical hemi-
plegia is usually of the left side, and frequently in hysterical
paraplegia it is more pronounced in the left leg than it is in
the right. The onset of loss of power is generally sudden,
usually from shock, which disturbs function and arrests
nutrition, contractions and tremors are common, ataxy is often
associated, the reflexes are normal or slightly exaggerated,
usually the latter, and there may be retention of the urine.
Electric irritability is normal. Gowers says, ‘‘ So constantly
is this true, that the nature of the rare cases in which a
marked change in electric irritability has been found is open
to grave doubt. As a rule there is no clonus. This is
characteristic of hysteria. When thereis a true characteristic
clonus it is probable that there is a considerable alteration
in the nutrition of the motor elements, although this may
have arisen from a primary functional disturbance.’ Spasms,
tremblings, and tremors, tonic and clonic, are common to
hysterical paralysis.

M. Charcot, who has had unrivalled opportunities for study-
ing these nervous states, applies the term ‘contracture ”’ to
that condition in which the muscles become rigid in tonic
spasm, fixing a limb or limbs in a certain posture for a few
minutes or for a much longer time. The contracture may,
without leaving any trace of its existence, disappear in a
few days, a few weeks, or even a year or more after its appear-
ance.

M. Charcot remarks (1,) ‘‘ That in hysterical hemiplegia
there is an absence of facial paralysis and of deviation of the
tongue when that organ is protruded.

(2,) The existence of an analgesia and of an anesthesia,
which may be termed absolute, extending over the entire
paralyzed half of the body, and consequently occupying the
face, trunk, etc. This alteration of sensibility involves not
only the skin, but also the muscles and perhaps the bone—it
stops exactly at the median line.

This kind of generalized anesthesia, occupying a complete
half of the body—head, trunk, and members, this quasi-
geometrical limitation of the anesthetic portion by a vertical
4 MASSAGE AND INDUCTION.

lane, dividing the body into two equal parts, are as it were
he peculiar property of hysteria.’

Hysterical paraplegia, with contracture (Fig. 21) and
deformity of the feet, resembling that of
talipes equino-varus, claims passing notice.
The contracture often succeeds an hysterical
fit; it persists during ordinary sleep, and
is only relaxed by the deepest chloroform
narcosis. When contracture takes place in
the upper limbs the arm is fixed in flexion.
When it occurs in the lower [limbs the legs
are extended (Fig. 32). Sometimes exten-
sion is so marked that the dorsum of the
foot is in a line with the front of the leg,
the flexor spasm of the foot which occasion-
ally accompanies organic disease is rarely
met with in hysteria. Charcot relates
several cases in which severe rigidity of
very long duration was removed by strong
emotion, and Gowers says that sometimes
: the effect of faradization is instantaneous.

Fig. 21. Hysterical ‘‘ One patient was thus cured in a moment,
ontracture of inferior but months later relapsed, and then all
xtremities. treatment failed until she fell into the hands
f a ‘miracle worker,’ at whose touch the spasm vanished
wnidst the plaudits of a public audience.”

Dr. Laycock, in his treatise ‘‘On the Nervous Diseases of
Women,” remarks that a woman may have been bedridden
or several months and quite unable to use her lower extremi-
les, the physician may have given up all hope of being of any
issistance to her, when suddenly under the influence of some
yotent moral cause she will be seen to rise from her bed, “no
onger the victim of nerves, but the vanquisher,’”’ as Thomas
Jarlyle says, and walk about as well as if she had never been
stricken with paraplegia. This is one of the terminations of
rysterical paraplegia which the physician should never lose
sight of, and which well shows what risk he runs in pronounc-
ng a case of this kind to be incurable.

Tremor, clonic spasms of the lower limbs, with or without
sxontracture, are frequent, and resemble the tremor accom-
oanying disseminated sclerosis.

I need scarcely say that all forms of hysterical paralysis
io which I have merely called your attention are particularly
wdapted to massage treatment; but this is a large and almost
nexhaustible subject, so I must pass on now, if you please,
i0 the consideration of neuralgias. And here again I must
repeat that in these troublesome affections, massage, either

 
NEURALGIA. 95

with or without galvanism, is pre-eminently useful. I have
spoken to you of neuralgias of the fifth and cervical nerves,
so that now I shall confine your attention to some other forms
of neuralgia which are extremely common, and which, by. the
way, are frequently very persistent and unyielding to drugs.

Neuralgia, as the name indicates, is a painful affection of a
nerve. It may arise from a gradual alteration in the molecular
nutrition of the axis cylinder, changing its excitability and
conductivity. This is perhaps the most common cause, for
neuralgia, as Romberg tritely expresses it, is the ‘‘ prayer
of the nerve for healthy blood,” and the fact that neuralgic
pains have a strange and constantly recurring periodicity is
substantial evidence in favour of this statement.

Neuralgia may be due to a chronic inflammation (sub-acute)
in the outer sheath of the nerve (perineuritis), in the connective
tissue between the bundles (interstitial neuritis), or in the
nerve fibres themselves (parenchymatous neuritis). Sub-acute
inflammation is equivalent to vaso-motor disturbance, both
conditions may lead to leucocytal infiltration of the textures,
malnutrition, atrophy and degeneration; and although a
nerve possesses the property of regeneration and repair in a
marked degree, still its functional integrity for the exercise of
prolonged strain after inflammatory change, is rarely, if ever
restored to its normal primitive standard. We can scarcely
believe that a nerve is diseased without the centre from which
it arises being likewise involved.

Neuralgias are sometimes due to injury (traumatic), or from
pressure, as they pass through bony foramina, or to morbid
growths in their neighbourhood. It is unquestionable that
neuralgias are associated with a “neurotic diathesis,” and that
they frequently originate from some cause which lowers the
vitality, the metabolic processes and the normal blood status.
I would put these causes before you as extrinsic and intrinsic ;
extrinsic in the form of malaria, exposure to vold, lead poison-
ing, prolonged fatigue, excessive anxiety, worry, mental strain,
sewer gases, vitiated air, and sudden atmospheric changes:
intrinsic, such as acid dyspepsia, diabetes, glycosuria, gout,
rheumatism, and hereditary predisposition. Women are much
more liable to neuralgias than men. But please remember,
that just as there are types of individualities so there are types
of neuralgias affecting certain centres of evolute nerve levels,
from the cerebral cortex to the lowest spinal centre and nerve
ganglion. To speak of neuralgias in reference to temperament
is merely begging the question which it is impossible for me to
discuss now; when I talk to you about pain, I hope to make
my meaning clear to you. I must make you acquainted with
the diffusion, the conduction, and the radiation of these neu-
96 MASSAGE AND INDUCTION.

ralgic pains ; and in massaging you will have to remember the
rough anatomy and distribution of the ordinary nerves which
are most commonly affected, I mean the fifth and cervical
nerves, the brachial plexus and its branches, the intercostal,
the lumbo-sacral, the sciatic and its branches, and the
anterior crural. Of course, I need not remind you that the
spinal cord is the source of these nerves, but I must ask
you to remember this, that a localized neuralgia specially.
demands spinal as well as general localized massage. Iam
quite sure, after what I have told you of the anatomy and
ganglionic distribution of the nervous system, you will compre-
hend how easy it is for us to have sympathetic or referred:
neuralgias. 1 explained this to you when dealing with the fifth
nerve. There is no organ in the body which may not be the
seat of a neuralgia in itself, or of experienced pain by sympathy.
As instances I might quote cardiac, gastric, hepatic, ovarian,
uterine, cystic and many other visceral neuralgias. You might
know that in incipient hip-joint disease the pain is referred to
the inner part of the knee. Gastric neuralgia might be referred:
to the head or to the heel; so that by massaging the periphery
of a nerve you are influencing, not only the nerve itself, but
also nerves which are in association with it by ganglionic
connections, as well as stimulating cerebral and spinal reflex
centres. Ifareflex act be called into existence by some sensory
impression, the efferent nerve conducts the energy which
results from the sensory stimulus, but when the energy so
generated meets with undue resistance in the centripetal nerve,
the centre becomes surcharged and over-excited, and undue
tension in the centre from confined energy is the result, which
reacts upon the sensory fibres and gives rise to pain, so that
the nerve centre is in fact the seat of the pain which may be
experienced along the course of the nerve and its periphery, or
on either singly. A neuralgic condition of a nerve may give
rise upon pressure on some part of its course to painful spots,
and by these painful spots we can trace the nerve to its origin
in the spinal cord, and tenderness of the vertebral spine
corresponding to the origin of the painful nerve can frequently
be elicited. I must without further remarks at once direct
your attention to the special neuralgias which we must consider
in this lecture, and the special kinds of massage necessary for
their cure.

Cervico-brachial Neuralgia corresponds to the distribution of,
the brachial plexus of nerves which arise from the cervico-dorsal
portion of the spinal cord. The parts usually affected are the
shoulder, the arm, the forearm, and the region bordering
the spinous processes of the four lower cervical and two upper
dorsal vertebre. When painful spots exist they are usually
MASSAGE FOR NEURALGIA. 97

found on the shoulder and supra-scapular fossa and the lower
angle of the scapula, also in the axilla, the flexure of the elbow
and inner condyle, and at the points of exit of the branches of the
musculo-cuéaneous nerve and of the ulnar nerve, along the course
of the radial nerve, as well as at the wrist joint. A common focus
for pain is four or five inches above the outer condyle, over the
musculo-spiral nerve. It may radiate to the chest and pectoral
muscles, and simulate angina pectoris. This is one of the most
common forms of neuralgia; it is paroxysmal, and interferes
with the movement of the arm, because any extension or back-
ward movement starts the pain. It may exist with rheumatism:
of the shoulder joint, but not unfrequently this joint becomes
stiffened more from disuse than from any other cause, and if
such be the case, all adhesions in the joint must be broken
down before massage is commenced ; therefore, if you please,
gee that the movements of the shoulder are free,—rotation,
abduction, adduction, elevation and backward movement.
Having made yourself sure that the shoulder-joint is free,
you massage the extremity in the ordinary way, by effleurage
and petrissage manipulations, and passive movement of every
joint; you then pick out the seats of pain, and you petrissage
them carefully, increasing your pressure until the pain is gone;
this process to the patient may be productive of some discom-
fort. You will find a mixture of equal parts of chloroform and
castor oil an exceedingly good lubricant; it has the effect of
deadening the acuteness of peripheral pain, and it will also
allow you to make your movements with greater freedom. In
this, as in all other forms of neuralgia, do not be rough or cruel
to your patient by forcible efforts, for I do not believe that you
gain anything by it. Itis of course impossible to avoid giving
your patient some pain, but mitigate it as much as you can.
If the arm is so painful that the necessary manipulations
cannot be borne, my practice is to inject a half-grain of morphia
into the deltoid muscle before operating, and in the course of
half an hour movements can be effected which could not
previously be tolerated. In all neuralgias it is best, as far as
you can do so, to put every muscle into a state of absolute
contraction and extension. For the first three or four days do
not let your patient make any voluntary movement of the
affected limb, but as the arm becomes less painful, graduate
volitional movement day by day of all muscles until the normal
action is restored. Then strengthen the limb by labile faradi-
zation (very weak). Never use the faradic current until the
pain is decidedly diminishing; but you may from the first use
the galvanic continuous stabile current, placing the kathode
upon the inner side of the arm, and letting the patient hold the
anode in the hand of the same side. The current must ue be
98 MASSAGE FOR NEURALGIA.

strong (five to seven milliampere), neither must it be inter-
rupted. :
- Newralgias of the trunk of the body are specially referable to
the dorso-intercostal and to the lumbo-abdominal nerves.
I must draw your particular notice to intercostal neuralgia, and
especially to that form which frequently affects elderly people,
it is sometimes associated with shingles and sometimes’ with
glycosuria. During the past twelve months I have seen seven
cases of this form of neuralgia where nothing but twenty grain
doses of antipyrin with three grains of quinine relieved the
pain, and then only for a very short time.
In one particular case where other drugs had been ad-
ministered by one of our most skilful physicians, all failed to
give any but the most temporary relief. In the case referred
.to the old lady would at times become distracted with the ap-
parent agony of the pain, which came on with great severity in
the evening. You mustdraw the distinction between intercostal
neuralgia and pleurodynia; the latter is localized, and does not,
like the former, take the courseor exit of the intercostal nerves.
“Intercostal neuralgia is not often bilateral, it is usually confined

to one side, and to those nerves running along the intercostal

spaces from the second to the tenth. If pressure be made over
the spinous processes of the vertebra corresponding to these
_nerves, great pain is frequently experienced : the pain is generally
very acute, burning, scalding, stabbing, are terms frequently
applied to it; the patient’s rest is disturbed night after night,

so that every function is deranged by the continuous administra-

tion of narcotics and sedatives.
I know of but one remedy for this form of neuralgia, and that
is massage and the continuous galvanic current; but both
“require special application, local and spinal; I have seen both
fail because they were improperly and injudiciously applied.
Then, if you please, do not faradize ; if you do the effect will be
unsatisfactory : 1 speak from experience. The first thing to be
done is to localize the nerves which are the seats of pain, from
the vertebral spine to the periphery. Galvanize first and
massage after, in the following manner. Get two flexible flat
electrodes, the one narrow and about four inches in length, the
other about six inches by three; let them be well moistened
with hot water and a very small quantity of dilute acetic acid ;
make the former the kathode, and the latter the anode; the
positive electrode must be placed upon the ribs and the negative
electrode to the mid-dorsal region of the spine; bind them to
the body by means of a soft flannel bandage. Now make your
connections, having the galvanometer in circuit, and never use
more than two milliampére current strength. This must be
kept up for half an hour ; alternate current and continue for
MASSAGE FOR NEURALGIA. 99

another half hour, then remove the electrodes, wipe the parts
dry, and massage between the ribs from the vertebra towards
the sternum ; each intercostal space must receive the most
careful attention ; every particle of skin should be picked up
and petrissaged with extreme care between the tips of the finger
and thumb, and then the intercostal spaces should be pressed
very patiently and firmly ; and, lastly, rub briskly into the parts
the mixture of castor oil and chloroform. This treatment
must |be continued daily until the pain has ceased. It is
usually mitigated after the first operation.

Lumbo-abdominal newralgia is of course usually found in thelum-
bar region ; sometimes it extends around the abdomen. It varies
from lumbago and the backache of women by its foci of pain
and tender points which are situated by the vertebre at the
back along the iliac crest and at the lower border of the rectus
muscle. The usual treatment for these forms of back pain is
the samein all threecases. The continuous current, of about five
milliampére strength, should be applied to the loins by means
of a large sponge electrode (kathode), such as I now show you,
whilst the anode is applied to the hypogastric region. Let the
current be maintained for half an hour, then reverse the current
and continue itfor ten minutes ; after this petrissage and tapote
the muscles thoroughly. This form of neuralgia might be “re-
ferred,” its cause being some abdominal growth or reflex of the
uterus.

Sciatica and Crural Newralgia.—These two neuralgias of the
buttock, thigh, and leg are of great interest to us from the
massage point of view. Let us take sciatica first. The sciatic
nerve is as you know the largest nervous cord in the body, and
supplies nearly the whole of the integument of the leg, the
muscles of the back of the thigh, and those of the leg and foot,
it also supplies the hip joint.

The crural nerve supplies the muscles on the front of the
thigh, sends cutaneous filaments to the front and inner side of
the thigh and to the leg and foot and articular branches to the
knee. The treatment of these forms of neuralgia is so similar
that it may be considered both at the same time.

I quite agree with Dr. Gowers who states that the vast
majority of cases of sciatica are really cases of neuritis of the
sciatic nerve, yet I have seen a number of cases which are
essentially neurosal rather than neuritic. Unquestionably gout
and rheumatism are common factors of this condition, and just
as we find a brachial neuralgia associated with a rheumatic
condition of the shoulder joint, so do we see cases of sciatica
associated with gouty and rheumatic changes in the hip joint.
Its exciting cause is exposure to cold and damp, sitting in wet

seats, such asone frequently finds in hansom cabs, or on wet
crass and dawn evannad es
100 MASSAGE FOR NEURALGIA.

. It generally commences with slight pain along the back of
the thigh, which is sometimes accompanied with tingling and
formication. The whole course of the nerve may be acutely
tender upon pressure, the pain is invariably increased by move-
ment. When we take into consideration the wide distribution
of this nerve, we can easily understand the reason why pain is
often experienced at different parts of the leg, notably near the
iliac spine, the sciatic notch, the lower third of the thigh, the
back of the knee, the head of the fibula, the outer malleolus
and the back of the foot, &e. The onset of this affection ig
often attended with fever, general malaise, and sleepless nights.
When the disease is persistent for months, and particularly if
the hip joint grows stiff, the muscles become flabby, weak and
wasted, and when such change takes place it seems to affect all
the muscles, buttock, back of thigh and calf of the leg. In
these cases the nerve has undergone some degeneration, and is
altered in its electrical reaction. I have seen several such, and
cure is almost out of the question. But we have to consider
ordinary cases.

Crural Neuralgia is an affection of the nerves of the front of
the thigh, leg and foot. I have not seen many cases of this,
but I happen to have one under my care at the present time.
He is a gentleman about thirty-nine years of age, who, after
getting wet and standing about in his damp clothes, first ex-
perienced pain which was not very severe and which hethought
was rheumatism in the left hip joint. After this he had what
he called wandering pains in both testicles, and then followed
very severe and excruciating pains in the right inguinal region,
extending to the testicles and right hip. It then spread to the
anterior and inner part of the thigh (he said the upper part of
the thigh seemed to himas though it were bound by a cord), and
to the anterior part of the leg and foot down to the instep. All
the front of the leg was extremely tender to the touch. He was
confined to his bed for nearly a month, and no form of
medicine did him any good until, at my suggestion, he took
twenty grain doses of antipyrin with three grains of quinine
three times a day in milk. He subsequently came under my
care for massage.

Now there are one or two points of value to be considered in
reference to the treatment of these cases. In the first instance
(acute stage) I should advise antipyrin and quinine to be given
so long as the acute symptoms last, and if the condition be-
came persistent and chronic the sooner they were under our
care for massage and galvanic treatment the better for them.
No doubt many cases of chronic sciatica disappear in an
almost miraculous manner by the injection of ether or the ap-
plication of blisters, and so on; but a very large number get
MASSAGE FOR NEURALGIA. 101

nothing more than relief from ordinary treatment. I have
notes of many cases, which were ultimately cured by massage
and electricity and extension movements only.

In cases of sciatica and neuralgia of the crural nerves the
treatment is somewhat similar. I am not in agreement with
the heroic treatment adopted by Schreiber, although I am quite
willing to admit that after the inflammation (perineuritic) has
subsided adhesions exist which demand active straining and
stretching, and until these are broken down neither nerve nor
muscle can perform its function aright. If there be no evi-
dence of central disease, and the pain becomes chronic and can-
not be relieved in any other way, I think it is quite justifiable
to cut down upon the sciatic nerve and thoroughly stretch it,
but therecan be no doubt that stretching the nerve can be
effected by forcibly flexing the thigh of the diseased side upon
the abdomen of the opposite side in the manner I now show
you (Fig. 15). And this, if necessary, should be thoroughly
and effectually done whilst the patient is under chloroform,
before massage manipulations are commenced. - This operation
sometimes relieves the. nerve, and the patient feels better
at once.

The limb must be massaged in the usual way and all joint
movements thoroughly carried out after the manner I have
shown you. I find it a good plan to flex the thigh upon the
abdomen and use hacking movements over thenerve asitissues
from the sacro-sciatic foramen. I prefer after massaging the
limb in the customary way, from below upwards, to work at the
nerve from above downwards, using careful and very complete
pressureupon it as it descends between the trochanter major and
tuberosity of the ischium. With regard to the application of
electricity, so long as there is pain upon pressure along the
course of thenerve, I never faradize, and remember, if you please,
that I never apply the faradic current.to the nerve if there is
evidence of some nerve degeneration. I have seen two cases of
this kind where there have been nerve degeneration and muscular
wasting, when after a strong faradic current the function of the
nerve has become lost, and irreparably lost ; so I always use the
continuous current, making my patient sit upon a large sponge
electrode (kathode), and putting the leg of the affected limb ina
salt and water bath (anode). The current should not be too
strong, about twenty milliampére, and it should be continued for
half an hour, reversing the current once only every ten minutes.
This form of treatment should be continued for a week or ten
days, and the patient during this time should walk with a crutch
rather than use too much voluntary effort.

There are certain forms of muscular paralysis due to
fatigue—some with and some without spasm—which are well
102 MASSAGE FOR MUSCULAR FATIGUE.

designated ‘occupation neuroses,” and amongst these we
have telegraphists’ cramp, seamstresses’ cramp, pianoforte
players’ cramp, and the most important of all, writers’ cramp.
The last named form of cramp is met with more frequently
than any of the former and is more difficult to cure, therefore
we will give it special attention. It usually commences with
a feeling of fatigue in those muscles which are called into
play in the act of writing, and which control the movements
of the thumb and two first fingers. Four forms of this cramp
are recognized, namely, the spastic, tremulous, neuralgic and
paralytic (Gowrrs.) As soon as fatigue has established itself
tremors set in, rendering further muscular efforts useless.
The muscles of the thumb are most affected. At the onset
an aching’sense of weariness extends up the arm which soon
renders the sufferer unfit for writing. The pen does noi
move quite as he intends it to do, the strokes are made
firregularly, they fall either too high or too low, and spasmodic
. movements create failure in definition. The first finger has a
tendency to slip off the pen, and the more firmly the pen is
held the greater seems to be the difficulty, until the pen is
‘either dropped or jerked from between the fingers. Muscular
fatigue, with aching, sickening and wearisome pain, may, for
a long period, be the only indications of this troublesome
complaint, but they will gradually increase in gravity and
intensity, so that day by day the act of writing becomes more
and more distressing and laborious and finally absolutely
impossible. A subject of this disease who at one time
could write fluently for twelve hours at a stretch is now
unable to write his own name. It is interesting to note that
this muscular weariness and inco-ordination seem in some
cases to be limited to the act of writing; for other movements,
such as playing the piano, or shaving, can be performed with
perfect facility, and the grasp of the hand is only a little
weaker than it isin health. The pain is very variable and
may be referred to the joints of the fingers or to the fingers
themselves, the thumb and the wrist, or it may extend up the
arm to the armpit. The large nerves of the arm—and of
course particularly the musculo-spiral—present signs of
tenderness on pressure. Sensory symptoms are sometimes
experienced, such as a feeling of tingling or pins and needles
in the fingers, which appear to be quite independent of
muscular derangement. This form of functional paralysis is
generally found in members of both sexes who are of decidedly
nervous temperament, anxious and over-worked, and who
have by heredity some tendency to nervous disease. The act
of writing or of copying, although volitional, should be
performed almost automatically, and it does seem that in a
MASSAGE FOR MUSCULAR FATIGUE. 1038

large number of these cases there is not only too great a
strain put upon the motor centres of the cord, but that when
the associated centres of the cortex are in action at the same
time in the processes of ideation the tendency to this condition
of disease is greater than under other circumstances.
Defective power in both nerves and muscles appears to be of a
purely functional character; there may perhaps be slight
wasting, but this is altogether exceptional, and, should it
occur, we are led conclusively to the opinion that the writers’
cramp has originated in a nervous system where centres are
prone to become, under given conditions, the seat of
degenerative changes.

We can scarcely admit that a localized fatigue can exist
with a healthy tonus of the muscular and nervous systems as
a whole. Many observers have endeavoured to elucidate this
vital element of the question. Some of the latest consider
the weakest link to be the peripheral apparatus, and the best
researches at least support such an opinion. Dr. G. V.
Poore, in his very interesting papers on “ Writers’ Cramp and
Allied Affections,” contributed to the Royal Medical and
Chirurgical Transactions, has brought forward many facts
connected with the living human body tending to support the
hypothesis which locates the mischief in such cases in the
peripheral apparatus. The experimental evidence adduced by
Dr. Augustus Walleris confirmatory of such a view and is besides
of a highly suggestive character. It is difficult to assign
adequate reasons for the notion, but a priori we should expect
that the points of junction of any apparatus would prove the
weakest points thereof. And so it apparently is in the nervo-
muscular apparatus. The weakness appears to exist neither
in the nerve cell of the motor cortex, nor perhaps even in
the motor cell of the spinal cord, nor further down in the
muscle itself, but rather in the junction between the pyramidal
fibres and the motor cell of the cord, and the similar place
(the motor end plate) in the muscle.

Another important point to be decided before we can be
fairly considered to have any real knowledge of the nature of
fatigue, is the causation of the nutrition of the terminal organs
—the actual conditions on which they depend for their
existence as functional elements. All the information at present
at our command would seem to show that the periphery is at the
mercy of the centres, that the central motor cells can live and
have their being without the aid of their terminal ramifications.
Angello Mosso, of Turin, states that fatigue, carried beyond
the moderate stage at which it is decidedly beneficial, subjects
the blood to a decomposing process, through the infiltration
into it of substances which act as poisons—substances which
104 MASSAGE FOR MUSCULAR FATIGUE.

when injected into the circulation of healthy animals induce
malaise and all the signs of excessive exhaustion.
That the chief cause of fatigue is the formation of certain
products and their action on the tissues is not a self-evident
proposition, because it seems to be clear that any tissue
excited unduly in a given space of time must become
exhausted; and it is equally possible that fatigue, as a
sensation, may be caused by the negative condition of
diminished reconstruction as by the positive one of actual
irritation by the products of metabolism. The facts at present
ascertained would seem to prove that the negative and
positive states are both operative in the causation of fatigue.
Erb (“ Lancet,” July, 1887) states that writers’ cramp (in
typical cases) depends upon a disturbance of nutrition of the
Ecentral nervous system, situated either in the cervical cord,
in the peduncles, or in the cortex.

. In the treatment of this affection most authorities are
“apreed that centralized rest of those muscles co-ordinated in
‘the act of writing is absolutely necessary..

“Nussbaum,” according to Schreiber, in an article published

in 1882, ‘directs his patients to write as much as possible
‘with the instrument figured and described below, which
compels the wearer to use his muscles in a way diametrically
opposite to that he has always practised. He says to his
_ patients: ‘Write much with this apparatus, for the more you
- awrite the sooner you will be cured, and be able to hold the pen
in the common way again.’”’ The celebrated Munich surgeon is
of opinion that over-exertion of the flexors and adductors—
_ these being the muscles chiefly used—is the cause of the
‘cramps, and that the condition may be cured by using the

 

Fig. 22.—Nussbaum’s appliance for writers’ cramp.

extensors and abductors instead. To this end he has
constructed the apparatus shown in Fig. 22.
MASSAGE FOR WRITERS’ CRAMP. 105.

It consists of a thin oval band of hard rubber, about two
centimetres broad, suitably curved for slipping over the thumb
and all the fingers except the little one, which remains outside.
By means of a clamp a penholder can be conveniently
adjusted. The long diameter of the oval being made
purposely somewhat longer than the breadth occupied by the
fingers over which it is to go, the fingers will have to be spread
apart, the thumb being drawn to the left, the fingers to the
right, to prevent it falling off. Muscles are thus forced into
use which are the exact antagonizers of those normally used,
and at the same time the act of writing is transferred from
the fingers to the whole hand, and motor impulses formerly
sent to the flexors and adductors are now delegated to the
extensors and abductors.

Nussbaum thus gives the result of his experience:

*(1,) Every patient who formerly was unable to even
scratch down his name, let alone write a couple of lines,
could, to his great surprise, write two pages consecutively
without fatigue with the apparatus.

(2,) No cramps ever occurred while using it.

(3,) All agreed when using it, that those parts of the hand
which were formerly the most painful, felt now even more
comfortable than normal.

(4,) After using the apparatus diligently for some time, a few
patients felt intuitively that they were again able to use the
pen in the old way.

(5,) In treating this disease, it simply stands to reason that
the cramped muscles must be thrown out of use while their
antagonizers must be strengthened by gymnastics.”’

During the past three years I have had several opportunities
of using this ingenious and clever little apparatus, and my
success has been simply complete when combined with massage
and the continuous galvanic current in a manner which I will
show and explain to you directly. But the doctor must be
pains-taking and persevering, and the sufferer must be patient,
compliant and reliant: I need scarcely say that these are attri-
butes which patients do not always possess. Gowers says,
“For this affection, treatment to be effective should be early.”
This remark applies to every form of disease. I have a patient
under treatment at the present time who has learnt to write
with considerable facility with the left hand, so that the right
hand is not brought into use at all; this, as far as treatment
is concerned, is a great advantage, and should be adopted if
possible in every case. The loss of writing power is a source
of great mental distress to some, especially to those whose
livelihood depends upon it, and this becomes a conflicting
element in the cure, and leads to physical weakness, and
106 MASSAGE FOR MUSCULAR FATIGUE.

sometimes to general nervous prostration, disquietude, irrita-
bility, and sleeplessness. We must take every means in our
power to arrest such a condition when it is present. I have
found it expedient to make the patient wear an india-rubber
band about two inches wide around the wrist, and this has
been in my experience all that is necessary in the way of
mechanical support. In all ordinary purposes the hand should
be used in the normal manner.

The points to be attended to in treatment are: rest. to
the affected muscles, massage, the application of the con-
tinuous galvanic current, digital gymnastics, and the
injection of strychnine into the upper and outer part of
the forearm. I have’ no faith in strychnine when there
is marked muscular wasting, but in functional paresis it is
invaluable. The patient should exercise the muscles of the
hand in writing, particularly the extensors and abductors by
means of Nussbaum’s apparatus three times a day for three
minutes each time, and after doing so, the entire arm should
be massaged precisely according to the manner directed in my
second lecture, from the tip of each finger to the shoulder-joint;
and this should be followed by massage of head, neck, and
spine night and morning—the time occupied at each operation
being twenty minutes. Every other day the continuous gal-
vanic current should be used in association with an arm bath
of hot salt and water for five minutes. The cathode (a flat
electrode) should be placed high up at the back of the neck,
the anode being placed in the water, a weak current of five
milliampére strength is all that is necessary. The patient
should be taught to exercise the fingers in marching order over
the surface of a table for one or two minutes at a time, always
beginning at the right hand lower corner by extending the
thumb to its utmost limit. He commences in the way I now
show you, and so marches onwards to the distant left-hand
corner in a diagonal direction, always stopping immediately if
it produces the least fatigue. This form of gymnastic move-
ment should be varied in the following way: the hand and
forearm must be laid flat upon the table on their extensor
surfaces, and the thumb must be extended to its utmost limit
and fixed in this position, whilst the terminal phalanges are
flexed rhythmically and slowly towards the palm not more
than half a dozen times. Now let me tell you that this is my
mode of treating writers’ cramp. In substance there is nothing
original about it ; in detail it differs from other recorded methods,
and it is in the carrying out of details very minutely and care-
fully that we can hope to cure this very troublesome and
distressing affection. You will have many opportunities of
treating all forms of occupation neuroses, and let me warn you
MASSAGE IN CENTRAL NERVOUS DISEASE. 107

against doing too much; small and repeated doses of treatment
will often prove of essential service when the reverse will
frequently do more harm than good.

I have to say a word or two to you relative to massage of
the limbs in disease of the central nervous system. Let us
take, for example, the various forms of hemiplegia, some right,
others left. In some the arm is most affected, in others the
leg. In some there is rigid persistent contraction, in others
the muscles are flaccid. The arms, rarely the legs, are some-
times the seat of burning, aching, wearisome pains. Right
hemiplegia is sometimes associated with spasm of the hand
and fingers (athetosis), the muscular sense of the paralyzed
limb is also greatly interfered with. The question arises, Can
we improve these paralyses, relieve pain, and help to restore
power to the muscles, and co-ordinate movement by massage ?
Well, I can assure you that in some cases it is very useful, in
others its influence is nil, and it does not require much know-
ledge of the physiology of the nervous system to tell us why it
isnot useful. But let me tell you this: IfI neglected to advise
massage and weak faradization to any patient who came to me
suffering from hemiplegia, I should consider that I failed in my
duty asa physician. It matters not one atom whether the brain
lesion be cortical or basal, thrombotic or embolic, anemic or
hyperemic, large or small, coarse or fine, gross or delicate,
whenever there be a paralysis, limited or extensive, purely
motor or sensory or motor only, massage should be used. For I
maintain that although the paralysis may be due to an exten-
sive lesion, still, by helping to maintain the nutrition of nerves
and muscles by massage and passive movements, we aid the
brain Gf such be possible, that is if the lesion is not too
profound) to compensatory effort, and to the restoration of
function in structures adjacent to the lesion. There are some
people who seem to think that massage has to do only with the
parts to which it is applied, say for instance, a muscle; of
course, this is a great mistake. The integrity of the muscle
depends upon the integrity of the nerve, and the integrity of
the nerve is dependent upon its nervous centre, and the integ-
rity of the nervous centre is dependent upon both nerve and
muscle.

Again, we cannot hope to cure a sclerosis of the brain or cord
by massage, to think of itis utterly preposterous, but we can
possibly arrest its spreading, and start compensatory processes ;
and we can relieve nutritional and functional nerve troubles
(usually peripheral), which frequently give patients much more
distress, pain, and discomfort than the disease itself. This is
a very wide and interesting subject, and deserving of study
from a great many points of view.
Lecrure VI.
MASSAGE OF VENOUS AND LYMPH CIRCULATIONS.

The nature of these Circulations-— Blood pressure influencing the
Lymphatic Circulation—The Lymphatics as Absorbents—The connection
between the Lymphatics and Lacteals — Peri-vascular Lymph Spaces —
Massage for Varicose Veins, Heart Disease, and Myxcedema.

In studying the value, the nature, and the effect of the
massage processes upon the human body, it does, at
first sight, appear that their influence upon the circulation
must be of greater importance then their influence upon the
nervous system; but these two systems are so intimately
correlated that it seems almost impossible to say that the one
is positive or negative to the other. We know quite well that
the ;circulation is governed and controlled by energy of
nervous origin, but you might just as well expect to get a
galvanic current from two elements without an exciting agent
as energy from a nerve cell without the blood as an exciting
agent. This dependency and intra-dependency, or subjection
versus antagonism, between all vital processes are phenomena
most intimately associated with vitality itself—life being the
sum total of an infinite variety of factors. Irritant action
is everywhere manifest in developing the energy of function.
Antagonism is the agent for the development of energy.
May not life be maintained and supported and energy created
by an increasing warfare between functions? This is a
doctrine with which the name of Sir Wm. Grove is notably
associated, which was so ably exemplified in his address at
the Royal Institute. Are not the processes of massage of this
nature? The nutriment of one creature may mean the
destruction of another.

All thinkers have had to note the existence of continual
war throughout creation— death and life, good and evil,
charity and malignity, are illustrations of it. Race has
been observed battling with and trampling down race. The
ravages of fire, the fury of the floods, the angry strife of wits,
have been marked and deplored by numberless generations of
moralists. By Darwin its virtue was perceived as well as its
power. He traced its invincible and indispensable utility
in compelling organized vitality to ascend through an infinity
of stages from imperfection towards perfection. In its
ordinary character it preserves the current of being in happy
and healthy action, it secures the regular beating of the
human pulse, as well as the pulse of the universe. The sense
MASSAGE IN BLOOD PRESSURE. 109

of tranquil comfort, when the physical functions perform their
duties accurately and fully, arises from the balanced struggles
of opposing forces, not from the unchallenged despotism of
one. Antagonism is a law above and beyond gravitation. It
holds the stars in their courses. It is that which gives the
sensation novelits charm. It is the secret of the fascination of
party controversies. Light, heat, and motion all illustrate its
activity. Health exemplifies it at least as entirely as disease.
Very possibly time may show that even the bacteria which
Sir Wm. Grove’s scientific benevolence does not prevent him
from stigmatizing as ‘‘unwholesome,” administer a necessary
incentive to the lauded white corpuscles to keep them vigilant
and alert. Sir Wm. Grove completes the chain by his claim
for it of the rank of a law of nature, inorganic as well as
organic, as active in life as in death, as potent for preserving
as for transforming, as sensibly benignant as it is ultimately
salutary. I would ask, how far cannot the physiologist carry
these views of antagonism into the never-ceasing functions of
life? We might fairly consider that there is a constant
antagonism existing between the fluids circulating throughout
the body varying with the laws of pressure, absorption,
diffusion, endosmosis, conduction, and resistance, and every
possible management has been made by nature, through the aid
of compensatory powers and processes, to remedy these defects
when they exist. When compensation is inadequate to cope
with excessive pressure, effusion, exudation, and dropsies
result.

It would be out of place for me to attempt to discuss the
pathological changes which give rise to increase of blood
pressure, to alteration of normal resistance, or inefficient
compensation, other than in a very general manner. We
have seen how nerve influence maintains the general tonus of
the circulation. The veins absorb equally with the lymphatics
under normal conditions; but when there is vaso-paralysis
venous absorption must be at a standstill, and the juices of
the tissues accumulate in the canals, peri-vascular lymph
spaces, and lymphatic capillaries. By massage manipulations
we exercise counter-pressure, and with marvellous results in
many cases where natural compensation and resistance have
been inadequate to overcome undue blood pressure; and,
remember, the same law which applies to the circulation of
a part applies equally to the body as a whole.

“All conditions which diminish the difference of pressure
between the arterial and venous systems increase the venous
pressure, and vice versa. General plethora of blood increases
it, anzemia diminishes it. f

Respiration affects specially the pressure in the veins near
110 MASSAGE OF VENOUS AND LYMPH CIRCULATIONS.

the heart; during inspiration, owing to the diminished tension,
blood flows towards the chest, while during expiration it is
retarded. The effects are greater the deeper the respiratory
movements ” (Lanpois and STIRLING).

These laws of pressure, particularly in the capillary circula-
tion, are of great interest to us in considering the more
immediate effects of massage manipulations. The resistance
to the blood-stream is greatest in the capillary area, and if the
diameter of the veins be narrowed leading from the capillary
area the intra-capillary blood pressure is increased. Changes
in the position of the limbs alter the venous pressure ; but if
the muscles of the veins give way the normal resisting power
of the wall of the vein is lessened, dilatation arises, and

. varicose veins result. When we pinch, knead, and compress a
muscle, for instance, or when it is stimulated to contract by
the electric current, or by natural means, the flow of blood
towards the heart is greatly accelerated.

_ Dr. Graham, in a few suggestive sentences, puts these physio-

logical facts concerning the circulation in such a practical form
that I cannot do better than call your attention to them. ‘‘ Hxer-
cise accelerates the action of the heart and diminishes blood
pressure, which means an increase in the rapidity of the
current, and in the quantity of the flow, through the relaxed,
distended, or stretched blood vessels. Massage also diminishes
blood pressure, but without increasing the activity of the

_heart; on the contrary, the heart’s action is lessened in force
and frequency. And on reflection this is what might be

“expected, for natural obstacles to the circulation are gravity

-and the friction of the blood against the walls of the vessels,
and these working backwards towards the heart have to be

_overcome at each systole of the left ventricle. These hin-

* drances are by massage, both directly and through the medium
of the vaso-motor nerves, in great part removed. The con-
tracting hands of the manipulator are as it were two more
propelling hearts at the peripheral ends of the circulation
eo-operating with the one at the centre; and the analogy will
not suffer if we bear in mind that the size of one’s heart is
about as large as their shut hand, and the number of inter-
mittent squeezes of massage that act most favourably on
vessels, muscles, and nerves, are about seventy-two per minute,
which is about the ordinary pulse rate. If this is not an act
that does mend nature, what is?’ *

That massage movements have a very decided influence upon
the lymphatics is beyond dispute, therefore it is important that
Tcall your attention to these chyle and lymph carriers. If we

 

* Dr. Graham, Practical Treatise on Massage.
MASSAGE OF LYMPHATICS. 111

compare the capillary blood system with the lymphatic system
we shall find that the former may be regarded as our irri-
gation system which supplies the tissues with nutrient fluids,
while the lymphatic system may be regarded as a drainage
apparatus which conducts away the fluids that have transuded
through the capillary walls. Some of the decomposition pro-
ducts of the tissues, proofs of their retrogressive metabolism,
become mixed with the lymph stream, so that the lymphatics
are at the same time absorbing vessels; substances injected
under the skin are in part absorbed by the lymphatics.

“ A study of these conditions shows that the lymphatic system
represents an appendix to the blood vascular system, and further
that there can be no lymph system when the blood stream is
completely arrested, it acts only as a part of the whole and
with the whole’ (Lanpo1s and SrrRuine).

Lymphatics originate in different ways. For instance, in
the villus of theintestine (where, bythe way, the lymphatic goes
by the name of chyle vessel or lacteal, and has enormous ab-
sorptive power) they originate by apertures or stomata, much
in the same way that they do in serous cavities, so that the
serous cavities are said to belong to the lymphatic system, and
fluids placed in serous cavities readily pass into the lymphatics.
Again, some lymphatics originate in what are called _pevi-
vascular spaces. The smallest blood vessels of bone, of the
nervous system, and of the liver, are completely surrounded by
wide lymphatic tubes, so that the blood vessels are completely
bathed by alymph stream. In our manipulations the lym-
phatics with which we have principally to deal are those which
originate in the juice canals of the connective tissue, such as
we find in the skin and lower epidermal cells and the fascia
between muscles, with which the minutest lymph capillaries
communicate. Physiologists tell us that blood vessels also
communicate with these juice canals, and that fluid passes out
of the thin walled capillaries into these spaces through their
stomata. This fluid being the nutritive fluid, each tissue with
which it comes into contact selects from it that which it re-
quires, whilst the effete materials pass back into the spaces,
and from these reach thelymphatics, which ultimately discharge
them into the venous blood.

The leucocytes, or wandering cells, appear to have the power
of absorbing colouring or foreign poisonous matter and carry-
ing it to other parts of the body. The pigment particles used
for tattooing the finger are usually found within the first lym-
phatic gland at the elbow. As far asI can understand, the true
leucocyte is frequently a carrier of death in much the same
way as the red blood cell is the carrier of oxygen or life by
means of hemoglobin, but I shall refer to this again when
112 MASSAGE OF VENOUS AND LYMPH CIRCULATIONS.

speaking of Mosengeil’s experiments upon the lymph stream.
It is interesting to us to note that all conditions which increase
the pressure upon the juices of the tissues increase the amount
of lymph. Paralysis of the vaso-motor nerves (Lupwic) or
stimulation of vaso-dilator fibres, by increasing the supply of
blood, increases the amount of lymph, while diminution of the
blood supply, owing to stimulation of vaso-motor fibres or other
causes, diminishes the amount. Muscles when in action, by
their contraction and relaxation, favour the pouring out and the
formation of lymph, which is absorbed by the tendons and the
fascie, as they are so intimately associated with the intrinsic
muscular elements, so that by the movements of these
structures corresponding with the motions of the muscles, a
suction pump-like action is engendered whereby the lymphatics
are alternately filled and emptied while the lymph is propelled
onwards. Please remember this, too, which is important, that
passive muscular movements act in the same way.

The fascia covering the muscles consists of two layers of
fibrous tissue with the lymphatics intervening. When a muscle
contracts, lymph is forced out from between the layers of the
fascia, while when it relaxes, the lymph from the muscle, carry-
ing with it some of the waste products of muscular action,
passes out of the muscle into the fascia between the now par-
tially separated layers. The numerous valves existing in the
lymphatics prevent any reflux.

In the case of those lymphatic vessels which begin by means
of fine juice canals, the movement of the lymph must largely
depend upon the tension of the juices of the parenchyma, and
this again must depend upon the tension or pressure in the
blood capillaries, so that the blood pressure acts like a vis a
tergo on the rootlets of the lymphatics.

With these physiological data to go on upon let us see in
what way they bear upon our general every day practice. Let
us see how these lymphatics act as absorbents and aid our
manipulations by the removal of the products of congestion
and inflammatory changes, such as exudations, transudations,
extravasations, adhesions, and the like of these. Petrissage,
kneading and pressure movements act like a pump to force
onward the flow of the venous blood and the lymph, and not
only so, but the normal capacity of the lymphatic system to
absorb is enormously increased by these mechanical processes.
Pressure is the all-pervading element in absorption ; pressure
without, in plain words, is the antagonist of pressure within,
active is far better than static pressure. Let me instance my
meaning in a very simple manner. Given a case of chronic
effusion into a joint, we can and we do frequently apply pres-
sure to bring about absorption by carefully strapping the joint,
LYMPHATIC ABSORPTION BY MECHANICAL MEANS. 113

but this is a tardy and oft-times a very incomplete process.
Compare it, however, with active pressure by means of ma-
nipulations, where the effused fluid, and it may be a certain
amount of débris, is driven into the lymphatics through their
stomata, whether the lymphatics are willing or no.

Mosengeil has studied this subject very carefully, and has
demonstrated by direct experiment how powerfully absorption
takes place by mechanical means (Von Mosengeil, ‘‘ Langen-
beck’s Archiv fur Klinische Chirurgie,’”’ 1878, 9 Band, 3 and 4
Hefte). I give you one of his experiments as quoted by Schreiber.

At 9 a.m. he injected a hypodermic syringeful of Indian ink
into both knee-joints of a rabbit. The temperature in the rec-
tum immediately following the operation was 100°8° F. At
9.30 a.m. the right knee was manipulated, the rabbit seeming
unaffected by the operation, being quite lively and running
about. -At 9.45 a.m. both knees were again injected with the
same quantity as before, but with a less concentrated suspen-
sion of the ink, and the right knee was again at once manipu-
lated. The pain seemed more intense than with the first
injection, the rabbit resisted violently and was hard to hold.
The manipulation of the joint, too, seemed to be more painful.
After manipulation, the knee previously swollen became of
normal size again. It was noticed that the left leg, which, as
a check experiment, had not been manipulated, was likewise
less swollen after the rabbit had run abouta while. At3 p.m.
injections were again made into each knee-joint, and the right
knee manipulated as before. In two minutes the swelling of
the right knee had disappeared, while the tumefaction of the
left remained permanent. In the meanwhile the temperature
had risen to 102°2° F., and at 8.30 p.m. it reached 104° FF.
However, to judge from its hearty appetite, the animal did not
seem to feel very badly. At 8.45 p.m. the knees were again
injected. It was now found that a whole syringeful could no
longer be forced into the left knee, but readily entered the right,
which was again manipulated. On the following morning
half a syringeful of a thick suspension of the ink was injected
into each elbow joint, both joints were manipulated, and the
animal then killed and examined. In the upper extremities,
the ink was found distributed in irregular patches, in the peri-
articular connective tissue about the puncture, and extending
into the subcutaneous tissue, and also upward along the
vessels, and the inter-muscular septa. The axillary glands of
one side were found to contain Indian ink, the lymphatics
leading to them being intensely black. On the other side, on
which a colleague had performed the injection, and attempted
the manipulations, no ink was found in either the lymphatic

vessels or glands. .
114 MASSAGE OF VENOUS AND LYMPH CIRCULATIONS.

Now from this experiment, which is often referred to,
it appears to be possible, within the space of a few minutes,
to remove a fluid injected into the knee-joint of a rabbit
by manipulations which force it into the lymphatics. This
is an exceedingly interesting proof of what can be effected
by massage manipulations. It shows us clearly what active
agents the lymphatics are in bringing about absorption. No
doubt in this case of Mosengeil’s the leucocytes were very
actively employed. In order to make our massage movements
with a fair certainty of success, we must manipulate as
previously demonstrated, from the periphery to the trunk, in
the course of the venous and lymphatic flow. Superficial
effleurage and stroking movements can be performed either

_ centripetally or centrifugally, but directly pressure is exercised

all movement must be centripetal. We have, I hope, seen the
reason for this, as far as blood pressure is concerned.

Let us foramoment consider the necessity of centripetal move-
ment in reference to the valvular arrangement which we know to
exist both in lymphatics and veins. We will take veins first.
Most veins are provided with valves which serve to prevent the
reflux of blood. We find the valves very numerous in the
extremities, and particularly in the lower extremities where
the veins have to conduct the flow of blood against the force of
gravity. The valve is formed by a reduplication of the inner
coat, its convex margin is attached to the wall of the vessel,
whilst its concave margin is free to move in the course of the
current of the blood. When regurgitation takes place the
opposed edges of the valve come into contact, and by this

; means any return of the column of blood is effectually stopped.

ree

If the valves are unable to close perfectly they are said to be
* incompetent, inefficient, or insufficient ; such a condition some-

times gives rise to venous pulsation. Veins, like other
structures, are liable to inflammation, and the blood becomes
clotted in the inflamed area; the clot may only partially, or it.
may completely occlude the lumen of the vessel. This is a
point of very great importance for you to bear in mind, because,
when such is the case, manipulations are quite out of place,
and cannot be for one moment permitted; their employment.
may give rise to detachment of these thrombi, which, if con-
veyed into the circulation, may be productive of the most.
serious consequences. Whilst speaking to you of veins, let me
draw your attention to varicosities of these vessels. We know
by this time, that the current of the blood in the veins is
dependent, not only upon the veins themselves, but also upon
the integrity of the heart, the arteries, and the capillaries ;
whatever interferes with the passage of the blood through these
channels will tend to venous dilatation and varicosity.
MASSAGE FOR VARICOSE VEINS. 115

Hence the venous blood flow may be retarded owing to a
weak and enfeebled right heart, or to any obstruction in the
arteries; pressure upon veins is often a cause of their dilatation,
such asa tight garter, the gravid uterus, an overloaded rectum,
, tumours and congestion of visceral organs, and last, but not
least, to vascular spasm. I shall have to speak to you in a few
minutes relative to congestions, and show you again how such
are influenced by massage.

Varicose veins are exceedingly troublesome, and in some
cases dangerous; the rupture of a large varicose vein not
unfrequently causes death within a few minutes from loss of
blood. The surgical treatment of varicose veins is not always
satisfactory ; hence you find a large number of persons with
their limbs encased in bandages and elastic stockings, often,
too, when they would be much better without them altogether.

From what we know of the circulation and the effects of
massage in lowering blood pressure and in helping on the flow
of venous blood, we ought to be led to the conclusion that
massage might be of service in the removal of these dilatations;
this is most indisputably the case, and its value in this
respect cannot be over-estimated. You have seen its good
effect so repeatedly amongst my patients that I will not say
any more about it, except to draw your attention to a patient
now under treatment for spastic paralysis. If you remember,
she had a lump of varicose veins in the bend of the left leg;
not only has the massage nearly cured the paralysis, but her
varicose veins have ceased to be noticeable.

We believe that the massage processes are extremely useful
in promoting functional activity in the lymphaticglands. These
glands you must know are exceedingly numerous throughout
the body, and when the blood becomes infected by poisonous
matter, either from within or from without, it does seem that
they are storehouses for such poisonous material ; they become
swollen and enlarged and frequently they are very painful. It is
quite possible that the poison of syphilis and the determining
agency or plasmic force of cancer and of tubercle may remain
latent in these glands for years, or even for a generation, until
some exciting cause calls them into activity. The clinicist
knows full well how these glands are subject to infective pro-
cesses, by determining laws with which at present we are not
fully acquainted. Continuity and environment are the most
common causes, but the infection may be indirect as well as
direct. If our leucocytes could speak they would in all proba-
bility give us more definite information concerning these
somewhat obscure and retrograde processes. There is nothing
more wonderful to my mind than the rapidity with which a
lymphatic gland will enlarge, and just as rapidly return to its
116 MASSAGE OF VENOUS AND LYMPH CIRCULATIONS.

normal proportions, when the irritating or exciting cause dies
out or becomes removed. ‘The sensitiveness of lymphatic
glands in some people is truly astonishing ; the least source of
‘irritation will set up in them a hyperplasia or adventitious cell
growth, running its course of existence, and dying out without
leaving a trace behind. Sympathy between glands is one of
the common and most interesting and characteristic features.
Dr. Groom, in a recent and thoughtful article in the Lancet,
on ‘‘TheLymphatic System and Cell Agency,” states : ‘‘I desire
to maintain that it is to the lymphatic system and cell agency
that most, if not all, forms of disease are due,’’ and he gives
fairly good evidence that this view has considerable foundation
in fact. But I cannot afford to be impractical or hypothetical,
for we have to deal with things as we find them rather than
with things as we would have them tobe. ‘Tangibility and the
revelation of the effects of massage upon disease must be the
motto of the masseur, rather than the etiology and pathology
of diseased states. (I assure you if I have any aim at all in
these lectures it is that they should be free from assumption,
that they shall be to you as food of the most assimilable kind,
giving you intellectual and physical potential energy).

_ Now lymphatics and lymphatic glands, or “ the lymphatic
> system,’’ is more liable to disease than the other circulatory
_ systems. Of course with the malignant forms we have
nothing whatever to do, but with the conditions of chronic
inflammation we have a very great deal to do, therefore I must
bring these under your notice. The lymph and chyle have to
pass through those glands on their way to the blood, so that
should those glands become obstructed to the passage of these
nutrient fluids, to put it in plain words, tissue starvation must
result. The lymphatic glands form a chain of ganglionic
nutritional foci of which it appears that the thyroid gland is
the all-powerful and important link. I shall refer tothis again
at the end of this lecture.

There is, however, another point which strikes me as
extremely probable. It is this. That there does exist a
functional derangement in these glands, (notably uremia)
excited by the too rapid generation and death of leuco-
cytes, and that the latter is the originating if not the source
of those poisonous animal organisms which are the chief
and main cause of autogenetic infection. Knowing that the
healthy functional activity of a lymphatic gland plays an im-
portant part in the nutritive processes, and seeing that our
manipulations upon the human body are attended by a great
augmentation in the powers of nutrition and assimilation, we
naturally come to the conclusion, although oft-times at the
expense of cynical incredulity, that massage processes do stimu-
MASSAGE IN HAMOLYTIC BLOOD DISEASE. 117

late and excite those glands to renewed energy when they are
in an atonic state of existence. Functional glandular inactivity
is of necessity co-existent with general failure of nerve power,
apart altogether from subacute congestive and inflammatory
changes to which the glands are particularly liable. It is quite
possible also that the primary lesion in scrofulous and tuber-
cular glands is due to these causes, and no one can say that
simple anemia, chlorosis, pernicious anemia, and lymphatic
leucocythemia are not primarily due to functional inactivity
of the lymphatic glandular system. Therefore you see it is
necessary that we should travel somewhat ahead of those who
believe that the Alpha and Omega of massage is merely to
hasten onwards the lymph and blood flow. No doubt as in
veins any impediment to the onward flow of lymph must give
rise after a time to dilatation of the lymphatic walls, leading
to varicosity, and possibly insufficiency of the valves, with
regurgitation. Then, if you follow my ideas, I think you must
agree with me, and absolute proof is by no means wanting to
verify my statement, that all forms of functional inactivity,
sub-acute and chronic inflammation, simple atrophy and
hypertrophy of lymphatic glands are best treated by our mas-
sage manipulations.

I might perhaps in this lecture just call your attention to
some forms of hemolytic blood disease, such as anemia, per-
nicious anemia, chlorosis and leucocythemia, which are some-
times so very difficult to cure. I have not had great experience
in the treatment of these cases by massage, but I cannot
help thinking that massage with oxygen inhalations and the
galvanic current to the spine and spleen should prove a very
efficient remedy; at all events I must say that I think it is
deserving of trial.

Massage and galvanism are particularly useful in chronic
congestions (hyperemia). I have told you before that in my
opinion you had better leave acute or active congestion alone ;
if resolution does not take place, and if pus is not formed from
degeneration, if the blood vessels become relaxed and the circu-
lation stagnant, then massage is more curative than any other
agent with which I am acquainted. I need scarcely tell you
that in congestion (of course I am referring to local congestions
due in the majority of cases to dilatation of veins and lym-
phaties, which is often accompanied by transudation of serum
and the migration of blood cells through the walls of the
capillaries) the absence or occurrence of dropsy will depend
in great measure upon the adequacy or inadequacy of the lym-
phatics to carry off the excess of fluid; the part so congested
will frequently present a darker hue than the surrounding skin,
usually it is harder, and will pit upon pressure, if the exuda-
118 MASSAGE OF VENOUS AND LYMPH CIRCULATIONS.

tions have not undergone any general parenchymatous or
fibroid change. By our massage movements we promote the
absorption of the inflammatory products, and remove those
disturbances of function to which they have given rise. This
absorption, as well as the restoration of the diseased vascular
wall, can only be obtained through the agency of an active
interchange of blood in the diseased part, and stimulation of
all the tissues therewith concerned.

The diseased vascular walls of chemically inflamed parts
can only be restored to their normal condition by contact
with normal healthy blood, it is therefore necessary for the
massage manipulations to be commenced as soon as possible
after the acute symptoms have subsided ; from my experience
the temperature of the part should be our guide. I do not
think that we can rely very greatly upon the nature of the
pain, neither can we depend entirely upon temperature unless
we consider its variability ; if during, say, twenty-four hours,
we note that the local temperature varies, sometimes being
normal, we may then conclude that carefully applied massage
may be commenced, for by massage compressions and relaxa-
tions the currents of the blood and of the fluids are promoted,
and a more rapid interchange of the streams is effected. By
this means only can the processes of diffusion and absorption
have fair play and the nutritive processes be advanced. WhenI
have to speak to you of inflamed joints, I shall consider this
_ question of congestion more fully. The next part of my lecture
refers to dropsies.

When we speak of dropsies we mean the accumulation
of fluid in the subcutaneous cellular tissue; this, as you
know, is usually termed cedema or anasarca. When an
effusion of fluid occurs in limited cavities it is usually named
after the cavity in which it exists. I might say that dropsies
depend upon the fact that more fluid is poured out from the
blood vessels than the lymphatics are capable of taking up
and returning again into the circulation ; this arises certainly
in the majority of cases from paralysis of the walls of the
capillary vessels due to vaso-motor nerve inhibition. Ranvier’s
experiments have proved that ligature of the vena cava in the
dog does not usually give rise to cedema of the lower limbs, but
if one sciatic nerve is divided, the corresponding leg at once
becomes cedematous ; this is fairly good proof that so long as
nerve communication is intact the lymphatics are able to ab-
sorb all the fluid which the capillaries can pour out, but when
the nerve is divided the arterial tonus is arrested and cedema
results, because more fluid is poured out than the lymphatics
are capable of absorbing. Positive obstruction to the arterial
circulation is not necessarily attended by dropsy, because the
MASSAGE IN THE TREATMENT OF DROPSY. 119

collateral arterial branches will in most cases compensate and
carry on the flow, although in a round-about way.

There are some dropsies which seems to arise almost entirely
from blood changes when the blood is thin andwatery and of a
lower density thannormal. Under such conditions, when there is
noimpedimentto the venous circulation beyond the mere weight
of the column of blood, transudation easily takes place through
the walls of the vessels. Of course it usually shows itself in
the feet and ankles. We find that the swelling subsides after
the body has been in the horizontal position, and it is absent in
the morning, but marked at night after gravitation has over-
come the lessened resistance. We must, however, remember
that the general tone of the vessels is deficient and capillaries
are oft-times dilated from this cause. -

Let me tell you, if you please, thatthese forms of dropsy are
best relieved by local massage, but general massage should be
employed atthe same time. There is no reason against the
use of other therapeutic measures, such as iron and tonics, to
improve the quality of the blood in those cases where such
remedies are demanded. We look upon massage as one aid to
treatment, and no physician would be so intolerant as to adopt
one remedy to the exclusion of every other. In the curative
treatment of disease our knowledge of remedies should be com-
prehensive, and our views should be unbiassed and free from
bigotry, narrow-mindedness, and especially should we be free
from prejudice. I shall never attempt to claim for massage
anything more than I have found by experience that it
deserves, and that reason and common sense dictate.

There is a form of cedema of the lower limbs which is
frequently persistent, and which no tonic medicine or diet or

‘change of air seems to relieve. I refer to the dropsy after
some acute form of disease, which seems to be dependent
upon a weak condition of the vessels rather than to the blood
or to the heart; it cannot be due to a deficiency of arterial
tonus alone. I was consulted not long ago about such a
condition. The patient had suffered from typhoid fever, of a
severe form; he was over fifty years of age, but he recovered,
and as far as we could make out there was no organic change
in any organ or obstruction to the venous blood flow; the
heart sounds were normal, and the arterial tonus, judging
from the pulse at the wrist, was also normal; his general
strength was good, but the lower extremities were so swollen
that he was unable to get about without considerable dis-
comfort. I have told you that tonic remedies had been tried
in vain. Now I am not exaggerating when I tell you that
after masséeing the lower limbs for a week, this gentleman
walked about with the greatest ease, and at the end of a fort-
120 MASSAGE OF VENOUS AND LYMPH CIRCULATIONS.

night he was quite cured. Surely this was no coincidence ;
nothing of the kind, it was a living, demonstrable fact, and it
requires only the merest knowledge of the physiology of the
capillary circulation, not only to explain the cause of the
dropsy, but in like manner to show the rationale of the effects
of massage upon the vessels in bringing about the cure.
I will give you another instance, and this is only one of many
of the same kind which I have seen. A lady consulted me
about a swelling of the left leg from the foot to the knee,
which came on gradually. The limb was quite painless and
had been so from the first, all she complained of was the
great inconvenience which it occasioned, she could not dance,
and in fact she walked with considerable difficulty. This
condition of the leg had been existing for nearly three months,
and for a great part of this time it had been bandaged, without
any good result. In other respects her health was excellent,
the spirits were good, the appetite was good, and every
function was regular and natural. The dropsy was local, and
due to vascular paresis, there was nothing to indicate any
hindrance to the circulation from plugging of vessels, there
was unquestionably local vascular paresis. This lady rapidly
recovered under the influence of daily massage to the limb.

I have now to draw your attention to a form of swelling of
the lower limbs, usually the left, most frequently due in some
way to, and associated with the puerperal state. Phlegmasia
dolens, or white leg, as it is commonly called, generally comes
on about the second or third week after delivery. At its
primary and later stages it pits upon pressure, but in the
intermediate stage it is hard, somewhat resillient, and elastic ;
its pathology has never been well defined. Now there comes
a stage in the history of this disease when massage should be
exceedingly beneficial and highly commendable. I am not,
however, speaking from experience, so my advice in this
matter must be taken for what it is worth; but I have seen
these cases in years gone by, and I well remember how long
it takes for these limbs to resume their normal condition, if
they ever do so. I can certainly recall to my mind cases
when the elastic stocking has been of necessity continuously
worn. It is only reasonable to conclude, as is the case, that
the limb remains for some time deficient in tone—circulatory,
muscular, and nervous. Sometimes there is a persistent
cedema left behind, with and without deficiency of muscular
power. The limb may undergo a considerable amount of
wasting, and the cellular tissue may be hypertrophied, from a
proliferative hyperplastic organization. Of course in manipu-
lating the tissues the movements should be performed with
more than ordinary care, they should be made with great:
MASSAGE IN VENOUS OBSTRUCTION. 121

steadiness, even slowness, definiteness, and precision; in fact
the pressure should be applied direct upon the tissues rather
than in a centripetal direction. If the pressure be applied in
a jerky, ill-timed, thoughtless, and careless way, thrombi may
become detached, which, if carried into the circulation, may be
productive of very serious consequences. You will no doubt
have many opportunities of proving the good effects of skilful
massage in these cases, and your manipulations can be well
aided by faradization to the weakened muscles. I saw some
months ago a case of persistent swelling and hardness of the
right leg and thigh in a young lad about seventeen vears of
age, due to inflammation of the veins, and certainly massage
and faradization were most effectual in bringing about a cure,
although the treatment had to be carried on for nearly two
months. In all these conditions there is of course the chance
which must never be forgotten, namely, that some of the
partially-organized matter, as I have before told you, may be
carried into the circulation, and I should be sorry in any way
to under-rate the importance or the consequences which may
follow such an unfortunate event, but I really think with due
care this may be avoided. I have had no experience of
massage in the treatment of dropsies of cavities except the
cavities of joints, and to these I shall refer when speaking
to you of joints. Some cases have been recorded where
massage has been used successfully in the treatment of
ovarian dropsy, but I know nothing about it, I cannot
therefore recommend it to you, and I certainly do not advise
you to try it; the statement would be interesting however if it
could be verified.

Before leaving the subject of dropsy, I must direct
your attention for a few minutes to edema due to heart
disease or to some obsiruction in the lungs. Where there
is defect in the tricuspid or mitral valves of the heart,
associated with dropsy, there is some imperfect closure of the
valves and widening of the orifices, giving rise to a backward
or regurgitant flow of blood, by which the venous circulation
throughout the body is obstructed: this is particularly the
case when there is disease of the right side of the heart, with
dilation of the right ventricle dependent upon obstruction to
the flow of blood throughout the lungs. Dropsies which arise
from defect in the circulation of the blood through this
side of the heart, generally make their first appearance in the
feet and lower extremities where the greatest obstruction to
re-absorption takes place. It is self-evident that in valvular
disease the perfection of the heart as a pumping machine must
be seriously interfered with, and this want of co-ordinate
sustaining and rhythmical action must necessarily disturb the
122 MASSAGE OF VENOUS AND LYMPH CIRCULATIONS.

normal relationship which should exist between the arterial
and venous circulations; but these deficiencies are often made
good by what is known as compensatory action. It is well
known that extensive valvular disease may exist without giving
rise to any very serious changes in the circulatory system,
and this state of things may go on for years without the
patient feeling any discomfort. But without compensation
this could not be, valvular disease must give rise to increased
resistance in one direction and lessened resistance in another,
in front of the lesion there is less blood, and behind it there is
more blood. All lesions of the valves of the heart enrich the
venous circulation at the expense of the arterial.

All resistance to the movement of the blood through
the various compartments of the heart and the vessels
communicating with it, must cause more work to be thrown
upon the portion of the heart specially related to this part of
the circulatory system; hence we find an increased thickness
of the muscular walls. It is this hypertrophy which gives
what is called compensatory power to the heart, and enables it
to overcome the increased resistance which the valve compli-
cation originated; plus resistance minus compensatory power
is the first cause of dropsy from heart disease. To increase
* compensatory power and to lessen resistance is the first and
. chief aim in all and every form of treatment; in other words,
to relieve undue pressure and venous stasis, which are the
causes of those serous transudations, which we know as
dropsies, and which are in excess of the normal power of the
lymphatics to absorb. We know that the tendency in valvular
disease of the heart is to upset the balance of power between
the venous and arterial currents, the quantity of blood in the
arterial system is lessened, whilst in the venous system it is
increased to overflowing; this, of course, extends to all parts of
the body, but it first makes itself evident in those dependent
parts in relation to the common law of gravitation and the
pressure of the column of the blood. Dropsies of the viscera
and internal cavities follow in progressive and developmental
order, in direct ratio with the exercise of the mechanical laws
to which I have just alluded. It is well to remember that
compensation and dropsy cannot go on together. Dropsy is a
sign that compensation has done its best and failed; but it is
not a sign that all efforts at compensation have ceased. If we
relieve the blood pressure by stimulating the circulation
through the veins, and by stimulating the lymphatics to
increased absorption, and the skin, the bowels, and the kidneys
to increased activity, we can lessen resistance and re-establish
compensation.

Well, so far, I have endeavoured in a very rough and humble
VALUE OF MASSAGE IN DROPSY. 123

sort of way to give you the merest outline of some points rela-
tive to certain changes in the circulation, the result of valvular
disease of the heart. Now I wish to tell you that massage is
not contra-indicated in any form of heart disease with which I
am acquainted, unless it be in aneurism or the extreme fatty
heart. On the contrary, I shall have very little difficulty in
explaining to you that we have in massage a valuable means
of restoring to the heart and to the circulation, locally and
generally, the very qualifications which they so much need, the
lessening of resistance, and the establishment of compensatory
power. Ineed not say anything to you concerning the manipu-
lations that are necessary, they are as I gave them to you in
my second lecture. The first effect of massage, then, in edema
is to relieve the veins, to free these distended vessels and their
dilated walis, to remove the pressure of the blood, to stimulate
the vaso-constrictor nerves into activity, and increase the
absorptive energy of the lymphatic system; by so doing you
increase the balance of power between the venous and arterial
circulations, which is one important step towards altering
venous stasis; the vascular tonus cannot fail to be increased,
and the heart is thus relieved of a certain amount of inertia
from which it has been suffering in consequence of that resist-
ance which its efforts at compensation have failed to overcome.
Massage, then, is of value in dropsy. If the cedema of the skin
and areolar tissue be removed by this method, you may rely
upon it every part of the body will be similarly influenced.
Function will be restored, and your patient’s condition will be
improved. But I tell you again, as I have told you before, and
I cannot impress this upon you too strongly, we look upon
massage only as one means of treatment ; therefore in this, as
in other diseased states, promote and stimulate the action of
kidneys, bowels, and skin, by diuretics, diaphoretics, and
hydragogue cathartics.

There is a form of disease known as myxedema, which I
must now bring under your notice; it has received considerable
attention by a committee appointed by the Clinical Society to
investigate its nature. During my career at the Central
London Sick Asylum I had many opportunities of making
observations upon patients suffering from myxedema, both
from the clinical and pathological side. I have seen several
cases lately in private practice, which have derived immense
benefit from massage and galvanism, therefore I believe firmly
in this mode of treatment over any other in this disease. We
must not forget that there are types of myxedema, some
presenting every characteristic feature, others, again, which are
marked only by certain of these signs. You might be inclined
to infer that this is merely evidence of various stages of the
124 MASSAGE OF VENOUS AND LYMPH CIRCULATIONS.

disease, but, in my opinion, this is not the case. Therefore
I would maintain that up to the present time the clinical
features presented by these varieties of type have not been
fairly and fully elucidated. The term myxcedema, however,
is applicable to these various forms, and denotes what are
really the most prominent pathological changes, namely, “the
invasion of the tissues of the body by a Jjelly-like mucous.
yielding dropsy.’”’ In the very elaborate and able report of the
Clinical Society’s proceedings these changes are made clear
and evident—and it does credit to the labour and research
of British medicine—so that myxedema, as we now know it,
by clinical and pathological signs, is an established disease
with an entity of its own. Still I feel sure that it is capable
of further division. The most interesting fact in relation with
these changes, which are principally brought about in the
connective tissues of the body, is the part played by the
thyroid gland, and a mass of evidence of all kinds has been
brought forward to substantiate this association. If the thy-
roid gland undergoes removal, destruction, or degeneration,
the signs and symptoms of myxcedema invariably follow.

‘The pathology of myxcedema is fairly substantiated. It
consists in the interstitial development of fibrous tissue
throughout all parts of the body, particularly in that of the
skin, increasing notably the bulk of the body, distortion of
the features, and the hands and feet; yet it appears that pa-
thology, up to the present time, affords no explanation of the
affections of speech, movement, sensation, consciousness, and
intellect. This being the ease, How are we to account for
these marked defects, which should be indebted to some definite
factor in the nervous centres; and why, may I ask, according
to some unknown pathological law, should the connective
tissue of the brain and spinal cord not be included in these
changes, when they are common to every other portion of the
body? For my own part, although these changes are not
discoverable after death, I have long thought, and still think,
that an excess of mucus does exist in this disease in the nervous
organs prior to any objective clinical manifestation. We have
clearly very much to learn concerning the etiology and rela-
tive pathology of this disease, and it may come out after all °
that the nervous system is the fons et origo mali; still we are
bound to admit, and I for one readily do admit, that the
evidence is, so far, against any such theory. Etiology and
association are so bound up with cause and effect, giving rise
to complex differentiations and degrees, that synthesis of desire
to formulate often exceeds the deep scrutiny necessary for
analytical deduction.

Iwas told only the other day ofaleading physician in the North,
MASSAGE IN MYXGDEMA. 125

who, when asked a question concerning some point in medicine
or physiology, invariably answered in the same way, ‘‘I do not
know.” Now this physician is admittedly a man of consum-
mate intellect. But I must not forget my duty, and that is to tell
you how to cure myxcedema, if it is to be cured at all. Out of
a hundred and nine cases of myxcedema tabulated by the
committee of investigation in their report just issued as part of
the Clinical Society’s proceedings, I do not find one case of cure,
and only very few where any improvement was manifested. I
do not know what you think, but from the patient’s point of
view I consider it extremely unsatisfactory. The treatment
consisted chiefly in the administration of cod liver oil, nervine
and blood tonics, iodide of potassium, nitro-glycerine and
jaborandi, and, as you might suppose by the influence of the
latter drug upon the skin, it seems to have been productive
of some benefit; not one single case was treated by massage,
and only two or three by galvanism.

In the fall of 1886 I was consulted by a lady about
fifty years of age, who was sent to me by Dr. Philpots, of
Bournemouth. The moment I sawher it was evident to me that
she was suffering from myxcedema; her tottering gait, puffy
face, masque-like features, hesitating speech, and pallor of skin
but not of lips, were quite sufficient to indicate to me the kind
of case with which I had to deal. Her husband was in great
distress, as he said the whole thing came on so suddenly and
a physician whom he consulted gave him a very hopeless
prognosis. I consider in this case that all the signs and
symptoms, objective and subjective, were well marked, memory,
temperament, sleep, motion, and sensation. She hada skilled
masseuse to live in her house, who massaged every part of the
body for one hour twice a day, and in the morning the limbs
and spine were well faradized ; all the medicine she took was
an alkaline bromide powder at bedtime. After a month’s
treatment she improved, and at the end of three months her
features had returned nearly to their normal condition, her
walk was still a little shaky, her voice was clear, the hesitancy
of speech had gone, she could walk for halfa mile without sud-
denly falling down, whereas before she could not walk a hun-
dred yards without support. The massage and galvanic
treatment was continued for six months, and I might say
perfect recovery took place. ;

A gentleman over fifty years of age, who had been my patient
for a long time, suffering from nervous exhaustion and (as
diagnosed both by Dr. Hughlings Jackson and myself) lateral
sclerosis of the spinal cord, with some mental defects, consulted
me one day on account of swelling of the feet. I had not seen
him for over six months, and I remarked to him, ‘‘ How stout
126 MASSAGE OF VENOUS AND LYMPH CIRCULATIONS.

you have got.” ‘‘ Yes,” says he; ‘‘ What does it all mean? I
am better in many ways. I can walk much better, and I feel
more cheerful and comfortable in myself, but look at my hands,
they are like legs of mutton.” And there, undoubtedly, was the
square spade-like hand of myxedema. The feet were not
cedematous, but they were like the hands, swollen and enlarged,
and the toes were like the fingers, remarkable for their square-
ness of outline; the features, too, were undoubtedly symptomatic.
Well, I saw this gentleman the other day, and he is now quite
free from myxcedema ; there might be some slight thickening
and blurring of the features, but the hands and feet have re-
turned to their normal state, and, oddly enough, his paralytic
symptoms have gone.

In the spring of last year I was consulted by a lady, aged
thirty-four, married, with children. She said her health had
been failing for three or four months, and she thought worry
had to do with it. Her speech was thick and hesitating, and
sometimes she used one word for another. At times she was
unable to walk straight, and her husband would chaffingly tell
her that she had taken a little too much. Upon careful
examination it was evident that the skin of the face and of the
hands was thicker than normal, and remarkably pallid and
wax-like. The lips looked thick, but were of a good red colour,
in striking contrast to the colour of the skin; she was obtuse,
and the memory was decidedly defective. She told me that
she had taken no end of medicine, which did her no good,
and after some hesitation she consented to undergo a course
of massage and galvanism. The body was massaged all
over for one hour night and morning, and the combined
current was applied by means of a foot bath, the negative pole
being attached to the bath, which, as you know, is made of
metal, and the positive pole was applied to the nape of the
neck, in the form of a long electrode of metal, covered with
chamois leather. No medicine was given, and by the end of
six weeks she was practically well. I could bring under your
notice other cases of a similar character to these, but I think
you have had enough proof that in these varieties of myxedema,
massage should be thoroughly and persistently tried, either
with or without galvanism. I have the greatest faith in this
ea of treatment in this disease when entrusted to skilled

ands.
 

Lecture VII.
THE WEIR-MITCHELL TREATMENT.

The Introduction of the Weir-Mitchell Treatment—Influx of Masseurs and
Masseuses—Instruction in Massage—Hxample of the class of Patient to whom
this Treatment is Applicable—Diagnosis of Proper Cases for Massage—The
Psychical Element in Weir-Mitchell cases—Fat—The nature of fat—Massage
Especially for Hysteria—Physicians as Masseurs—Dr. Hale White on Massage
—Dr. Seguin on Massage—Seclusion—Rest—Massage— Dosage of Massage—
Electricity and Galvanism—Feeding—Some Points of Importance for
Consideration.

Wuen more than twelve years ago we first received tidings
from Philadelphia of an original mode of treating certain forms
of nervous disease specially known as hysterical, by seclusion,
rest, over-feeding, massage and electricity, they were received
with considerable incredulity and doubt, and had they been
associated with any other name than that of one of the most
eminent physicians in America, it is quite possible that we
should not at the present time have heard very much about it.
For -years it was allowed to slumber and to smoulder, until
Dr. Playfair applied the torch, when, in a very short space of
time, it was burning brightly, and now there is scarcely a town
in this country where there does not reside a living monument
standing out as a record of its well deserved reputation.

It is only natural to find that this form of treating disease,
which has been attended with such marked and unprecedented
success, in some cases almost miraculous, should have given
rise to a large following of people, calling themselves masseurs
and masseuses, and the physician in truth cannot possibly
do without them. Some are thoroughly qualified for the
work, and others are utterly unsuitable. Of course this is to
be expected, but as time goes on the chaff will be sifted from
the grain, and only those who are best qualified and
accomplished in their work will remain.

Thave studied massage, with and without electricity, for many
years, long before it became notorious, and it has been my
delight to impart my knowledge to others, and my class is com-
posed only of those who are blest with a good physique and
sometimes with more than an average amount of intellect.
I am in no way ashamed of my occupation in this direction,
for I am confident that if massage is to take its place as a
therapeutic agent its manipulations must be carried out by
those skilled and practised in its use; but there must be a
system and a science in everything, and the treatment of
disease by massage in a perfunctory way, without a complete
128 THE WEIR-MITCHELL TREATMENT.

and systematic knowledge, simply leads and gets the whole
thing into discredit, and also, unfortunately, involves those who
have associated their names with it. There is, however, some
consolation in knowing that it has been the means of curing
a large number of nervous disorders which were looked upon
as hopeless and incurable.

It is my object and my desire to make you acquainted
with all that I know, both from my own experience and
from that of others, in reference to what we now recognise
as the ‘‘ Weir-Mitchell Treatmeni.’’ Of course we are
already acquainted with all forms of massage manipulations,
how they are to be applied, when they are best applied,
and what are the usual effects produced by their application ;
we have also considered the influence of massage more or less
upon the temperament and upon the character. Now, I
have told you more than once with reference to massage,
that just as we build up the physical side of the human
body, and just as we restore the functions of the muscles, so we
also improve and restore the integrity and the normal balance
which should exist between the mind, on the one hand, and the
body on the other, so that by our mechanical manipulations
upon the physical side of our existence we also hope to restore
derangements in the mental processes which are so intimately
connected therewith.

I will first draw your attention to one or two points
upon which Dr. Weir-Mitchell lays some stress. He
says that his treatment is particularly applicable to
a certain class of cases, and ‘‘the cases which I have
treated have been chiefly women of a class well known to
every physician—nervous women, who, as a rule, are thin and
lack blood. Most of them have been such as have passed
through many hands and been treated in turn for gastric,
spinal, or uterine troubles, but who remain at the end, as at
the beginning, unable to attend to the duties of life—a source
alike of discomfort to themselves and anxiety to others.”
This is a text upon which any medical man could easily
preach a sermon. No man can have been in practice more
than six months at the very outside without coming across
some cases precisely similar to those referred to by Dr.
Mitchell. They are constantly presenting themselves to the
physician’s notice. They form a class of invalids who really
do a great deal to support the doctors. Their temperament
becomes so morbid that nothing can soothe them, nothing can
quiet them, nothing, apparently, can do them any good but
the assurance that they have a doctor at hand who, in case of
trouble, will be equal to any demand made upon him.

We may say that the particular cases, then, which come under
TYPICAL CASE FOR WEIR-MITCHELL TREATMENT. 129

the Weir-Mitchell treatment are people suffering essentially
from a weak condition of the nervous system,—an unbalanced
condition of the nervous system, weak, not so much in intellect
or in body, but weak whenever their nervous system is strained,
it does not matter from what cause. They break down easily.
They are generally people with spurts of energy, but this
energy with which they are endowed is incapable of any
prolonged and sustained effort. In all probability there is
some hereditary cause for this. There may be a family
history of alcoholism, insanity, epilepsy or diabetes;
causes which we know are likely to give rise to an
unstable, erratic and ill-balanced nervous system, commonly
known in women as hysterical. At one time they may be
bright, happy, and cheerful, and pleased with everybody and
everything; they are frequently highly intellectual and
accomplished, and the very soul of the society in which they
move and have their being—still they are usually almost
morbidly excitable. This may go on for years, with occasional
exceptions of headache, lassitude, weariness, sleeplessness
and sudden emotional outbursts, the cause of which seems
inexplicable, when a change comes over the scene, some
disturbing element arises, it may be of a slight nature, leading
to grief, jealously or fear, and the once jubilant, gay, cheerful,
high-spirited, light-hearted woman is converted into the very
antithesis of her former self. She becomes retiring, and
shuns her former friends and associates; her occupations,
which at one time gave her so much pleasure, are now forsaken
and cast aside; her chief aimis to be alone; her features grow
careworn and pale; her appetite fails; the least thing tries
her, and she appears indifferent to those formerly most dear
to her; she is usually to be found lying upon the couch;
every movement seems to be associated with effort. To move
wearies her; to read wearies her; to play the piano wearies
her; to eat and even to speak weary her; and so the day
passes, in dream-like monotony. She is tired on going to bed,
and in the morning after a sleepless night feels still more
tired, until finally she takes to her bed altogether. Tonics are
prescribed and possibly never taken, sleeping draughts are
sought for with avidity, and, unfortunately, morphia is largely
given to relieve imaginary pains. The bowels become obsti-
nately confined, and the stomach is so irritable that nothing
remains within it; everything taken feels like a dead weight.
So matters not unfrequently go on from day to day, from bad
to worse, until the hopeless, exhausted, and emaciated creature
seems to be living a life more like that of an automaton than
a human being. If we examine carefully this patient's

physical condition, one great feature is slowness and oe
130 THE WEIR-MITCHELL TREATMENT.

of the circulation, coldness of the body generally, but
particularly of the extremities, an icy coldness. The palms of
the hands and soles of the feet are bedewed with clammy
sweat, the skin of the body is dry, wrinkled, shrivelled and
parchment-like to the touch. The muscles are wasted and
flabby and quite unequal to any sustained effort. Her friends
are constantly watchful, anxious and solicitous, and both they
and the nurses are wearied with their constant efforts to do
something, which is generally declined and no sooner declined
than called for. This is by no means a fanciful picture of
a ‘ Weir-Mitchell case,’’ and it is a condition which seems to be
a basis for other superstructures. Manifestations analogous
to those of central nervous disease are sometimes added to
the above, and in some cases it requires intuitive skill and
experience to determine the exact nature of the disease. We
may have a simulated ataxic paraplegia, or disseminated
lateral sclerosis. In the consideration of what cases are, and
what cases are not likely to be benefited by this treatment, we
must b2 as careful as possible to exclude all sources of error ;
still, however careful we may be in diagnosis, there are some
cases which baffle even the most consummate skill, and my
rule invariably is, when in doubt, to have the benefit of a
second opinion, and, if still in doubt, to explain the whole
matter clearly to the friends, so that all misgivings and
misunderstandings may be averted. When in doubt the
massage treatment should be had recourse to, and after a
few months, if no decided improvement takes place in any
way, it should be discontinued, and the patient relegated to
the class of incurables.

Let me tell you this frankly, I would much rather have
thoroughly good cases to treat, such as I have just depicted,
than half and half cases, for they usually yield much more
rapidly to treatment, and the cure of them is considered much
more wonderful than is the cure of the latter.

I would like to say a word or two relative to other cases
adapted to the Weir-Mitchell treatment, and I shall then briefly
refer tothose thatare not so adapted. I am not going to give you
the history and treatment.of many cases, I would rather endea-
vour to lay before you the characteristic features upon a broad
basis, by which means it seems to me you will the better com-
prehend what a Weir-Mitchell case really is.

Now the first thing above all others to be settled is this:
Has the patient any organic disease upon which the illness
or state of the body depends? Is there organic disease
of either the brain or the spinal cord? Again: Has the
patient any uterine or pelvic trouble which may possibly
influence the treatment? Has the patient anything
CASES NOT SUITABLE, 131

upon her mind which is just as likely to mar its effects
as would some serious uterine displacements? At all events,
before I commence treatment I endeavour to get these points
cleared up; it is simply cruel, to say the least of it, to place
patients under an expensive course of massage if there be no
chance of its proving beneficial. Strangely enough, one morn-
ing last week I was consulted by a man in the prime of life,
a country gentleman, well built, of florid complexion, and
altogether of excellent physique, muscles hard and with a grasp
ofiron. His chief complaint was despondency and dread. He
had heard of the massage treatment, and was greatly surprised
when I told him that I thought it would do him harm. The
cases which are most likely to receive benefit from the Weir-
Mitchell treatment are those where nutrition is defective.
Massage always benefits weakness and feebleness when the
cause is due to arrest of function.

We can scarcely hope to be successful in those cases
of hysteria -which have advanced beyond the _ border
land of sanity. Here we have to use great discrimi-
nation, not only in diagnosis, but also in the application
of treatment. I know it isa common practice with those who
ought to be better acquainted with a scientific system of mas-
sage and all that pertains to the Weir-Mitchell treatment, to
serve all cases in the same way, without due regard to the
psychical elements which materially avert the success we
hope will attend our efforts, This is a great and serious error;
for, as we have seen that itis essential and necessary to guard
against any obstruction on the physical side, so have we to
adapt our methods to antagonizing influences on the psychical
side. Every case has to be and must be treated upon its
especial requirements. No orie would be foolish enough to
expect remedial results from an irrational mode of procedure,
but in many cases of signal failure which have come to my
own personal knowledge, those failures have arisen simply from
want of system and a due appreciation and consideration of
cause and effect, and the cases have subsequently yielded to a
treatment supported by a careful discrimination of their neces-
sary requirements, and the application of methods associated
with, though in some ways divergent from, the integrity of a
system which cannot be counted upon as applicable to all forms
of either mental or physical derangements, although in the
main the principles of that system have been sound and irre-
futable. It must not be forgotten that in those cases which
we believe to be suitable to the Weir-Mitchell treatment there
is a marked mental disturbance. I never yet met with a case
of hysteria where there was not, and although up to the present
time I have not ventured to treat a case of confirmed mania by
182 THE WEIR-MITCHELL TREATMENT.

this system, still I believe and hope that before long some man
will arise with an inventive mind like Weir Mitchell and
organize a system of massage by which the psychical side of our
nature may become as amenable to treatment as the physical.
Hopeless as it may now appear, this result may yet be attained.
The main points for thought and reasoning in the Weir-
Mitchell system of cure are rest, feeding, seclusion, massage,
and galvanism ; but before considering these I should like to
make you acquainted with one or two facts relative to the
changes in tissue which we know are brought about by our
manipulative modes of procedure. A word or two about fat.
No one, I think, can deny that some fats are wholesome, whilst
others are unwholesome. Weir Mitchell writes of an old nurse
who assured him that in her experience ‘‘ some fats is fast, and
some is fickle, but cod oil is easily squandered,” therefore, as
he says, the fat of an obese anemic person may vary from the
fat of a fat and florid person. ‘‘ The flabby relaxed state of
many fat people is possibly due, not alone to peculiarities of the
fat, but also-to want of tone and tension in the areolar tissues
which, from all that we know of them, may be capable of under-
going changes as marked as those of muscle. I think there
can be little question about there being fats which are stable
and firm, and fats which are prone to rapid disintegration and
absorption. This must be the case, I should presume, for some
of my patients have lost fat rapidly after the massage treat-
ment has been discontinued, whilst others have maintained the
gain when the conditions of treatment have been precisely
similar. One thing we must bear in mind, and upon which
Dr. Mitchell seems assured, namely, ‘‘ That increase of fat, to
be a wholesome condition, should be accompanied by gain in
quantity and quality of blood, and that while increase of flesh
after illness is desirable and a good test of successful recovery,
it should always go with improvement in colour. Obesity with
thin blood is a most unmanageable condition.” We must not
forget that a person under massage treatmentif he is by heredity
of the lean kind cannot hope to gain fat after the same rate as
a person who by heredity is prone to develop a superabundance
of this material. Ihave a lady about thirty years of age at the
present time under my care, who was excessively thin prior to
undergoing the Weir-Mitchell treatment, and during the course
she gained only five pounds in weight; but shortly afterwards
she increased in weight with enormous rapidity, on account
of the sudden and rapid development of fat; this was attended.
with the manufacture of good blood and a general improve-
ment in health. We know of many cases of hysterical women
who have lain in bed and apparently eaten nothing, and yet they
have grown immensely fat, but it has not been good fat, they
VALUE OF MASSAGE. 133

have been pale and anemic and given to vomit blood, and how
they gain in fat is oft-times mysterious. Fat gained by mas-
sage is almost always accompanied by gain in blood, that is to
say, ‘‘ massage fat” is the best of all fat. :

There are some cases which are greatly benefited by
the Weir-Mitchell cure, who have nothing very special
the matter with them, certainly they have no marked
hysterical symptoms ; women who very easily get tired, and
complain of vague pains, particularly in the back, spine,
and head, who constantly suffer from dyspepsia and consti-
pation, and to whom life seems a burden. They know and feel
that they suffer from nervous exhaustion, they have taken
no end of medicine, visited every Spain Europe without be-
coming in any way changed, and they remain for years feeble
and for ever tired. For them, as for the whole class, the
pleasures of life are limited by this perpetual weariness, want
of resolution, and failing resistance. The mode of applying
massage in these cases does not vary from the methods with
which I have already attempted to make you acquainted, but
I would have you bear in mind that, as these hysterical cases
improve and gain in fat and weight, the massage manipulations
must be increased in strength, especially to the muscles of the
back and the buttocks. You know we all have different ideas
concerning, not only the value of massage, but the mode of
manipulating also. There are some physicians who declare it
does not matter how massage is done, so long as the muscles
are well thumped, beaten and punched about. Dr. Graham
writes as follows : ‘‘ It is to be regretted that physicians do not
oftener try their hands at massage themselves. They would be
fully indemnified for their time and trouble inthe improvement
of their tactus eruditus which would enable them to appreciate
the changes in the tissues brought about by massage, and this
would open a new and interesting field of observation to them.
Furthermore, the benefit of their visit would then be immediate
in place of mediate, as when it is the medicine prescribed and
not the physician that does the work ; and a still greater reason
is, that they would often prevent their glory from departing to
another, and that other frequently an ignorant and obnoxious
layman, whom the physician is obliged to tolerate or lose the
family practice.”’ ;

Although I do very little massage myself, still I quite
agree with Dr. Graham that those who do not know should
not attempt to teach. Dr. Hale White, assistant physician to
Guy’s Hospital, in a clinical lecture on a severe case of hysteria
treated by massage, over-feeding and isolation, published in
the ‘British Medical Journal” for July 30th, 1887, gives the
following instructions to his class in reference to massage, which
134 THE WEIR-MITCHELL -TREATMENT.

to me has avery comical aspect. He says : “‘ You will probably
perform it very much better if, remembering what you wish to
effect, you set to work as you think best, than if you follow
many of the quackish descriptions in print. When you have
to instruct a nurse, it is best to give her some definite method and
perhaps something like this is as good as any: First grease the
parts with vaseline or oil (what is this for ?), and if the skin be
very hairy it may be necessary to cut the hair; then stroke the
muscles firmly several times with the edge of the hands in the
direction of the venous flow. In places where this is impossible,
such as the back, always stroke in the same direction (what does
this mean ?); on the abdomen follow the course of the colon;
next you may take up the skin between the thumb and _fore-
finger and rub it between them, one hand following the other in
the same direction as the stroking ; then thoroughly knead the
muscles with one or both hands according to the size of the
part, in the same direction as already mentioned ; after this
move all the joints in every direction ; then you may conclude
by striking the muscles with several small blows, but
this is not of much importance. The full time should
‘be about an hour twice a day for the whole body.
If there be a painful spot, and the case is one of hysteria,
particularly direct your energies to this part. Of course, you
will teach the nurse to avoid the bones. I have left out all
the uncouth terms that are often applied to massage, in order
to make it as simple as possible.”’

I have given you word for word an instance of how massage
is taught in one of our greatest London Hospitals, and of its
value, or the effect such teaching can have upon the minds of
students, you can judge for yourselves. The eminent physician,
Dr. E. C. Seguin, in the “Archives of Medicine”’ for April, 1881,
says that even in New York there are few manipulators who
can be trusted to do massage well. Non-medical people may
become expert and skilful in the individual manceuvres em-
braced under the term massage; but they ought to have their
efforts directed by a physician. Physicians, in addition to want
of time, may lack the necessary qualifications for doing mas-
sage well; but they would often find it to their advantage to
be their own mechanics as well as architects in this, as already
intimated. You know I always advise my pupils to practice the
different massage manipulations upon each other ; it is the only
way to learn thoroughly. And never forget that all procedures
should be commenced with moderation and gentleness, and
that their force should be gradually increased as the patient
gets accustomed tothem. But Ihave made you so conversant
with all this by teaching, by demonstration, and by practice,
that I need scarcely say anything more to you about it.
SECLUSION. 135

We have considered our patient who is to be put under
the Weir-Mitchell treatment, and we know the remedies which
we mean to adopt for her cure. Let us analyse the nature
of these remedies, and the effects they are likely to produce
upon the patient.

Seclusion.—In the matter of seclusion, I am entirely and
wbsolutely in agreement with Weir Mitchell; and it undoubtedly
forms the basis of his cure. These hysterical and nervous
people must be disentangled from the meshes of their old
habits, and removed from contact with those who have been
the willing slaves of their caprices. This is true, and has
been thoroughly and completely borne out in practice. For
years I failed in curing these hysterical cases, because I
was unable to remove them from their friends and their
surroundings, which had become part of their life of sickness.
During the past summer I cured a very bad case of hysteria ;
but I had the greatest difficulty in removing the patient from
her friends and adopting a system of isolation. The mother’s
words were: “If she must die, pray let her die at home. I
cannot be separated from her while she lives.” Fortunately,
good counsels overcame the mother’s scruples, and her daughter
was completely isolated for one month; and in three months
she was completely restored to health. The importance, then,
of isolation in purely hysterical cases must be absolute. When
cases of this kind come under my care for the Weir-Mitchell
cure, the first thing which I sometimes see upon entering the
room is no end of photographs of the patient’s friends. These
are at once taken bodily out of the room without the slightest
comment, and so are books in which sympathetic verses from
friends are written. We must break the chain which has for
such a long time truly been the means of binding the captive in
captivity. No letters, or messages, or any other forms of com-
munication are permitted; and neither threats nor entreaties
must overcome the confidence of the nurse in this matter. Of
course, in a large number of cases seclusion is not required,
especially where we have merely exhaustion, with pallor and
dyspepsia, and with no special loss of tissue. Therefore you
see we have patients for whom isolation is absolutely necessary,
and others for whom it is not. ;

The cases demanding separation from friends belong particu-
larly to the hysterical, though not necessarily to the emotional
class, where the morbid condition of the mind is co-relative
with bodily defects. But when the mental condition is worse

than the physical, then absolute seclusion is unwise and un-

justifiable. I do not say that the Weir-Mitchell treatment is
unjustifiable, but only the seclusion item of it.
Rest.—At first sight it may seem strange that the cure
136 THE WEIR-MITCHELL TREATMENT.

should in part consist of rest, absolute and complete rest ; the
patients not moving except to perform the ordinary offices of
nature. They are fed like children, and must in this, as in all
other matters, be made to feel themselves subordinate, and to
practise and exercise obedience and self-restraint. In this
way we are helping to rebuild a shattered moral constitutional
state, which is equally as important as restoring the physical
part of their being; but we work on both at the same time,
hoping and believing that we shall repair the mental in direct
ratio with the’ physical. Many of these patients, it must be
remembered, have been lying in bed for months and years,
but they have not been at rest. On the contrary, they have
suffered from great inquietude, having so given way to a chronic
feeling of discontent that they have been almost constantly
alternating between agitation, peevishness, fretfulness, and out-
bursts of really uncontrollable temper ; or moody, morose, and
in a condition of unrest, possibly from imagining themselves
neglected, when in reality those about them have been half dead
of exhaustion, fatigue, and distress on their account, ever trying
to please them, but always failing. ‘Let us think, then,”
says Dr. Mitchell, ‘‘ when we put a person to bed, that we are
lessening the heart beats some twenty a minute, nearly a third;
that we are making the tardy blood to linger in the by-ways
of the blood round, for it has its by-ways; that rest prone binds
the bowels and tends to destroy the desire to eat, and that
muscles in rest too long get to be unhealthy and shrunken in
substance. Bear these ills in mind and be ready to meet
them, and we shall have answered the hard question of how
to help by rest without hurt to the patient.”’

We wust not, then, forget, and of course it is apparent to the
most superficial observer, that confining a patient to absolute
rest in bed, must, under ordinary conditions, be productive of
a serious train of evils: exhaustion and debility are increased,
the muscles become feeble, the joints stiff, the bowels consti-
pated, the appetite impaired, the circulation enfeebled, and
digestion and assimilation weakened. But we shall see in
describing this treatment how these evils are overcome.
What we want is a maximum of rest with a minimum of
unrest of function. I have constantly been endeavouring to
impress upon you that the healthfulness and activity of a part
depends upon the due performance of function. If the natural
function of a part be withheld its integrity becomes weakened
and impaired. Nutrition and function work together. Many
people suffer from indigestion because they give their stomachs
too little work, and many also suffer from indigestion because
the stomach is asked to accomplish more than it is able to
perform. But we have considered, and shall be constantly
REST. 137

considering, this question of supply and demand, knowing
that an exact balance between the two is essential to health.

To exemplify this let me give you one of Dr. Weir Mitchell's
own cases: ‘‘Mrs. P—, aged fifty-two, was brought to me from
New Jersey, having been supine in bed for fifteen years. I soon
knew that she was free from disease, and had stayed in bed at first
because there was some lack of power and much pain on rising,
and at last because she had the firm belief that she could not
walk. After a week’s massage I got her up. I had won her
full trust, and she obeyed or tried to obey me like a child.
But she would faint and grow deadly pale, even if seated a short
time. The heart beats rose from sixty to a hundred and
thirty, and grew feeble; the breath came fast and she had to
lie down at once; her skin was dry, sallow, and bloodless ;
her muscles flabby ; and when at last, after a fortnight more,
I set her on her feet again, she had to endure for a time the
most dreadful vertigo and alarming palpitations of the heart;
while her feet after a few minutes’ feeble walking would swell
so as to present the most strange appearance. By-and-by all
this went away, and in a month she could walk, sit up, sew,
read, and, in a word, live like others. She went home a cured
woman.”

In this case we have an undoubted and typical example of the
evil and pernicious results of prolonged rest, vitiating, though
not annihilating, every healthful function of the body. And
we have also a complete and teaching instance of the good
results which can be produced by a treatment thoroughly and
systematically carried out, under the observation and by the
skill of a highly practical physician.

I am endeavouring to exemplify and teach you Dr. Mitchell’s
system, and for this reason : I should fail in my great indebted-
ness to this accomplished man, if I gave you my experience
rather than his own; and in making it appear to you that my
success was due to my own powers, rather than to his original
and thoughtful mind. I shall have, however, something to
say to you upon some points in reference to this system, which
my study and increasing knowledge of these cases have made
evident to me.

Massage.—I have said so much to you about massage, and
in the course of these lectures I shall have to say such a great
deal more, that I need scarcely allude here to the manipulations.
themselves. It is far better for the nurse in attendance upon
the case not to be the masseuse. There are many reasons for
this. In the first place the nurse must be selected who has
special qualifications; she must have a will of her own,
and the patient must be caused to feel that the nurse is
the machine by which the doctor's mandates are to be
138 THE WEIR-MITCHELL TREATMENT.

unhesitatingly and unflinchingly executed ; firmness and in-
tegrity of purpose are most essential attributes. Very much,
then, depends upon the nurse, and no seductive or truckling
influences of the patients should for a single moment allow her
to neglect her duty ; the physician himself should be the only
court of appeal. I do not agree with taking morning and
evening temperatures and noting variations of pulse, taking
specific gravities of urine, and so on. Examinations of this
kind may be made once, after the weight has been taken, with
any other physical observations which may be deemed in-
teresting and useful for clinical record ; but constant note-taking
only tends to lead the patient to believe that she must be a centre
of lively clinical curiosity and study, a belief which we rather
want to avoidthan inculcate. The practised eye of the physician
will readily discriminate the effects which the treatment is pro-
ducing, and the masseuse should clearly understand that her
work is to massage and nothing else. After a short time the
patient will look forward with eagerness to the appearance of
the masseuse ; it is a break to the monotony of the day’s pro-
ceedings, it is a fresh face which in a measure relieves the
weariness of the daily seclusion. Now, with some people, the
first effects of massage are to irritate rather than compose and
soothe, but in my experience this depends really more upon the
masseuse than it does upon the patient. I cannot impress too
strongly upon you—though I know I have done this over and
over again—that when you first begin to manipulate a patient
your movements should be very gentle, and quiet and slow in
execution. You must, I am sure, see the necessity for this, for
independent of the influence they have upon the sensibility of
the patient, the textures will not bear rough handling. Re-
member you have to deal with wasted, exhausted, feeble, weak
and irritable muscles, which, if roughly handled, become still
more weak and irritable, and an induced irritability of muscle
only leads to an increased irritability of the patient. You might
just as well expect good to result by causing a patient to walk
immediately upon rising from a severe illness, as to expect a
muscle to respond to severe manipulations when weakened and
exhausted from prolonged disuse. Therefore for the first week
merely effleurage and petrissage in the quietest manner possible.
Do not begin passive movements until after the first week; it
is astonishing how in some cases you can pass suddenly from
the passive to the active. Even with this week’s gentle manip-
ulation you will invariably find improvement; the muscles
themselves will be firmer, the extremities will be warmer, the
skin will have a more healthy feel, there will be less moistness
about the hands and feet, and the circulation and temperature
of the body generally will have undergone a change. My
"MASSAGE. ‘ 139

established rule is never to increase the diet beyond milk and
water, beef juice, very thin and crisp dry toast, stewed fruit,
cream and butter, until my patient is under the full swing of
the massage treatment, which is usually at the second week,
when the massage should be combined with passive movements
of the limbs for one hour night and morning. The best times
are 10 to 11 a.m. and 9 to 10 pm. You know I particularly
advise the lower limbs, the abdomen and the buttocks, for
morning massage, and the spine, upper extremities, and head
for evening massage. This is my rule, but it has exceptions,
and if I do not get the effect I anticipate, I then reverse this
order of things and sometimes with advantage ; the reason why
I cannot tell. The feet and legs to the knee usually require to
be manipulated at night as well as in the morning. Above all
things do not expose the body of your patient unnecessarily,
and maintain by every possible means the gain in temperature
which your manipulations have brought about.

Now experience has taught me a great many things of con-
siderable practical value and importance relative to massage,
and the chief of these concerns the dosage. I have been led
to conclude that massage may be continued for too long a time
without getting a corresponding advantage. It is the rule in
these cases that it should be continued for six weeks, and this
rule is a good one, with very few exceptions, but we occa-
sionally find that in masséeing paralyzed muscles we induce a
gain up to a certain point and then its good effects begin to
wane. Jam, therefore, inclined to think that it is best, when-
ever this becomes apparent, to discontinue it for a fortnight
and then begin again. The muscles and the tissues become
too much accustomed to its influence, they seem to be weary
of it, and wishful for its discontinuance in order that they may

ursue their functions by their own unaided efforts. Or, if it
be ‘not absolutely discontinued, its administration should be less
frequent, say once, instead of twicea day, and then once every
other day. Massage, like everything else, can be overdone,
and function is then promoted and sustained by a too artificial
means. I¢ should not be discontinued suddenly and entirely;
both its commencement and its relinquishment ought to be
most carefully regulated. 7 .

We consider that a course of massage should be divided into
three stages: (1,) A period of gradual increase ; (2,) A period
of sustained activity ; (8,) A period of gradual decline. We say
that by the Weir-Mitchell method the third and fourth weeks
constitute its period of greatest activity, and at the end of the
third week we stimulate the muscles into increased activity by
the use of electricity. ee oboe :

Electricitya—We invariably employ faradization. The in-
140 THE WEIR-MITCHELL TREATMENT.

duced current may, as suggested by Weir Mitchell, be applied
with slow interruptions. This may have its advantages, but I
am rather doubtful about it. I prefer placing a flat electrode
upon the spine, and moving the sponge electrode from one
motor point to another. The current must be sufficiently strong
to produce good muscular contraction, and independent of this
the skin should be stimulated by carrying the sponge quickly
over the surface. Of course the current should be weak at first,
and certainly not continued sufficiently long to induce fatigue.
Half an hour at the utmost once a day is all that is necessary.
Dr. Weir Mitchell seems to attach great importance to the value
of electricity in increasing the temperature of the body, and in
his work on ‘“‘ Fat and Blood, and How to Make Them,” he
gives some very interesting tables showing incontestably that
this is one of its effects. This, however, has long been known,
but in some experiments made by myself many years ago quite
confirmatory of these results, I found that this rise in tempera-
ture was remarkably evanescent, and that in ten or fifteen
minutes the register was actually less than before the electricity
was applied; and I well remember coming to the conclusion
which I now hold, that the rise in temperature was due to
nervous excitability, and not, as he concludes, to increased tissue
change. But this is beside the point for our consideration.
There is no doubt, as we have seen, that muscular contractility
is attended with increased metabolism, so that we may fairly
conclude that faradization of the body does aid both circulation
and nutrition, which may be sufficient to bring about a rise of
temperature ; therefore | may be wrong, but the gain by the
use of faradization in the treatment of these cases appears to
me to be the influence which it exerts upon the intrinsic molecu-
lar activity of both nerve and muscle, and also of spinal cord.
Be very careful, if you please, in the application of electricity
never to commence the treatment until the end of the third
week, and then do not apply too strong a current, for the in-
judicious use of electricity may undo all the good which your
massage is capable of doing, though its judicious administration
is exceedingly useful. I desire, therefore, to put you on your
guard. Ihave proved much by my own experience, and my
object in giving these lectures is that you and others who are
not too proud to be taught should derive the benefit of this.
There are some of these cases which take electricity wonderfully
well and with very marked advantage, but there are others who
do not. I have some interesting records of these, but in this re-
spect there are no special signs to guide you until you have by its
application put it to the test ; therefore, as I have just told you,
begin with a mild current, and gradually increase its strength.

Before leaving the subject of electricity, I wish to say that
DIETARY AND THERAPEUTICS. 141

I have in these cases without any doubt obtained excellent
results from the combined faradic and galvanic currents used
about the fifth week of treatment. I employ a very weak
current by means of a strong salt and water foot bath, the
positive pole being applied to the nape of the neck, the operation
lasting about ten minutes, alternating the current some dozen
times. I firmly believe that it aids nutrition more than when
the faradic current is used alone. Thus far we have con-
sidered some important points in the nature of these cases, their
management and their treatment by seclusion, rest, massage
and electricity ; I have now to draw your attention to dietary,
and one or two other matters of no less importance.

Dietary and Therapeutics—Now this is the most important
part of the Weir-Mitchell treatment—inasmuch as it requires
the utmost care and judgment in its management. I believe
thoroughly in the seclusion for appropriate cases, in massage
and electricity, but not in over-feeding for every case. I have
records of a large number of instances where I have over-fed
and well-fed, and I really think, upon comparison, the well-fed
have ended in the most persistent and most permanent cures.
Thorough and complete feeding is, of course, in all cases abso-
lutely necessary, but gluttonizing is not essential. The require-
ments of people for food are extremely variable, and what might
be well considered over-feeding in one is really ordinary feeding
in another. I might tell you, then, once for all, that I have no
definite rules for feeding. I can build up better stuff, and more
durable and blood making material, by a diet regulated upon
definite lines of requirement according to inherent physical and
constitutional tendencies, than I can by maintaining the stereo-
typed system of over-feeding. To say the least, there are three
classes of patients which come under our notice for the Weir-
Mitchell cure. The first is the thin, emaciated, bed-ridden,
helpless and hopeless invalid. The second is the thin, wiry,
anxious, exhausted, but acutely lively invalid, who is constantly
aiming to do something, but fails to do anything because she
becomes weary and exhausted with any attempt at prolonged
effort, and suffers habitually from headaches. The third is the
fat, excessively pale invalid, who fails to make blood, whose
muscles are flabby, and who is always tired and constantly
complaining of weariness and inability to do anything, with
sinkings, sighings and yawnings in superabundance. These
may be taken.as typical of the three classes, but there are no end
of sub-classes and species, which I have no time to deal with
at present. : :

Now I have just said that an appropriate dietary for these
patients forms a very essential element in the curative
process. Let us first consider the dietary for class No. 1, the
142 THE WEIR-MITCHELL TREATMENT.

chronic invalid, the neurasthenic, in whom hysteria may or may
not be present. Of course you know we can have suppressed
hysteria as well as suppressed gout, the one and the other may
be metaphysical as well as physical. But we have to discuss
dietary and not metaphysics. I hope that I shall be able to
prove to you that we can, in the majority of cases, get better
results from good, fair, average feeding than from over-feeding.
If we knew more of the secrets of those so-called massage
homes, rather than the garbled reports which appear from time
to time of exceptional cases with which we are now so familiar,
I am inclined to think the gluttonizing modes of procedure
would be proved to have met with many failures, as in fact I
know that they have.

Every body has a minimum and a maximum limit with refer-
ence to its metabolism, according to the amount of work done
by the body and its weight. If less food be given than is neces-
sary to maintain the former, the body loses weight; while if
more be given after the maximum limit is reached, the food sv
given is not absorbed, but remains as a floating balance, and is
given off with the feces. When food is liberally supplied and
the weight increases, of course the minimum limit rises, hence
during the process of ‘‘feeding’’ or “ fattening,” the income
necessary is very much greater than in poorly fed animals for
the same increase of the body weight. By continuing the
process a condition is at last reached in which the digestive
organs are just sufficient to maintain the existing condition,
but cannot act soas to admit of new additions being made to
the body weight. ‘

The absolute amount of food stuffs required by an adult in
twenty-four hours depends upon a variety of conditions. As
the food represents the chemical reservoir of potential energy
from which the kinetic energy (in its various forms) and the
heat of the body are obtained, the absolute amount of food must
be increased when the body loses more heat as in winter and
when more muscular activity (work) is accomplished. As a
general rule, an adult requires daily 130 grammes proteids, 84
grammes fats, 404 grammes carbohydrates (Lanpois and
STIRLING).

I know I shall be told that ordinary physiological estimates
are quite out of place in the consideration of these Weir-Mitchell
cases, but Iam not so sure of this. Anyhow, our aim should
be to favour nutrition, healthy metabolic activity, at the lowest
expenditure of vital energy on the part of the patient. You
must know that milk forms an essential part of the dietary of
these patients during the first week ; admitted, then, that milk
is atypical food and contains all the constituents necessary for
maintaining the life and growth of the body, we certainly find
DIET AND THERAPEUTICS. 143

that in all cases milk cannot be digested ; it may be peptonised
with zymine or with Benger’s alkaline peptic fluid; it may be
taken hot or it may be taken cold; in may be taken in large
or it may be taken in small quantity—it will not digest; it
creates distension, flatulence and constipation, and cannot be
tolerated. It is no use forcing patients under these circum-
stances to take it. But on the other hand, milk will sometimes
agree splendidly, and then it forms an excellent part of the
dietary. I make it a rule never to force an excessive diet upon
a patient if it engenders indigestion and liver derangement. I
have proved the fallacy of this over and over again. Well, if
we cannot give pure milk, we try milk that has been skimmed.
Weir Mitchell commences in this way by giving daily about
two quarts, well skimmed. It is used as Carel directs, cold or
warm, not hot, and the amount given is divided so that the
patient takes every two hours enough to make up the full share
during the waking day. I prefer whey made hot to either milk
or skimmed milk, and to every pint of hot whey I add the juice
of a lemon.

There is a lady still under my care who commenced
treatment three months ago. She was a living skeleton
when first she went to bed. After a week of nothing in the
way of food but three quarts of whey and lemon juice, and very
thin crisp dry toast, well baked, and fresh butter, in the twenty-
four hours, I ordered a material alteration in the diet, but she
quietly said to me, ‘‘ Don’t you think you had better leave well
alone, I feel quite different already, Jam sure that I am daily
getting stouter and stronger,” and upon a careful examination
I certainly found that this was the case. The jelly-like feeling
of the muscles had given place to something more tangible, and -
the nurse, the patient, and the doctor were all agreed that the
improvement was so definite that nothing should be altered.
By the end of the second week, without any addition to the
diet, the improvement was not only maintained but increased.
The masseuse and nurse were delighted and surprised, and
wanted to know where the gain came from. Every function
was acting well, the sleep had immensely improved, the tongue
was clean, the bowels were acting, the temperature of the body
was more natural and equable, the pulse was stronger, and the
muscles were developing. The patient was wishful now for a
change of diet, but I declined to agree to this, and for three
weeks she took nothing but three quarts of whey daily with the
lemon juice and a plentiful supply of thin dry toast and any
amount of fresh butter.

Now we took a good account of the patient. In the three
weeks she had gained eleven pounds in weight, the
muscles were firm, with decided tonicity, and during
144 THE WEIR-MITCHELL TREATMENT.

the whole of this time there was no complaint whatever
of any form of functional derangement. We still kept to a
moderate diet. The first meal, at 7.80, consisted of equal parts
immediate tea, milk, dry toast, fresh butter, and the lean of a
mutton chop nicely grilled. At 10, half a glass of milk ; at 11,
massage as usual for one hour; at 12, a claret glassful of beef
juice ; at 1.30 p.m., slice of mutton, dry toast, fresh butter,
stewed fruit and cream, half a tumbler of hot whey ; at 4 p.m.,
half an hour’s faradization ; at 5 p.m., acup of tea and bread
and butter ; at 8 p.m., half a dozen oysters and half a tumbler
of stout—this was the daily dietary for another week ; still de-
cided improvement. She was now allowed to communicate
with her mother by letter only, and to sit up in an arm chair
for an hour in the afternoon whilst the electricity was being
administered, and thus, with little variation, passed five weeks
of treatment, and no case ever did or could do better. Wehad
no hitch from first to last, the patient’s condition demanded
the treatment which was arranged to adapt itself to the case.
For the last, the sixth week of treatment, the patient took three
good meals a day with very little farinaceous food stuff. It
may seem rather strange that I should object to the hydrocar-
bons in the form of starch when they are apparently needed,
but it is so, and my experience is against them. She took in
addition beef juice three times a day, rose at 10 a.m. and went
to bed at 7 p.m. Her gain in weight at the end of the sixth
week was twenty-three pounds. She returned to the country
a different being. She is now under massage treatment for a
fortnight, not that she absolutely requires it, for she has more
than maintained her strength and weight, but she has adopted
-it at my special request. Ialways advise my patients to return
if possible one month after treatment for two week’s massage ;
some do not return, others do, and I feel sure that it is to
their advantage to do so.

Now if we analyze this case we shall find in it several
points of interest. The first is that from the beginning
to the end the patient was not over-fed, in fact from the first
by the aid of massage oxidation of tissue was promoted, and a.
rapid but withal a consistent gain in nutrition was secured.
Not one single particle of medicine did this patient take—no
iron, alcohol, nor coffee, no cod liver oil, malt extract, nor
aloes pill, for you see after a few days I had no functional
defect to combat. I gradually promoted functional activity,
both in voluntary and involuntary organs, and brought it to a
standard of well-defined strength before I gave the digestive
apparatus any very especial work to perform. In my past ex-
perience I am sure that in some cases I have been unsuccessful
from my anxiety to do too much, in fact from over-stuffing. I

 
TREATMENT OF NERVOUS CASES. 145

now act upon and treat every case according to what, in my
mind, are its individual requirements. I never hesitate to give
my patients alcohol or champagne, or anything, in fact, if I
believe they will be the better for it. I have sometimes suddenly
changed the masseuseand thenurse with very decided advantage.

Let us now consider the second class of patient: very thin,
but withal wiry, anxious, irritable, wanting to have a reason
for everything, and exceedingly difficult to please, yet would
not be disagreeable for the world, cannot. sleep, and full of
pains here, there and everywhere. She submits to the treat-
ment to please her husband or somebody else, and she is quite
sure that it will do her no good. With this case, you may depend
that the nurse will have a lively time of it; still, if you go
carefully through the patient’s history, you will probably find
her friends will tell you that -it is only lately she has become
so pale, so thin and intractable, and so apparently tired with
everything and everybody. Iwas very much amused with one
of my patients of this class, who said she thought there must
really be something the matter with her, for her servants, who.
had been with her a long time, had told her that they could
not think what had come over her, as it mattered not how
well they did their work, they never gave satisfaction. And
this is really the state of affairs. The symptoms usually run
in the following sequence: Indigestion, worry, neuralgias, sleep-
lessness, irritability, even peevishness, pallor, distaste for food
and want of appetite, loss of flesh, and a ceaseless activity
without any fixed object in view. The age of the patients
usually varies from forty to sixty. There is marked defective
nutrition of all the tissues, and the mind, in a measure, suffers
co-relatively.

Now cases like these require careful handling, for there
is no difficulty in curing these people, the trouble consists
in getting them to undergo treatment. The two chief
points to attend to after the patients have submitted to seclu-
sion, &c., are digestion and sleep. It is unreasonable to
believe that they are going to submit at once to extravagant
feeding; therefore the dietary should be such as will be
easily digested —skim milk or whey with dry toast and
butter for the first week; and after the evening’s massage,
a tumbler of stout may be tried, to induce sleep, and half a
dozen or a dozen oysters. You will find that these patients will
go on, with many misgivings, until the third week, when
they not unfrequently become well nigh unbearable; but
get over the third week, and then (such has been my experience)
matters improve, and the cure can be accomplished in the
ordinary way: at the end of six weeks or two months
your patient will be an altered creature, wholesome ee in

0
146 THE WEIR-MITCHELL TREATMENT.

mind and body, calm, quiet, collected, and agreeable, with an
entire absence of that fidgety, suspicious manner, which is
very characteristic of defective nutrition and impoverished
blood.

Let us now take the third class of cases, perhaps the most
troublesome of the three to cure. Remember again what I tell
you, each class of case is curable by this treatment; but its
requirements if not apparent must be sought for; what will
cure one person will go a long way to kill another.

The flabby, fat, anemic patient is frequently the woman who
cannot keep anything upon her stomach; she vomits blood,
though not very much. There is gastric pain soon after eating,
and also upon pressure over the stomach, and she vomits every-
thing she takes; probably for days or weeks together. These
people take apparently little or no food, still they keep fat; but
are exceedingly pale, good for nothing, too prostrate to do any-
thing, and they do not caretomove. There is frequently great
pain just before the menstrual period,and the ovaries are exceed-
ingly hyperesthetic and irritable. These organs are sometimes
removed, rarely with any improvement following in the patient’s
condition. Such invalids try the different Spas, take large
quantities of iron, consult the various specialists, and even
take an interest in their practice and the patients constituting
their clientéle. They are generally even tempered, kind
hearted and generous in disposition, getting a large amount of
sympathy, considering it to be their due. Their age ranges
usually from twenty-five to thirty-five.

Fat people, as a rule, are fat because they have relatively
less blood. Women with fewer red blood corpuscles are usually
fatter than men. The consumption of alcohol favours the
conservation of fat in the body; the alcohol is easily oxidized,
and thus prevents the fat from being burned up. And in
addition to the great size and weight of the body, corpulent
people suffer from fatigue and breathlessness, and even
apoplexy. The recognised rules for the reduction of corpulency
are, not to eat too much, arise from the table with an appetite,
avoid sugar, bread, potatoes, and alcohol, drink freely of hot
water an hour before each meal, and eat fish and good fresh
meat. Tell your cook to throw the frying-pan away, and order
fish and flesh, to be taken either grilled, boiled, or roasted.

To treat this class of chronic invalid we have to lessen the
fat, and in order to do this we must discontinue any kind of
food which increases it; and we must also do everything to
improve the quality of the blood. Therefore my plan is to give
the patient three quarts of whey daily, with the juice of four
lemons, thin dry toast and butter. Fairly active massage is
necessary, and can be well borne from the first. It may
DIETARY FOR FAT ANAMIC PEOPLE. 147

appear strange to you, no doubt, that I commence to treat these
stout patients in the same way that I do lean patients. >This
is perfectly true, for you must remember what I have told you
before about massage, namely, that massage manipulations
possess the power to bring tissues into their normal state. If
a patient be unduly fat, massage will decrease it; and if the
patient be unnaturally lean, massage will promote "the growth
of fat. Both in the absence and presence of fat we have a
train of symptoms somewhat analogous, but an anemic, fat,
flabby patient, is more difficult to cure than an emaciated,
bloodless patient, for we have seen that good fat and good
blood go hand-in-hand, therefore in our flabby, fat patients we
have to create a fresh class of fat altogether.

Then what do we do? We put this jelly-bag-like individual
to bed, and for the first fortnight the diet should consist of
nothing but whey, lemon juice, and dry toast, or whole meal
biscuits; and as soon as possible active massage is commenced.
The tissues about the loins, buttocks, and thighs are pressed,
kneaded, and compressed in every possible way. Now it is
astonishing how rapidly this kind of fat melts. In ten
days this fat patient will have lost more than‘ten pounds in
weight, and ten pounds loss of fat will cause the patient to
look comparatively thin. The kind of dietary should be as
follows: 7.30 a.m., 4 ounces of well grilled-steak, cup of weak tea
drunk as hot as possible, no sugar or milk; the juice of a lemon
may be taken with the tea; 10 a.m., glass of beef juice; 11 am.,
massage, particularly of abdomen, buttocks, and thighs; 12
a.m., glass of beef juice; 1.30, two thick grilled mutton cutlets
free from fat and bone, dry toast, a glass of good burgundy ;
4 p.m., galvanism; 5 p.m., beef juice; 6.30 p.m., beef juice ;
7 p.m., boiled sole, dry toast, glass of burgundy; 9 p.m., tumbler
of whey with the juice of a lemon; a baked apple without
sugar to be taken after each meal.

In these fat anemic people I always commence treatment
with whey and dry toast until a certain reduction in fat has
taken place; I then give a relatively small quantity of fluid ;
no milk or soups; the fluid consisting chiefly of two glasses
of good burgundy and sixteen ounces of beef juice in the
twenty-four hours. I never give bread, rice, sago, tapioca, or
macaroni. Again, in these cases, I rarely refuse either
fresh or stewed fruit; and in ordinary cases cream may
be taken to the extent of half-a-pound a day.

Perhaps those of you who are familiar with the Weir
Mitchell treatment will perceive that I rather lean to very
careful, and what I consider feeding which is especially appro-
priate to the case. It is necessary during the course of this
cure to take every point of detail into the minutest considera-
148 THE WEIR-MITCHELL TREATMENT.

tion; this is the only way to meet with uniform success.
There is one important point to be considered after the
treatment is over, namely, what is best to be done with the
patient in order to maintain the gain in strength and flesh ?
At one time it occurred to me that a sea voyage ought to
possess special advantages, but in this I have been deceived.
Out of eleven cases during the past twelve months that I have
sent to sea after the Weir-Mitchell cure, only seven maintained
and improved upon their gain; the remaining four were little,
if any, the better for this kind of change.
Lecture VIII.

MASSAGE OF THE CHEST AND ABDOMEN.

Massage of the Chest—Passive Gymuastics of the Chest—Modes of
Manipulating the Abdomen — Obesity — Constipation — Scybalee — Hepatic
Congestion and Hypertrophy—Atony and Distension of the Gall-Bladder—
Gall-stones—Retained Bile—Ovarian Congestion, Displacement, Irritation,
Neuralgia, Hyperesthesia — Uterine Displacements — Amenorrhcea and
Dysmenorrhea—Neuralgias—Spasmodic Strictures, and Neuroses.

I wave to-day to bring in review before you the viscera of the
trunk of the body, and endeavour to explain to you the best
manner of operating upon these parts for certain forms of
disease. I have not much to say to you about the chest, the
heart and the lungs contained within it are so thoroughly
protected by the framework of this osseo-cartilaginous cage
that we are quite unable to affect these structures in any
other but an indirect way; still in certain forms of nervous
exhaustion, when respiration is defective, and in the first stage
of pulmonary disease, and even in some forms of heart
trouble, I would especially commend to your notice passive,
and even active gymnastic exercises which bring the upper
extremities into play and so tend to deeper inspiration and
more complete expiration. I have spoken to you concerning
what is called internal respiration, when the exchange of gases
takes place between the blood in the capillaries of the systemic
system and the tissues of the body ; respiration by the lungs
is known as the outer respiration, which embraces the exchange
of gases between the external air and the blood of the
respiratory organs, namely, the lungs and skin. The
movements of respiration are also important factors in
moving the lymph onwards in the pulmonary lymphatics.
The movements of the lungs themselves are entirely passive
and dependent upon the movements of the chest, therefore
you must see the importance of thoracic movements, if the
blood is to be duly oxidised, not only for the removal of the
carbon from the venous blood, but also to give oxygen to the
haemoglobin to be carried to the tissues for their respiration.
Respiration, then, is essential to oxidation, and we know that
oxidation is essential to our existence. But I have no intention
to weary you with the physiology of respiration. However,
let me tell you that in nervous exhaustion and prostration the
muscles of respiration frequently fail in their normal work, and
when this is the case I always include artificial respiration as
part of my system of treatment, and if need be I make my
patient inhale oxygen at every third inspiration. The method
 

150 MASSAGE OF THE CHEST AND ABDOMEN.

T adopt for passive movement is that known as the Sylvester
method, and it was introduced by him for restoring life after
drowning. I will demonstrate this method to you upon this
patient. I place the patient in the horizontal position upon the
table with the head and shoulders raised, I then seize the
arms just above the elbow and draw them actively over the
head (Fig. 23). I then flex the arms upon the forearms and
bring the arms well into the sides of the chest, using a
fair amount of pressure (Fig. 24).

  

Ne

ic
er

\ we «
K ii \ I WT i
A D \

  

 

 

 

Fig, 24, —Passive Gymnastics for phthisis, neurasthenia, &c.

This passive form of lung gymnastics should be of great
service in incipient tuberculosis of the lungs and in pulmonary
MASSAGE OF THE ABDOMEN. 151

respiration, my only wonder is that it is not more frequently
had recourse to. The skin and muscular tissue over the
chest must now be stimulated by progressive petrissage
movements from above downwards and outwards, in the course
of the ribs.

Abdomen.—You will remember when speaking to you of the
anatomy of the abdomen we divided it into nine different
regions, each of which was related to the various structures
which it contained, or which were to be found in the
immediate neighbourhood; but apart from this I must to-day
give you some information relative to one or two other points
with which I think you ought to be acquainted. To press
and pommel the belly is one thing, but to massage with skill
and to know the principal structures upon which your
movements are being exercised is another.

I will firstly, then, call your attention to massage as applied to
the abdomen from a general point of view, and to the intestinal
tract for constipation, picking up as we go along some scraps
of physiological knowledge, which will, I hope, give us more
interest in our work, and offer us some explanation of those
changes which we believe result from our manipulations.
You know abdomens differ very greatly, some are distended
and covered with thick layers of fat, others are without fat,
but the recti muscles are hard and rigid, so that it is difficult
to relax them. Again, the anterior abdominal wall may be
soft and supple so that the posterior wall may be reached
without difficulty.

Before manipulating the abdomen, always see that the
bladder is empty; this is very important in hysterical cases,
for the bladder may be distended above the umbilicus without
the patient being conscious of the fact.

Your patient being in the horizontal posture, raise the
head and shoulders some six or twelve inches, the thighs
must also be raised by placing a pillow or two at the under
part, towards the bend of the legs. In order to get the
abdominal muscles relaxed, make the patient keep the
mouth open and draw up the legs to the trunk as high
as possible; but the first is the best position for ordinary
massage. Try the sensitiveness of the abdominal muscles to
reflex action, which you will always find very variable; in
some it will be so active as to produce abnormal movement in
the bowel itself. Before commencing to manipulate make
pressure upon different parts; firstly, to discover if there is
anything abnormal, and, secondly, to find out if there is any
tender spot. When massaging for constipation, always smear
some lubridant over your hands; there is nothing better than
liquid vaseline or castor oil; it is scarcely credible, but upon
152 MASSAGE OF THE CHEST AND ABDOMEN.

several occasions I have thought that the use of castor oil in
this way increased the tendency to peristalsis.

You now effleurage over the abdominal wall, and remember
that all your movements should be in the course of the large
bowel, from right to left of your patient, upwards on the right
and downwards on the left.

Pick up the skin, areolar tissue, and fat by the usual
petrissage movements, beginning in the right inguinal
region and working round to the left inguinal region. If you
have to bring about the absorption of fat, great rolls of fat,
you must grasp it firmly in your hands and knead and squeeze
it as though it were dough.

Now smear the hands with castor oil and commence the
deeper movements, which are in the main mechanical. These
manipulations are not easily described, so watch my mode of
operating carefully. Let me first say a word or two to you
about the colon. This bowel commences in the right iliac
fossa in a dilated part called the cecum. It ascends through
the right lumbar and hypochondriac regions to the under
surface of the liver, it then passes transversely across the
abdomen, on the confines of the epigastric and umbilical
regions, to the left hypochondriac region, descends through
the left lumbar region to the left iliac fossa, when it forms the
sigmoid flexure; finally it enters the pelvis and descends
along the posterior wall to the anus.

The cecum is a blind pouch or cul-de-sac, in which the
large intestine commences, and in which the lower end of
the ilium terminates. Its position in the abdomen is at the
inner part of the right iliac fossa, in a line with the middle
of Poupart’s ligament, and from this point I wish you
to begin to operate. You can see the course of the colon
in the model before you. Place your two thumbs over

 

 

 

Fig. 25 shows the position of the thumbs and the hands for upward and
circular movements in the course of the colon. All movements being
directed from right to left.
MASSAGE OF THE ABDOMEN. 1538

the cecum, the right hand lying flat upon the abdomen,
the left hand lying flat also upon the left side, so (Fig. 25).
You must proceed upwards by gentle continuous pressure
along the course of the ascending colon until you get to the
free edge of the right lobe of the liver, but during the progress
of this movement the right hand must be exerting a rotatory
form of pressure from left to right, in the direction of the
transverse and descending colons. When you get to the free
edge of the liver, manipulate this part well with your thumbs,
for you are immediately over the gall-bladder. After having
done s0, still press onwards with your two thumbs in the
direction of the transverse and descending colon. Remember
that these manipulations must be done slowly, purposely,
quietly and regularly, never let abdominal massage be done
hurriedly or jerkingly. After three minutes operating in this
way you make use of a rather more active and general move-
ment with both hands, the inner side of the left palm going
up the right side of the abdomen, and the inner side of the
right palm descending on the left side of the abdomen; in
this way the small intestines are masséed together, the hands
being crossed at the end of each circuit. Another mode by
which the large bowel can be satisfactorily, progressively and
continuously kneaded, is to work with the tips of the fingers
of one hand placed upon those of the other, after this manner.
(Fig. 26).

 

 

 

Fig. 26 shows the position of the hands one over the other for pressure
movements in the course of the colon.

You know now the special movements which are to be used
to the colon, let me show you a particular form of manipula-
154 MASSAGE OF THE CHEST AND ABDOMEN.

tion for kneading the cecum with the bent hand, in this way
(Fig. 27). Of course great care must be exercised not to press

 

 

 

Fig. 27 shows position for carefully and nicely graduated pressure move-
ments in cecal region in chronic perityphlitis and impaction.

too heavily, and the pressure should be graduated according
to the resistance to be overcome. This portion of the large
intestine (the cecum) from its structural peculiarities and
anatomical relations, is more liable to disease than any other
part of the large bowel. It may become impacted with feces,
which may harden, forming a painless doughy mass, and very
likely at any time to give rise to obstruction, and sometimes
to serious obstruction. When this occurs massage in the way
just indicated is very useful. The cecum is not only liable to
suffer from the accumulation of fecal matter, but it is also
liable to acute and chronic inflammation. After the acute
symptoms have subsided a chronic condition is usually persis-
tent for some months; this is particularly the case when the
inflammation has extended to the surrounding cellular tissue.
Perityphlitis often gives rise to exudations, which become _
partially organized, forming large lumps in the right inguinal
region and sometimes giving rise to serious discomfort. Mas-
sage as I have indicated will disperse these growths, and give
tone to the bowels, and also prevent its being the seat of
flatulent distension.

Constipation may be looked upon as one of the most common
ills of life, and it is associated with, if it is not the cause [of
MASSAGE FOR CONSTIPATION. 155

many of those troubles which are known as functional. The
contents of the small intestine remain in it about three hours,
and in the large intestine about twelve hours. The faces
become formed in the lower part of the large intestine, and
pass on to the rectum, where the sensation of requiring to go
to stool occurs, that is when their presence is referred to the
brain, where there exists an inhibitory centre for the reflex
action of the sphincters.
Defecation should take place once in twenty-four hours
and the bowels from childhood should be habituated to move at
early morning. There are some women whose bowels are not
moved more than once a week, but this is unnatural and very
likely to lead to uterine congestion and misplacements, in fact it
is a common source of uterine trouble. Dr. Hughlings Jack-
son’s Nerve Theory of Normal Defecation is interesting
(Dis. of Brain, ‘‘ Brit. Med. Jour.,” July 14th, 1888). He
says: ‘There is a motor (viscero-motor) centre in the
medulla, and a controlling (viscero-inhibitory) centre in the
dorsal region of the cord. From the former pass polio-enteric
fibres by way of the vagus to make the intestines contract,
and from the latter leucenteric fibres to keep them dilated,
both sets of fibres are fibres of the level extrinsic downwards—
both in their short course before their emergence from the
medulla and cord and afterwards. But we must suppose
that these are intrinsic fibres, fibres in and belonging to
the level itself, connecting the two centres, bulbar and dorsal ;
by these in quiescence there is amicable antagonism between
the bulbar and dorsal centres. When the operation of defeca-
tion is started by some afferent impulse, the medulla centre,
we shall suppose, inhibits the inhibitory splanchnic centre by
the intrinsic fibres, and acts positively by the extrinsic fibres
(in the vagus) in the intestine. Thus there is positively forcing
and there is negatively yielding.” Intestinal movement is
known as vermicular or peristaltic, and can certainly be called
into increased action (involuntarily) by emotional or mental
disturbance. Some people are very sensitive in this direction,
worry, fear, dread, pleasure, will often stimulate the bowels
to move; the presence of an east wind will with some people
give rise to an attack of diarrhea. The intestinal canal con-
tains an automatic motor nerve centre within its walls which
is normally in action during waking hours ; if this centre is not
affected by any stimulus the movements of the intestines cease.
“When blood containing the normal amount of blood gases
passes through the intestinal blood vessels, the quiet peri-
staltic movements of health occur (enperistalsis), provided no
other stimulus be applied to the intestine. The condition of
the blood flowing through the intestinal vessels has a most
156 MASSAGE OF THE CHEST AND ABDOMEN.

important effect upon the peristaltic movements” (Lanpots
and STIRLING).

The splanchnic nerve is the sensory nerve of the intestines,
and it is also the vaso-motor nerve of all the blood vessels. In-
testinal paresis or exhaustion of the intestines arises from over
stimulation; this condition is common to such diseases as
cholera, septic poisoning, &c., and must not be confounded
with functional inactivity of the muscles and motor nervous ap-
paratus of the bowel, which is the common cause of constipation.
The latter, then, is the condition which we believe we can over-
come by massage. I shall leave the consideration of obstinate
constipation for my lecture on neurasthenia, because its asso-
ciation with this state of the nervous system is so constant,
and the troubles of constipation are so firmly implanted in the
minds of neurasthenics, that it really requires special considera-
tion, and it must be dealt with as an abdominal neurose. To
sum up, constipation is due to defective peristalsis from, (a)
Central nervous disease; (b) Functional inactivity of the spinal
centres ; (c) Animperfect supply of healthy blood ; (d) A deficiency
of healthy bile; (¢) Theformation of scybala ; (f) The existence of
spasm, pressures, or exudations. It is well for us to remember
these, which are the most common causes of constipation. You
will much more frequently have to massage the abdomen for
blood and nerve and bile defects, than you will for scybala,
spasm, pressures, or exudations.

I have spoken and demonstrated to you the ordinary
processes of abdominal massage; I have also told you of
the common causes of constipation. If the passage of the
bowel be partially occluded by cancerous or other growth,
massage is useless; but if it be due to scybala, defective
blood or bile supply, or defective nerve supply, massage
is a good and valuable remedy. I must now tell you that
habitual constipation is not so easily cured. I believe in occa-
sional thorough and active purgation ; it appears to be very
beneficial in many ways, but then the tendency to constipation
isnot cured, and very frequently after a brisk purge the bowels
are more constipated than before. To purge the bowels is an
easy task, but to regulate the bowels is difficult. Certainly
massage seems to be the best regulator. I do not believe in
abdominal massage alone to cure obstinate constipation ; occa-
sionally it might have a good effect, but as a rule it will be
necessary to massage the spine, back, and buttocks, as well as
the bowels ; I find this particularly necessary in the constipation
associated with ovarian irritation, anemia, chlorosis, hypo-
chondriasis, &c. Frequently we meet, however, with men and
women suffering from constipation which will not yield to any
ordinaryremedy. These are, for the most part, associated with
USE OF ELECTRIC ABDOMINAL COMPRESS FOR CONSTIPATION. 157

neurasthenia, and as the nervous prostration becomes cured so
the constipation ceases. Iam in the habit of ordering these
patients the abdominal electric compress, in addition to the abdc-
minalmassage. Theabdomenis first massaged for twenty minutes
with castor oil and the liver succussed and shaken; then the
electric compress is prepared and used in the following manner:
Fold an ordinary sheet to the width of eighteen or twenty
inches, wring it out of cold water (or the water may be hot if
the patient cannot bear it cold), and wrap it quickly and tightly
around the gastro-hepatic region ; then slip between the folds
of the sheet a metal plate (6 in. by 4 in.) having an insulated
wire attached thereto, this plate must form the anode in the
electric circulation ; the cathode consisting of along narrow
plate (6 in.) is now applied between the shoulders, the wires
from the electrodes are carried above and beyond the patient’s
head, and connected with the combination currents of the
galvanic and faradic elements, the patient’s body being well
packed in blankets, and if necessary a bottle of hot water is
applied to the feet ; now turn on a weak combined current (five
milliampére galvanic will be quite enough) and sufficient faradic
current to be comfortably appreciable. The patient must be
kept in the pack for thirty minutes. This is what I call my
‘“‘ Abdominal Electric Compress,” and let me tell you that I
consider it simply invaluable; it quickens and tones the ab-
dominal circulation, promotes absorption and interchange of
gases, stimulates vaso-motor and secretory action, increases
peristalsis of the muscle of the intestines, promotes also glyco-
genesis and the elimination of urea and uric acid. The electrode,
which ought to be long enough to extend nearly the whole length
of the dorsal vertebre, should be well padded.

Von Ziemssen speaks very highly of the physiological action
of the abdominal compress in the following words. ‘The
blood-warm watery vapour reacts upon the skin and excites the
peripheral cutaneous nerves. The warm vapour exercises a
powerful dilating stimulation upon the cutaneous vessels, the
skin becomes more vascular, and the circulation is ac-
celerated.

“This circulatory acceleration in the skin is not without its
effects upon the vascular conditions, in the more deeply situated
organs beneath the bandage, and it acts partly derivatively,
partly by the moist vapour, which, as we know, penetrates the
skin and subcutaneous cellular tissue, and perhaps has effect
even at greater depths, exerting an influence over the nutritive
processes in the abdominal organs. This would be the local
action. But even the original nervous stimulus is conveyed to.
the central organs of the nervous system, namely the brain, the
spinal cord, and the medulla oblongata. The most important
158 MASSAGE OF THE CHEST AND ABDOMEN.

vital processes will be influenced by exaltation of innervation
through various reflex pathways.

“Tn irritable conditions of the abdominal organs, the stomach
or the intestines, amuch higher degree of stimulationis required
to set free the action of counter-irritation, and to bring about
revulsion by way of reflex. (This I claim to be effected by the
use of the combined current, with which Von Ziemssen appears to
be unacquainted.) The contraction of the skin and its vessels,
caused by the cold irritant, diminishes the vascular region of
the skin, and elevates the surrounding pressure, and thetension
in the vascular region of the internal organs. By the lessening
in the amount of vascular space, the obstructions to the circu-
lation are increased, and in consequence thereof also the driving
force of the heart. The result of this will be an acceleration
of the circulation in the internal organs. When the bandage
becomes warm a dilatation of the cutaneous vascular system
takes place, and the blood is now driven with greater force into
the dilated vessels, which contain little blood on account of the
primary contraction, an alteration in the blood distribution
takes place, and upon this depends the change in the activity
of the organs. The function of the skin is stimulated, and the
pathologically increased activity of the abdominal organs is
moderated. The primary functional retrostasis in the affected
hyperemic tracts is followed by a reactionary vascular con-
traction, which forces the blood out of these tracts, and drives
it towards dilated cutaneous vessels. Hyperemia, congestions,
catarrhal, and inflammatory phenomena, even in internal
organs, may be improved or cured by this very simple pro-
cedure.” This is Ziemssen’s opinion of the value and physio-
logical action of the ordinary cold abdominal compress, which
is very interesting, particularly to myself, because by the addi-
tional use of the combined electric current, I get more decided
and definite results than Ziemssen does by the compress alone.

I have very little doubt that exhausted nerves, by their
connection with the semilunar ganglia, together with other
important plexuses, are stimulated to increased activity by
these means. Of course, if I wish to stimulate the medulla,
base of brain, and cervical sympathetic, I either increase the
length of my spinal electrode, so that it extends to the occiput,
or put the original electrode in the cervico-occipital origin.
It is ‘often useful to lessen the resistance of this electrode by
saturating it with dilute acetic acid, the galvanic current being
slightly reduced in strength. After the operation is over, the
body should be quickly rubbed with a towel saturated with a
solution of strong sea salt and water for thirty seconds, then
briskly rubbed until dry with a coarse hot towel. It is well for
the patient to recline and rest for twenty or thirty minutes after
MASSAGE IN INTESTINAL OBSTRUCTION. 159

heis dressed. In some cases of glycosuria I have by these means
reduced the quantity of sugar eliminated from fifteen grains to
three grains to the ounce. I have no hesitation in saying that
both absorption and secretion go on much more rapidly whilst
the patient is in the pack than when he is out of it. Sometimes
I make my patient, whilst he is in the pack, swallow through
an elastic tube and mouth-piece a pint of hot water (120° F.)
with excellent effect, not only in promoting diaphoresis, but
diuresis also.

Dr. Fagge reports a case full of interest and instruction in
the “Lancet”’ of July 27th, 1872, entitled “Intestinal obstruc-
tion of five days’ duration cured by kneading, after injection per
rectum.” The patient was an adult and a free liver. To the
right of the umbilicus and above it, there was distinct hardness,
which gave the impression that a transverse coil of the bowel
could be felt above, bending on a vertical one below. The
vomited matters were brown, with flocculi of a darker colour,
but not stercoraceous.' Anodynes, hot fomentations, and
injections had been thoroughly used, but no relief was obtained
until the abdomen was kneaded by the surgeon who attended
the case, Mr. Brookhouse, of Deptford. Dr. Fagge remarks
that ‘‘ the life of the patient was saved by kneading the belly,
and so satisfactory an issue may well encourage other surgeons
to adopt a similar procedure.” Yet it cannot be denied that
too forcible manipulation of the abdomen might in many
instances involve great risk of tearing through parts softened
by inflammation or sloughing, and thus counteract the curative
processes of nature. Massage in 1872 was different to the
massage of 1888. Practice and experience cannot fail to
have given us a better insight into the various modes and
degrees of manipulation, which are necessary and suitable
to different cases under varying conditions. No doubt
some of you remember that. when massaging Mrs. W—’s
abdomen, you pointed out to me two distinct and separate,
irregular, hard lumps; one was in the ascending colon just
above the cecum, the other was in the descending colon not
far from the sigmoid flexure. I told you that, in my opinion,
they were hardened masses of fecal matter (scybala), and
that massage would soon remove them altogether; this turned
out to be true, for in three weeks not a trace of them remained:

There are many cases reported in the German medical
papers of the use of massage in intussusception, all ending im
recovery ; but in the literature of this country we find very
little relative to this subject. No one should attempt to
massage the abdomen in suspected cases of intussusception,
unless they were not only skilled in massage, but also knew
precisely what the movements were likely to effect, and what
160 MASSAGE OF THE CHEST AND ABDOMEN.

they were expected to effect. Doubtless a great deal of harm
might be done by rough, indefinite, misplaced manipulations.

Mr. Warrington Haward, in a very excellent article, on
‘Surgical Aspects of Constipation,” in the ‘‘ Lancet” for April
28th, 1888, to which I shall have to refer again when speaking
of the diseases of advanced life, gives the following case, with
some remarks which may interest you: ‘“‘A young lady of
nineteen, the sister of one of our pupils, was brought to me on
account of a lateral curvature of the spine. There was a slight
curve, the convexity in the lumbar region being to the left.
The patient complained much of a dull pain in the loins,
especially on the left side. She stooped a good deal, and was
very easily fatigued. She was, moreover, extremely thin and
anemic, had but little appetite, a coated tongue, foul breath,
and very cold hands and feet. An examination of the abdomen
revealed a large fecal accumulation in the sigmoid flexure ;
and on being questioned, she admitted that the bowels were
extremely constipated, often acting only once a week.

This is one case out of a series of the same kind that has
come under my notice, in which a supposed lateral curvature
is merely the habitual position assumed by young girls suffer-
ing from obstinate constipation and loaded sigmoid flexure.”’
“Such cases,” Mr. Haward goes on to say, ‘‘are best treated by
massage, feeding and aperients, under which the anemia
disappears, the bowels recover their power, appetite is regained,
flesh is made, and the yielding of the spine comes to an end.”

Obesity and Corpulence.—I do not think I can do better than
bring the subject of obesity before you in this lecture. It
means disease, and in somes cases it forebodes a serious
termination ; it certainly indicates an excessive deposit of fat
in the connective tissue structures of the body; it is, as you
know, invariably associated with excessive corpulence, and is
more common amongst females than males. Weir Mitchell
speaks of different kinds of fat, and unquestionably there are
fats and fats. You know my opinion about the absorption and
dispersion of fat by massage; it is simply this: If a woman
becomes fat, who should be so naturally and by heredity, it
will take a vast deal of massage to make her thin and give her
that lightness and grace, for which she so vainly sighs. On
the other hand, if a woman rapidly puts on fat to which she is
not entitled, on account of some change in diet or mode of
living or time of life, or some freak of nature, the absorption
and dispersion of this kind of fat is by no means a difficult
matter. Ladies of the Semitic race are frequently predisposed
to the development of adipose tissue and corpulency; the fat
is usually bad stuff, and these subjects not unfrequently suffer
from glyccsuria, of which they are ignorant; they are, as well,
FAT IN HEALTH AND DISEASE. 161

often pale, and bad oxygen carriers. Now these are the patients
upon whom, with hygiene and appropriate diet, massage has
such wonderful power in the dissolution of fat and the inhi-
bition of certain fat making agents in the nervous system.
Excessive fat means a perversion of the normal nutritive
processes, and it is extraordinary what a small amount of food
is sometimes consumed by fat people, and what a large amount
of food may be taken by leanly disposed people without
giving rise to a particle of fat. Fat people are, on the
average, of shorter lives than lean people. No means should
be neglected or pains spared to diminish excessive fat. The
remedy is unquestionably to be found in massage, exercise,
diet, and hot water.

I was called to see a lady some few weeks since who was
remarkably stout. She told me that she was equally thin
previous to two months’ Weir-Mitchell treatment, which
she went through last summer. During the treatment the
increase in weight was nothing remarkable, but ever since she
had grown stouter and stouter: how far this means a perversion
of nutrition remains to be seen; at the present time her limbs
are quite firm. _

Many people have tried the Banting system, with the same
success as Banting himself, who lost by dietary alone in one
year forty-four pounds in weight, and without the recurrence
of corpulence when the ordinary diet was resumed. Others
have tried it with very baneful results, for just as they lost
weight so they got so miserably out of health that they have
been glad to resume their ordinary diet in order to get fat again.

You have had opportunities here of seeing fat people lose fat
and lean people gain fat. The alteration in weight from the
effects of massage is always of great interest, therefore I am
at all times very careful to take the height and weight of my
patients before and after a course of massage; also their
muscular power and breathing capacity, and their resisting
power to both the faradic and galvanic currents.

I may not possibly have an opportunity of referring to this
matter again, therefore I will say now all I care to say about
it. <A certain amount of fat is, or appears to be, necessary to
a healthy existence and to a normal condition of the blood.
Rapid thinning is accompanied with more or less anemia, and,
as Weir Mitchell says, the blood thins with the decrease of the
tissues, and enriches as they increase. The loss of fat,
especially its rapid or steady loss, nearly always goes along
with conditions which impoverish the blood, and, on the other
hand, the gain of fat up to a certain point, seems to go hand-
in-hand with a rise in all other essentials of health, and
notably with an improvement in the colour and ee the
162 MASSAGE OF THE CHEST AND ABDOMEN.

red corpuscles. On the other hand, we often see people
between fifty and sixty putting on fat rapidly and suddenly,
and becoming at once unwieldy and feeble; the fat collecting
in masses about the belly and around the joints. Such an
increase is usually accompanied with fatty degeneration of the
heart and muscles, and with a certain watery flabbiness in the
limbs which, however, do not pit on pressure. Obesity with
thin blood, says Weir Mitchell, is one of the most unmanageable
conditions I know of. And this I have certainly proved before
I adopted the massage treatment.

Setting aside fat as a disease, and dealing with it as we
frequently do, in persons who are called stout with a tendency
to corpulency, it must be a comfort to them to know that with
ordinary attention to diet, and general massage once a day
for three or four weeks, they can be greatly reduced in
weight, and improved in health at the same time.

There are, of course, some people in this world who cannot
be anything but inactive, who will not exercise their muscles
although they have every opportunity, they drive about from
place to place, and enjoy the pleasures of the table to their
heart’s content. Again, there are people who by occupation
are unable to take that amount of exercise which is necessary
for a healthy existence. In each case massage must be very
useful in promoting tissue changes, increasing nutrition and
keeping secretion and excretion, repair and waste at a normal
and natural level. Massage is truly a factor of energy, and
the best tonic known.

The Liver ig one of the most important and the largest
glandular organ in the body. Its chief function is to secrete
bile which flows into the gall-bladder, so that in masséeing
this organ we must not forget to manipulate the gall-bladder.
It is true that one important function of the liver is to form
and stir up glycogen, which is eventually useful in evolving
heat and muscular energy. There is another point for us to
remember, that the liver receives from the intestinal circula-
tion poisonous substances, such as peptones and ptomaines,
and thus prevents their entering the general circulation
unchanged. Dy. Brunton says, ‘‘ The liver acts as a porter or
door-keeper to the circulation, all the substances which are
absorbed from the intestinal canal having to pass through the
portal vein and the capillaries of the liver before they can
enter the general circulation.’’ The functional activity of the
liver is very important to health, and derangement of this
organ means constipation, indigestion, and a whole train of
troublesome symptoms, so that the stomach, the liver and the
intestinal tract are of necessity immediately associated in the
processes of digestion and assimilation, and it would be
EFFECTS OF MASSAGE UPON THE LIVER. 163

useless to massage the intestines without including the liver,
and vice versa. Functional derangement, then, gives rise to
partial arrest of secretion of bile, and to its excretion when
secreted. The terms torpid and inactive are very appropriate,
and there can be little doubt that the liver is frequently torpid
and inactive, and it then refuses to perform its biliary and
glycogenic functions.

The whole of the chylopoetic viscera sympathises with this
inactivity, and the general circulation becomes impregnated
with poisonous and effete material, giving rise to acidity,
flatulence, furred tongue, headache, nausea, loss of appetite,
prostration, hypochondriasis, languor, slow pulse, and loaded
urine of high specific gravity. In plain words, there is
a general arrest in the normal functional activity of the
nervous circulatory, secretive, excretive and assimilative pro-
cesses of every organ in the abdominal cavity, and possibly
outside it as well. This inactivity of the liver may be due to
the nervous system as a cause, to overwork, anxiety and
worry, to shock, to sudden depressing influences, to overfeeding,
and not unfrequently to over-drinking and smoking, cold or
excessive heat. If the liver is too long inactive from drink as
a cause, and if the presence of such an exciting agent be
maintained, the result is vaso-motor paresis and enlargement,
interlobular exudation, connective tissue proliferation, and,
finally, contraction. Now we believe that if massage be
adopted early enough we can, and do, arrest degenerative
change.

Again, we talk of a torpid liver as functionally deranged.
In some people, possibly those of a bilious temperament, the
liver is exceedingly liable to derangement; it becomes over-
sensitive and gets into bad habits; we know that drugs are of
some use in such conditions, but they are often given to
relieve symptoms, rather than to bring the liver to its normal
tonus and standard power of resistance; no better proof of
the truth of the assertion is to be found than in the large
number of people who are taking bilious medicines all their
lives. We claim for abdominal, gastric, and hepatic massage
that it will do what medicine fails frequently in doing.

The movements of the diaphragm assist very greatly in
aiding the expulsion of bile from the liver; this they do in
ordinary respiration, but their effect is much greater in extra-
ordinary or forced inspiration. Exercise which increases
respiratory movements acts as a mechano-therapeutic agent
upon this organ. There cannot possibly be any better exer-
cise than rowing to induge pressure upon the liver and
squeeze out its contents. Of all forms of exercise I maintain
that rowing is the best, and it is accomplished with less
164 MASSAGE OF THE CHEST AND ABDOMEN.

expenditure of energy than any other form of exercise with
which I am acquainted, therefore I consider it of essential
value in neurasthenia.

I have often shown you the best way to work at the liver.
In my experience I have found it exceedingly difficult and in
some cases absolutely impossible to work into the substance of
this organ. I have demonstrated to you what an almost hope-
less task this is, unless the organ is very much enlarged,—of
course, when this is the case there is nothing between the free
surface of theliver which is enlarged and the abdominal wall, so.
that you can actually pick up the margin of the liver and
pinch and knead it, but even this is not easily done. There
are two positions in which to place your patient; the first is
that just described for abdominal massage, with the thighs
and thorax well raised. I prefer this position both for acting
upon the liver and the gall-bladder. I place the palm of my
left hand firmly upon the ribs in the left hypochondrium, and
the palm of my right hand firmly upon the ribs in the right
hypochondrium, making the left hand a fixed point by its
steady continuous pressure upon the ribs. I now produce
with the heel of my right hand a series of pressure and relaxa-
tion movements over the liver, exercising a fair amount of
force. I make my pressure synchronous in time with each
inspiration, but what is better still I ask my patient to breathe
by extra-inspiratory efforts, and then use pressure just at the
pause between inspiration and expiration, relaxing the pres-
sure at expiration. This action upon the liver is percussive,
concussive and succussive, and does more to stimulate the
liver to excrete its bile than any other process with which I
am acquainted. These movements must be continued for five
or six minutes, and I must not forget to show you that the
pressure must sometimes be applied by rapid, jerking, vibratory
action of the arm. It requires a little practice, but if it be
well done it positively shakes the liver. We now turn the
patient upon the belly, and we map out carefully the exact
position of the mass of the liver, from the fifth or six rib
downwards, and here we use tapotement movements freely
and thoroughly. Sometimes I petrissage the skin very care-
fully overthe hepatic region and use intercostal pressure with my
thumbs, in this way, but I rely more upon the percussive
action which I have just shown you. Some authorities think
it better to have the patient in the sitting posture, resting
upon the elbows with the body inclining forward, as it is said
to relax the abdominal walls and allow the liver to gravitate
downwards and forwards. I do,not deny that this position
may be a good one. I never adopt it; firstly, because the
position of the patient is an inconvenient one for the operator,
MASSAGE OF LIVER AND GALL-BLADDER. 165

and, secondly, because it is generally admitted that in the up-
right and sitting posture the liver usually recedes behind the ribs.
If you have to massage the liver specially you must not do so
after a full meal; two or three hours should have elapsed.
The best time is when the chyme is passing into the duo-
denum, when in fact the chyle function is in full operation and
the gall-bladder and pancreas are in a state of activity. The
position of the liver, it must be remembered, varies according
to the greater or less distension of the stomach and intestines ;
when the intestines are empty the liver descends in the
abdomen, but when they are distended it is pushed upwards.
At every meal there is an increased flow of blood to the liver
and also to the stomach.

I am particularly anxious to tell you as much as I can
reasonably, from the massage point of view, about the liver,
because in functional abdominal disease this organ and the
gall-bladder are not unfrequently primarily at fault, and
abdominal massage can never be complete without the liver
receiving its due share of attention. ‘‘ Hepatic affections,” says
Dr. Roberts, in Quain’s Dictionary of Medicine, ‘‘ by interfering
more or less with the physiological functions or anatomical
arrangements of the organ, may give rise to diverse pheno-
mena, not only of a local character, but associated also with
the general system.”” Functional hepatic disorders are regarded
by many eminent physicians as being of peculiar significance,
and as demanding special attention, particularly with reference
to those derangements which influence the secretion of bile, and
likewise I might add the expulsion of bile. Then, I maintain
that by massage, local and abdominal, we find a cholagogue of
definite value; if we want an hepatic stimulant we use the
electric abdominal compress as well. You must again allow
me to state that I never forget to administer drugs when I
believe they may prove advantageous, but the cases which
often come under our care are those where drugs have been
tried and tried in:vain. Still, drugs without massage may in
functional affections of the liver prove useless, but (and J am
speaking from experience) they may be of greater utility when
used with massage.

The gall-bladder is the reservoir for the bile; it is to be found
in a fairly direct line with the curve of the ascending and
transverse portion of the colon, behind the ninth costal car-
tilage. In operating upon the ascending colon you will
remember that I particularly impressed upon you that when
you reached the ribs you were in the immediate neighbour-
hood of the gall-bladder, and that here you made a halt and
worked by deep petrissage over this viscus. You must know
that it is now a common operation to cut down upon the gall-
166 MASSAGE OF THE CHEST AND ABDOMEN.

bladder and remove gall-stones from its interior, and also
from the common duct; but from what I have heard of these
operations, that is from cases which have been brought for-
ward at the medical societies, 1 am of opinion that obstruc-
tions in the common duct can be removed by massage quite
as well as by operation, without the great risk of losing life.
But I shall say nothing more of this. I must call your atten-
tion, however, to several points in connection with this gall-
bladder and the bile it naturally holds, which, in my opinion,
are of very great importance, for I believe that the liver not
unfrequently gets blamed when the gall-bladder is actually at
fault. The bile under normal conditions is continually being
secreted by the liver cells, and is stored up in the gall-bladder,
and it should have a very definite composition, but this for
many reasons is variable. It is poured out copiously into the
duodenum when the chyme distends this portion of the intes-
tine, but demand and supply should be equally balanced,
which is not always the case. If the bile-ducts become
occluded by catarrh, spasm or calculi the bile stagnates,
becomes viscid and thick, and refuses to flow through the
natural outlets ; then the gall-bladder becomes distended, some-
times so great is the distension that its walls are completely
paralyzed, and the smooth muscles when stimulated by the
spinal nerves cannot contract, although they endeavour spas-
modically to do so, hence the pain which so frequently attends
this condition. The bile, under these circumstances, is reab-
sorbed and carried into the circulation, giving rise to jaundice, -
and a very unwholesome train of symptoms frequently follow,
chiefly of a dyspeptic, acid and flatulent character. The feces
become clay coloured, fatty material passes through the intestines
undigested, and the bowels are constipated owing to the hard-
ness of the feces and to the absence of peristalsis, due to
deficiency of bile. Bile pigments pass into the urine, and give
to it a characteristic deep brown colour.

Spasm of the bile-ducts and paralysis of the gall-bladder,
partial or complete, is much more frequent than is usually
supposed ; it is not always attended with pain, neither is it
associated with dyspepsia, although these symptoms are
frequently present, and in some instances they are exceedingly
distressing. Worry, anxiety, and shock, which give rise to
persistent depression of spirits, are most frequently the cause,
far more frequently than cold or over-eating or drinking, yet
the latter are sometimes factors. These conditions of the
gall-bladder and gall-ducts are sometimes very difficult to
relieve by medicine, they are very liable to recur even after
the patient is supposed to be cured. I have no hesitation
in saying that massage and the electric abdominal compress
DERANGEMENTS OF THE PELVIC VISCERA. 167

are the curative agents for spasm and catarrh of the bile-
ducts, atony of the gall-bladder, and inspissated bile.

Chronic Dyspepsia is a name given to various alterations
associated with the stomach and intestinal tract; it may be
catarrhal, congestive, neurosal, fermentative, glandular, and so
on. It is frequently accompanied with great irregularity and
variability of the bowels, constipation and diarrhcea alternating
with each other, but constipation usually predominating. Some-
times pain is felt in the stomach like a lump of lead immediately
after taking food, or there is a strange feeling of sinking and
want in the bowels; occasionally the bowels become greatly
distended, and acid flatulence and colic are then very trouble-
some symptoms. At times this form of indigestion is
attended with melancholy (hypochondriasis), and here, again,
I say abdominal massage and galvanism are the remedies.

Disease and Derangements of the Pelvic Viscera.—The organs
of the pelvis which we have to consider more particularly are
the uterus and the ovarics. Let us deal with the uterus first.
The womb, you know, is a pear-shaped body, suspended by
ligamentous structures. It is freely moveable, and on this
account is liable to displacement ; aloaded rectum will exercise
pressure upon it from above and behind, and a distended
bladder from below and in front. From the massage point of
view only, it seems to me necessary that we should know some-
thing of the common ailments of this organ. It is composed
chiefly of muscular tissue which is plentifully supplied with
blood vessels, lymphatics and nerves. It is capable of great
changes, chiefly at the menstrual period, and, secondly, at the
period of gestation. The upper part of the uterus is called the
fundus, which is in direct communication with the ovaries by
the Fallopian tubes, the lower part is called the cervix
terminating in an aperture known as the os with its labia.
In difficult menstruation the channel through the cervix is
contracted so that the menstrual fluid escapes tardily,
accompanied with great pain; this contraction is often
spasmodic and unrelieved by incision or even dilatation.

Dysmenorrhea, asit is called, or mechanical dysmenorrhea, is
usually accompanied with lassitude, languor, backache, and head-
ache, and in some cases there is every reason to believe that the
difficulty of exit of the fluid is dependent upon blood clots and
masses of mucous débris, which choke up the passage and so
bring about retention. This is no doubt a frequent cause of
dysmenorrhea, otherwise incising and dilating the cervix should
bring about relief, which it does not always do. If there be
congestion or sub-acute inflammation of the uterus, the pain
extends over the pelvis, and excites general irritability and over-
sensitiveness of the pelvic nerves, which may extend to the
168 MASSAGE OF THE CHEST AND ABDOMEN.

buttocks and the thighs. Reflex irritation set up in this way may
be accompanied with vomiting, hysteria, and delirium. Pain
usually comes on before the discharge makes its appearance,
sometimes a few hours after. It isadmitted that dysmenorrhea
is a most troublesome and obstinate condition, and one which
sometimes does not yield to any form of treatment. The
usual remedies are dilatation or incision of the constriction,
attention to the general health, rest, hot baths, and anodynes.

I was first struck with the value of massage in dysmenorrhea
some seven years ago, in thecase of a lady about thirty-five years
of age, who was undergoing a course of treatment for nervous-
ness. After it was over she expressed her astonishment and
pleasure at the beneficial influence it had exercised over the
menstrual flow. For years it had been accompanied with diffi-
culty and great pain, and she had undergone several severe
operations, but on the last two occasions there had been no pain
whatever. Her feelings of surprise, satisfaction and delight
were immeasurable, because, as she said, she never expected
any freedom from what she termed her monthly period of
agony and distress. In this case the lady was having general
massage, including, of course, abdominal, but no special uterine
or ovarian massage of any kind was used. No one can doubt,
who has had experience, as I have had, in the treatment of
dysmenorrhea by massage and faradic massage, that it has a
very specific influence over all uterine function, and I may say
especially over the function of the ovaries. What is good for the
one is unquestionably good for both. I assure you I have no
wish whatever to interfere with the gynecologist, for if I have the
slightest doubt about the state of the uterus or its appendages
I always seek his opinion prior to commencing a course of
massage or electric treatment.

Before speaking to you of displacements of the uterus, I
must call your attention to the value of massage and the
combined electric current as emmenagogues in some forms of
amenorrhea. My mode of applying galvanism in these
cases is by means of the hot salt and water foot-bath, connect-
ing the bath with the negative pole of the battery, the positive
sponge electrode being applied to the hypogastric region. The
patient places the feet in the bath for about ten to fifteen
minutes, and a current of from ten to twelve milliampéres is
administered at each sitting; this form of galvanic foot-bath
may be used every other day, but abdominal and spinal
massage should be applied every morning for about twenty
minutes. The hot salt water foot-bath, independent of the
galvanic current, ‘‘ causes dilatation of the arteries of the legs,
and it is probable that this dilatation extends up the iliac
vessels, so that nore blood may be sent to the genitals by this
DR. GRAHAM ON UTERINE MASSAGE. 169

means. In addition, however, it is probable that a close
nervous connection exists between the vascular supply of the
uterus and the feet, for we know that hot mustard foot-baths
promote menstruation, whilst, on the. other hand, cold to
the feet retards it. I need scarcely say that this is worth
knowing and remembering, for absence of menstruation is
associated with, if it is not the cause of, some of the
most troublesome forms of disease with which young life is
afflicted. Sometimes drugs act very satisfactorily, at other
times they seem to be quite ineffectual. Please to remember,
however, that massage and galvanism are intended to improve
nutrition and restore or generate function, and there is no reason
whatever against this treatment being supplemented by the
administration of emmenagogues. The cases which come under
our care, however, are generally those upon whom all other
forms of treatment have been tried and have failed, therefore
the success is all the more pleasing and instructive. The
uterus is particularly liable to congestions, or congestive
inflammatory changes. I have not had any large experience of
the effect of massage in these conditions, yet they form an
important class of women’s diseases, and I must therefore
call your attention to them.

There are authorities upon massage who speak very
highly of manipulations in bringing about absorption of
exudations in chronic endo- and para-metritis. Dr. Graham
is one of these authorities. Chapter VI. in his “ Practical
Treatise on Massage,’ has the following heading : ‘“ Mas-
sage of the uterus and its surroundings, with a report of
two hundred and thirty-nine cases,’”’ so, if you please, I shall
take Dr. Graham as my authority in all that I have to say to
you in reference to the treatment of chronic congestive
inflammatory changes of the womb and its surroundings.

“‘ Massage of the pelvic organs should be intrusted to those
alone who have ‘clean hands and a pure heart,’ and such a
thorough knowledge of the pathology and treatment of uterine
atfections as is possessed by the most accomplished gyne-
ecologists. It should not be confided to any professional manipu-
lator, however skilful. Credit is given to Major Thur Brandt,
a Swedish gymnast, for having been the first to use massage
in the local treatment of uterine affections, about ten years
ago, in 1874. His method excited much adverse criticism,
which, however, has passed away, as the excellent results
obtained became better known. In the hands of a layman it
was, doubtless, at first used without proper discrimination,
and extravagant results were obtained. The next to interest
himself in this was a physician, Dr. Gustaf Norstrom, of
Stockholm, who used the treatment rationally and in cases
170 MASSAGE OF THE CHEST AND ABDOMEN.

that he could understand. He found massage especially suc-
cessful in chronic meitritis that had not arrived at the period of.
induration, and after this in the affection known as hemor-
rhagic endo-metritis. He also obtained good results in prolapse
of the vagina and in chronic inflammations of the ovary. The
catamenia, acute and sub-acute affections, and pregnancy are
contra-indications. In his report of 1876 is given his ex-
perience, which extended over two years and a half, and which
shows that in 188 cases of chronic metritis he obtained forty-
three complete cures, and more than seventy nearly complete.
Nine cases of hemorrhagic metritis were cured, and in seven
cases of sterility, complicating chronic metritis, there occurred
conception in two soon after the cure had been effected.

“The operation consists in introducing an index finger into
the cul-de-sac behind the cervix, in such a manner that the
posterior surface of the uterus is reached. This is then raised
as far as possible, while the fingers of the other hand grasp.
and knead the uterus through the abdominal walls. Some:
times the uterus is pressed against the walls of the pelvis.
laterally or against the posterior surface of the symphysis.
pubis. Massage acts in these cases by removing and prevent-
ing the inflammatory stasis, by producing resorption of
leucocytes and elements which have migrated into the
surrounding tissue, and by restoring tonicity to the tissues.
Dr. Jackson, of Chicago, who seems to have had great experi-
ence in this form of massage, says, ‘Not every case of uterine
enlargement is amenable to squeezing and kneading, in some
it might be injurious. Massage is available in the first stage,
when the uterus is found low down in the pelvis, enlarged,
tender, and spongy, and having a doughy elasticity, its sinuses
gorged with blood, and newly formed connective tissue in its
walls. If the first or hyperemic stage is passed, and the organ
has become firm and indurated like cartilage, massage and all
other remedies will be useless.’ The author makes a note-
worthy distinction in pointing out the fact that the pains and.
discomfort accompanying enlargement of the uterus are really
seated in the walls of the abdomen, though usually referred to-
the uterus; and these are first subjected to massage, gently
and superficially to begin with, then more deeply and vigor--
ously, until sensitiveness lessens sufficiently to allow the uterus.
to be kneaded. If this cannot be done effectually through the
abdominal walls, the first and second fingers should be passed.
into the space behind the vaginal portion which is pulled
gently forward, and then permitted to return to its former
position. Thisis repeated half a dozen times or more, when
the fingers are pushed higher up so as to reach the supra-
vaginal portion of the cervix and lower part of the body. The
DR. BUNGE ON UTERINE MASSAGE. 171

upper part of the uterus being now steadied by the hand on
the outside, it is pressed between the fingers of both hands.
repeatedly for a few seconds at a time and then relaxed.
Every portion of the organ which can be reached should be
subjected to these momentary squeezings. Then the manipu-
lations should be reversed. The intra-vaginal fingers should
be drawn in front of the cervix, and the latter pushed back-
wards several times, as far as possible short of causing pain.
Then their ends being passed between the bladder and the
cervix, and their pulps turned against the latter, the fingers of
the outside hand should be so adapted that the exterior body
may again be brought between the compressing forces, when
the squeezing and imparted movements are to be repeated as.
before. Alternating with the process described, the uterus.
should be frequently elevated on the pelvis, and held for a few
seconds.

“Dr. Otto Bunge, of Berlin, has published an article report-
ing favourable results from massage of the abdomen. He
has used massage most frequently for the removal of the
sequele of peri-uterine cellulitis and pelvic peritonitis of the
most various forms, which had bade defiance to the customary
methods of treatment. His mode of using massage was very
much similar to that of Norstrom and Jackson; but as his
aim was often the loosening of adhesions and the dispersion
of indurations, the manipulations in such cases were directed
towards the seat of these, working more around the uterus,
internally and externally, and pushing, pulling, or raising it.
in such ways as would detach the adhesions. The good effects
of this treatment showed themselves by the dispersion of the
pathological products, thus increasing their surface for reab-
sorption by furthering the circulation and by stirring up the
contractions of the uterus. Cases were treated in which the
uterus was so closely fixed to one or the other part of the pelvic
walls by adhesions, that at first it was not possible to penetrate
between them: with these only gentle, steady pulling or pressure
could be used; but by patience and perseverance they became
the most thankful of all cases.” Dr. Graham then gives the
tables of Dr. Bunge’s cases.

Now I have quoted thus largely from Dr. Graham’s book
because the subject is one with which I am not familiar, and I
have had no practice in this mode of operating. Neither am
I going to question the necessity for intra-vaginal manipula-
tions. I do not think they are necessary, otherwise than in
exceptional cases. I will now call your attention to mechanical
displacement of the uterus, and to my mode of manipulation
in order to put this organ right. If you think for one moment.
how the uterus is suspended, so to speak, in the pelvic cavity,
172 MASSAGE OF THE CHEST AND ABDOMEN.

pressed upon from behind by a loaded rectum, and from before
by a distended bladder, and how liable it is to become top heavy
from congestion of the fundus and from growths of an adven-
titious kind inside its cavity and within its walls, the only
wonder is that the uterus is ever just where it should be. If
compensation in the human tissues did not exercise itself to
remedy to some degree the physiological disturbances in the
animal economy due to the modern habits of so-called civiliza-
tion, Iam afraid the poor little uterus would be constantly sky-
larking from one part of the pelvis to the other. There is no
organ in the body so liable to displacement, but nature has in
her best way arranged for this; and if we consider the function
of the uterus in regard to gestation, the necessity for absolute
mobility is at once apparent. There are no physiological
processes in the body to be compared with the marvellous
workings of the uterus and ovaries in fecundation and gestation.
There can be little doubt that uterine congestions with some
amount of displacement are as common as piles; and to some
women the one is as great a source of annoyance and discom-
fort as the other. Nor can we wonder at this. Just imagine
for one moment the uterus of a young lady of a somewhat lax
habit of body, not fond of exercise, the waist imprisoned in a
tight corset, the feet squeezed by sheer effort into a pair of
tight boots, with the calls of nature utterly neglected, the
bowels relieved possibly once in a week or ten days; the result
is uterine derangement and displacement, the sexual organs
must suffer, the ligaments fail to duly antagonize each other,
they yield for want of tone, and prolapse and displacement
must of necessity result. The great question to my mind is
this, Do slight displacements require the constant use of
pessaries? Is it well to concentrate a woman’s mind too much
upon this part of her organization? Iam inclined to think to
the contrary. I would neither massage nor support a uterus
unless I were quite sure that the displacement was of such a
nature that some kind of operative procedure was absolutely
necessary. Meddlesome local uterine medication is, to my way
of thinking, not only unjustifiable, but unpardonable.

Dr. Playfair divides displacements into two classes, ‘‘ versions
and flexions. In the former, the body of the uterus retains its
normal shape, but not its normal direction, the entire organ
being displaced either forwards, backwards, or to one side;
in the latter the shape of the uterus is altered, and its body is
more or less acutely bent over the cervix in the form of a
retort.”’

Now you know have told you more than once that massage.
does possess the therapeutic power of going so far and no
farther; of doing much work that cannot well be undone, by
OPERATION FOR MASSEEING THE UTERUS. 173

merely aiding nature to repair errors of omission as well as
of commission. If your manipulations are exercised with just
sufficient excitation, force and pressure, the tendency, and the
one tendency only, is to bring parts to their normal, anatom-
ical, and physiological status. In righting a displaced or flexed
uterus we not only have to consider the condition of this
organ, but we must also make ourselves acquainted with the
nature of its environment, and its blood and nerve supply.
Setting aside all indirect causes, we must conclude that
a loaded rectum, and a retarded circulation through the
_ abdominal veins, leading to a plethora of the abdominal viscera,
are common factors of maltaxis of the womb, therefore I hold
that local and general abdominal massage should be, and is
a most efficient and permanent remedy.

Let me now direct your attention to the manipulative
processes. In the first place you perform general abdominal
massage after the manner and according to the rules which I
laid down at the beginning of these lectures, stimulate every
part of the abdomen from the skin to the deeper parts, then
place both your hands flat upon the ilio-hypogastric regions
(first make sure that the bladder is empty), pinch up the skin
and underlying fat, so as to gauge its thickness and the
amount of pressure required to get beneath the abdominal
muscles, which must be relaxed to their fullest extent; your
movements must be lateral and impressive. Standing as I
am now, to the right of my patient, place your fingers just
outside the left ovary and your thumbs on the near side of the
right ovary, make deep pressure with the thumbs, pressing
the contents of the pelvis to the left side; now press your
fingers well down and narrow the distance as much as you
can between the fingers and thumbs; carry the pressure as
far as possible without inflicting any severe amount of pain
until resistance renders further movement impossible; then
roll the intervening structures. You have now included within
your grasp the uterus and its appendages ; repeat this operation
some twenty times, and then use pressure with your fingers.
across the pelvis backwards and forwards from one anterior
superior spinous process of the ilium to the other. Of course
a great deal will depend upon the amount of fat and the
rigidity of the abdominal muscles, but these obstacles can be
overcome by care and determination ; finally tapote with the
ulnar side of the fingers. I must admit that these, like other
manipulations, require practice, and the success which attends.
you in your work will be dependent upon your practical skill,
dexterity and insight.. We pass on now to consider the
ovaries.

The Ovaries.—In the first place I think it is exceedingly
174 MASSAGE OF THE CHEST AND ABDOMEN,

important that you should know as far as is practicable the
exact position of these organs as they exist in the living body.
Upon this patient I have mapped out with pencil the
abdominal regions as correctly as it is possible to do.
M. Charcot, who has given great attention to this subject,
says, ‘If from a line uniting the anterior superior spines of
the ilia you let fall the perpendicular lines which form the
lateral limits of the epigastrium, the seats of the ovaries
will be exactly at the spots where these lines cross each
other.” Therefore we are justified in coming to the conclusion
that at these points which I now show you the ovaries are to
be found in the abdominal cavity ; in fact M. Charcot goes so
far as to say, that if you pass a needle into the abdomen at
these points you transfix the ovaries as he has repeatedly
proved. Deep exploration of this region allows us readily
to recognize the ovary, especially when enlarged and swollen,
which is not unfrequently the case. I shall have to bring
before you certain points in my next lecture in connection
with the ovaries, when speaking to you of hysteria, but I had
better give you a little more information upon this subject
at the present time.

I have often drawn your attention in masséeing the
abdomen in women to the pain which they frequently
experience in the ovarian region, particularly of the
left side; it is exceedingly common at the extreme limit of the
hypogastric region. This pain is indicative of the neurosal
state of the individual, but it is not of necessity indicative of
hysteria as this term is usually and sometimes vaguely
employed; it unquestionably denotes exhaustion. A tender,
painful, irritable, hyperesthetic and sometimes swollen
state of the left ovary is of itself a sign of nervous weakness,
prostration and debility, and oft-times of a purely hysterical
state. In women who suffer from hysteria you learn
the fact that their attacks commence by peculiar sensations
in this region, and that they spread from point to point,
that is to the epigastrium (lst node), thence to the
throat (nd node), and finally to the cortex of the brain,
leading to unconsciousness and convulsions, therefore the
sensation experienced in the ovary and its irradiation is known
as the aura hysterica. M. Charcot says, ‘If am to judge
from my own observations, this iliac pain always precedes
in point of time, however small the interval may be, the
epigastric pain, in the development of the aura, and
consequently it constitutes the first link in the chain.” Iam
always inclined to accept everything M. Charcot says as true,
without much thought or reflection, but I am not quite.in
agreement with him on all he says relative to hysteria.
THE UTERUS AND OVARIES. 175

It may interest you to know that methodical compression
of the ovary in the hysterical can determine the pro-
duction of the hysterical aura, and that energetic com-
pression is capable of stopping the development of the
attack when beginning, or even of cutting it short when
advanced. Although I have rather led you away to the
momentary consideration of hysteria, I think you will see
that my object has been to show you that the ovary as part of
the abdominal viscera is one, and a very important link in the
chain associated with emotional neuroses, and a chain, by the
way, whose links are so interwoven that the task of ‘picking
them asunder and determining their connection and relative
value is very far from being accomplished ; but massage, as
we saw in our last lecture, is so important in the cure of these
conditions that I think you should be acquainted with some
of the leading principles and common phases of hysterical
conditions. No man can take an interest in his work unless
he knows the nature of the soil he is cultivating, the seed
which he is planting, and the crop which he may hope to
realize.

Hysterical symptoms, and this must not be forgotten, often
complicate and cloak those of organic disease. Gowers says,
“The effect of disease of one part is often to disturb the
functions of other parts, and of this disturbance hysterical
symptoms are a frequent result.” I have seen serious
mistakes made on this account. Weir Mitchell’s remark is
here most appropriate, “‘ The symptoms of real disease are
painted on an hysterical background.’ Of late years it has
‘become the practice to remove the ovaries in severe cases of
hysteria, and in the majority the patients have been relieved.
Doubtless the operation exercises a profound moral influence
upon the nervous system, yet unquestionably it must be
admitted that one source of irritation has been withdrawn.
I know a lady well whose ovaries were removed, and her more
severe symptoms subsided, but still she cannot be said to be
cured.

We must not forget that functional troubles of a reflex
nature may arise from a congestive hyperesthetic condition of
the uterus and the ovaries. Persistent vomiting may have
such an origin, therefore I advise you to try abdominal and
spinal massage in such cases. I have done so upon several
occasions with most excellent results, when other means have
failed to do any good whatever.

Sir Spencer Wells writes very graphically of the function
.of the ovaries in Quain’s Dictionary. ‘‘ We have to remember
that at each menstrual period one or other ovary becomes
swollen, that one or more of its ovisacs enlarges, opens, and
176 MASSAGE OF THE CHEST AND ABDOMEN.

admits of the escape of the ovum it contained; that the
fimbrial end of the Fallopian tube grasps the ovary, receives
the ovum, and allows of its passage into the uterine cavity ;
that the uterus itself receives an increased supply of blood,
and that its mucous membrane undergoes a series of ex-
foliative changes. We must consider further how these
periodical processes are associated with much that is of
supreme importance in the state of the nervous centres, and
in the mental condition of women. When we bear in mind
their highly complex processes, conditions and relations, the
wonder is, not that ovarian diseases should be frequent, but
that so many women pass through life without suffering from
them.”

Visceral Newralgias are occasioned by some departure from
the normal automatic and reflex activity of the sympathetic
and cerebro-spinal system of nerves. This want of correlative
integrity is manifested by spasm and frequently by retrograde
metabolism.

The functions of organic life are, fortunately for us, carried
on by a system of reflex acts without our being in any way
conscious of their mysterious and wonderful doings. Very
few of our movements which are being constantly performed
by voluntary muscles are executed by really volitional efforts ;
but let voluntary muscles become fatigued, as for instance in
writers’ cramp, then the automatism is destroyed, every
act becomes purposively volitional, and co-ordinate automatic
acts become inco-ordinate when associated with intensified
volition and fatigue; then follow strain, spasm, cramp and
pain. Let me reverse this picture and draw your attention to
the ceaseless activity of the great sympathetic system of
nerves. They are ever recording their existence by impressions
upon the spinal cord and brain, in a sphere which is purely
their own, disassociated from the conscious ego; but when
the integrity of their machinery is interrupted, when, in
fact, the human battery becomes short circuited, the
ordinary sub-conscious impress becomes intensified and
perceived, and this conscious perception generates the sense
of pain. .

It is probable that some cause deranging the functional
activity of the spinal cord is frequently the source of visceral
neuralgias. It is certain that disease of the spinal cord as we
find it in tabes dorsalis may give rise to acute pain in any of
the viscera, but of course this is a subject which is quite
foreign to my teaching upon this occasion. Neuralgia of the
lungs is rare. Neuralgia of the heart is not common.
Pain referred to the heart is not uncommon. I have had one
case of pure cardiac neuralgia lately under my care in the

 
NEURALGIA OF STOMACH AND LIVER. 177

patient whom you have seen suffering from tic-douloureux.
But we must go below the diaphragm for visceral neuralgias.
I can do little more than merely refer to them.

Neuralgia of the Stomach must not be included in the
pains associated with indigestion, for it may exist when the
stomach is empty, and it may be relieved by the introduction
of food, and the appetite is not usually lessened; the
stomach may be exceedingly irritable, and reject its contents
en masse. Pressure does not give pain; on the contrary,
it often affords a sense of relief. Periodicity of recurrence
must also be noted, and if pressure be made upon the
mid-dorsal spines they will be found extremely tender.
Anodyne medicines frequently fail to give relief; scruple doses
of antipyrin or ten grain doses of quinine are sometimes
efficacious. I have found blistering the spine useful, but the
best remedy is the combined electric current. A large flat
electrode (kathode) should be placed over the epigastrium, and
the anode should be fixed to the dorsal spines ; the current, a
weak one, must be kept up for half an hour. I have been
disappointed with cocaine as a permanent cure; in grain doses
it certainly relieves.

_The Liver is at times the seat of neuralgia, but I am
inclined to believe that it is often a referred pain from some
impediment to the flow of bile in the bile ducts. Massage
and galvanism are the remedies in all these cases.

Neuralgia of the lower part of the rectum frequently
attended with spasm, and neuralgia of the bladder are best
relieved by massage and galvanism. I am very partial to
the use of large doses of the mixed bromides in obscure
abdominal pains.

The generative organs to which I have just referred are
frequently the seats of pain, and here again if you wish to
cure you must have recourse to massage and galvanism. In
conclusion I should like to say a few words to you about the
application of galvanism to the abdomen from a general point
of view.

The application of galvanism to the abdominal organs.—You
know I have the greatest faith in the value of the combined
currents applied to the abdomen in all forms of abdominal
disease (malignant disease may be excluded), the result of im-
paired function, whether they are purely neurosal, neuralgic,
dyspeptic, circulatory or catarrhal. I have spoken in this
lecture of my electric compress, the use of which I consider to
be the best mode of applying galvanism. Faradisation, uncom-
bined with galvanism, may be compared to the stimulant effect
of water without spirit, but the two to spirit and water com-
bined ; if you wish to influence the deep parts the ow
178 MASSAGE OF THE CHEST AND ABDOMEN.

faradic current is really of little value. The galvanic current
should be reversed every two or three minutes so as to
increase its stimulating effect. Do not use the currents too
strong. There are some electricians who are known to be good
physicists, but who apply currents of great strength. I used
to do the same years ago, but I now consider this system not
only pernicious, but inefficacious. I have now been ap-
plying electricity in every known form and mode for many
years, and after daily practice in its application, and noting
carefully the effects in all forms of disease, I flatter myself that
my opinion is not altogether valueless. I have referred to the
strength of electricity before, and in my lectures I never fail to
mention it; if youdo not use the stabile current, such as we
have in the electric compress, you should use it after the labile
method, by means of a large sponge moistened with salt and
water (the salt, you know, lessens the resistance), by this means
we hope (the theory admits of question) that we increase the
catalytic action. The current passing through the sponge
must be kathodic, whilst the electrode (anode) may be placed
upon any part of the body most convenient; but in galvanizing
the abdomen I prefer to place it upon the mid-dorsal spines.
This is the sponge electrode which I use. You see the sponge
is set upon a zine plate, which is attached to a long glass
handle; you can move it about the abdomen as you please. If
you have a case of dyspepsia to treat you press the sponge
firmly upon the tissues in the epigastrium, and keep it there
for five or six minutes, alternating the voltaics ten or twelve
times ; if you wish to act upon the liver and gall-ducts you
apply it to the right hypochondrium ; if to the uterus, ovaries,
or bladder, you place it on the tissues in the ilio-hypogastric
regions, and so you pass it on to any part of the abdomen.
Massage, combined with galvanism, is certainly capable of
effecting what either of these agents will not do alone. For in-
stance, in chronic constipation of neuro-paralytic origin, not
unfrequently associated with spasm, I apply the current by
means of the sponge to the umbilical region for ten minutes,
and then I have the abdomen well masséed for another ten
minutes, and to make the treatment more effectual I pass this
electrode three or four inches up the rectum, still keeping the
sponge upon the umbilicus. For the rectum operation it is well
to disconnect the voltaic current and use only the faradic; this
latter mode of operating has been known to relieve the most
obstinate constipation when other means have failed. I
feel sure that this procedure would prove highly satisfactory
in cases of tympanites and in chronic typhlitis, where there is
paresis with distension and dilatation of the muscles and walls
of the intestine. In future generations when electrization will,
APPLICATION OF ELECTRICITY TO THE ABDOMEN. 179

in all probability, be well known and universally appreciated
and adopted, we shall have endless recorded cases of its suc-
cessful application; at the present time, however, it seems to
be looked upon with a great deal of suspicion, distrust and
disfavour ; and this possibly arises from the fact that it is
associated with a set of advertising quacks, although surely
this ought not to militate against those who use it in the
spirit of scientific truth and inquiry.
Lecrure IX.

MASSAGE IN NERVOUS EXHAUSTION AND
HYSTERIA.

Diseases of the Nervous System—Difficulty in tracing their origin—The
Correctness of the term Neurasthenia—State of the Nervous System in Neuras-
thenia—-Characteristic Features of Nervous Exhaustion—Sir A. Clarke’s paper
on Neurasthenia—A Typical Case of Neurasthenia—Will the Effect of
Psychic Hnergy—Automatism—Close Alliance between Nervousness and
Neurasthenia—Symptoms of Neurasthenia—Cases quoted from Note Book
in which Massage and Galvanism were very effective in this disease—Irri-
table Spine—Treatment—Sea Voyages and Prolonged Travel not always bene-
ficial after Massage Treatment—Case of Hysteria in which the Weir-Mitchell
Treatment was eminently successful—Definition of Hysteria and Symptoms
most frequently exhibited—Amblyopia—Aphonia—Hysterical Vomiting—
Hysteria distinguished from Epilepsy—Charcot on Hysteria in the Male—
Shock to the Nervous System experienced in Railway or other Accidents—
Railway Brain—Notes of cases of Shock inducing Dementia and Melan-
cholia, also other abnormal Mental conditions —Railway Spine—Charcot on
cases of Hysteria and of Hystero-Epilepsy in the Male.

Tue subject for our consideration to-day is of the greatest
possible interest. I shall endeavour to bring into review a
class of nervous affections which are allied in their history,
heredity, etiology, diagnosis, prognosis and nature. They are
essentially diseases of the nervous system.

It is entirely out of the question for me to consider any other
than the absolute salient points in reference to the most pro-
found, the deepest, and, I might almost add, the most secret
enigmas of the human entity. The greatest learning, sagacity
and knowledge up to the present time have been expended to
unravel, evolve, interpret, and arrange the connections which
link and bind together the physical, physiological, anatomical,
and pathological signs and symptoms which are developed,
extracted, and produced by some unknown factor directed in the
evolution and dissolution of that strange, wonderful, related,
but, to us, exceptional region which forms an oasis between
the physical, the material, the moral, the intellectual, the
mental, the ideational, the metaphysical and the psychical,
and which, when viewed from the hopeless belief of the
physicist, the materialist, and the scientist, forms a realm
entirely subordinate to the great evolutionary doctrine, which
at one time was looked upon as the revolutionary, transmitting
and metagenetic power which should bring light out of dark-
ness, and convert an unknown problem of infinite omniscience
to the level of the sagacity, the intelligence, and the under-
standing of the mind of man. When we look around and note
the feeble, weak, illogical, impotent stuff of which the human
NEURASTHENIA. 181

mind, even in its most exalted form, is built up, we can well
step aside, and allow the express train to pass (as Dr. Wilks so
aptly puts it) and smile as it hurls itself and its occupants into
an unknown region, traversed, it is true, by lines of demarca-
tion, but leading only to dissolution, irrelative separation, and
destructive disintegration.

This may seem a strange introduction to the subject
of nervous exhaustion, but the more we: study, analyze;
investigate, experiment, and reason upon that state which
goes by the name of neurasthenia, the more do we feel
that we are approaching an unknown goal, a problem of
absolutely unknown quantity, whose very existence is lost in
illimitable space, but from which agency arises the transfor-:
mation of other living forces known only to our occult minds
as dissolution. You may believe me or not, just as you
please, but let me tell you that neurasthenia, as I know it, is
inseparably chained to, and indissolubly connected with, every
retrograde, deteriorating, and degenerating process which
alters the normal constitution of all animate matter, for in
those living organisms in whom no nervous system has been
detected, there must be its equivalent in an organizing force,
which to that living organism is as much a governing and con-
trolling agent as the nervous system is to ourselves. Perhaps
I have made clear to you my meaning of the term neuras-
thenia ; it is the catabolesis of our existence.

_Just as conscience is to our faculty of knowing ourselves,
the moral faculty, the moral sense, pertaining to a cognate
integrity of or within us, so is neurasthenia to our organic life.
Conscience often creates neurasthenia, and neurasthenia often-
begets conscience. Chance, I might say good chance, led me a
‘few days ago to look over some old numbers of the ‘“‘ Lancet,”
and in a copy dated January 2, 1886, I found an article en-
titled ‘“‘ Neurasthenia,” written by the most eminent physician
of modern times, a physician whose opinion I greatly respect ;
and I must admit that after reading it carefully I was com-
pelled to read it again, thinking that I must be mistaken. Sir
Andrew Clarke, who was the writer of this article, not only
denounced the term neurasthenia, but he also denounced those
who ventured to useit. Sir Andrew considered that neurasthenia
was a term embodying too much, that it embraced every
symptom of every form of disease, that it was, therefore,
vicious and misleading, and many other strong adjectives were
used to sweep it out of medical literature altogether, and
substitute for it the highly classical term nervousness.

Nervous exhaustion has a different explanation to nerve ex-
haustion, and nervousness may or may not be identical with
nervous exhaustion. Foolishness may exist in a very wise
182 MASSAGE IN NERVOUS EXHAUSTION AND HYSTERIA.

man, andit does not indicate that he is a fool, but both a wise
man and a fool may suffer from nervousness, and yet not
necessarily from nervous exhaustion..

‘Now we are told that to introduce such a term as neuras-
thenia is to violate a fundamental canon in the framing of a
scientific nomenclature, and is in the order of science an un-
pardonable sin. This is, indeed, matter for reflection, and
many a scientist should be humbly though vainly seeking for-
giveness at the shrine of science for his errors of commission.
Again, we are informed that the term neurasthenia is at once
vicious, inaccurate, and therapeutically misleading. I do not
admit either the one or the other. I have given considerable
attention to conditions which are now generally known as
neurasthenic. I see during the year a fair number of patients
who are so suffering, and after examining them most carefully,
I frankly tell them that I find no organic change in any tissue
of the body, that the state is one of functional nerve derange-
ment; and I would much rather do so than tell them that they
were on the border land of diabetes, or that in six months they
would be suffering from blood-regurgitation through an incom-
petent valve, or that spasm of their vessels in the brain might
ultimately lead to starvation of brain matter, paralysis, melan-
cholia and dementia. These results may, and do, follow the
symptoms which we attribute to neurasthenia, but it would be
far more vicious to tell the patient what might be, than what
really is the truth. The former is the hypothesis and the
theory, which might pass away, the latter is the central con-
dition of things as they stand. Well, Inow want to be told in what
way theterm neurasthenia is clinically misleading. If there
exists, as thenameindicates, an asthenic condition of the nervous
system, it indicates that the asthenic state requires something
to remedy this defect ; it might be very slight, possibly a little
oxygen thrown into the blood might suffice, or a well regulated
diet, or a course of massage with or without galvanism. There
is no drugin the whole Pharmacopeia that can be looked upon
as curative ; medicines said to be good for nervousness as laid
down in Brunton's ‘“‘ Materia Medica” are useless. I was in
the habit at one time of recommending neurasthenics to
take a voyage, seek change in some genial bracing climate,
but they invariably returned not one bit the better. What
a tale one could unfold of the impotency of ordinary remedies
in curing neurasthenics ; therefore we consider that we are
more than justified in resorting to those which are extra-
ordinary.

Leaving the malediction of Sir Andrew Clarke against the
term neurasthenia, and against myself and others who clearly
from his point of view are unpardonable sinners, to whom
NEURASTHENIA DEFINED. 183

science can never extend the hand of charity or forgiveness,
let us, notwithstanding our burdens, pass on to consider what
may be the possible state of the nervous system in neuras-
thenia or nervous exhaustion. Is it cerebral? Is it spinal ?
Is it nerve, or is it all the lot combined? Can we find
definition from the teachings of Victor Horsley, either directly
or indirectly, for he has told us as the result of experiment
many things relative to nerve exhaustion which ought to be of
incalculable value to the clinical observer? I think it will be
admitted by the most carping and captious of critics :

1st.—That in neurasthenia there exists a want of correlative
integrity between the cerebro-spinal and sympathetic centres,
and in my opinion, this is the fundamental cause, and is often,
but not necessarily hereditary.

2nd.—That there is defective antagonism between the centres
at the various levels, cerebral and bulbo-spinal, by which a
process or processes of inhibition are started and maintained.
Governing and controlling centres are subjugated by restraint,
so that controlling power is greatly diminished.

8rd.—That the normal activity and interaction which should
exist between the nerve centres is inactive and atonic.

4th.—That, without doubt, a state of discord reigns supreme,
evidenced by instability, irritability, and mutability, functional
depression, dulness and apathy.

5th.—That reflex, automatic, and vaso-motor actions are
controlled and inhibited by resistances which they are unable
to overcome.

6th.—That the sensory and sénsorial side of the nervous
system is equally or more involved than the motor.

7th.—That it cannot be conceded that the basal ganglia and
the bulb are particularly affected, or that such a condition
exists as impoverished nerve force.

8th.—That the tissues and the nerves are incapable of
conducting the electric current as in health, their resisting
capacity is increased, and the impress is received more slowly
by the nerve centres.

The reverse of this occurs frequently when the nerve is
weakened from central disease. The nerve centres are so many
batteries for engendering nerve force, and it has occurred to
me that the human brain may be compared to the galvanic
battery. The current strength of electricity is equal to the
electro-motive force, divided by the resistance which it encounters
in the circuit of the battery; the nervous energy may be said
to be equal to the force evolved, divided by the resistance
which it experiences in the nerve cell which evolves it, so that
the activity of the battery, as well as of the nerve cell, is deter-
mined by an increased production of force, on the one hand,
184 MASSAGE IN NERVOUS EXHAUSTION AND HYSTERIA.

or by a diminished resistance on the other. Therefore knowing
that the current of a galvanic battery may be modified by
changes in the electro-motive force, or in the resistance, or in
both, so we may by analogy be fairly and warrantably led to
conclude that nervous energy may be similarly modified by
changes either in the nervous force, or in the resistance, or in
both. If we analyze and compare the electric battery and its
excitant fluid with the human battery, the nerve cell and its
excitant fluid, the electric current and its electro-motor force
with the nerve current and nervous force, the conduction of
the electric fluid with the conduction of the nervous fluid, the
resistance which they both meet with directly they are gene-
rated, and the inter-action which takes place in the battery and
in the nerve cell when the circuit is completed, we shall be
able to form an adequate idea of the similarity of the capacity
of both.

I must now endeavour to portray to you some of the leading
and characteristic features of nervous exhaustion. They seem
to me to be distinct in most ways from what is called nervous-
ness. Neurasthenics are most careful to make you understand
that they are not nervous. The majority of the symptoms are
subjective. If there is absolute motor weakness it is generally
referred to the left side of the body, weakness of the left arm,
dragging of the left leg, and so on. I shall read you from
Sir Andrew Clarke’s paper the following paragraph, which
is the best and the most graphic account which I have
ever seen of a compound of nervousness and newrasthenia.
“But hidden within the signs described as characteristic
of neurasthenia, and concealed under such terms as astra-
phobia, topophobia, agorophobia, claustrophobia, anthropo-
phobia, monophobia, photophobia, mysophobia, pantaphobia,
and the like. These are symptoms, various, but related,
‘ which anyone with sufficient experience and competent facul-
ties of observation and critical analysis can easily discover,
arrange into a well defined group, and present to clinical
medicine under the justifiable name of sheer nervousness.”
(This is, of course, a name or term admitting of scientific
definition, which neurasthenia does not! Truly a rose by any
other name would smell as sweet.)

‘All persons exhibiting this group of symptoms have a
tolerably uniform natural history, possess what is understood
as the nervous temperament, and are said by members of our
profession, as well as by the general public, to be sufferers from
‘Nervous debility.” But it is more than doubtful if weakness,
used in its ordinary meaning, is the sole or the chief character-
istic of sufferers from nervousness.

“For the most part they present the appearance of health.
SIGNS OF NEURASTHENIA. 185

Always excitable and sometimes depressed, they are often
animated and joyous, procrastinating, fragmentary, and incon-
stant. There are, nevertheless, to be found among them the
greatest workers of the times; talking occasionally for hours
without fatigue ; they are sometimes silent and grave; for the
most part, fastidious, refined and cultivated; they fall occasion-
ally under the dominion of sensuousness and the lower
emotions; habitually tormented by a physical self-conscious-
ness, they can yet suffer themselves in their devotion to others;
despised to the flesh and the world, they often attain to the
greatest heights of spiritual life. Always ailing, they are
seldom ill. Often condemned to premature death, they live as
a rule long beyond the average duration of life, and are
regarded by the hard, stolid, and superficial with feelings akin
to contempt. It is nevertheless from them, far more than from
any other class of persons, healthy or disordered, that we get
all that is truest and highest, best and noblest, in science or
letters, in art or song.”

This description is very excellent and elegant, but we must
go a little further and put in a few shades of colour here and
there to make it a complete picture of neurasthenia, without
however drawing from the signs and symptoms of any allied
disorder. In neurasthenia we have, then, in addition to the
foregoing defective will power, defective resisting power,
defective memory, defective power of application and attention,
and not unfrequently the special senses are defective and
perverted, perversion really reigns supreme.

A strong, athletic, active man, with nerves like iron bands,
the head of a large business firm, a man of great capacity and
business powers, regular in his habits, temperate, idolized by
his family for his social qualities, plays cricket with his boys
and beats the lot of them, sleeps well and eats well, can take
his twenty mile walk without fatigue, suddenly becomes
desirous to increase his income, and expecting’ to realize a
large fortune he launches out into other branches of trade,
he fails in his object, and is crushed by opposing forces.
It is ascertained that some members of his family are epileptic,
asthmatic, diabetic or insane. What is the result? Why the
entire being of this strong man is changed. His nights are
bad, he turns and tosses in the bed with his head full of cob-
webs and confused ideas, a thousand things flash across his
mind in as many seconds; still there is a constant reversion to
an ever-present something which cannot be well defined, but
which he believes to be the cause of his woes. The terrible
stillness and dead of night strikes and palls upon his weak,
feeble, irritable, active, and acutely conscious being, and
banishes sleep, but not dull care and worry; even the beating
186 MASSAGE IN NERVOUS EXHAUSTION AND HYSTERIA.

of his heart, the throbbing of his pulse, or the call of nature is
welcome as a slight diversion to the stress, the strain, the
tension of an overwhelming, but not overpowering monotony.

The dawn and grey twilight of early morn succeed the
fulsome, blank and dreariness of chaotic darkness only to find
him wakeful, weary, afflicted, and distressed. The hour for rising
has come, and our once strong man, chained and shackled by
the demon neurasthenia (it is foolish and puerile to call it
nervousness), is found weak, impotent, and powerless; his
character, which at one time was distinguished by perspicuity,
clearness, fixity of purpose, definition and decision, is now
remarkable only for its feebleness, irresolution, indecision,
hesitancy, vacillation, doubt, dread, and capriciousness. Just.
as energy is the capacity for work, as we know it in the
physical world, so was this man’s nervous sthenicity, his
capacity for action. But where is it now? Can it be absorbed
in that effete, old-womanly, classical, clinical, canonized, and
scientific term nervousness? No; nothing of the sort. It is
sheer nonsense to admit, or to make bold an attempt to admit,
anything so utterly vague, unreasonable, and obscure.

I have only drawn your attention to a part, and a very small
part of this man’s being. Let us observe him in his social
sphere, and we find a dislike, a distaste for, and almost a
positive aversion to those very things which at one time gave
him the most pleasure. This indifference, unconcern, and
insensibility towards his belongings and surroundings are:
clearly outward and visible signs of an inward and normal
volitional effacement. The best, the purest, the noblest and
highest instincts of his character have fought the fight for
priority and superiority, with the lowest, the basest, and most
profane; and the devil for the time holds sway over the
spiritual. If we follow this man to his counting house, we
there find an utter distrust in those in whom formerly he had
the most implicit confidence. He then tries and forces, culti-
vates and coaxes, his will, to endeavour to bring it into play,
but he fails in will power, and the more he exercises energy to
will, the more does the effort fade away, until finally energy
and will seem extinguished.

I hold, and so does everybody else I should think, that defect.
of will power is one of the most prominent, if not the most:
characteristic sign of neurasthenia. Volition and function go:
together ‘hand-in-hand and shoulder to shoulder. The will
link is only part of the volitional chain, and if the latter be
impaired, will is comparatively influenced. Movement is the
special function of muscle, and is associated with the lowest
level of nerve organization. Combined movements relating to.
complicated and purposive acts are connected with a higher
VOLITION. 187

level, and if these combined movements are generated, elabo-
rated and co-ordinated by a process of forethought and
inductive reasoning, they then belong to the highest level of our
nervous organization. And this is not an automatic or reflex
condition, it is an accomplishment, will being the imaginary
force through whose agency energy is subordinated to act in
certain lines of discharge and conduction. Will is a function
of the moral side just as movement is a function of the
physical side of our being. Will, volition, force, energy, power,
and result, are co-related, transmutable, and transformable.
The power, force, and will may exist in the neurasthenic, but
the capacity or energy, as I told you before, is inhibited.

Will, then, must be the effect of psychic energy. We are
unquestionably much less volitional than we would have our-
selves believe. Automatism is really and truly our normal
state. How seldom do we reflect, seriously consider, and use
our judgment, in fact our reason, to bring about so-called will
effect. The very cause of the neurasthenic state is that the
neurasthenic has too much by far of the ideo-volitional, that
his normal automatism is subjective to his weak, irritable,
and to him, ever present volition. It is only when a muscle is
paretic that we recognise its normal automatic function, and
we then are made conscious of what volition in respect to that
muscle really means; and it is only by an effort of will, and
enforced will, that the function of the muscle can be called
into action, and not unfrequently the very effort of will
annihilates its will power. So with the neurasthenic, his
consciousness of a desire to will inhibits the power to will, and
although the efforts to will are abortive, as long as fixed
attention exists, directly this is withdrawn automatism executes
what will is unable to perform.

In my opinion, nervousness is a condition distinct from
neurasthenia. That the symptoms and signs of the one merge
into those of the other, and that they are allied, there can be
no doubt; but to my way of thinking, rightly or wrongly, we
shall, as science advances, find the term neurasthenia accepted
by the profession as indicative of certain phenomena which
some would have grouped under the banner of sheer nervousness.

Let us follow up the condition of our neurasthenic patient,
for we can now dispose of him in a few words. He is for the
most part one of the most unhappy of happy mortals. Over-
sensitiveness and joyousness alternate with depression and even
melancholy. When the latter exists he is called hy.pochondriacal,
and always has a dread or fear of something that may happen ;.
when the former state prevails, he is pronounced excitable and
even hysterical; and so the emotional elements of his nature
move in cycles, just as the seasons follow each other in rotation.
188 MASSAGE IN NERVOUS EXHAUSTION AND HYSTERIA.

From the purely physical side we find a general arrest of
function and defective metabolism. The action of the heart
is variable, easily excited and easily depressed; the pulse is
small, soft, and weak; the skin is usually dry and harsh, but
sudden and profuse sweatings are not uncommon ; dyspepsia,
flatulence, and acidity are frequent ; the bowels are irregular,
but usually constipated; the extremities are invariably cold
(dead hands and feet) even in the hottest weather; the extremi-
ties are moist and clammy, and tender spots in the spine are
easily elicited. These, then, are some of the most common
signs and symptoms indicative of neurasthenia.

Pray do not imagine that I have exhausted this subject, for
there are many other evidences of the neurasthenic state of a
purely clinical nature, associated with respiration, circulation,
excretion, and secretion ; but I must pass them by, as they do
not come within our present investigations, interesting though
they may be. I think it would be as well if I gave you from
my note-book a brief sketch of one or two cases which have
been treated by massage and galvanism with good results. I
will not select them on account of any wonderful effect of
treatment, but rather to show some of the various phases
which neurasthenia presents.

The first is that of a gentleman, aged fifty, who was brought to
me by an exceedingly skilful observer, Dr. Whitehead, of Ventnor.
My patient at the age of thirty-five broke down in health from
over-anxiety and worry, he then became subject to periodic ner-
vous attacks, accompanied with headaches and utter prostration.
During the time from thirty-five to fifty years of age he was,
with occasional intermissions, a chronic invalid, with all the
symptoms of nervous exhaustion, with the details of which I
will not weary you. Sometimes the head was wrong, and he
could not collect his thoughts; sometimes the heart was wrong,
and he felt a sense of emptiness over the cardiac region, a sort
of vacuum (this feeling of nothingness, particularly in the
bowels, is very common in neurasthenics); sometimes his diges-
tion was wrong; and sometimes all his functions were wrong
together. At times he felt utterly weary upon the slightest
exertion, and the least effort would cause his limbs to shake
under him. He tried some massage and galvanism upon the
continent, but it did not seem to agree with him. He came
under my care on the 27th of March in this year, when his
chief symptoms were prostration and defective will. Attempts
to compel attention in ideation gave rise to intellectual
blank and depression. Solace was found only in rest, quietude,
and freedom from excitement. The hands and feet were cold,
moist, and clammy, the bowels were irregular, and the urine
of high gravity (1082), free from sugar. Treatment con-
CASE OF NEURASTHENIA. 189

sisted in massage to the lower limbs, buttocks, and abdomen
for one hour in the morning, and to the upper extremities,
spine, head and neck, at night; hot water bath with electricity
for ten minutes in the afternoon, followed immediately by cold
abdominal compress with pack for half an hour. Diet: One
pint of hot water sipped down at 7 a.m.; breakfast 8.30 a.m.,
white boiled fish, cold boiled bacon, dry toast, plenty of fresh
butter, equal parts immediate tea and milk; luncheon 1.80
p.m., chop, dry toast, butter, one glass of claret; tea 5 p.m., one
pint of hot water sipped down with just a dash of tea to flavour
it; dinner 7 p.m., cut from joint, principally mutton, dry toast,
and a little green vegetable, one or two glasses of claret.

Notrr.—On the 12th day the treatment so far has been
quite satisfactory, the gravity of urine is 1020; sleep greatly
improved; extremities less cold; the masseur says the feet are
warmer and much less moist, and normal in their sensibility ;
before treatment they felt as though they were wrapt in wet
chamois leather. His gloom and despondency before treatment
gave rise to suicidal intentions, these have quite disappeared ;
he now takes an interest in his surroundings and cracks jokes ;
says his bowels are now acting regularly, which quite astonishes
him ; he had been fighting against constipation for fifteen years.

Notz.—On the 30th April is as follows: There is a very
decided improvement in every way, mental, moral, and physical.
He is never depressed, rarely feels exhausted; joins in conver-
sation, and enjoys an argument (has great brain power,and when
well his will is inflexible), bowels acting well, tongue clean;
urine clear, gravity ranges from 1016 to 1024, of acid reaction; is
not taking medicine, and he has increased two pounds in weight,
which was not wanted, his height being five feet nine inches,
and his weight a hundred and eighty-six pounds.

I wish now to draw your attention to an irritable condition
of the spine, which was discovered in this patient, and which
is common in neurasthenia and hysteria. It was not elicited
by ordinary pressure, but it became manifest upon the appli-
cation of the faradic current (and let me tell you this is
frequently the case, and in obscure disease of the spine this
test should be utilized, for by so doing many errors of diagnosis
would be avoided). The masseur found that when using faradic
massage it became quite painful as he neared the lower part of
the back, and he called my attention to it. I then made care-
ful notes of the reaction of the spine to faradization, and I
found anarea of hyperesthesia to the current, extending from the
tenth dorsal to the second lumbar vertebra; it extended slightly
to the right of the spinous processes. I applied dry cupping to
this painful region with decidedly beneficial effect, for after the
third daily cupping the pain had quite disappeared. To make
190 MASSAGE IN NERVOUS EXHAUSTION AND HYSTERIA.

a long story short, this patient got quite well. I have seen him
since, and he says that the last five months have been the
happiest that he has spent for the past fifteen years.

The next case is that of a young gentleman, aged eighteen.
He was brought to me on April 30th of this year by his father,
for my opinion as to whether massage would or would not do
him good. He complained that for the past two years his
health had been failing, losing strength and weight, energy and
interest. His intellect was dull and inappreciative, and he
was listless, apathetic, and indifferent to everything. Very
little exertion fatigued him. The appetite was bad, and he
complained of a feeling of stuffiness, and a load at the stomach
after taking any solid food ; therefore as exercise, on the one
hand, fatigued him, and eating gave him very great discomfort,
he avoided both. He was pale, the muscles were flabby, and the
extremities were cold and livid, pulse 60, bowels most obstinate.
I might tell you that before he came under my care he had
sought the advice of many leading physicians in London with-
out deriving even temporary benefit ; in fact, the treatment by
massage was the only course left as yet untried. After six
weeks of massage, applied night and morning in the usual way,
he had acquired strength, lost his indigestion, and gained over
a stone in weight. I cannot say that his constipation was
cured, but the bowels acted to a slight aperient, whereas before
massage the strongest aperients had scarcely any effect upon
him. In addition to the massage, the cold abdominal water
compress was used for three hours every morning. His diet
was highly nutritive and similar to that which we employ in
the Weir-Mitchell cure. For the last three weeks general
faradization was employed daily. The treatment and the
results were highly satisfactory; but I sent him for a long
voyage, and I am sorry to say that he returned much in the
same state that I first found him.

I have drawn your attention to this case to show you
what I have now proved by experience, that sea voyages
and travel are not promoted to maintain the good effects
which massage and galvanism unquestionably create. If I
had kept this gentleman under my care and repeated the
treatment at intervals, I believe that I should have per-
manently cured him. The question here arises relative
to the course to be pursued after the massage treatment is
concluded; but I have discussed this before in my lecture on
the Weir-Mitchell course. I shall say nothing more about it
now; but from my experience I cannot recommend sea voyages
and prolonged travel, though of the good effects of the treatment
there can be no question or doubt; it did for this young
gentleman what every other remedy had failed to do.
CASE OF NEURASTHENIA. 191

Upon comparing the two cases you will see that they differ
in most respects in their nature. In the first the patient
was a man of mature years; he had been an invalid for many
years; his condition was allied to the lithemic and gouty
diathesis ; his weight was quite equal to the given standard,
and his metabolism was fairly active, though imperfect, and the
treatment I adopted was such as would have been inapplicable
in the last case, which was managed entirely after the Weir-
Mitchell method.

The third case which I shall bring before you of the purely
neurasthenic type is that of Miss C—, twenty-four years of age.
She came to me with a highly neurotic history, pale, emaciated,
careworn, fretful, fractious, peevish, complaining of aches and
pains in allher joints. Her mother said that for the past four
years shehad sought the best advice wherever it could be found,
but without avail. For the past three years she had been
gradually and surely getting worse. Before that time she had
been a fine, robust, strong, healthy looking girl, played a good
game of tennis, rode to hounds, and enjoyed excellent spirits.
The break down of her daughter was to her inexplicable. There
was a clear history of consumption on the father’s side, and
she thought, and in fact she concluded, that her child was fast
drifting into consumption. The catamenia had ceased for
over twelve months. At times she was so persistently
obstinate and self-willed that she could not get her to do any-
thing, threats, kindness, and solicitation were alike unsuccess-
ful, it was just as impossible to drive as it was to lead her. She
had abandoned her companions, and thrown aside all her
pleasures and enjoyments; she came to the breakfast table
looking more weary and tired than when she went to bed. She
always sat down to meals, but rarely ate more than a mouth-
ful, complaining that it was absolutely impossible to do more,
for she could not swallow. The most she partook of from day
to day was a little milk and beef tea, and even this she would
often refuse. At times for a day or two she would brighten
up and lead her to hope that she was getting better, but she
soon relapsed into her terrible state. Her mother said that if
she continued in this way much longer it would break her
heart; but she had heard of the massage cure, and she had de-
termined that her daughter should try it, although the girl had
declared she would not do so. I examined her very thoroughly
‘ and could find no organic disease. The circulation was de-
fective ; extremities cold and bluish looking; the pulse at the
wrist could scarcely be detected, but the heart sounds were clear
and well defined ; the hair was crisp and the scalp was tender
to the touch ; the pupils contracted sluggishly when exposed to
a strong light; the tongue was furred and the breath was
192 MASSAGE IN NERVOUS EXHAUSTION AND HYSTERIA.

offensive ; the bowels were relieved about once a week ; she said
that she had not slept for months; the spine was not tender to
the touch ; she had never shown any of the ordinary symptoms
of hysteria. Of course she had been surrounded by a host of
sympathetic friends and relatives who were constantly recom-
mending her mother to try all sorts of treatment and consult
innumerable doctors. She had, in the course of two years,
tried homeopathy, hydropathy, galvanic belts, change of air,
and baths too numerous to mention, and finally, as I say, it
was determined that the massage cure should be resorted to, so
she came under my care in February of this year. I gave her
clearly to understand that she was going to be cured, and that
she must submit to any means which I thought proper to
adopt. I felt quite sure that in a case of this kind nothing
but the Weir-Mitchell treatment, carried out in its entirety,
would or could be of any avail, and the mother was quite
willing to accept the prescribed rules—seclusion, rest, massage,
and galvanism.

The treatment was commenced on the 12th of February, and
carried out strictly until the 8th of April, and I can only tell you
that this was the most successful case I have ever had. Mas-
sage was carried on continuously, night and morning, for one
hour during the wholeof this time. The diet for the first ten days
consisted entirely of milk, of which she took six pints in the
twenty-four hours ; and upon this diet alone she gained seven
and a half pounds in weight, and slept fairly well. At first she
was inclined to be rebellious, but this was soon checked by the
firm but kindly conduct of the excellent nurse to whose care I
entrusted her. The bowels were relieved once in about three
days by a morning dose of decoction of aloes. I then ordered
her more solid food, which, to my surprise, she took readily,
and expressed her delight that she had been relieved of the
milk. It was now evident that she was, so to speak, ‘‘ turning
the corner.’ At 7 a.m. she had the stereotyped cup of black
coffee ; 8.30 a.m. six ounces of grilled steak, plenty of fresh
butter, bread and tea and milk; 10 a.m. beef juice; 11 a.m.
massage ; 12 a.m. tumbler of milk; 1.30 p.m. cut from joint,
fresh vegetables, stewed prunes; 3 p.m. beef juice; 4.30 p.m.
tumbler of milk; 6.30 p.m. boiled fish, light pudding, bread
and butter; 7 p.m. massage; 9 p.m. beef juice; 10.30 p.m.
tumbler of milk. At the end of three weeks she had gained
13 Ibs. in weight. Up to this time she had neither seen nor
heard of her friends, and she was now anxious to know what
the seclusion meant and how long it was going to continue,
and when she was going home; but the nurse was equal to the
occasion, and managed her most judiciously. At the end of a
month she was allowed to feed herself, and after five weeks
HYSTERIA. 193

from the commencement of the treatment she was allowed to
get up and sit in an arm-chair for two hours in the afternoon.
At the end of six weeks she rose at 12.80 after the morning
massage, and did not goto bed until after dinner. She had
now gained nineteen pounds in weight; but the transforma-
tion in her appearance was simply surprising, she was now a
well-developed, handsome, pleasant looking young woman.
The formerly careworn, haggard countenance was now radiant
with smiles, the pointed features were now replaced with
rotundity, and the pale skin was of a good healthy tone.

From first to last no medicine was taken but the aloes, and
that was discontinued after the first month, for it was not
required. I wish I could tell you that all cases went on
continuously well, without interruption, as this one did, but
a few such as this are quite sufficient to give you hope and
confidence that the result will, in the majority, be the same,
and in my experience I am happy to say that it is so. I forgot
to tell you that the extremities and trunk of the body were
faradized for one hour every afternoon after the first three
weeks. I do not find it advisable to commence galvanism until
the patient shows definite signs of improvement and begins to
take some interest in the curative process; this rarely occurs
until the expiration of three weeks.

Hysteria.—I am anxious to say something to you about hys-
teria, for the reason that it is so difficult sometimes to cure in
the ordinary way, and it yields so readily to extraordinary
means; of course you know what I imply by extraordinary means,
the expression may sound strange toa very orthodox mind, but
that does not matter one jot to me. By extraordinary means
I wish you to understand modes of treatment such as massage,
various forms of galvanism, moral control, and not well regu-
lated diet, for in the treatment of hysteria nothing should be
well regulated. Women not unfrequently drive themselves into
hysteria and a host of nervous troubles by trying to regulate
their lives by a system of organized machinery. I am perfectly
convinced of this myself, if I cannot convince others, that such is
the case. I do not believe existing in a stereotyped, unvarying,
and unswerving groove, it is not compatible with our environ-
ment. Change is necessary to functional, intellectual and
moral activity. From the earliest ages men have sought
diversion because they have found it salubrious. Amusements
have been invented, music and song originated, Divine worship
has taken different forms, fashions are ever changing, and
nature herself assumes different garbs at different seasons, to
please, to charm, to change and make glad the heart of man.

Hysteria is a strange morbid perversion of the senses and
sensibilities ; it is not distinct from nervousness, and it is allied

13
194 MASSAGE IN NERVOUS EXHAUSTION AND HYSTERIA.

in many ways to neurasthenia. A revulsion will oft-times cure
hysteria, but it will not cure neurasthenia. The former is more
frequently associated with the emotional part of our nature,
the latter rarely, if ever. All neuroses, however, run one into
another, but the prime factors are distinct. The term hysteria
has unfortunately such a wide and vague significance that its
incomprehensiveness, its illusory and delusive phenomena often
attach to it an interest and attractiveness which are sometimes
unaccountable. Let us take hysteria from its dissimulative
point of view; I can only glance at this subject, but it is never-
theless very interesting. These cases not only yield to
massage, but they give to the operator an immense amount of
credit (to which, by the way, he is not always entitled); and
further, I believe a consideration of this subject, however
slight, will pave the way to our recognition of a complex state
known as ‘“ hysteria in the male.” Weir Mitchell, in his work
on “‘ Diseases of the Nervous System,”’ writes of hysteria as “‘ the
fertile parent of evil. However produced, it is a fruitful source
of mimicry of disease in its every form, from the mildest of
dreamed pains up to the most complete and carefully devised
frauds. Its sensitiveness and mobility, its timidity and emo-
tionalness, its greed of attention, of sympathy, and of power in
all shapes supply both motive and help, so that while we must
be careful not to see mimicry in every hysteric symptom, we
must, in people of this temperament, be more than usually
watchful for this form of trouble, and at least reasonably sus-
picious of every peculiar and unusual phenomenon.”

This is really true, for it has been my experience to
see many cases of organic disease masked by hysteria in its
most marked and pronounced forms. But in order to demon-
strate this without further comment I will call your attention
to the “‘ Lancet’’ of December 29th, 1888, in which will be found
an article by Dr. Smith, medical registrar to the London
Hospital, entitled ‘‘ A case for diagnosis,” of which the follow-
ing are the most important points. A well nourished girl,
slightly anemic, two months before her admission into the
London Hospital, was thrown across a bedstead and injured in
the back. The injury seems to have been slight and was
scarcely referred to. After examination by four physicians of
recognised position and ability, it was argued that every organ
in the body was sound, and although she complained of severe
pain, which appeared to shift from place to place, at one time
being in the middle of the back, and again appearing at the
sides of the abdomen, the case was considered to be of an
hysterical nature. However, the patient lost strength and
flesh very rapidly, and died apparently from exhaustion.

At the post mortem examination it was found that on the
HYSTERIA. 195

inner side of the lower ribs, one inch to the right of the
sternum, was a small mass of a soft melanotic growth; all the
lumbar and several of the lower dorsal vertebrae were affected
with a similar growth, and very carious. The glands along the
bodies of the vertebra and those of the anterior mediastinum
were enlarged, and some of them were blackened, as were also
the pelvic and inguinal glands.

T have referred to this case in order to show you how it is
possible that pain, the result of obscure cancerous disease,
may give rise to hysteria, which, in its turn, may mislead
those who are in attendance, however skilful they may be.
And again I will call your attention to the fact that the injury
to the back would have been, in my judgment, quite sufficient
to have given rise to the hysteria, and certainly would have
led me to conclude that the case was essentially of an
hysterical nature. I have seen several such in my time where
moral control had been exercised almost to harshness, thinking
that the condition was one of pure hysteria, but after death
some obscure cancerous disease was discovered. The wisest
and the best of physicians are not infallible, therefore it
certainly is necessary, as I have told you, that before com-
mencing operations, and especially for conditions of hysteria,
you make perfectly sure, as far as you can do, that you have
no organic disease whose existence is veiled by what we know
as hysterical symptoms. Hysterical blindness (amblyopia) is
not very common. Hysterical loss of voice (aphonia) is
very common. The patient can only speak in a whisper.
Frequently this is merely one of many hysterical phenomena,
but sometimes it exists alone. Gowers speaks of a patient
who had been aphonic for two years, with occasional intervals,
during which the slightest fright would at once remove her
voice. Hysterical amnesia, ischemia, chorea, dyspnoea, and so
on, are to be met with, in fact there is no form of disease
which hysteria cannot simulate. Possibly the most
common condition that we meet with is nervous or hysterical
vomiting, which is sometimes exceedingly obstinate, lasting
for many months, but never giving rise to that emaciation
which usually attends vomiting in connection with acute
dyspepsia or organic disease.

. If we refer to the motor symptoms of hysteria we find
general and localized convulsions, spasms, tremors and
paralysis. Convulsions are never associated with that
profound state of unconsciousness which we find in epilepsy,
yet the two diseases run one into the other and give rise to
what is known as hystero-epilepsy. The convulsions of
hysteria, whether confined to the body generally, or to one
side of the body, or to one extremity, are of the tonic kind
196 MASSAGE IN NERVOUS EXHAUSTION AND HYSTERIA.

with intense rigidity, whereas in epilepsy they are both tonic
and clonic, and the circulation is markedly influenced by
vascular spasm in epilepsy, which is not usually the case
in hysteria. The epileptic may be as emotional as the
hysteric, but this is the exception rather than the rule. There
is a sub-consciousness in hysteria which is lost in epilepsy,
that is, during the seizures. The epileptic is constantly
exposed to danger from the suddenness of the attack; this
is rarely the case in hysteria. The aura of epilepsy is
unknown in hysteria, and so are the well known post-
epileptic states so well described by Trousseau. The
hysterical fit terminates by deep sighs, sobbing and weeping ;
the epileptic fit is usually followed by sleep. In the latter the
tongue may be severely bitten, but never in the former, if so
it is exceptional and denotes a mixed condition. Hysterical
paralysis of a single muscle, or group of muscles of one
extremity or of both, particularly the lower, may simulate
organic disease of the brain or spinal cord, and the diagnosis
is not at all times easy. In paraplegia of an hysterical
nature the reflexes are usually exaggerated, the sphincters are
unaffected, and nutrition is unimpaired, and so, as a rule, are
the electrical reactions. In both we may have retention of
urine which, if not attended to, may lead to rupture of the
bladder. I have seen this viscus enormously distended in
both conditions without the patient feeling any discomfort or
being in any way cognizant of the fact. As I have told you
before, it 18s very important to remember, in hysterical
patients never to begin abdominal or other massage without
knowing that the bladder is empty. In hysterical hemi-
plegia (which is not common) the mouth is unaffected, and
the arm, if raised, remains in this position and does not
fall limp by the side as it does when central disease exists.
There are some conditions of simulated disease, the result of
the hysterical state, and some points of differential diagnosis
which it is well to know. From the little that I have told
you,—and time will not permit me to tell you more, although
I would like to illustrate each point by cases from my note-
book—you will see that hysteria is an unreal or functional
disease, it is in fact phenomenal,. nevertheless it has a reality
and an entity of its own, and its essentially morbid nature
indicates defection in the regulating and controlling centres
from the highest to the lowest level, to correct which, good

moral influence, guided by sound ‘judgment and a com:
prehensive well balanced mind and will, is absolutely essential.
Massage and faradization are unquestionably most importeAt
aids in the cure.

Hysteria in the male, railway spine, railway brain.—I am.
HYSTERIA IN THE MALE. 197

now going to call your attention to what Professor Charcot
designates ‘‘ Hysteria in the Male.” Of course everybody
knows that men and boys may be hysterical, but M. Charcot
has dealt with this subject in a manner which is more or less
complete and irrefutable. It is quite true that in the study of
phenomenal nerve disease this distinguished observer has
better opportunities than possibly fall to the lot of most other
observers. The Gallic nature seems to be of less enduring
stability than that of the Saxon, and is more liable to exhibit
exalted hysterical manifestations.

Iam very much interested in this affection, as everybody
must be who cares to reflect upon, and if possible to investigate,
the more occult phenomena of disease. During the past
seven years I have seen a fair average of these ‘cases of
unquestionable type resulting from accident, and induced by
shock. I shall have occasion to refer to some of these to
illustrate my subject. It is quite possible that a large part of
the profession is perfectly conversant with what I am going
to talk about, and know and appreciate in a thorough
and complete manner the points evolved; but there are some
members of the profession who have not had the oppor-
tunities in their ordinary work of making themselves familiar
with these phases and caprices of hysteria. If I may judge
from the evidence which I have occasionally heard given in
courts of justice, there certainly has been clear want of know-
ledge concerning these strange and peculiar conditions. I believe
Mr. Page refers to it in his work ‘‘ On injuries of the Spine
and Spinal Cord,’”’ and in America it has been for years well
known, but it was unquestionably M. Charcot who laboured
and worked out this subject in a way most complete. His
views first appeared in the form of clinical lectures, in
“Le Progrés Médical,” which were translated and published in
the ‘‘ Medical Press and Circular,” 1885, and [have no hesitation
in saying that my first interest in the study of this affection
arose from my reading those very excellent lectures of the
learned professor of the Salpétritre Hospital in Paris, and
although I have myself a good store house of facts to
corroborate nearly everything brought forward by M. Charcot,
I shall, in what I have to say, take M. Charcot as my guide,
my counsellor, and in this matter my friend.

I think everyone will agree with me that it has been noted
and observed as long as man has had power of observation
that accidents to the body, no matter of what kind,
have been followed in some persons by derangement
in health, especially of the nervous system. It will be
remarked, ‘‘So-and-so has never been the same since
he met with an accident,” either in the hunting field, or
198 MASSAGE IN NERVOUS EXHAUSTION AND HYSTERIA.

in some other way. If this be the case it cannot be doubted
that the nervous system receives a shock which may not and
frequently is not appreciated at the time, but which produces
such a change in the man’s nervous system, as to give rise to
emotional and psychical disturbances to which the term hysteria
as we now understand it may be justifiably applied. These con-
ditions are commonly brought practically before us as the result
of railway accidents, and the railway companies not unfre-
quently have to pay heavy damages, when shortly after the sum
has been received the patient may suddenly lose his paralysis
and very naturally thinks himself a fortunate man; but the
authorities representing the company, I might say naturally
from want of knowledge, come to the conclusion that they
were swindled and that the recipient of the damages was
nothing more nor less than a humbug and an impostor.
Now this is not true in a great many, perhaps I may say
in the majority of the cases, for it is now well known that
very -serious and troublesome conditions of the nervous
system may arise from railway collisions which render the
subjects of them utterly unfit to carry on their occupations
for years afterwards. This condition may occur without
traumatism, and is simply the result of nervous psychical
commotion, therefore we can have this state of “ nervous
psychical commotion,” as M. Charcot calls it, the result of an
accident, with or without objective bodily injury: and it is
a remarkable fact that the more slight the injury the greatet
may be the disturbance to the nervous system. The nervous
symptoms rarely arise immediately after the receipt of
injury, it is commonly the case that the patient recovers
from the shock of the accident and is making a start to
resume his vocation in life, when, from defective will power, he
fails in almost every essential particular to carry out his
object.

Tiegh to conclude my lecture by bringing this subject of
railway brain before you in a clear, practical, straightforward
manner, which I can do by the able guidance of M. Charcot’s
lectures.

We must first of all admit that hysteria is induced in men
and women by accident, or by anything which produces
conscious or unconscious shock to the nervous system; meeting
with some bodily accident being the chief cause, the gravity of
the hysterical state not being dependent upon the nature or
severity of the accident, wounds, contusions, or fractures, the
result of the accident, or the state of the health of the sufferer
at the time of the accident. Thus a man who may have
received a fracture of the thigh may be incapacitated for work
for three or four months, while another who may have
CASES OF HYSTERIA FROM SHOCK. 199

sustained nervous injury apparently of much less gravity, may
be incapacitated for work for six months, a year, or more.

Let me, before proceeding, give you very brief notes of four
cases which may the better illustrate my meaning; each differs
somewhat in its causation.

A woman about forty years of age was admitted into the
Central London Sick Asylum under my care, suffering from
ataxy of the lower limbs with hysterical symptoms, marked by
periods of vacancy and extreme depression, hesitancy of speech,
and general anesthesia. Remember, if you please, that this
woman was noted for strength and courage. She lived upon
the coast, and one day during a terrific gale, standing upon
the sea shore, she saw her son and his craft submerged and sink
in the depths of the ocean. Her friends around were astonished
to see the calm indifference with which she viewed the calami-
tous scene, and beyond the words ‘“‘My God, my God!”’ not
a word escaped from her lips. For some days she performed
her usual work in her usual regular and methodical manner. In
a short time, however, she became reticent, gloomy, and dull.
She would be seen wandering by the beach alone, frequently
at night when she ought to have been in bed, her cries
and sobs were sometimes heard above the fury of the tempest
or the roaring of the waters. Everyone thought she was
going mad. But no; her memory began to fail, and with it
the attributes of reason ; dementia threatened, and for a while
mind and dementia were pretty evenly balance, but she took
what I am sure I may be permitted to call an ‘‘ hysterical turn,”
and it was in this state that I first saw her, some three months
after the shock.

Tam not going to enter further into the signs and symptoms
of this case, if I remember rightly they are published in some
medical periodical, suffice it to say this woman after more
than two years recovered, I will not say completely, because I
do not believe in the complete recovery: of these cases.

Case 2 differs in some respects from that just quoted.
A lady about thirty-eight years of age consulted me for a form
of melancholia into which she had drifted. Some months
previous to my seeing her she had met with an accident and
cut the ball of the thumb severely. For atime all went well ;
the wound healed, and her general health continued unimpaired.
But gradually her manner altered, and she conceived the idea
that she was going to have “locked jaw,” and so strongly did
this become impressed upon her mind, that every time she sat
down to the table to partake of food her jaw became fixed, so
that she lost the voluntary power to open her mouth; yet the
jaw was easily depressed, both by her own hands and by the
hands of those about her. This continued for some weeks,
200 MASSAGE IN NERVOUS EXHAUSTION AND HYSTERIA.

and then passed away; but the nervous system had received
a shock which remained behind; her health suffered, and she
became feeble and highly hysterical. At times excitation
reigned supreme, at other times she was depressed with evil
forebodings of various kinds. Her friends were extremely
anxious, and they could not account for her condition, as there
was no family history of mental weakness or insanity. She
was always complaining of a fixed pain in the thumb. After
two years with occasional massage and faradization, her
nervous system regained its normal balance, and her general
health was restored.

About two years ago, through the kindness of Dr. Gibson, I
was consulted concerning the state of aman about thirty years
of age, who was travelling on the underground railway at the
time of a collision. He was thrown from one side of the
carriage to that immediately opposite. He felt dazed for a few
minutes, but walked home apparently not much the worse for
what he looked upon asa ‘“‘bit of a shaking.” No trace of
direct injury could be detected, except some slight bruising
over the left shoulder. In a few days he recovered from the
effects of the concussion; but, feeling a little out of sorts, went
to the seaside, hoping and believing that he would entirely
regain his health and strength. He accepted some small sum
from the company, not thinking for one moment of any ulterior
bad effects. But gradually and surely nervous symptoms super-
vened, in other words, psychical disturbance and commotion
set in. After his return from the seaside he made an attempt
to follow his occupation, which was that of a diamond cutter,
but although previous to the accident he was a skilled workman,
always giving satisfaction to his employers, he now did his
work so badly (and for what reason he could not tell) that his
master in self-defence was obliged to dismiss him. His health
failed, he lost flesh and strength, and became a wreck. In
fact, from an even tempered man, an athlete, a good husband,
temperate in his habits, and fond of his wife and children, his
temperament and his character became completely changed.
When I first saw him he was lying in bed, looking the picture
of misery, pale, thin, and dejected. On one occasion he made
an attempt to put an end to his wife’s existence; the society
of his children was now utterly distasteful to him; he was
taciturn, morose, and distrustful. At times, without cause, he
would burst into a furious and uncontrollable fit of rage, and
then again he cried and sobbed like a child; he had what he
called ‘“‘horrible dreams,” and was fearful of doing anything.
He walked with apparent difficulty, the reflexes were exaggera-
ted, but no definite form of paralysis could be elicited.

A man, aged thirty-five, was sent to me by Dr.

 

, for my
CASES OF RAILWAY SPINE AND BRAIN. 201

opinion. He had caught his left foot somehow in the tram-car
rails, and fell as he said with it twisted and doubled. He was
picked up, and walked home a few hundred yards with great
difficulty. There was considerable swelling and bruising of the
ankle joint, but no bone was broken. Some months after the
accident he walked by the aid of crutches into my consulting
room. He gave me an account of himself from the time of
the accident, which is not important, excepting perhaps that he
passed blood with the urine upon one occasion, and his nights
were sleepless, and his dreams horrible. He had scarcely got
out of bed for three months. When I saw him there was
want of voluntary power over the left limb, and he could not
move a single toe. He complained of the whole of the left side
feeling weak, the left arm felt heavy, and the left half of the
body was anesthetic. When he attempted to think he became
confused. He said at times his breathing was difficult; but on
examining him carefully I felt convinced that there was no
organic disease. Twelve months after this 1 saw him again,
and he was in much the same condition; the left leg was flexed
at aright angle with the thigh, and he declared that he had no
voluntary power over it, although the muscular reaction to
galvanism and faradization was quite normal, and the reflexes
were normal also.

I have in the shortest manner possible made an attempt to
bring before you the leading points only of four cases similar
in their psychical manifestations, which were due to what we
call hysteria, the signs and symptoms differing in degree only,
and varying with the inherent capacity of the individual. In
some cases the signsand symptoms are aggravated, accentuated,
exaggerated, redundant, obstinate and persistent ; in others
they are ill defined, feeble, vacillating and. unsubstantial ;
nevertheless, the same centres of the nervous system are alike
deranged, the exciting cause being conveyed to, and producing
an impress upon these centres, through the special senses,
through bodily concussion, or through positive physical injury.
Now there are some who seem to hold the opinion that in
hysteria the symptoms and signs are necessarily fleeting,
changeable, explosive, and capricious; but these,as M. Charcot
points out, are not unequivocally characteristic of hysteria,
even in the female. In woman the phenomena of hysteria
may be slight, of low or of high intensity, but they may be
durable and permanent, extremely hard to modify, and some-
times resist all remedial interference. It is the permanence
and obstinacy of hysterical symptoms in the male which render
difficult the recognition of their real nature.

“Some,” says M. Charcot, ‘‘in presence of phenomena
which resist all therapeutical agencies, believe that they have
202 MASSAGE IN NERVOUS EXHAUSTION AND HYSTERIA.

to deal with (especially if there exist sensorial troubles with
nervous crises) a central organic lesion, an intercranial neo-
plasm, or if simulating paraplegia, an organic lesion of the
spinal cord. Others will voluntarily recognise or even affirm
that there can be no doubt in such cases as to an organic
alteration, a dynamic lesion simply existing ; but in presence of
symptoms whose tenacity does not accord with the theory
which they entertain of hysteria, they consider that they have
here to deal (railway spine) with a special malady not yet
described, and which merits treatment apart.” It is well, then,
that we should make up our minds thoroughly, once and for
all, in agreement with M. Charcot and with my own experience.
1st. That in the male in particular the depression and melan-
cholic tendency are observed most frequently in the cases less
accentuated. 2nd. That the sensorial perversions may, even
in the female, present a remarkable obstinacy, and that in the
male this habitually pertains.

In order to demonstrate those conclusions, I shall offer for
your consideration some of M. Charcot’s cases, because I find in
them a complete and classical study of facts drawn from experi-
ence, and conclusions formulated and based upon the practical
consideration of the signs and symptoms presented by a large
number of patients, tabulated, arranged, and compared with
the consummate skill, powers of observation, and judgment, of
a master mind. M. Charcot’s cases are as follows.

“To illustrate the persistent obstinacy of hysteria in the
female, let us consider the patient L , well known in the
records of hystero-epilepsy, and distinguished by the ‘ demoniac’
character of her malady which presents convulsive crises. Her
age is 63. She became a patient at the Salpétriére in 1846,
and we have had her under observation since 1871. At that
time she was affected, as she is now, with complete right hemi-
anesthesia, sensorial and sensitive and ovarian hyperesthesia of
the same side, which, during the long period of fifteen years,
has not been even temporarily modified either by the often
tried influence of esthesiogenic agents, advancing years, or by
the menopause. It is now five or six years since our attention
has been particularly drawn to the changes which the field of
vision undergoes in the hysterical, and we have found in this
patient a marked diminution of the visional field on both sides,
but much more pronounced on the right side. Repeated
examinations, once or twice during each year since that
period, have not failed to demonstrate the permanence of
this diminution.

“‘ Case I.—The patient R , a shopman, aged forty-four,
became a patient in the Salpétriére on the 12th of May, 1884,
now almost a year ago. He is a stout, muscular, well-developed

 

 
MALE HYSTERIA. 2038

man. He was formerly a cooper, and bore well the fatigues of
his work. The hereditary antecedents of this patient are very
striking. His father, aged seventy-six, still lives. During the
period from his thirty-eighth to his forty-fourth years, he suffered
from ‘nervous attacks,’ as to the nature of which the patient
is unable to enlighten us. His mother suffered from asthma
and died at the age of sixty-five. His grand-uncle on the
mother’s side was epileptic and died in consequence of injuries
received from falling in the fire during an epileptic seizure.
R—— has had seven brothers and sisters, none of whom
suffered from any nervous affection. Four are dead, and of
the three remaining one is asthmatic. He himself is the
father of nine children, of whom four died in infancy. Of
the five still living, a daughter, aged fifteen, is. the subject
of nervous crises, another, aged ten, has had attacks of
hystero-epilepsy, another daughter is of feeble intelligence;
two remaining sons present no physiological or pathological
features worthy of note.

“In the personal antecedents the following facts are to be
noted. At the age of from nineteen to twenty-two the patient
had been the subject of an acute attack of articular rheumatism
without any heart complication. As an infant he was timorous;
his sleep was troubled by dreams and nightmare, and further-
more he was a somnambulist. He frequently rose during the
night and did work which surprised him on finding it accom-
plished on the following day. This condition lasted from twelve
to fifteen years. He married at the age of twenty-eight. There
is no proof of any antecedent syphilitic or intemperate history.
In 1876 he met with his first accident. He cut himself deeply
with a razor, which he was sharpening, and blood flowed
copiously. The hemorrhage and fear combining, he fell to
the ground insensible and motionless. He was long in
recovering, and for the period of two months he remained
markedly anemic and unable to work.

“Tn 1882, three years ago, when lowering into a cellar a cask
of wine, the rope by which it was suspended suddenly broke ;
the cask rolled down the stair, and he would certainly have
been crushed had he not had time to throw himself on one
side; this he was unable to do sufficiently to prevent receiving
a slight wound on the left hand. Despite the fear which he
suffered he was enabled to assist in remedying matters, but five
minutes afterwards he lost all consciousness, and remained in
this condition for twenty minutes. On recovering himself he
found he was unable to walk, his limbs being so feeble, and he
was obliged to be taken home in a conveyance. For two days
he was absolutely unable to do anything ; during the night his
sleep was troubled by terrible visions and interrupted by cries
204 MASSAGE IN NERVOUS EXHAUSTION AND HYSTERIA.

of ‘Ah me, Iam killed!’ He saw in dreams the scene of the
accident. On resuming work, and ten days after the accident,
during the middle of the night, he had his first attack of hystero-
epilepsy: Since that time the attacks return almost regularly
every two months ; and often in the interval during the night,
or at the time of his first sleep, he is singularly troubled by
visions of wild animals.

“ Formerly, on recovering from these crises, he could recall
what he dreamt during the attack, a circumstance which he is
unable to do at the present time. Sometimes he fancies himself
in a sombre forest, either pursued by brigands or horrible
animals; at other times the scene of his accident opens out
before his eyes, and he sees casks which roll upon him and
threaten to.crush him. Never, he affirms during the lucid
interval, has he had dreams or hallucinations of a gay or
agreeable nature.

‘* At this period he went to Sainte-Anne for consultation. He
had bromide of potassium prescribed for him, and that medicine,
it is noteworthy, had never the slightest effect upon the attacks,
notwithstanding that his system had been absolutely saturated
with it. It isin consequence of this condition that Rig—— has
been admitted into our clinique at the Salpétriére, and on his
entry we marked the following state :—The patient is pale and
anemic; he has little appetite, especially for solid food, of
which, however, he prefers acid dishes: altogether, his general
health is far from satisfactory. The hysterical stigmata are
very marked in him. They consist of double hemianesthesia
in plaques, over a large extent of surface, to pain (pricking,
&e.),and cold. Sensorial anesthesia does not exist generally,
save in a very slightdegree. The sense of taste and smelling
are normal ; hearing is blunted in a marked manner, especially
on the left side. The patient does not hear better when a
sounding object is applied to the skull. With respect to what
concerns vision the symptoms are much less equivocal, and
would suffice alone to decide the hysterical nature of the
affection. There is a marked diminution of the field of vision,
more accentuated, however, on the right side. He distinguishes
all colours, but the field of vision for blue is narrowed more
than that of red, beyond which it passes, a phenomenon when
met with which is characteristic, so far as I know, of the field
of vision in hysterical subjects—a fact of which I have satisfied
you by many examples. Finally, to finish with the permanent
hysterical stigmata, there exists in the case of Rig two
hysterogenetic points, the one cutaneous, and situated below
the false ribs of the right side, the other deeper in the popliteal
space of the right side, and where an extremely tender cyst
exists. There is no hysterical hyperssthesia of the testicle in

 
MALE HYSTERIA. 205

 

the case of Rig . Pressure, either purposely or accidentally,
exercised on the spasmogenistic points in our patient evoke all
the phenomena of the hysterical aura, precordial pain, con-
striction of the neck and hysterical globus, singing noises in
the ears and beating of the temples, the two latter phenomena
constituting, as you know, the cephalic aura. These points,
whose excitation can thus cause, with singular facility, an
hysterical attack, are not, on the contrary, following the termi-
nology proposed by M. Pitres, spasmo-frénateurs; that is to
say, that intense and prolonged excitation of them arrests but
imperfectly an attack in process of evolution.

‘In the mental condition of Rig , at present, as in the
past, anxiety, fear, and sadness predominate. He cannot sleep
in the dark ; even in daylight he disinclines to work alone; he
is of extreme sensibility, and the sight or remembrance of
certain animals, such as rats, mice, and frogs, causes him great
terror. These he frequently sees in frightful nightmare or
frequent hypnagogic (sleep-inducing) hallucinations. He is
always sad. ‘I am sick of life,’ he exclaims. A certain
volatility of spirit is manifested in the fact that he cannot con-
centrate his mind upon anything, and that he undertakes and
abandons with equal inclination five or six enterprises at once.
Otherwise he is tolerably intelligent and well-informed, and
is of a placable temperament and entirely free from vicious
instincts. The attacks are either spontaneous or provoked.
However produced, they always arise by a feeling of burning
at the spasmogenistic points, after which epigastric pain
succeeds, and then a feeling of constriction in the neck and
globus, and finally the cephalic aura, consisting of noises in the
ears and throbbing of the temples. At this moment the patient
loses all conscience, and the attack, properly speaking, com-
mences. It is divided into four periods, well defined. In the
first the patient manifests some epileptiform convulsions. Then
comes the period of violent spasm, interrupted from time
to time by convulsions, at one time of an emprosthotonic
nature, at another of an opisthotonic nature, the feet and head
alone touching the bed. During that time the patient emits
wild cries. Then comes the third period, during which he
speaks and emits cries in harmony with his sombre delirium
and the terrifying visions which pursue him. Sometimes it is
the forest, the wolves, and other wild animals which frighten
him ; at other times it is the ladder, and the wine-cask. Finally
he regains consciousness, knows the persons by whom he is
surrounded, and is able to name them; but the delirium and
the hallucinations continue still some time ; he searches around
him and under his bed for black animals which menace him ;
he examines under his arms for the bites of animals which he

 
206 MASSAGE IN NERVOUS EXHAUSTION AND HYSTERIA.

believes to feel. Then he comes to himself; the attack is
terminated, but to return most frequently a few instants after-
wards, when, after three or four successive attacks, the normal
condition is attained. During these attacks he never bites his
tongue nor passes urine in bed. For one year R—— has been
treated by means of static electricity, which, as you know in
such cases, has given good results in our hands. At the same
time we have prescribed all the tonics and invigorating agents
imaginable. Notwithstanding the hysterical stigmata and
attack persist without any appreciable change, though
they have now existed for a period of three years. We have
here to deal with a case of hystero-epilepsy with mixed crises, as
sharply defined as-possible. Itis clear that the permanence
of the hysterical stigmata in this case ought not to cause us
hesitation in our diagnosis.

“To conclude with the details of a case so perfectly unique, I
shall indicate some particulars brought into prominence by
- clinical analysis.

“Tn the first place we have the strong hereditary nervous
family history ; hysteria apparently in the father; grand-uncle
and cousins-Germaine, epileptic ; two sons, one hysterical, and
the other hystero-epileptic. You will frequently encounter the
conditions of heredity in hysterical males more accentuated
even than in the female.

“I would recall to you how, in our patient, the hysterical
manifestations developed themselves after an accident which
threatened his life. The wound of which they were the conse-
quence was of a trifling nature—could it have been sufficient
to provoke the development of the nervous disease? That is
possible, but I would not confidently affirm it. In all cases of
injury it is proper to keep in view a factor, which, in the
genesis of nervous complications, operates probably in a
stronger manner than the injury itself. In this case we have
the terror experienced by the patient at the moment of the
accident, and which manifested itself. afterwards by a loss of
consciousness and a kind of transitory paresis of the inferior
extremities. That same psychical element existed in the cases
described by MM. Putman, Walton, Page, Oppenheim, and
Thomsen, and its influence, often predominant, ought not to be
overlooked.

“That same circumstance of the development of hysterical
phenomena in consequence of shock, with or without trau-
matism, but where emotion strongly operates, you will discover
in most of the other patients whose cases 1 am about to bring
under your notice.

‘Case II.—The man under your observation is named G., et.
twenty-seven, a locksmith by trade. On the 28th February, 1884,
MALE HYSTERIA. 207

he became a patient of my colleague, M. Luys. As to his
parents, he knows only that his father died at the age of 48,
a confirmed drunkard, and that his mother still'lives, and has
never suffered from any nervous affection. He has had seven
brothers and sisters. But one of his brothers is living, and
he is not aware that he has ever suffered from any nervous
affection.

“‘Towards the age of twelve or thirteen he became very
timid, and was unable to remain alone in a room without
experiencing a feeling of anxiety. Otherwise he was not
irritable, nor of a troublesome character. At school he
learned easily, and later, towards the age of seventeen or
eighteen, he manifested marked proficiency in his trade. He
frequently obtained medals of proficiency in competitions in
connection with his special calling. Towards this period he
unhappily developed an inordinate penchant towards females
and drink. He wrought during the day at his trade, but his
evenings were passed at taverns or with females. Such
excesses were repeated frequently during the week. He was
thus deprived of the normal amount of sleep. Meanwhile he
did not appear to be unduly fatigued; he wrought as usual,
and satisfactorily acquitted himself of his duty.

“At the age of 21, in 1879, during one of his nocturnal
expeditions, he received a cut from a knife which penetrated
the left eye. He was immediately taken to the Hétel-Dieu, and
placed under the care of M. Panas, who after some time
enucleated the injured eye. On leaving the hospital G. was
not slow to resume his riotous life.

“Towards the commencement of 1882, at the moment of
shutting his eyes in order to sleep, he experienced the vision
of a monster in human figure advancing towards him.
Frightened, he emitted a cry, and on opening his eyes the
vision disappeared, but to return whenever he closed his
eyelids. He fell into a state of extremely painful anxiety, and
he frequently remained in this condition for a great part
of the night, being consequently unable to sleep.

“These hypnagogic hallucmations continued during six
months, when in July, 1882, the patient was the subject of a
more terrible accident than the first. Occupied in fixing a
balcony on the third story of a mansion, when doubtless in a
state of intoxication, he fell to the ground, landing, as he
alleges, on his feet. During an hour subsequently he was in
a state of total unconsciousness. On recovering he was again
carried to the Hétel-Dieu, and placed under the care of
M. Panas. It would appear at this time a fracture of the
skull was suspected. Meanwhile the progress towards
recovery was slow, and it was only after a lapse of two
208 MASSAGE IN NERVOUS EXHAUSTION AND HYSTERIA.

months that the patient was able to return home. Soon
after the terrible nocturnal hallucinations reappeared, and for
the first time the spasmodic attacks. At first these were not
so characteristic as they subsequently became. They
consisted especially of vertigoes coming on suddenly, and
followed by rigidity, and then by trembling of the members.
There was no loss of consciousness. Furthermore, they
were not frequent. Matters remained.in this state during
eighteen months. About this time the treatment of the
various physicians was found to have no effect, and G. left,
in order to enter the Salpétriére (under M. Luys).

“A short time after his admission G. became subject to
frequent abdominal and gastric colic, followed by a feeling
of constriction about the pharynx, and. vomiting, which
supervened, without any effort. These complications, for
which medicine was employed in vain, suddenly ceased about
six weeks afterwards. Towards this time the existence of a
right hemianzsthesia was discovered, and likewise a particular
trembling of the hand instantly to be considered.

“In January, 1885, in consequence of changes in the staff,
the patients of M. Luys were committed to our charge, and it
was then that G. was seen for the first time. He is, as you know,
tolerably muscular and vigorous, and his general health
appears satisfactory. His mental condition does not present
any marked anomaly. The nocturnal (hypnagogic) halluci-
nations have almost entirely disappeared for a year. G. is
not sad, and he willingly converses with the other patients,
and renders himself useful in the ward.

‘‘ The right hemianesthesia is absolute ; neither contact nor
pricking is felt on this side of the body. The organs of sense of
the same side are equally affected—hearing, the sense of smell,
and taste in particular. With respect to the organ of vision,
regular examination discloses characteristic abnormalities.
On the right side—you have not forgotten that the left eye is
wanting—the field of vision is extremely diminished. Red
only is perceived by this eye, and the circle of that colour is
reduced almost to a point.

“The trembling of the right hand above referred to is
remarkable for the perfect regularity of its rhythm. It
consists of oscillations numbering on an average five in a
second. In this respect it is intermediate between the slight
oscillations of paralysis agitans and the vibratory trembling
or rapid oscillations of general paralysis or the malady of
Basedow. It is not exaggerated under the influence of
voluntary movements. The patient is able to use his hand
for the purpose of eating and drinking, and is even able to
write tolerably well, providing he balances his right wrist on
HYSTERO-EPILEPSY IN THE MALE. 209

his left hand, a manceuvre which arrests the trembling for an
instant. The muscular sense is entirely preserved in every
part of his right arm. The sole hysterogenetic zone found
in G. occupies the course of the spermatic -cord, almost up
to the right lom. The skin of the scrotum of this side is
extremely sensitive, and when it is pinched firmly the same
effect is produced as by compression of the cord, that is to
say, either the development or the arrest of an attack.
“These attacks, either spontaneous or provoked by excita-
tion of the hysterogenetic zone, are always preceded by the
sensation of a perfectly characteristic and painful aura, which
originates in the right scrotal region, extends to the epigastric
and cardiac regions, then to the throat, determining a feeling
of constriction, and finally affecting the head, causing singing
_ noises in the ears, especially the right, and throbbing, chiefly
of the temple of the same side. The patient then loses
complete consciousness ; the epileptoid period has commenced ;
the trembling of the right hand is increased, the eyes are
turned upwards, the extremities are extended, and the fists are

 

Fig, 28, Are of a circle backwards.

in a condition of exaggerated pronation. Soon the arms are
approximated to one another in front of the abdomen in
consequence of a convulsive contraction of the pectoral
muscles. After this the period of contortions supervenes,
characterized especially by extremely violent movements of
salutation, intermingled with mixed gestures. The patient
breaks or tears whatever he carries in his hands. He puts
himself in the most ridiculous poses, so as to justify the term
clownism, which I have suggested to designate that ae of
210 MASSAGE IN NERVOUS EXHAUSTION AND HYSTERIA.

the second period of the attack. After a time these contortions
cease to be followed by a characteristic attitude designated an
‘are of acircle.’ Soon there is a veritable opisthotonos, in
which the loins are raised above the bed to a distance of fifty
centimetres, the body reposing only on the head at the one
extremity and the heels at the other. In other instances the
circle is forwards, the arms are crossed upon the chest, the
thighs are in the air, the trunk and head are raised, and the
buttocks and loins alone rest on the bed. At other times, in
the attitude of the arc of a circle, the patient reposes either

   

Fig. 29. Arc of a circle forwards,

on his right side or on his left. All this part of the attack in
G. is exceedingly pretty, if I may thus express myself, and
each of the details deserves to be fixed by instantaneous
photography. I show you representations thus obtained by
M. Londe. You notice that, as a work of art, they leave
nothing to be desired. For us they are otherwise most
instructive. They show us, indeed, so far as concerns the
regularity of the periods and the typical character of the
diverse attitudes that the attacks in G. are not wanting in
anything which we daily observe in hystero-epilepsy of the
most classic type in the female sex, and that perfect corre-
spondence is peculiarly worthy of being pointed out, seeing
that G. has never entered the female dormitory so as to see
feminine attacks and be thus influenced by contagious
imitation.

“The period of hallucinations and passionate attitudes is
alone wanting in G. Sometimes we have seen towards the
end of a crisis his physiognomy express alternately fear or joy,
and his hands extended as in search of an imaginary being.
HYSTERO-EPILEPSY IN THE MALE. 2Q11

“The end of an attack is, in our patient, frequently marked
by a kind of motor aphasia which does not generally continue
more than eight or ten minutes; but on one occasion it
persisted for six days. Then when the patient desires to

 

Fig. 30. Attitude illegique.

speak, some ropy, inarticulate sounds only escape his mouth.
He becomes impatient, but agitates himself so as to make
himself sometimes understood by very expressive gestures.

In such cases he has been known to take the pen and legibly
avrite some correct phrases.

 

Fig. 31, Forward are of a circle.
212, MASSAGE IN NERVOUS EXHAUSTION AND HYSTERIA.

 

Vig. 32. Backward arc of a circle.

“‘ This is sufficient in regard to this perfectly classical case.

‘*Case ITI.—This case does not quite come under the category
of those already referred to, inasmuch as it is that of a growing
young man, and not a fully matured individual. But here, also,
the disease presents the character of permanence and tenacity
which! we have already encountered. M , et. sixteen,
entered our clinique on the 29th of April, 1884, that is to say
about a year ago. He was born and lived in the country up to
the age of fourteen. In 1872 his mother had some hysterical
attacks. His grandfather was a dissipated man, and of a very
violent vharacter. This is all that can be determined as to he-
reditary antecedents; the young man himself is well-developed,
though in infancy he suffered from some strumous manifesta-
tions, such as discharges from the ears, and glandular swellings.
in the mastoid region. He is intelligent, of a gay character,
and has never exhibited abnormal timidity; but he manifested
paroxysms of anger in which he broke everything he could
_ lay his hands upon. Two years ago he was placed as an
apprentice with a baker in Paris. A short time afterwards he
had an inflammation of the chest, and the consequent enfeeble-
ment of health which ensued was not without its influence in
developing the complications which supervened. Some time
after this, while yet convalescent, he received a fright,
from being attacked in the street by two young men.
He fell without consciousness, and was in this state conveyed
to the house of his employer. He showed no trace of any
wound. From that time he remained during several days in a
state of hebetude. He commenced to have painful nightmares.

 
HYSTERO-EPILEPSY IN THE MALE. 213

which torment him to the present time. He dreamt that he
was being beaten, and wakened with cries. Ultimately, in
about fifteen days, the hysterical attacks commenced. At first
they occurred daily, and presented a series of from eight to ten,
sometimes even two series in the same day; then they dimin-
ished in number and in intensity.

“At the period of admission into the Salpétriére the following
conditions were revealed:—The hysterical stigmata are very
marked. They consist of an anesthesia in plaques disseminated
irregularly throughout the entire surface of the body, and in
which there is complete inability to touch, to cold, or to pain.
The sense of hearing, taste, and smell is blunted on the left
side, and with regard to vision a double diminution of its field
exists, being more marked on the right side. On this side the
patient is unable to distinguish violet, while on the left he can
distinguish all the colours; but on both sides there exists a
remarkable phenomenon to which I have frequently called your
attention, and which we have already observed in the first of
our cases, the field of vision of the red is more extended than

that of the blue, a condition as you know at variance with that
which exists in the normal condition. There exists but one
hysterogenetic point, and that occupies the left iliac region.
At the present time, notwithstanding that the disease has
existed for two years, the attacks came on spontaneously, at
short intervals, about every ten or twelve days. These attacks
can be provoked very easily when a moderate pressure is
exercised on the hysterogenetic point. A more energetic
pressure on this point arrests the attack.

“The attack, whether spontaneous or provoked, is always
preceded by an aura; iliac pain at the level of the hysterogen-
etic point, a sensation of a bolus reaching the throat, buzzing
sounds in the ears, and beating of the temples. Then the
attack commences, the eyes are turned upwards in their sockets,
the arms are extended, and the patient, if standing, falls to the
ground with complete loss of consciousness. The epileptoid
phase is in general not marked, and is short, but the period of
great contortions which follows is excessively violent and of
long duration. The patient utters cries, bites everything
within his reach, tears curtains, and performs characteristic
hysterical movements, the body ultimately taking the form of
an are of a circle. The scene terminates by the phase of
passionate attitude, which is very marked in him, and differs

_ somewhat according as the attacks may have been produced.
Thus, when the attack has been spontaneous, it happens that
the hallucinations are of a gay character, while if the crisis
has been produced by excitation of one of the hysterogenetic
plaques the delirium is always sombre, furious, and accompanied
Q14 MASSAGE IN NERVOUS EXHAUSTION AND HYSTERIA.

by reproachful speech. In general many attacks succeed one
another so as to constitute a series more or less numerous.

“Tn this subject I must point out the permanence and immo-
bility of the hysterical features, recalling what is often observed
in the male. Thus, as you may have remarked in our young
patient, notwithstanding that two years have now elapsed, the
convulsive crises are as frequent as ever, at the present
moment, in spite of all our efforts, and the hysterical stigmata,
anesthetic sensorial, and sensitive are not altered since the
day that he came under notice for the first time. There is
nothing to hope that they may be soon modified.

“ This is not the case usually with young persons, especially
if the disease develops before the age of puberty. At that
period of life, according to numerous observations which I have
collected, the hysterical symptoms are, in general, more tran-
sitory, and no matter how pronounced they may be, they are
most frequently amenable to appropriate treatment. *

“Here, then, we have an attack of hystero-epilepsy, which in
one aspect notably forms an exception to the classic variety.

 

* Two days after this lecture was delivered, Professor Charcot
admitted under his care a young Belgian of twenty-one years of age,
spare, tall, and with fair hair, who, as in the cases referred to, presented
the classic characteristics of hystero-epilepsy with mixed crises. In
the hereditary history there was nothing noteworthy save a history of
alcoholic indulgence in his father. In the personal history figured
nocturnal terrors, frequent nightmares, even in full daylight and some-
times visions of animal and horrible figures. In November, 1¢84, F
was seriously attacked with cholera. His convalescence was protracted,
and for many weeks he remained feeble, subject to cramp in the inferior
extremities, and abdominal pains. Three months after his recovery,
being still in hospital and convalescing, the sight of a body which was
being carried frightened him, and almost immediately his first attack
supervened. A subsequent fright decided the situation, for from that
period F did not cease to be under the domain of terrifying
hallucinations, while the convulsions took place regularly every
night. From the time of his entry into the Salpétriére the following
condition existed :—Cutaneous anzthesia in disseminated plaques; a
blunting of the sense of taste and smell on the left side; diminution
of the field of vision limited to the right eye: hysterogenetic points,
very extended, under the form of hyperzsthesic plaques occupying in
front, almost all the abdominal surface, and behind, the scapular region,
the buttocks, the popliteal space, and the soles of the feet, &c. The
attack could easily be produced by moderate friction of the hyper-
eesthesic plaques. After the usual auraamarked epileptoid state followed.
Equally characteristic was the period of the grand movements, and the
position of acircle. Finally, succeeded the stage of passionate attitudes,
during which the patient seemed to be a prey to a sombre and furious
delirium. In this case, as in those we have considered, the hysteria
has supervened after an enfeeblement of body caused by a serious
malady, or in consequence of a fright, and here likewise was observed
all the genuine characteristics of hysteria as frequently observed in the
female.

 

 
HYSTERIA IN THE MALE. 215

In the first period, indeed, we observe the convulsive complica-
tions reproduce themselves almost to the perfect limitation of
the symptoms of partial epilepsy, while the contortions, the
grand movements, and the arc of the circle are wanting. But
in the female this variety is well known, though while rare, I
have set before you recently several perfectly authentic
examples. This subject, * during the past year, has been
attentively studied by M. le Dr. Ballet, one of my former
clinical assistants. In considering the cases narrated by
Ballet, and that with which we are presently concerned, you
will be struck with the resemblance which exists between
hystero-epilepsy in the male and that of the female. Another
anomaly less rare and less unexpected, in the hysteria of the
female, is the absence of convulsive crises. You are aware
that, according to the teaching of Briquet, about a fourth of
hysterical females have no attacks. The disease in such cases,
without losing anything of its autonomy is sympathetically
represented only by permanent stigmata, with sometimes
several spasmodic or other manifestations, such as nervous
cough, permanent contractions, certain arthralgias, forms of
paralysis, and hemorrhage from diverse channels, &c.; but the
attacks may be equally absent in male hysteria. The case
which I am about to submit to you, as it presents itself to us,
offers a good example of this kind. The disease is in a sense
complete, for attacks actually do exist; but during a long period
of eleven months it was abortive in form, a fact difficult of
explanation in certain respects, as you will be able to appreciate.
Since the 10th of March last, the young man under observation
has been afflicted with left brachial monoplegia, without any
trace of rigidity, the limb, in a word, flexible in a high degree,
which condition he states extended to ten months previously,
and supervened on a wound on the anterior aspect of the left
shoulder. There is no trace of paralysis or paresis of the
corresponding inferior extremity or of the face. No trace,
notwithstanding the remote date of the paralysis of atrophy of
the paralysed muscles, a circumstance which, conjoined with
the absence of any modification of electric reactions in the
muscles, leads at once to exclude the influence—at least the
‘local direct influence of the wound. We were further struck
on noticing the carotid regions agitated by violent arterial
throbbings. Corrigan’s pulse was well marked, and ausculta-
tion of the heart revealed the existence of a bruit synchronous
with the second sound at the base; and on the other hand we
find in the personal antecedents of the patient, a history of

 

* Ballet et Crespin, Des attaques d’hystérie 4 forme d’epilépsie
partielle. “Arch. de Neurolgie,” 1884,
216 MASSAGE IN NERVOUS EXHAUSTION AND HYSTERIA.

acute articular rheumatism which confined him to bed during
five or six weeks. The idea naturally flashed upon us conse-
quently that this monoplegia depended on a cortical cerebral
lesion, limited in the motor zone, in the brachial centre and
consecutive to the valvular affection of the heart, but a closer
study of the case disabused us of this supposition. Without
doubt the monoplegia in question is due to a cortical cerebral
lesion principally localised in the motor zone of the arm, but
it is not of the nature of a gross material alteration, the lesion
is purely ‘“‘dynamical’”’ “‘ sine materia,” in short, of that nature
which we formulate to explain the development and the
persistence of the diverse permanent symptoms of hysteria.
That is the conclusion, at least, at which we have arrived from
an accurate and detailed examination of our patient.

““Case IV.—The patient P , et. eighteen, a mason by
trade, entered the Salpétriére on the 11th March, 1885. His
mother died at the age of forty-six in consequence of “ rheu-
matism”’ (?); his father is an inebriate. One of his sisters, et.
sixteen, is subject to frequent nervous attacks. He is a young
man, apparently robust and muscular, but his nervous system
functionally leaves much to be desired. From the age of five
to seven he was troubled with incontinence of urine. He has
always been of mean intelligence, his memory is feeble, and he
seems to have made but little progress at school. Further, he
is of a timid nature, and is the subject of nocturnal terrors.
From the moral point of view he is of unstable equilibrium.
From the age of nine he frequently left his father’s house and
slept under bridges and in railway waiting-rooms. His father
having placed him as an apprentice to a fruiterer, then with a
pastry-cook and others besides, then commenced his escapades.
One night he was arrested in the company of a band of vaga-
bonds, and interned at la Roquette, where his father allowed
him to remain for a year.

“Two years ago, at the age of sixteen, he was attacked with
general acute articular rheumatism, preceded by erysipelas of
the face, and from this time dates the organic affection of the
heart, which we recognise at the present moment.

ue On the 24th of May, 1884, eighteen months afterwards,
P——,, then an apprentice mason, fell from a height of about
two metres, and remained for some minutes unconscious on
the spot on which he fell. He was carried home, and then
there were discovered some contusions over the anterior surface
of the shoulder, of the knee, and of the left ankle-joint—slight
contusions which did not seriously interfere with the use of the
affected parts.

‘For two days subsequently matters remained in this state,
but on the 27th of May, three days after the accident, P.

 

 
BRACHIAL MONOPLEGIA DUE TO SHOCK. 217

noticed that his left upper extremity became feeble. He then
went to consult a physician who recognised a paresis of all the
movements of the left arm, with anesthesia of that member.
‘On the 8th of June, that is, fifteen days after the fall and
eleven days after the commencement of the paresis, he entered
the Hétel Dieu. Here he was examined with care, and the
following conditions were demonstrated :—Characteristic indi-
cations of aortic insufficiency ; the parts which had been
contused were not the seat of any pain either spontaneous or
provoked by active or passive movements. There was incom-
plete paralysis of the left superior extremity. The patient was
able still, sometimes very incompletely, to flex the hand upon
the forearm, and the latter upon the arm ; but all movements
of the shoulder were impossible. The paralyzed member was
absolutely flexible in all its articulations, and there was no
rigidity. The condition of the face, and of the left lower
extremity was absolutely normal. So far as concerned the
power of motion this was a case of monoplegia in the rigorous
acceptation of the word. An examination of the function of
sensibility furnished the following results. At this period there
existed a general hemianalgesia of the left side ; the anesthesia
was complete only in the upper extremity. From this period
there was a double diminution of the field uf vision, much more
marked on the left side. Finally, on the 25th of June, that is
to say, twenty-two days after the commencement of the
paralysis, it had become absolutely complete. The diagnosis
was undetermined, and the treatment proved inefficacious.
Faradization, many times applied, on the left side, resulted
only in rendering the sensibility of the trunk less obtuse, and
had the same effect on the face and inferior extremity. The
anesthesia and paralysis persisted in the superior extremity.
The condition of the field of vision was not modified when
P—— left the Hétel Dieu.

“Tt was on the 11th of March, 1885, and consequently ten
months after the accident, and nine months after the complete
establishment of the monoplegia that P. entered our
clinique at the Salpétriére. We verified the conditions already
referred to, and a more minute examination furnished the
following results. The aortic insufficiency was very charac-
teristic, and there existed a souffle with the second beat at the
base, violent arterial beating in the neck, visible to the eye,
Corrigan’s pulse, and capillary pulse on the forehead.

‘‘The motor paralysis of the left superior extremity is abso-
lutely complete. There are no traces of voluntary movement.
The muscular masses have retained their volume, their normal
outline and their electric reactions, faradic and galvanic, and
are in no sense modified. The tendon-reflex of the elbow and

 
218 MASSAGE IN NERVOUS EXHAUSTION AND HYSTERIA.

forearm is slightly exaggerated. To cold, pricking and the
most intense faradisation throughout the whole extent of the
extremity, the hand, the fore-arm, and the shoulder, the:
cutaneous anesthesia is complete. In respect of the trunk the
anesthesia is limited by a line passing vertically by the arm-
pit and sub-clavicular space in front, and the external third of’
the scapular region behind. The insensibility extends in an
equal degree to the deep-seated parts. The muscles may be
strongly faradized, the nervous trunks themselves, the articular
ligaments may be drawn, and diverse movements of the joints,

torsion, &c., may be performed without the least consciousness.
on the part of the patient. The ideas attaching to the muscular

sense have disappeared. The patient is unable to determine

even approximately the attitude in which diverse segments of
his body may be placed, the place that they occupy in space,

and the direction and nature of the movements to which they

have been subjected. Apart from the left superior extremity,

there does not exist on this side any modification of motor
power, either on the face or the inferior extrémity, but on these.
points, as on the left half of the trunk, analgesia exists as
during the patient’s stay in the Hotel Dieu. An examination

of the field of vision reveals a normal condition on the right

side, while on the left it is enormously diminished, moreover
the circle of the red is carried out with that of the blue. Since

being in the Hotel Dieu an interesting change in the field of

vision has been produced. Furthermore we discover by the
usual methods that the sense of hearing, smelling, and taste

is much blunted on the left side. It now devolves upon us to
endeavour to determine the nature of that singular monoplegia.
supervening on the traumatism. The absence of atrophy and
of any abnormal electric reactions in the muscles in a case of
paralysis extending to ten months antecedently repels, at first
sight, the hypothesis of a lesion of the brachial plexus, while
the absence of any atrophy alone, and the intensity of the per-.
version of sensibility permits us to reject the idea that we have.
here to do with one of those cases of paralysis so well investi-
gated by Professor Lefort and M. Valtat, and which are caused.
chiefly by violence to an articulation.

“‘A brachial monoplegia may, it is true, in exceptional cases,.
supervene on certain lesions of the internal capsule, as has.
been demonstrated, among others, by Bennett and Campbell in
Brain; * but in such a case we do not certainly encounter
the sensorial and sensory hemi-anesthesia which is sometimes.
superadded to total common hemiplegia by lesion of the capsule.

“The occurrence in the right hemisphere of a little hemor--

 

* Brain, April, 1885, p. 78.
HYSTERIA IN THE MALE. 219

rhagic point, or of ramollissement, determined by embolism in.
consequence of an organic affection of the heart, a point which
one can suppose limited strictly to the motor zone of the arm,
one such lesion, I say, may account for the existence of left.
brachial monoplegia. But on this supposition the paralysis.
ought to supervene suddenly as on a stroke, however light that
might be, and not progressively ; it would have been charac-
terised almost certainly, many months after its commencement,
by a certain degree of contraction, and by marked exaggeration
of the tendon reflexes ; it certainly would not be accompanied
by perversions of cutaneous and deep sensibility as pronounced
as those we have observed in our patient.

‘We are obliged, then, to exclude in our diagnosis that last
hypothesis, and likewise that of a spinal lesion which we do not:
think even worthy of discussion, as being inadmissible. On
the other hand, our attention had been vividly directed towards.
the significant hereditary antecedents, on the psychical state
and habits, on the perversion of sensibility extended—though
unequally—on the whole of one side of the body, on the
diminution of the field of vision so pronounced on the left side,
and marked by the transposition of the red circle, and on
other sensorial troubles on the same side. All these constrained
us, especially in the absence of any other reasonable hypothesis,
to interpret the case as an example of hysteria. Further, the
clinical characters of the monoplegia, its traumatic origin—
and on that point I refer you to what I have already said—are
in no way subversive of this view. Indeed, the limitation to
one member of motor paralysis, without involving at any time
the corresponding side of the face, the absence of marked
exaggeration of the tendon-reflexes, of muscular atrophy, and
of the ordinary electric reactions, the absolute stoutness of the
member many months after the commencement of the disease,
the cutaneous and deep anesthesia carried to a high degree in
that member, the total loss of notions pertaining to the mus-
cular sense, all these phenomena united in one case, as in that
of our patient, suffice to reveal the hysterical nature of the.
paralysis.

“In consequence the diagnosis ‘ hysteria’ was frankly and
resolutely adopted. Without doubt, the convulsive attack was.
an element wanting ; but you do not ignore the fact that this.
is not inseparable from the nature of hysteria ; consequently
the nature of the prognosis changed. We had not to deal with
an affection arising from an organic cause, perhaps incurable.
We were able to anticipate, despite the long duration of the
disease, either spontaneously or under the influence of treat-
ment, some one of these sudden changes, which are not rare
in the history of hysterical paralyses, and of paralysis of
220 MASSAGE IN NERVOUS EXHAUSTION AND HYSTERIA.

flexibility in particular. In any case we were able to prog-
nosticate that sooner or later the patient would recover. The
subsequent event soon justified our hopes, and amply confirmed
our diagnosis.

“On the 15th of March, four days after becoming our patient,
we diligently searched him for what had not been done up
to this date, to ascertain if there existed any hysterogenetic
zones. We found one situated under the left breast, and
another in each of the iliac regions. It was noticed
that even a slight excitation of the sub-mammary zone
easily determined the diverse phenomena of the aura—a sen-
sation of constriction of the thorax, and then of the neck,
beating in the temples, and buzzing sounds, especially in the
left ear. But on insisting a little more P is suddenly
noticed to lose consciousness, to throw himself backwards, to
extend his arms, and thus we aided in causing the first attack
of hystero-epilepsy which the patient ever experienced. This
attack was absolutely classic, and to the epileptoid phase
immediately succeeded that of the greater movements. ‘These
were of an extreme violence; the patient, in the act of
salutation, went so far as almost to strike his face against his
knees. Shortly afterwards he tears his clothes, the curtains
of his bed, and turning his fury against himself, he bites his
left arm. The phase of passionate attitudes immediately
followed. P appeared a prey to a furious delirium ; he
provokes and excites to the murder of imaginary persons.
Ultimately he comes to himself, and he affirms that he retains
no knowledge of what occurred. It is remarkable that during
the whole of that first attack the left superior extremity took no
part in the convulsions ; it remained flaccid and perfectly inert.
From this time the attacks recurred the following days spon-
taneously, many times presenting also the same features. In
one of them which took place during the night of the 17th
March the patient passed his urine in bed. Two other attacks
followed on the 19th. On the 21st a new crisis supervenes,
during which the left arm is agitated. On awaking, the patient
found to his great astonishment that he was able voluntarily
to move the various segments of the limb, of which he had not
the use for a single instant during the long period of almost ten
months. This motor paralysis was not cured, for, without doubt,
there remained a certain degree of paresis, but. this con-
siderably improved. The perversions of sensibility persisted
as formerly.

‘This cure—or, to speak more properly, that sketch of
a cure—after the diagnosis at which we arrived, ought
not to be a matter of surprise to you. But, from our
point of view, it occurred prematurely, untimely. Indeed, it

 

 
HYSTERIA IN THE MALE. 221

was no longer possible to afford to you ocular proof, in their
detail, of the characters of that monoplegia so worthy of study.
The idea occurred to me that, perhaps in acting on the mind
of the individual, by way of suggestion even in the waking
state—we learned previously that the subject was not
hypnotisable—we might produce it at least for some time.
It was thus that the following day, finding P coming out
of an attack which had not modified the state of matters, I
endeavoured to persuade him that he was paralyzed anew.
‘You believe yourself cured,’ I said to him, with an accent of
entire conviction; ‘it is an error; you are not able to raise
your arm, nor to flex it, nor to move the fingers; see, you are
unable to grasp my hand,’ &. The experiment marvellously
succeeded, for at the end of a few minutes of discussion the
monoplegia returned. I was not anxious on this account, it.
may be said in passing, for I know from long experience that
what one can do he can undo. Unfortunately, this did not.
persist for more than twenty-four hours. The following day a
new attack supervened, in consequence of which the voluntary
movements became definitely re-established. On this occasion
new suggestions which we made were found useless. It remains
for me only to-day to apprise you of the modifications which,
in that which concerns voluntary movement, are produced in
consequence of an attack in a limb formerly completely
paralyzed.

“The patient, you will notice, is able voluntarily to move all
the parts of that limb. But these movements are not energetic ;
they do not overcome the least resistance which one opposes
to them, and while on the right hand the dynamometric force
is equivalent to seventy, the left hand represents only ten.
Hence, as I have already stated, if the motor paralysis is not
so absolute as formerly, it still persists in a marked degree.
Further, the troubles of sensibility were not only in the
weakened member, but in all the left side of the body, and
embraced the sensorial apparatus. On the other hand, the
attacks continue frequently. We have here simply an
amendment, and for a complete cure much more has to be
undertaken.

‘“‘T intend to return, in order to estimate properly, to a con-
sideration of some of the facts of this interesting case, with
reference to a study of hysterical paralysis caused by injury,
and which I shall lay before you soon. For the present, leaving
aside the monoplegia, wnich constitutes but an episode in the
history of our patient, I remark, in terminating, that in the
case of this man, as in the preceding cases, hysteria exists in
its characteristic phases.

“Tn considering with you in these two lectures the six signifi-

 
222 MASSAGE IN NERVOUS EXHAUSTION AND HYSTERIA.

cant cases which chance placed under our observation, I have
been desirous of convincing you that hysteria, even grave
hysteria, is not a rare disease in the male; that it may be
found here and there in the ordinary clinique, where alone the
prejudices of another age prevent its being recognised. I
venture to hope that after the accumulation of so many proofs
in these times, that notion is destined to hold in your minds
the place to which it is entitled.” ,

I have perhaps dwelt too long upon this subject of hysteria,
but it is of never failing interest to the physician, and it is one
of great importance from its medico-legal aspects. In reference
to the latter point I am bound to admit that the predisposition
to hysteria and nervous disease should form a basis for the
rightful consideration of judge and jurist in awarding damages
in all cases where accidents may produce very serious conse-
‘quences in some, although without predisposition they may
produce no effect whatever.
LECTURE X.
MASSAGE OF THE SPINE AND BACK.

Importance and great value of Spinal Massage—Its effect in raising the
Temperature of the Body, the Volume of the Pulse, and the Circulation
in the Spinal Cord—Tender points in the Spine—The Hysterical Spine—
Cases and Treatment—Tllustration of Spinal Massage Manipulations—
Faradization through the Body of the Masseur—Illustration—Hammond
on Spinal Irritation, caused by Spinal Anemia — The Application of
Galvanism to the Spine—The hot water foot bath as the Negative Electrode—
A mild current preferable to a strong one—De Watteville on Ascending
and Descending Currents—Static Electricity—Spinal Curvature—Dr. Busch
on the Spinal Column—Mobility of the Vertebre—Molliére on the Etiology
and Treatment of Curvature — Barwell on Curvature — Value of
Massage Manipulations in Curvature—Dr. Busch on the desirable position
for Students in Writing—Muscular Gymnastic Exercises—Dr. Liebreich’s
Lectures on School Life—Lumbago and Intercostal Neuralgias.

In masséeing the back we have to consider, not so much the
parts which come immediately under the influence of our
manipulations, as those which are influenced indirectly by
them. It is quite true that we have to deal directly with a
mass of muscles, whose activity and inactivity deserve
consideration. I think it must be obvious that in languid
circulations the venous and lymphati¢ currents in these parts
must be subject to considerable retardation, and of necessity
metabolicchanges must be inactive; both ordinary respiration
and more especially extraordinary respiration aid the circula-
tion of the blood through them. I am inclined to believe
that nitrogenous products, such as urea and uric acid,
accumulate unduly in the juices of their tissues; and
although I know that this is hypothetical, still, it is
quite possible that they may be the means of imparting
to the general circulation an amount of waste material
with which the ordinary processes of oxidation are unable
to cope, giving rise to gout and rheumatic gout, and
probably to disease and functional disturbance in other
ways. Let this be as it may, we know that by our
massage movements we stimulate the circulation through
these muscles to increased activity, and we believe that by so
doing we also stimulate the circulation of the spinal cord.
The vast importance of masséeing the back can only be
underrated by those who are blind to experience and common
sense.

I have often drawn your attention to several interesting facts
in reference to the effects of massage upon the back. You
have frequently seen the capillaries of the skin of this region

vy
224 MASSAGE OF THE SPINE AND BACK.

become intensely active, the whole surface responding by a.
glow of warmth and increased colour most unmistakable. In
other cases, do what you will, the result is negative, or the
effect may be to produce a mottled blue appearance. Again,
we have frequently observed our patient’s surprise at the:
warmth brought about in the extremities, particularly in the
feet, by masséeing the back. Too much consideration cannot
be attached to these every day facts; they are of far greater
interest and practical value to us than the variations in the
elimination of urea, or the increase of temperature taken by
the mouth or by the rectum, or by the changes in the pulse
at the wrist. Let me tell you that ten minutes’ work at the
spine will increase the volume of the pulse and the tempera-
ture generally more than an houv’s work at the body, as a
whole, the spine being omitted. You will do well to bear this
in mind. I have already spoken to you of the circulation of
the spinal cord when dealing with its anatomy and physiology,
but I must call your attention again to the fact that the
grey matter of the nervous centres is far more vascular
than the white substance, and that the grey matter of the
spinal cord varies in its area at different levels. You can see
this in these diagrams before you, also in any good work on
anatomy ; it is exceedingly well delineated in Ross’s work on the
spinal cord. Take, for instance, the cervical and lumbar
regions, where it is very extensive compared with the dorsal
region. Of course it is evident that this should be the case, seeing
that the nerves originate from these parts which go to form the
great brachial and lumbar plexuses, and the activity here must
be greater than in the dorsal region where the nerves are
small and their function limited. Observe that the
white substance surrounds the grey matter except at the
two points at which the posterior horns come to the
surface.

There is no doubt that the functional activity of the spinal
cord is frequently impaired owing to some impediment
to the normal circulation of the blood through it; in plain
words, spinal congestion is more common in so-called functional
troubles and nutritional defects than is usually supposed.
I have drawn your attention to this because I am a great
believer in spinal massage under such conditions; but let me
first speak of the diagnosis and therapeutic value of “‘ tender
points’ elicited on pressure with and without galvanism along
the course of the spine. This is a subject in which Iam much
interested, but it has not been thought of so much importance
in this country as upon the continent. Braun and Tiirk have
published some excellent monographs on the question, and
- Trousseau spoke highly of the value of tracing a neuralgia
TENDER SPOTS IN SPINE. 225

long the course of the nerve to the spine from which it emerged,
and then blistering the painful and tender spinal spot. The
hysterical spine is different altogether from the congested
spine in reference to pain. The pain in congestion may be
accentuated at a given spot where it is so acutely tender that
the patient cannot bear it touched, but the whole of the
vertebre in hysterical spine is painful and tender, “it is not,
as a rule, a localized tenderness.”

I have an exceedingly interesting case of hysterical spine
under my care at the present time ina lady who is particularly
anxious to tell me that she generally has such excellent
health that nothing ails her. However, she had been
upset, troubled and vexed about something, her appetite had
failed, she could not sleep at night, her memory was bad, and
her brain seemed strange and confused. She was suffering
agony, aS she expressed it, all down the centre of the back.
If the back were touched at a certain point in the dorso-lumbar
region it made her vibrate all over. The left leg felt numb
and heavy, and movement of the legs produced severe back-
ache. I looked upon this case as one of neurasthenia of the
spine. The nerve exhaustion being productive of spinal
irritability and hysteria, general massage was first applied
which produced sleep, it was then applied to the spine with
excellent results. :

I was consulted a few months ago by a gentleman
whose occupation in the city gave him a great deal of
brain work. He told me that he found it most difficult to
follow his business, capacity for work had failed in the
most complete manner. At one time he could go through a
mass of figures in a mechanical way without the slightest
strain or hitch, but now he became confused, and the more he
tried to overcome this the more vacant he grew, until he was
compelled to throw his papers aside or he feared he should
have a fit, for he felt hot, his sight became dizzy, and his
hands clammy, and his forehead covered with sweat. He
knew of no cause for this change in his condition; on
the contrary, everything was going well with him, but
he thought that something ought to be done, for he was
getting worried and irritable; his appetite and his sleep also
were failing. He had consulted several physicians, and they
advised change and rest, and special diet; he had been
away and felt better in many respects, but directly he
resumed work the same condition persistently returned. As
part of my examination I made him lie upon his stomach whilst
‘Lcarefully pressed every spinous process; no tenderness was
‘licited, neither did he flinch. I then applied a very weak
@alvanic current to each spinous process, which gave s no
226 MASSAGE OF THE SPINE AND BACK.

pain whatever until it came in contact with the spine of the
eighth dorsal vertebra, when he jumped up and declared that
I had been cutting him. At the same time there was violent
eructation of wind from the stomach. The galvanism was tried
again, of less strength, but with the same result. I told him
that however singular it might appear it was my belief that
some derangement of his spine was at the bottom of his trouble,
as s0 it proved, for three weeks of spinal massage cured
im.

Icould give you records of many similar cases, but what the
exact condition of the spine may be other than congestion I am
unable to say. It is, however, quite possible that in some rare
instances there may be periosteal exostosis affecting the lateral
masses and transverse processes on one side, and it is quite true,
as pointed out by Dr. Meyer and others, that unilateral tender-
ness may sometimes exist over the transverse process rather
than over the spinous process of a vertebra. I must tell you this,
that in all obscure conditions known as functional, or what is
much more popular, “‘ liver cases,” where relief has been sought
and not found in other quarters, I feel it to be my first duty
to examine the spine most carefully, and if I find a tender spot
or spots, I also find as the tenderness subsides by galvanism, dry
cupping, and massage, my patients improve and in most cases
get well. Do not think that I am alone in this experience, for
similar observations have been made by a number of other
physicians: Anstie, Rockwell, Beard, Onimus, Remak, and
Trousseau being amongst them.

We have this morning a new patient for massage treatment
in this young woman. She tells me that she is twenty-four
years of age; and her mother states that for some time her
health has been indifferent. Menstruation is scant and
accompanied with great pain. She is listless, apathetic,
and sleeps badly, says the least exertion tires her, and
everything she takes gives her indigestion. You see she is
bloodless, and she is losing flesh. Her employment is to
serve behind the counter in a linen draper’s establishment.
I propose to examine the spine and massage the back, and in
order to do so she must be placed thus, in the horizontal
position, with the arms over the head, just as you see people
when they are about to dive into the water. The first thing I
do is to examine the vertebral spines, to ascertain if there be
any curvature. I now make pressure upon the spinous
processes, one by one, asking her to speak if I give her pain.
I begin with the seventh cervical, known as the prominent
vertebra. In employing this pressure test, observe that I
generally use the knuckle of my first finger, after this manner,
so. You see she flinches, I am now pressing the spine of
TENDER SPOTS IN SPINE. 22:7

the second dorsal. Well, I go on, there is no pain apparently ;
again she flinches, I am now pressing the first lumbar spine.
Let us try once more. Again you see it hurts her, when I
press upon the spines of these two vertebre, the second dorsal
and the first lumbar; but upon no other spine does she feel
pain. What does this indicate? I really cannot tell you, for
if there was organic disease of the spine the chances are against
pain being produced by pressure; all I can say is that spinal
tenderness in these regions is often associated with spinal
irritability and exhaustion. Spinal tenderness upon pressure is
not often elicited in the cervical or mid-dorsal regions. We must,
as I have just told you, remember that the second dorsal is
in close relation with the expansion of the cord from which the
brachial plexus of nerves is given off, and the first lumbar is con-
nected with that portion of the cord from which the lumbar
plexus takes its origin. Be this as it may, we will massage the
back from the seventh cervical vertebra to the coccyx. I will
endeavour to go through every movement slowly and carefully
so that you may follow me. First of all, I effleurage quickly
and lightly with the flat of my hand the whole surface from
the cervico-acromial ridge to the crest of the ilium; I then use
my fingers and the thumbs of both hands, planting my thumbs
near to the seventh cervical spine and my fingers in the
natural way just ahead of my thumbs; my fingers and thumbs
now travel downwards and outwards in the direction of the
ribs, performing a succession of quick, light, rolling petrissage
movements. If you watch you will see that my thumbs are
more or less fixed points, upon which my fingers are playing
with a layer of skin intervening. I then return, making the
same movements upwards and inwards, but my fingers are
now fixed points and my thumbs are doing the active work.
I repeat these processes until one half of the back is done;
I now carry out precisely the same manipulations upon the
opposite half. Ifinish stage number one, now for number two.

 

 

 

Fig. 33.—Digital petrissage for the back; the fingers are made to travel up
the back and drag the wrists after them, without raising the hands from the
surface of the flesh. ‘
22.8 MASSAGE OF THE SPINE AND BACK.

I place my hands upon the lower and central line of the back
(Fig. 38), walking up the back, so to speak, with my fingers, and
using grip and pressure with them so that they drag the heel of
the hand after them. When my hands reach the flesh at the
serratal angles of the scapule I grasp the tissues firmly and
walk my hands backwards in the opposite direction: these
movements are repeated some half dozen times. I finish stage
number two, now for number three. This is done by working
the heels of the hands upwards, with the fingers uplifted ; then
the return movement is effected with the knuckles.

We have now to consider what I always tell you are
essentially back manipulations: tapotement, vibration, per-
cussion, and hacking. These must be performed quickly,
in fact as quickly as possible; they must not be done with
undue force. Fix the arms to the sides of the body, and
work from the elbows. There are four modes, each of which
I will show you. In the first the hand is made into a
partially clenched fist, that is to say, the two first fingers
press firmly upon the ball of the thumb, so that really
the hand forms a cavity, and the ulnar side of the hand and
fingers only come into contact with the body of the patient
(Fig. 34).

 

 

 

 

 

Fig. 34.—Tapotement ; vibratory percussion.

The second is not to clench the hand, but to bring the
metacarpus and the fingers together in the form of a boat.

The third method is to use the fingers as a flail, working the
hand from the wrist; you may use the dorsal surface of the
fingers after this manner, or you may use the extreme ends of
the fingers in the way I now show you: this is useful to
excite the superficial circulation, particularly of the buttocks.

The fourth method, or hacking (Fig. 35), is performed by the
ulnar side of the hand, or the fingers alone. I do not see any
advantage in this over the other methods, still every method
FARADIC MASSAGE. 229

has, as we shall see, its special uses in given directions for
different parts of the body. I have now finished the back,
so far as the massage manipulations are concerned.

 

 

 

 

Fig. 35.—Tapotement: position of hands for hacking.

1 will take the next patient and show you my method of
applying faradization by passing the current first through the
body of the masseur. I have referred to this before, but not in
the practical manner I should like to do. I take these two
flat metal electrodes, well covered with thick chamois leather ;
they must be made thoroughly damp, not too wet. Remember,
what we want is induction and resistance; if the electrodes are
too wet, or if your hand or the back of the patient is too moist,
their conducting power will be too great; and the effect will not
be what we desire; therefore we dry the back well by rubbing
it with a hot towel, and if need be, cover the surface of the
back with a very thin layer of starch powder. Place the larger
of the two electrodes underneath the patient’s sternum, and
the lesser electrode can be fixed upon your arm, or it can be
230 MASSAGE OF THE SPINE AND BACK.

held in your left hand, or placed at the back of your neck. I
prefer the last method because it leaves your hands quite free.
I have been very careful to see that my electrodes are just
sufficiently moist. The dorsal surface of the hand always works
better than the palmar surface, and frequently you will find
that your arm works better than either.

I now make my effleurage movements over the surface of
the back generally, and up and down the spine, around the
back of the neck and even behind the ears. This form of
applying the faradic current is refreshing and gently stimula-
ting; it cannot be strong enough to be painful or to excite
muscular contraction if proper precautions are taken. Neither
the patient nor the masseur should be painfully impressed by the
current. This manual form of faradization is exceedingly
useful in all functional troubles of the spine, neurasthenia,
hysteria, spinal anemia, spinal irritation, inhibition, exhaus-
tion, and nutritional defects.

Spinal irritation.—Dr. Hammond, of New York (A Series
of American Clinical Lectures, edited by Dr. Seguin, Vol. ii., p.
277, New York, 1876), has sagaciously endeavoured to prove
that the diseases commonly called spinal irritation, hysteria,
spinal congestion, exhaustion, neuralgia, etc., should be called
posterior spinal anemia, inasmuch as it consists essentially of
an anemic condition of the posterior columns of the spinal cord.
He says, ‘“‘ The symptoms of spinal irritation are both centric
and eccentric. Of the former, pain excited by pressure on the
spinous processes, or on either side of them, is the most
constant, it is sharp, lancinating, and remains for a minute
or more after the pressure is removed. Spontaneous pain is
not so constant, but may be produced immediately by
emotional disturbance. Amongst the eccentric symptoms may
be mentioned vertigo, headache, noises in the ears, dis-
turbances of vision, tenderness of the scalp, fulness in the
head, loss of power in some of the cerebro-spinal nerves,
clonic spasms of the muscles, contractions of the arms,
aphonia, and hiccup. The mind may be unhinged, sleep
deranged, the dreams unpleasant, and a tendency to somnam-
bulism may be present. Occasionally there is excessive
salivation, or the mouth and tongue are parched; nausea and
vomiting occur persistently after eating, and there is pal-
pitation of the heart and irregularity of its action. Epilepti-
form paroxysms, and choreiform movements, beginning
in the muscles of the face or arms, and extending to other
parts, may also occur.

** Such are the symptoms when the cervical portion of the
cord is suffering. Where the dorsal part of it is affected, there
are gastralgia, inframammary pain and intercostal neuralgia,
APPLICATION OF GALVANISM TO THE SPINE. 231.

nausea, vomiting, pyrosis, flatulence and acidity, cough,
epigastric pulsation, and asthma. The lumbar portion, when
affected, gives rise to neuralgic pain in the lower extremities,
uterus, vagina, ovaries, intestines, or muscles of the back or
abdomen, and, in the male, in the testicles. There may be
various symptoms on the part of the bladder, and hip and
knee-joints.”’

Dr. Hammond combats in detail the objections which
have been, or might be, raised against his theory of
posterior spinal anemia. He ridicules the idea that the
spinal cord could not be anemic unless the whole system
were in a like condition ; urges that anemia may be confined
to the posterior columns without involving the other portions
of the cord, just as the lesion of locomotor ataxy is confined
to a limited sphere in the same organ; and he then gives his
reasons why the symptoms of spinal irritation should be more
referable to anemia than to any other condition. Irritation
means weakness, and weakness means defective nutrition or
anemia. An anemic retina cannot bear the full light of day ;
an anemic heart beats with great rapidity ; an anemic brain
aches ; and in the same manner an irritable spinal cord is the
seat of pain; and organs in anatomical relations, through
their nerves, with such a cord, should exhibit indications of
morbid sensibility.

The application of galvanism to the spine.—Now that I am
speaking to you of the application of massage and faradic
massage it seems to me that this is a fitting opportunity to
say something of the use or administration of the faradic and
galvanic currents to the spine, or of the two currents combined.
The first thing which we have to find out is this : Is there any
localized organic lesion, or is the condition one of functional
derangement? In the former case it is better to apply the
stabile galvanic current (bipolar). Place the kathodic electrode
over the upper cervical spines, and the anodic electrode over
the spines which are adjacent to the seat of lesion. Do
not use too strong a current; five to ten milliampére strength
is all that is required. You had much better apply a weak
current for twenty minutes than a strong one for ten minutes.
The current should be reversed during its transit five or six
times. Do this slowly: rapid voltaic alternatives might be
highly prejudicial in cases of organic disease. If the spine be
irritable and over sensitive the unipolar method is preferable
to the bipolar, therefore place the anodic terminal upon the
spine (the positive current having a soothing influence) whilst
the kathodic terminal is placed upon some distant part of the
body. Iam very much in favour of the hot water foot bath as
the negative electrode ; by this means the density of the more
232 MASSAGE OF THE SPINE AND BACK.

active current is reduced. If there be no organic lesion, and
the state of the spine is that of functional derangement only,
faradization can be more profitably employed than gal-
vanization, and the labile method is to be preferred to the
stabile: sponge electrodes are better than any other: let the
sponges be of good size and firm in texture. Hold one of them
upon the cervical spines whilst the other is drawn down the
entire length of the vertebral column: repeat this process
some twenty times; then use the two electrodes conjointly,
carrying them from above downwards about two inches apart.
It is better to moisten the sponges with strong salt and water,
using a weak current; by so doing you are on the safe side,
and you avoid any chance of doing harm, you will not be
guilty of inflicting unnecessary pain upon your patient, and
there will be no fear of aggravating his symptoms. I have
often endeavoured to impress upon you the importance of not
using too strong currents, though exceptional cases may
occasionally require exceptional means. This rule applies
equally to galvanization as it does to massage, and my
instructions to you in the one case are equally applicable in
the other. But I shall again refer to this in my lecture on
electrical therapeutics. ,

As I have been speaking to you of tender spinal spots,
I may tell you that these are best influenced by the anodic
current. Therefore please to remember, as a general rule
in galvanism, that the kathode should be applied to those
parts in which there is diminished sensibility, and the
anode to those parts in which there is exalted sensibility.
Always let your kathodic electrode be much larger than
the anodic. When we have localized a neuralgia, and
traced the nerve to its origin in the spinal cord, which we
probably find gives the reaction of tenderness upon pressure,
we can use the combined galvanic and faradic currents with
greater chance of success than by using either singly. In using
the faradic current alone to over-sensitive and neuralgic
parts the object seems to be to over-stimulate and thus benumb
them. In recent cases of neuralgia this is all very well,
but in cases of some duration, or molecular alteration,
where there is a possibility of degeneration, never use a
strong faradic current: it checks the onward flow of the
blood, depresses the action of the heart, and ends in bring-
ing about dilation of the blood vessels: a weak faradic current.
on the other hand, acts reflexly, accelerates the flow of the
blood, increases the heart’s action, and tones the circulation.
Therefore use a weak faradic current in combination with a
weak continuous or constant one in all forms of neuralgia,
where you want to produce catalytic and cataphoric effects,
APPLICATION OF GALVANISM TO THE SPINE. 233

for the reason that we want to diminish the excitability of the
nerve, in fact to produce a condition of anelectrotonous.
Having graduated the combined current to the required
strength (seven milliampére constant) place the anode on
the nerve near to or at its centre, and the kathode upon
some indifferent part of the body, or upon the periphery of
the nerve known to be implicated : a weak descending current
applied in this way for some twenty or thirty minutes is not
unfrequently followed by the most effective and lasting
beneficial results.

There are some observers who conclude that the direction in
which a current is applied to a nerve determines an exciting
influence, on the one hand, or a depressing influence, on the
other. Dr.de Watteville dissents from this view, and in common
with other electro-physiologists, gives the following reasons
against this doctrine, relative to ascending and descending
currents which, however, may or may not be conclusive: (1,) ‘In
physiological experiments on human beings, as well as on frogs’
nerves, all the phenomena observed are best explained on the
theory of polar influences only ; (2,) That it is impossible tosend a
current of any density in a given direction through a moderately
long piece of embedded nerve; (8,) That catalytical effects
are independent (so far as can be ascertained) of the direction ;
(4,) That the theoretical claims set up in favour of specific indi-
cations for the use of ascending or descending currents in the
treatment of various disorders are not justified by experience.
‘In fact,” says Dr. de Watteville, “‘among the writers who
have based their systems upon the assumed directional differ-
ences, a great deal of divergence prevails as to the indications
for the current to be used; whilst their practical results agree
among themselves, as well as with the results obtained from
the application of the ‘ polar method’ to treatment.’ These
observations and deductions are well worth serious considera-
tion. But, let me tell you, there is much to be learned
concerning the application of electricity to the human body,
and an ounce of practice is always better than a pound of
theory. If points like these are to be settled—and there is no
reason why they should not be—it must be accomplished by
the most careful and painstaking investigations from the
clinical aspect, based upon a sound knowledge of electro-physics.
It is often a great mistake, and one which tends to retard the
development of sound scientific inquiry, to attempt to reduce
the effects of electricity to definite laws before we can formulate
with exact certainty the precise existing conditions between
cause and effect.

Static electricity—Let me now call your attention to the
value of static electricity to the spine, particularly in cases of
2B-A MASSAGE OF THE SPINE AND BACK.

hysteria. I have used it in hospital and private practice for
many years, and I can speak highly of its worth; and although
its therapeutic effects are not generally acknowledged in this
country, still upon the continent its application is by no means.
limited. There are one or two reasons for this. The first is
that our usually humida tmosphere, compared to that of Paris
and Vienna, is prejudicial to its generation and conduction. The
second is that in our published works on electricity nothing
whatever is said about it, so that great ignorance prevails.
regarding its principles. The third is that difficulties are
experienced in its production just at the time when it is most
wanted, for a dry clear air is essential to its liberation. How-
ever, when all things are equal, it possesses one great advantage
over faradization, and it is this, that its effect can be produced
without the patient undressing, thereby saving considerable
inconvenience. I do not think it is wise to compare the
advantages or disadvantages of this form of current to that of
galvanism or faradization ; it appears to me that its effects are,
in a way not yet accounted for, dissimilar to either. All those
who have noted these, after practice and experience, have come
to the conclusion that its influence in spinal irritation and
hysteria in all its manifestations, gives to it as a therapeutic
agent marked priority over the other forms of electricity.

It is necessary to have a good machine, dry air, and a good
insulator upon which the patient can be comfortably seated.
A few turns of the handle, as you see, will charge the machine,
and I attach the rheophores with the brass poles negative and
positive respectively ; one is connected with the earth, and the
other with the body of my patient. In order to keep up the
continuous generation and flow of electricity, the handle
should be turned in an active and regular way.

The discharging electrodes vary according to their conduct-
ing power ; if it is required to withdraw the current in a diffuse
and almost insensible manner, this clothes brush answers the
purpose perfectly; if, on the other hand, you wish to withdraw
the electricity in a concentrated form, you use some pointed
metal instrument, such as this which Inowshow you. Among
the many other forms of electrodes, we use a carbon ball, a
roller, a rubefacient, an ear and uterine electrode, multiple
copper, and steel point electrodes, &c.

I will now discharge my patient through this metal point,
by applying it to the muscles of the ball of the thumb. You
see with what activity the muscles are stimulated to contract.
Let me tell you that this form of electricity is valuable in
protopathic muscular atrophy. My experience is, and I have
recorded many cases, that muscles can be made to contract,
their nutrition improved, and their substance regained by this
SPINAL CURVATURE. 935

means, when other forms of electricity have been tried for a
considerable time and found to be quite useless. These are
incontrovertible facts, and they ought not to be lost sight of.

I have detained you some time with these remarks relative to
electricity ; they are not only instructive, but of practical
value. We will now proceed to the consideration of spinal
curvature.

Spinal curves——I have explained to you the nature of
angular and lateral curvature of the spine; and I have told
you that massage to the spine itself is useless in the former,
still I pointed out to you the great value of massage to
the extremities in angular curvature, where the patient is
unable to take exercise. You know that patients with spinal
abscess are necessitated to adopt enforced rest, not only to
prevent the spread of the degenerative process in the bodies
of the vertebra, but to aid the processes of bone repair ; it is
apparent that this must be attended by nutritional defects,
therefore, massage in these cases is simply invaluable. I am
quite sure that before long this will be fully recognised and
generally adopted.

In lateral curvature of the spine the case is quite different to
that of angular curvature. Here we have no organic disease,
and I venture to make the statement (which I know, to say
the least of it, will not meet with general acceptation) that
nineteen-twentieths of the cases of lateral curvature, where the
patients are incarcerated in irons, would get well much more
quickly under the influence of massage, galvanism, and suitable
gymnastic exercises, than by the use of some of these instru-
mental appliances, which oft-times increase the condition they
are sought to cure, and ruin the health of the wearer. Thanks
to Mr. Sayre, of New York, the plaster jacket has in a great
measure superseded them, and both Dr. Roth and Mr. Barwell
have done a great deal to supplant these cumbrous machines
by other more enlightened and satisfactory modes of treatment.

There are other curves distinct from the lateral, and which
are not due to organic disease. I will merely mention these
as laid down by Dr. Busch, in volume five of Von Ziemssen’s
Handbook of General Therapeutics.

1st, Rachitic posterior curvature occurring in young children.

2nd, Posterior curvature of youth known as round back.

8rd, The posterior curvature where the back is bent by
labour.

4th, The bent back of old age.

I cannot recommend massage as being likely to benefit any
of these forms of curvature. Professor Dr. Freidrich Busch
refers to the spinal column in the following simple but com-
prehensive way: “‘To the vertebral column are attached all
236 MASSAGE OF THE SPINE AND BACK.

other parts of the body; in its cavity is enclosed the central
nervous system, the upper part of which in the course of
development becomes gradually enlarged and forms the brain,
while the bony portions which surround it widen and form the
skull. It not only forms the support for the central nervous
system, but also for the vitally important thoracic and
abdominal organs, and thus Galen not unjustly compared it to
the keel of a ship. Corresponding with its great physiological
importance, anomalies in position of the vertebral column have
a disturbing influence upon a great number of the more
important organs of the body, and corresponding to the many
structures which are supported by this column, it is peculiarly
exposed to various anomalies of position. In this last respect
we may also notice the peculiar formation of this bony column,
consisting as it does of seven cervical, twelve dorsal, five lumbar
vertebra, and five sacral vertebre (coalesced into one bone), as
well as the four coccygeal vertebrex, the coccyx (an unimportant
rudimentary appendix). The erection of these small bones
upon a proportionately narrow basis, their connection by the
elastic inter-vertebral discs, their limitation by the oblique
processes and laterally projecting transverse processes, which
in the thoracic vertebre articulate with the ribs; the ligamen-
tous union of all these parts which cover the bodies consists
only of the weak anterior and posterior longitudinal ligaments,
but attains the highest degree of firmness at the processes;
the attachment of numerous muscles which are amongst the
strongest in the whole body; the continued weight sustained
by it owing to the erect attitude of man—all these peculiarities
produce mechanical conditions of such complexity as to make
our comprehension of the normal carriage of the body, and
espécially of the pathological deviations therefrom, extremely
difficult. Itis not, therefore, surprising that deformities of the
vertebre have attracted more attention than have deformities
of other parts of the body, and that their comprehension is as
yet, on many points, imperfect.”

Lateral curvature of the vertebral column is more frequent
than any other form. It is not unfrequently caused by con-
genital inequalities of the vertebral column itself, or on
unequal operation of weight upon the two halves of the spinal
column, or on unequal muscular action, or on cicatricial
contraction.

The normal movements of the vertebral column consist in
antero-posterior and in lateral flexion, as well as in rotation
upon the vertical axis of the body, by which the front of the
body may be turned more or less to the right or the left while
the pelvis remains stationary.

The cervical vertebre have the greatest mobility ; next to
SPINAL CURVATURE. 237

these the three lowest dorsal and two highest lumbar; then the
three lowest lumbar vertebre ; the least movable part of the
spine consists of the upper nine dorsal vertebra.

In a clinical lecture by Dr. Mollitre, surgeon to the Hotel
Dieu in Lyons, upon the etiology and treatment of curvature
of the spine, the causes are divided into three main groups:
(1,) Affections of the head and neck, including astigmatism,
enlarged cervical glands, goitre, contraction of the sterno-
mastoid, and hysterical or other paralyses of the muscles of
the neck. (2,) Affections of the lower extremities, including
congenital dislocation of the hip, coxalgia or ‘‘ growing pains ”
in the hip, knock-knee, rickets affecting the tibia, fractures
with shortening, a relaxed state of the foot and other ligaments,
and juvenile paralysis. (8,) Affections of the vertebre them-
selves, or of the thorax, causing true or essential curvature,
including pleurisy and excessive exercise of the muscles of one
side—such, for example, as existed among the early pressmen,
who are represented in old caricatures with a hump near the
left shoulder. In addition to these causes, it must be confessed
that in a large number of instances there are others which
cannot so satisfactorily be made out. Dr. Molliére has given
a good deal of attention to this subject, studying the thoracic
functions of hunchbacks and examining such muscular theories
as appeared to present any hope of a solution of the question.
Is, he asks, curvature caused by paralysis of the muscles on
the opposite side, as is supposed by some writers ? Post-mortem
examination of hunchbacked women negatived this theory, as
no muscular or nervous lesion could be found, and no com-
pression of vessels or nerves in the vertebral foramina. Again,
is curvature due to muscular contraction on the affected side?
Still less is this the case, for the electrical conditions of the
muscles and the want of success in the divisions of muscular
tissue proposed by M. Guérin both show the incorrectness of
this theory. In order to elucidate the subject, M. Molliére
some years ago divided three of the intercostal nerves of one
side in a young rabbit close to the foramina, reuniting them
immediately. The rabbit became hunchbacked, the curvature
being on the side operated upon. The animal was allowed to
grow up, and was then killed and examined. No trace of the
operation could be discovered, the cicatrisation of the nerves
being perfect, and no muscular or nervous lesion being dis-
coverable. This experiment proves, according to M. Molliere,
that true curvature of the spine is due to temporary paralyses
of the intercostal muscles during youth. These paralyses pass
away, but the curvature which is produced on the paralysed
side remains.

Mr. Barwell, in a very interesting post-graduate lecture at
+

°

238 MASSAGE OF THE SPINE AND BACK.

the Charing Cross Hospital, on lateral curvature of the spine,
says: “‘Itis impossible to exaggerate the importance of detecting
the malady early, that is, in the first stage if possible, at latest,
in the second. I would wish that ail parents would subject
their children once a year or so to skilled examination. As it
is lateral curvatures are very often first discovered by the dress-
maker, who finds that she has to make the body of the dress
about the shoulders larger on one side, or that the skirt, made
equal, hangs lower on the left than on the right. But a
curvature discovered by such means is already well advanced,
we ought to have it under treatment earlier.

“In order, however, to obtain the earliest possible treatment
of a curvature, it is necessary that the initial signs of the
approaching deformity be well understood, and let me hope to
be pardoned for saying that only a very few people in the

_profession know what are the early signs of lumbar and dorsal
curvature, and therefore it will be doubtless permitted me to
go into this subject with some little detail.

“The patient should be placed opposite, and with the back to
a window, all cross lights being avoided. The hair is to be
gathered up and fastened at the top of the head. The trunk
must be bared to the level, at highest, of the great trochanters.
All fidgettiness from fear of the garments falling lower must
be calmed. A little elastic belt round the pelvis quite secures
them. The feet are to be placed together, the hands passed
over the lower limbs ascertain that the knees are straight. All
this being arranged, the surgeon falls back a step or two and
examines the figure as a whole. And nowI am going to say
something that sounds like, but is not, a paradox. in order
to detect a very early spinal curvature, you must not look at
the spine. In the first part of this lecture it was said that the
vertebre so rotate that the spinous processes move towards the
concavity of the curve; thus it happens, of course, that a
certain amount of lateral deviation is compensated by rotation.
Thus the tips of the spinous processes may lie in a straight
line and yet the spine be crooked. Moreover, the skin of the
back has a central mark, the hair bulbs even run from it out-
ward as well as downward, it is always perceptible, though
more so in some persons than in others, and is very apt to
deceive any one inexperienced enough to look at the spine or
what he takes to be the spine, for the first sign of curvature.
No, the form and the outline of parts on each side of the
column must almost exclusively engage your attention. Let
me show the conditions in this patient who has a left lumbar
curvature not in the very earliest stage which I could hardly
demonstrate in this light to hearers scattered all over the room,
but still in a quite early phase and before any consecutive
SPINAL CURVATURE. 239

dorsal curve has begun. Fix your attention on the side outline
of the figure and note that on the right (concave) side this line
traced from the axilla down to the waist (I will call it thoracic
portion) is unusually convex or round, bring your eye to the
waist and here commences the pelvic portion of the figure with
a strong projection, the two portions meet at a pretty sharp
angle, or I might express the condition by saying that the
incavation of the waist is greatly deepened, and this not merely
at the side outline, for running inward from that angle towards
the spine is a pretty considerable depression which lies in
well marked shadow. Now trace the other, the left (convex),
side of the outline from the axilla downward, and note that it
is much less curved, the incavation at the waist is much less
marked, often nearly absent, while the projection of the hip is
slight or almost effaced, there being at junction of thoracic and
pelvic portions of the figure no angle as there is on the right
side. Ifthe girl has worn stays tightened at the waist, there
will be, it is true, at that point a certain narrowing, but the
angular incavation is never present on the left side as it is on
the right. You can, if you like, follow the advice of Lorenz,
of Vienna, and letting the arms hang equally by the sides,
consider the gap between them and the side outlines as triangles
of which the thoracic and pelvic parts of the figure are the
subtending sides, the arms the bases. Ido not advise this
method, as it is easy to be deceived by uneven hanging of the
arms. Nevertheless, placing this patient’s arms as evenly as I
can, you perceive that on the left side the angle in question is
very obtuse, and a line let fall from that angle to the base (the
arm) is very much shorter than on the right, where the angle
is much more acute.

“Having noted these points, the surgeon should approach his
patient, and, giving such notice as will prevent a start,
should place his forefingers on the crest of each ilium, taking
care to have them on the same spot, and should note if the
one be higher than the other. In my consulting-room I
always place my patient so that in front of the patient a dado
or footboard may serve as a horizontal line to assure the eye
against being misled.

“Tf now we turn our attention to the spine and the parts
immediately next it, you see on the left (convex) side a slight
fulness running along by the side of the central spinal mark
upward to the tenth dorsal vertebra, on the other side this is
absent. And those of you who will after the lecture examine the
patient, will feel that this elevated part is rather hard, while
on the right it is soft and yielding, this hardness is perceptible
to touch some considerable time before any fulness can be seen.
It is not the hardness of muscular contraction, excess of
240 MASSAGE OF THE SPINE AND BACK.

contraction, if any, must be on the other side, it is solely due
to the rotation of vertebre, which is in such direction as to
bring the transverse processes nearer to the surface on the
convex side, where they form a hard bed for the erector to lie
on; while on the right (concave) side those processes have sunk
deeper from the surface, and the muscles having in great
measure lost their support are softer and more yielding to the
finger.

“These changes, suBtle as they are in the beginning, can
always be detected by an eye gifted with the power of apprecia-
ting form; practice, of course, renders that power greater, and
let me strongly impress upon you the necessity of making such
arrangements as I have described. An imperfect lighting,
with reflections and cross shadows, or permitting the patient
to hold up her remaining garments with the hands, and so be
rendered fidgetty by the fear of their falling may easily baffle
attempts at diagnosis.

“ Tt need only be added to this part of my subject, that left
curve is the more usual in the lumbar region, but that the
bend sometimes occurs in the other direction: the above
description, only putting the word left for right, and vice versa,
will apply to this form. A long simple curve, extending
through both dorsal and lumbar regions, is far less usual.”

Thus far I have given you the views of three of the most
experienced surgeons, relative to some points connected with
lateral curvature of the spine, namely, the pathology and
diagnosis. There are three grades of this curvature, and it is
only the first grade, to which from the massage point of view
I wish particularly to call your attention, and which in my
opinion is due to nerve and muscular defects. It is attended
with slight deformity, no special disturbances, and the
outer form of the clothed body gives very little indication of
its existence. It is different from the second grade, where
there is marked defect in the symmetry of the external
appearance which at once strikes the practised eye on account
of the shortening of the upper part of the body, the projection
of the back, and the large circumference of the waist; and
although in the second grade of curvature we cannot hope to
obtain such good results by properly applied massage as in
the first, still I look upon it as an essential and important aid
to treatment. Therefore please let it be understood that I
particularly recommend massage for lateral curvature of the
spine in the first grade. I have tried it in many cases with
the best results. It is far from my object to tell you of the
recognised methods for the treatment of this form of curvature,
but from the writings of others, with which I have made
myself familiar, I fail to see that systematic massage has been
BUSCH ON LATERAL SPINAL CURVATURE. 241

adopted. It is quite possible that after a time we shall find
its application becoming more general than it now appears to
be. Even Dr. Busch, whose experience in the direction of
massage manipulations appears to be greater than that of most
surgeons, writes with some hesitancy and doubt concerning this
treatment. He says, ‘‘ Systematic massage of the muscles of the
back may possibly have some good effect, but must be limited to
slight rubbings and kneadings, applied equally to the two
sides, as there is too little support for unsymmetrical massage,
and therefore the latter would be rather detrimental than

otherwise.’ These observations, coming from a man of large

experience, are certainly rather negative than positive, and I
should be sorry to recommend the use of massage alone, but
as an auxiliary of the highest possible value, its adoption
cannot be ignored. If it be done at all it must be done
thoroughly and completely for an hour every night, when in
bed. Of course the general strength should be maintained in
every way. The clothing should be warm, light and loose; the
diet plain, good, and easy of digestion; cold river and salt water
baths are strengthening and stimulating, but never should it
be carried so far as to induce fatigue. The question of fatigue
is important, and should be carefully studied in every occupation
of daily life, such as exercise, writing, sewing, pianoforte playing,
and the like. Not only should the erect posture of the
trunk of the body be maintained in every possible way,
but the inclination should be promoted in the direction
opposite to the curvature.

Dr. Busch gives some good advice in reference to the
position to be adopted in writing; for instance, he says, ‘‘ In
writing it is necessary that the child should sit at a large
table with straight (not rounded) edges, the chair so placed
that the edge of the table is exactly above the front edge of
the seat, the height of the seat such that the elbow can rest
on the table in a natural position, the copy-book must lie
straight upon the table and the head must not be inclined to
one side. The seat should have a tolerably high back, slightly
inclined backwards, so that the child when fatigued can rest
his back against it. The two ischial tuberosities should rest
firmly upon the middle of the seat, and not upon a corner or
edge.’ Muscular gymnastic exercises so excellently portrayed
by Schreiber in his work on mechano-therapy should be care-
fully and systematically carried out, but supervision by a skilled
hand is absolutely necessary, or more harm than good may
result. If you wish to become acquainted with these exercises
let me advise you to consult Dr. Schreiber’s book, it is
excellently written, and well worthy of study, but to instruct
you fully in these and other modes of treatment for rae
242. MASSAGE OF THE SPINE AND BACK.

curvature is beyond the range of my teaching; nevertheless,
as opportunities offer, I shall endeavour to demonstrate them
to you to the best of my ability, and although they may be
considered too mechanical for the scientific mind of the
physician, they are yet full of interest, and it is refreshing at
times to be able to lay aside the stethoscope and forget
arterial tension, and devote one’s self to the consideration of
other more objective phenomena, which are so intimately
associated with the well-being of man.

My experience has led me to the conclusion that any form
of curvature, no matter how slight, gives rise to some spinal
ne irritability, and variability of function of the spinal
cord.

Dr. Liebreich, the consulting ophthalmic surgeon to St.
Thomas’ Hospital, gave two interesting lectures, (1,) On school-
life in its Influence on Sight; (2,) School-life in its Influence
on Figure, and especially on the Spine. He maintained that
many of the defects of vision in childhood were mainly due to
some slight curvature in the vertebral column, and immediately
developed under the influence of school-life. These defects of
sight are three in number. ;

(1,) Decrease of the range of vision, short-sightedness(myopia).

(2,) Decrease of the acuteness of vision (amblyopia).

(83,) Decrease of the endurance of vision (asthenopia).

Iam not going to consider the fundamental principles of
these valuable lectures, but I merely bring the fact before you.
Prof. Liebreich, when consulted by an anxious mother regarding
her daughter’s eyes, would say, ‘‘ It is not the eyes, my dear
madam, it is the spine which is wrong.”” My own experience
quite leads me to this conclusion.

Lumbago and intercostal newralgias are best treated by
massage, and so is the terribly agonizing pain following
shingles ; lumbago, which you know is a common painful
affection of the muscles of the loins, is frequently conquered
by a single masséeing. Pinching, kneading, and hacking are
required. The manipulations must be continued until all
pain has subsided, and should it not yield to massage alone,
the application of the kathode large sponge electrode of a con-
tinuous current (15 milliampére) will, in nineteen cases out of
twenty, complete the cure. ;
Lecrure XI.
MASSAGE IN JOINT AND BURSAL AFFECTIONS.

The anatomy of joints—Health of joints necessary to health of muscles
—Dislocations—Massage treatment for joints—Inflammation ‘in joints—
Point when to begin Massage manipulations—Method of application—Sprains
—Mansell Moullin on sprains—Massage applied to sprains—Prolonged rest
inductive of anchylosis—Charcot’s joint disease—Opinions of Drs, Baker,
Barwell, and Sir J. Paget—Rheumatoid arthritis—Drs. Garrod, Ord and
Bruce on rheumatoid arthritis —Preference for Massage over other forms of
treatment in this disease—Bath as a resort for invalids—The Thermal
Baths of Bath—The medicinal properties and great value of the waters—
The Massage and Electric Treatment at Bath—Dr. Macpherson’s opinion—
The Spa at Contrexéville—Bursal swellings—Mucosal and Synovial—Dropsy
of the bursa—Stiff joints—Rheumatic and gouty—Treatment,

THe anatomy oF goints.—In previous lectures I have dwelt
upon the anatomy and pathology of joints. To-day I have to
speak to you of those which have undergone no serious
alteration of structure, no change, in fact, which cannot be
remedied by manipulations and exercises. Please remember
that we have to deal with the movable ones, and I may say
with them alone. The function of these is to limit and to
facilitate movement, so that a joint is essentially concerned
in movement. Every organ and! every part of the body
is best supported and maintained by the due and regular
performance of its own function, no matter what that function
may be. If its furtction fail, its special attributes fail in like
manner, its nutrition becomes impaired, and it must and does
undergo a retrograde metamorphosis of some sort or degree.
Remember, if you please, that muscles and joints are
functionally and intimately associated; the muscle is the
master of the joint. The function of a muscle is movement,
the joints respond to a limited degree, and they therefore
assist in the co-ordination of movements. If a muscle or
group of muscles be deprived of their function, or even if their
function be in part arrested, as in anterior polio-myelitis,
deformities arise, and the joints become involved.

On the other hand, if a joint is diseased so as to interfere
with and arrest muscular action, the nutrition of the muscle
becomes faulty, and it undergoes a primary atrophic change
(functional atrophy). These are merely passing remarks, but
from the massage point of view they are of interest and
importance ; and they serve to explain to you, in part, why
in massage processes I make it compulsory that every
joint shall be manipulated and put through its normal
movements before the muscles which control those movements
are pinched and kneaded and masséed.
244 MASSAGE IN JOINT AND BURSAL AFFECTIONS.

Every structure entering into the formation of a joint has
its own special duty to perform. Each structure of which a
joint is composed is liable to its own form of degenerative
change, but all ‘structures combine for the fulfilment of one
definite end, namely, to maintain its integrity as a living
organism. Covering the ends of bones we find a soft yielding
membrane, the articular cartilage, with its smooth surfaces,
which facilitates an easy gliding movement of one upon another,
and tends to resist concussion and moderate shocks or impulses
communicated to the bones. The joint is enclosed by the
synovial membrane which, with the capsule to which it is
adherent, forms a shut sac. The synovial membrane has the
property of secreting a viscid, semi-fluid, colourless material,
known as synovia, whose function is to moisten and to keep
the joint lubricated, whilst the outer surface of the capsule is
provided at various parts with bands of fibrous tissue, some of
which strengthen it, whilst others restrain or limit the move-
ments of the joint. Lastly, we have blood-vessels carrying
the pabulum to nourish this structure, and the nerves to give
to it sensibility, and to control its vascular supply, and special
trophic nerves to regulate anabolic function. The movements
in some cases are limited by special osseous development,
but in the majority of instances by strong fibrous bands
known as ligaments, which aid greatly in keeping the bones in
apposition.

I have upon other occasions discussed with you the value,
the importance, and the necessity of your making yourselves
thoroughly acquainted with the normal appearance of every
joint, and with its respective movements in every direction, so
that I can pass these considerations by upon this occasion.
The more movable a joint is the more liable it is to dislocation.
The shoulder and the hip have the greatest tendency to this
form of injury, whilst the wrist and the ankle are most subject
to sprains. Again, the shoulder, the hip, and the knee
respectively, are most frequently the seats of rheumatic pain,
the hip and the knee are more prone than any other joints to
be the seat of neuralgia, and the hip to arthritic and scrofulous
degeneration.

You must know that joints, of all structures, are the most
frequent seats of pain, either from injury or from atmospheric,
gouty, or rheumatic influences, therefore it is natural to
presume that massage will be called into requisition in the
treatment of joint affections as much, if not more, than for
any other disease ; and this is only just and right, for I am
perfectly convinced that we have no remedy of equal value. I
am sorry that I have not time to give you the physiological
reasons why this is the case. Iam, however, sure that many
RHEUMATISM OF JOINTS. 245

stiff joints (not unfrequently the result of a too conservative
treatment) might have been made adequately free to be
serviceable if a system of massage had been carefully and
judiciously carried out at a period sufficiently early. Nor can
we be surprised that joints have fallen into the hands of quacks
and illiterate impostors, and in many cases wonderful cures
have been said to have been effected. I hope, and I believe,
that as massage manipulations become better known and
scientifically considered they will be adopted much more freely,
and without bias, in the treatment of joints, so that in time
the joint-man and the bone-setter will cease to have an
existence. Hvery one must have heard of the supposed wonder-
ful and miraculous cures made by these individuals. Some
few years since I had a patient under my care suffering
severely from an attack of rheumatic gout. I do not think I
ever saw a Worse case; muscles, joints and nerves were all
involved. During convalescence the pain centred itself in one
knee, and whilst examining this joint my patient exclaimed,
“Leave it alone, pray; that is H——’s joint,” mentioning the
name of a well-known bone-setter. A few months after this
the patient walked into my consulting room with his head
fixed, so to speak, upon the shoulders; if he wanted to turn
the head he was obliged to rotate the spine. After a few
words he said, ‘‘I am going to H——-; he cured my knee,
and I mean him to have a go at my neck,” and it was really
some time before I could persuade him to allow me to break
down the adhesions of the atlo-axoid joint. Of course this
was readily effected by a quick and somewhat forcible bilateral
jerk; yet after it was done he expressed himself more sorry than
grateful that the joint-man had not been the operator. I need
scarcely tell you that my fee was very small indeed in com-
parison to that which he would willingly have paid in the
other direction; but there are ways, manners and means
which at times baffle our understanding and defeat all rules
of logic and sense.

Well, in the practice of massage you will meet with all
kinds of joints—painful without swelling, and swelling with
and without pain; joints with constant pain, joints with
intermittent pain, joints where pressure relieves the pain, and
those where pressure produces and intensifies the pain ; some-
times associated with heat, sometimes with cold. Remember,
if you please, that pain in a joint is more often relieved by
extension than by flexion, therefore before flexing a painful
joint grasp its proximal and distal ends firmly, draw, if Imay so
express it, the ends of the joint asunder, and then flex quickly
or slowly according to circumstances.

It may be better for me to give you now some general
246 MASSAGE IN JOINT AND BURSAL AFFECTIONS.

indications in reference to “joint massage” before I proceed
to inform you of the various conditions of joints which are
specially benefited by this mode of treatment. .

To massage a joint or to attempt any undue movement
during the acute stage of inflammation would be unwise and
improper, and if a joint is known to contain pus its liberation
is necessary before any manipulations are commenced. Rest
and extension are the true requirements for an acutely
inflamed joint. Rest prevents the rubbing of one inflamed
bone against another; and extension removes the injurious
pressure which the inflamed articular surfaces exert upon each
other from muscular contraction or weight. Before masséeing
a joint after acute inflammation it is necessary to have some
skilled surgical opinion. There is undoubtedly a stage after
the more acute symptoms have subsided when absolute rest is
positively harmful, for at this time the effused material if left
alone rapidly becomes organized, and a stiff joint is sure to
follow. It is at this period, or I may say at this juncture,
that carefully applied massage and well-directed passive
movements, not only frustrate organization, but bring about
absorption and the healthy restoration of tissue. I need
scarcely tell you that skill in these manipulations is absolutely
essential, and the most delicate handling and watchfulness are
called for. Slight elevation of the temperature indicates that
extreme caution and care are required, and as long as the
increased temperature persists the joint must be left alone.
If, however, the temperature rapidly subsides the processes of
massage may be resumed and followed up. It is not my
practice to leave the joint for two or three days between the
manipulations, for in this time organization may have pro-
duced very firm adhesions which, if broken down with any
degree of force, must result in elevation of temperature ;
therefore, if you please, take temperature as your guide for
massage operations. I have spoken to you of the necessary
association of muscles with joints, and if a joint be acutely
inflamed the surrounding tissues are also involved in the
inflammatory process. These are the first to undergo repair,
the tissues of the joint itself being last; therefore, the
structures around the joint will invariably bear being
manipulated a week or ten days before the joint itself, and in
my opinion these ex-articular pressings and kneadings
accelerate the reparative changes in the joint. We are led to
this conclusion upon physiological grounds. John Hilton says,
‘“‘ The same nerve trunks whose branches supply the groups of
muscles moving a joint, furnish also a distribution of nerves to
the skin over the insertion of the same muscles, and the
interior of the joint receives its nerves from the same source.
MASSAGE OF JOINTS. 247

This implies an accurate and consentaneous physiological
harmony in these various co-operating structures. Without
this normal consentaneous muscular and sensitive function
precision of action would be lost, and unnecessary exercise of
muscular force would be employed during the performance of
any of these functions.”

We have seen that rest and extension are absolutely
demanded for an acutely inflamed joint, but let us now con-
clude, once and for all, that the tissues around it will bear
massage manipulations some ten days or a fortnight prior to
operating in any way upon the joint itself. Of course I am
now alluding to one in which an acute inflammation is
subsiding, but not entirely subdued. In making these manipu-
lations about joints I always advise the use of equal parts of
castor oil and chloroform (to which I sometimes add the oleate
of mercury), it prevents the chance of jarring the structures,
and greater and firmer pressure (which is what we want) can
be exercised by the use of this lubricant, and thereby
unnecessary pain is avoided.

Now it isa question how much time should be spent over
these manipulations in this special stage of joint inflammation,
and I give you the following gradation: 1st, 2nd, and 3rd
operation, five minutes; 4th, 5th, and 6th operation, ten minutes ;
7th, 8th, 9th, 10th, 11th, and 12th operation, fifteen minutes;
subsequent operations (if all goes well) thirty minutes. After
twelve or eighteen operations, being guided by circumstances, you
may commence slight flexion; in all probability if you try more
you will find it impossible. Pray, do not try too much. You must
treat the joint much in the same way that you would commence
to feed a person after a continuous fast, or after hemorrhage
from the stomach. Very slight attempts at flexion every day
will do much more than at first sight appears either probable
or possible. In a little while, of course, the patient will be
called upon to make voluntary effort, and it is surprising how
rapidly after massage volitional efforts are brought into play,
and how great is the general improvement which speedily
follows. I advise you not to meddle with joints at night;
always take the morning for your manipulations. I happen to
have a case of chronic synovitis of the knee-joint in a patient
otherwise nervous, and she is in attendance in order that I may
demonstrate to you one or two points in reference to these
massage movements. LHEffleurage and tapotement are out of
the question altogether; petrissage movements alone are
necessary, not so much in the pinching form, what we want is
pressing and kneading; well directed pressure, evenly, firmly,
and gradually applied, must form the basis of our exercises.
My patient, now lying upon the couch, I place two pillows
248 MASSAGE IN JOINT AND BURSAL AFFECTIONS.

as you see at the back of the leg, and the knee is supported
by the addition of a third. Lubricating my hands well with
castor oil and chloroform, I place one firmly about six inches
above the knee and the other six inches below it (Fig. 36).

 

Fig. 36.

Making pressure, I advance my two hands, the one upwards,
the other downwards, until they are within three inches of each
other: I now suddenly remove my hands altogether. I repeat
these operations very slowly and deliberately a dozen times,
allowing an interval of about thirty seconds between them.
My thumbs now become the executive with my fingers, or alone.
For instance, you see I work my thumbs upwards on either
side of the patella, or I place my fingers above the swelling
and my thumbs below it, and very gradually, with as much
pressure as my patient can bear, I bring them towards each
other. When first operating upon a joint, two or three of
these movements only are required. As we gain ground and
the pain is lessened the movements are varied and localized
with rotatory pressure over special points where we find the
tissues to be thickened. We know by experience, to which I
have called your attention before, how pressure produces
absorption, even mechanical pressure. At one time I used to
strap joints to bring about this result; now I never think of
doing anything of the kind. There is no comparison between
mobile pressure by massage and that produced by mechanical
means: the former restores the absorptive power of lymphatics
and veins, and at the same time their normal function and
tonicity, so that the change brought about by massage is not
only more effective but it lis also permanent. With a little
more experience, more faith in the massage treatment must
result, and its general adoption will be ensured.

If I were inclined to rhapsody I should become so over the
wonderful effects of massage in joint affections even more
MOULLINS ON SPRAINS. 249

than in any other form of disease which I have brought under
your notice. I can only say that in some cases I have been
more than pleased, I have been fairly astonished at the results.
Time is a necessary agent: the tendency of massage is to cure
by the restoration of function in the part diseased, therefore
the change must of necessity be gradual, though on this
account it is all the more sure.

Sprains.—I must say a few words to you about sprains.
Mr. Mansell Moullins has written a little handy and practical
book about sprains, which ought to be read by those who are
interested in this subject. There is a saying, which is by no
means untrue, that ‘‘a bad sprain is worse than a broken
bone.” We can have degrees of sprains—slight and severe.
As a rule the inflammation resulting from a sprain is primary
to the weakness accompanied with pains which follow in
the joint for a long time after the injury has been sustained.
There are some sprains .which are best treated by massage
from the first, but if the injury be very severe, the part
extremely inflamed and highly painful, it is wise to let the
inflammatory stage pass by before massage is commenced.

Let me call your attention to a short paragraph in Mr.
Moullins’ little book at the commencement of chapter five,
because it should be of interest to you. It relates to imperfect
recovery from sprains, and reads as follows: ‘‘ One of the most
annoying things in connection with sprains is the frequency
with which they improve up to a certain point and then come
to an abrupt standstill. It is not merely that convalescence is
protracted, it is delayed so long that it becomes a question if
the joint is ever to recover. For the first few days, perhaps,
everything progresses as well as it possibly can. The patient
is wise enough to recognize the situation, and to reconcile
himself to the necessary confinement, though this (as only
those who have suffered themselves know) is very often far
from being an easy matter. The dread of inflammation passes
off, the swelling begins to diminish, the colour of the skin
changes from black and purple to green and yellow, the tender
points can be touched again and again, and a certain range
of movement is permitted once more, though in a tentative
and cautious manner. With moderate good fortune this
continues until, at the end of two or three weeks, the injury is
repaired and the joint as sound and as trustworthy as before.
Very often, however, it happens as time goes on that the
improvement becomes more and more slow, until perhaps it
comes toan end altogether, and the joint is left stiff, painful it
may be, and almost useless. The tissues seem to have been
repaired, but freedom of movement does not return.”

Let me add to these remarks of Mr. Moullin that the tissues
250 MASSAGE IN JOINT AND BURSAL AFFECTIONS.

do seem to, and apparently have been repaired, but this is not
actually the case: neither the capsule nor the ligaments of the
joint have regained their normal condition; their natural
tonicity still remains decidedly at fault, and their nutrition is
imperfect. So long as this is the case you may depend upon
it that the joint itself is also imperfectly nourished, and in all
probability slight adhesions exist in some parts, which are
not fully recognised. In all such cases massage must be
continued daily until the joint does become such as it was
previous to the injury. I never hesitate when I have these
conditions to deal with. Time and rest, and the ordinary
rubbing with liniments, only make matters worse. I place the
patient under chloroform, and I not only manipulate the joint
freely, but I put the structures by extension movement fully
upon the stretch in every direction. In some of these cases so
operated upon the pain ceases and the joint by these means
regains its function in a remarkably rapid manner. I cannot,
for my part, understand why it is that massage is not resorted
to more early in these joint cases; neither can I see why
injuries to joints in strong healthy people, free from blood
disease, should be boxed up until not only the joint itself
becomes stiff but the muscles also are affected by the same
cause: the enfeebled muscles are, of course, liable to contraction,
and spasmodic efforts and cramps are by no means uncommon.
I have spoken to you before of muscles enfeebled by disuse,
80 I shall deal with this matter now in a few words, though it
might be made a very long tale.

Admitting that joints have trophic centres in the cervical
and lumbar regions of the spinal cord, and that these centres
are controlled by a higher centre in the medulla oblongata,
which is very possible, but without proof, and that the trophic
nerves pass with the motor nerve fibres, it certainly seems
more than probable that the function of these nerves is
arrested so long as a mobile joint remains immovable. Let
me say again that the nutrition of a part is essentially bound
up with its function, and that the function of a joint is
movement; therefore I cannot bring myself to believe that
prolonged rest is essential to anything other than anchylosis,
and to the enfeeblement of intrinsic and extrinsic structures
of the joints and of the muscles in association therewith. If
the normal co-relationship or partnership between muscles
and joints is severed entirely or in part, one must go to the
wall, and the joint, being the least organized and the weaker
of the two, it invariably suffers first and most. It may be
the case that muscle wasting is primary and joint wasting
secondary, as we find in some cases of deuteropathic muscular
atrophy, but I should expect to find this from a physiological
CHARCOT’S JOINT DISEASE. 251

point of view. Charcot’s joint disease is perhaps one of
the most interesting of all forms of joint change, and from
the result of its discussion at the Clinical Society in the year
1885, it would seem that its pathology in reference to
causation has yet to be elucidated. It cannot be doubted,
however, that it is a condition of wasting without repair, as
pointed out by Mr. Baker. This is the rule, but even this has
its exceptions, as referred to by Sir James Paget in some
specimens shown by Mr. Barwell, though this does not
detract from or invalidate the rule. Irritation of trophic
centres by sympathy with changes in the posterior root zones
of the spinal cord, is most likely to lead to malnutrition of
those structures which have the lowest organization. Sir
James Paget was, in my humble opinion, quite right when he
said that, ‘“‘ Though rheumatic arthritis and the joint disease
of locomotor ataxy could be broadly distinguished from one
another, it was not fair to assume that there was in locomotor
ataxy no measure whatever of rheumatic arthritis. It might
well be a rheumatic arthritis modified by its coincidence with
a disease of the spinal marrow, which hindered the ordinary,
however ill-directed, processes of repair found in the ordinary
rheumatic arthritis. The general feature of the most marked
cases of locomotor ataxy was wasting, but all the cases of
partial wasting with some new production of bone about the
articular borders brought it so near to the characteristics of
some of the cases of rheumatic arthritis that one could not
doubt that there was a certain relation between the two.”

It is quite clear that more extended comparative observations
of joint changes and of other lowly organized structures in
locomotor ataxy are necessary before a final solution of the
question can be obtained. They cannot fairly be studied from
advanced and very demonstrative specimens, they must be
worked out from initial changes. If there is (and I believe
that in reference to causation there is) some relationship between
Charcot’s disease and rheumatic arthritis, then comes the
question to be answered, What is rheumatic arthritis? As all
that I have to say in reference to this subject must be very
brief, and what 1 do say is merely to draw your attention to
these conditions for a purpose, I will refer at once to a very
valuable paper on this subject by Dr. Archibald EK. Garrod,
read before the Medico-Chirurgical Society, in November,
1887, entitled ‘‘ A Contribution to the Theory of the Nervous
Origin of Rheumatoid Arthritis,” and the arguments which
he adduced were in support of the following propositions :
(1,) That the causes of rheumatoid arthritis are such as might
be expected to act upon the central nervous system; (2,) That
the distribution of the lesions is such as would be likely to
252 MASSAGE IN JOINT AND BURSAL AFFECTIONS.

result from nervous lesions ; (8,) That the distribution of the
lesions is similar to that of certain arthropathics of spinal
origin.

Dr. Garrod’s views were supported by so careful and
accurate an observer as Dr. Ord, who was of opinion that
nervous influence had a great deal to do in the causation
of this disease. He believed that nervous influence was
reflected from the uterine organs to the spinal cord and on to
the joints. He compared rheumatoid arthritis to progressive
muscular atrophy. In a case of chronic cervical pachy-
meningitis there was much muscular and cutaneous wasting,
and later on a remarkable degree of chronic osteo-arthritis
developed itself. In another case of spinal injury joint
trouble followed the muscular wasting after a long interval.
At one time of my life, when I had more leisure for studying
these cases, I was much interested in these conditions, but
that opportunity is gone, and I therefore draw from the
conclusions of others, which are as familiar to me as
household words.

I mentioned that I had a purpose in bringing these
conditions before you, and it is this, that treatment, to be of
any use at all, must be early and active. It is generally
admitted that the ordimary remedies are eminently un-
satisfactory and do very little to check or retard the onward
progress of the disease. I think it may be stated that the
hands and knees are more frequently affected than other
parts, but the hip is no uncommon seat of this affection.
In an excellent article on rheumatoid arthritis by Dr. Bruce,
in “Quain’s Dictionary of Medicine,” it is recommended to paint
the joints with very strong iodine liniment, and to rub them
with turpentine liniment. I must admit that I do not care
for either the one or the other, particularly the strong iodine
liniment. If local treatment is to be of any avail at all it is
our massage manipulations combined with passive move-
ments of the joints. I believe the effect of manipulations is
considerably increased by the use of castor oil, chloroform and
the oleate of mercury, at all events this is my experience.
Now in addition to massage locally I have great faith in its
application to the spine with the combined electric current,
and if I were asked what I considered to be the best
treatment for rheumatic arthritis, my answer would be, the
actual cautery to the spine, the combined electric current and
massage also to the spine, and local daily massage with joint
movements.

I must not omit to tell you that I have great confidence in
the massage bath for joints, and also the douching system
which is so well carried out at Bath.
BATH AND ITS WATERS. 258

Mr. W. H. Freeman, the surgeon to the Bath United
Hospital, has written an intensely interesting work entitled ‘‘ The
Thermal Baths of Bath, with the Aix Massage and Natural
Vapour Treatment.” Mr. Freeman did me the honour when
I was at Bath last summer to personally show me all the
bathing arrangements, and there is nothing in this country to
be compared with them. In a short time, when complete,
these baths will hold their own against any in Europe.
Applications of massage and electricity with spray and with
the hot water vapour are most thoroughly and efficiently carried
out by experienced hands from the continent. It does seem
strange that so handsome a city, with its famous Roman baths
and its most valuable mineral waters rising from the earth at
a temperature of 120° F'., which were once sought after by the
nobility of every country, should have sunk into disuse, and
almost into neglect; but now a healthy reaction has taken
place, and Bath will be itself again in a very short time.
There is no reason why it should not become a great health
resort. Nothing can surpass the new baths which have
been and are still being erected under the very able supervision
of Mr. Freeman.

The medical value of these waters, when taken internally
and applied externally, combined with massage and electricity,
is not as yet thoroughly known. There must bea great future
for these forms of treatment in this grand old city. Bath is
peculiarly adapted to the requirements of the gouty and the
rheumatic invalid. There is in this city a quiet serenity and
calmative influence, undisturbed by business turmoil and con-
fusion which are sometimes disastrous to the cure of chronic
invalidism ; and I know that the Town Council, under the able
guidance of Mr. Freeman, are determined to spare no expense
or leave a stone unturned to make the sojourn of all those who
seek the Bath cure in every way specially compatible with
their requirements. The water when recently drawn from the
springs is clear, colourless, and sparkling ; in large quantities it
presents a pale pea-green tint. It is free from any odour, and
possesses a pungent, slightly saline and somewhat chalybeate
taste, and though, perhaps, a little unpalatable at first, the
invalid with whom it agrees comes to relish it, and even to
desire it. Ifit were a little hotter it would be simply perfect.
No chalybeate water should be swallowed hastily, it should be
sipped down slowly, and for this reason I suggested to
Mr. Freeman, and in my opinion with good judgment, that it
should be diluted with plain hot water, so as to raise its
temperature to 180° or 185° F., and the patient should then
sip and swallow it gradually. These waters should be taken in
this way early in the morning when the stomach is empty.
254 MASSAGE IN JOINT AND BURSAL AFFECTIONS.

I have recommended several of my patients whom I have sent
to Bath to adopt this method, and they have invariably borne
testimony to the increased effects under such conditions.
From the analysis of the water of the Bath Thermal Springs,
one feels confident of their medicinal value. Fortunately,
they do not contain an excess of any mineral ingredient, but
they are rich in iron and alkaline salts, so essential to those
who suffer from the impoverished blood and defective assimi-
lation, to which so many of our joint troubles are really due.
Dr. Macpherson, the author of the ‘“‘Baths and Wells of
Europe, and the Lime Sulphated Waters,” bears the following
valuable testimony to the efficacy of the Bath Waters: ‘“‘ Many
complaints which were treated with great success in Bath
have been remitted to similar baths upon the continent.
Gradually, however, Bath has resumed its ancient repute.
The most popular class of water abroad is that of Contrexéville,
and this—although cold—presents a striking analogy in its
chemical constituents to those of Bath, including its gases,
especially the carbonic acid gas, and the same mildly exciting
and stimulating effect is ascribed to the prudent drinking of
both, and as the Contrexéville water is so celebrated in biliary
and urinary concretions, so in Bath the mineral waters were
formerly employed for the same diseases,” and he particularly
asks, ‘“‘ Why should they not be used again?”

Dr. Macpherson sums up by saying, ‘‘ What has been done
in Bath can be done again. The hotels in Bath are good;
lodgings in the fine squares, parades, and crescents are equal to
anything abroad; whilst many of the complaints sent to the
continent could be treated just as wellin Bath, where it is
commonly desirable for these cases to remain in England ; and,
moreover, the waters can be drunk and the baths used all the
year round.” I can bear testimony, and it is my object to
give testimony from personal knowledge and experience, to the
truth of these statements of Dr. Macpherson. There are
thousands of persons who can ill afford the expense, and to
whom the journey is simply disastrous, who put themselves to
great personal pain, discomfort, and inconvenience, to be
treated at certain continental Spas, when they could be far
better and even more successfully treated at Bath. On the
other hand, those invalids who seek change, travel and excite-
ment, and can get it to their heart’s content, in a truly royal
manner, at the fashionable European Spas,—are they the
better for it ?

After these rather discussive remarks about Bath, let me say a
few words about swellings of the Burse Mucose and Synovial
Bursa. You will remember that when speaking to you of the
anatomy of joints I called your attention to these structures. I
BURSAL SWELLINGS. 255

told you that they consisted of spaces in the connective tissue,
and that their walls were formed of this membrane covered by
epithelium ; that they contained a fluid in many respects analo-
gous to synovial fluid, the use of which was to prevent undue
friction when tendons glide over projecting bony surfaces ; they
form, in fact, simple or irregular cavities in the subcutaneous
areolar tissue. or my purpose it is enough if I class these
two forms of burse together. They exist in the neighbourhood
of, and sometimes communicate with the cavities of joints,
notably on the inner and lower part of the thigh, between the
integument and front of the patella, over the olecranon
malleoli, and other prominent parts. They are in direct com-
munication with the lymphatics, and inflammatory products
are absorbed from them with great readiness. These burse
may be acutely inflamed, and extend to suppuration, as in
housemaid’s knee. But I am desirous to call your attention
to what is usually designated Dropsy of the Burse, frequently
of rheumatic or gouty origin. It usually consists of an
accumulation of serous fluid which distends its walls and gives
rise to considerable swelling. There may be both pain and
tenderness, but this is exceptional. Yet, if these collections of
fluid are permitted to remain without treatment, the result is
that the walls become thickened, and then they are very
difficult of cure, and sometimes, even when cured, they are
liable to recur. As far as my experience goes, these swellings
are less simple than they appear, and they do not readily yield
to the counter-irritant treatment which is usually adopted. I
allude to painting them with tincture of iodine, the application
of blisters, setons, incision, drainage tubes, &c.

In my teachings to you relative to the effects of massage
and electricity, I do not think that the greatest sceptic can
accuse me of relegating to these modes of treatment a potency
which I have not proved by experience and practice that they
undoubtedly and unquestionably possess, and when I look
back through the past at those cases in the treatment of which
I have been unsuccessful, my only regret is that I was not at
one time so conversant and familiar with these modes of
treating disease as I have been during the later years of my
professional life. If I told you that heterogeneous solid
growths were to be dispersed by massage I should rightly and
justly conclude that everything which I have said or shall
have in the future to say relative to the potential value of
massage would be treated with doubt, scepticism, and in-
credulity ; but I have substantiated, and can give evidence
and make good every and all claims which I have ever
put forward in reference to this most valuable mode of
treatment.
256 MASSAGE IN JOINT AND BURSAL AFFECTIONS.

In bursal swellings, mucosal or synovial, massage is the
remedy. The more recent they are the more rapidly do they
yield. I have under my care at the present time a gentleman,
naturally gouty, who suffers from these swellings at the lower
and inner part of the thighs communicating with the knee
joints. The latter are very little enlarged, but the swellings
have extended to huge dimensions. They are slightly painful
upon pressure, but he wakes every morning on account of
the dull, aching, wearying, and, as he calls it, sickening pain
which they cause him; no doubt this pain is due to the
tension and pressure exerted upon surrounding structures.
This is the third time that he has suffered from them, and in
each case they have been associated with gouty and dyspeptic
symptoms, but they have readily yielded to careful and well
directed massage manipulations. In other, but similar con-
ditions, my masseurs have met with the same success. I can
only maintain that these results are extremely gratifying, and
such proofs cannot be conscientiously ignored or set aside.
Some surgeons have said to me, “ It’s all very well, but any
treatment will cure certain cases, or no treatment at all. T’ll
give you a case, and see where your massage will be.” I am
quite open to receive such cases and put them to the test, but
I will first exercise my judgment upon them and base my
verdict as to the result according to their nature.

Stiff Joints—Rheumatic and Gouty Joints—Joints become
stiff from disuse, from acute inflammation, or from sub-acute
and chronic inflammation. The most common form of stiff
joint is from disuse, with co-existent disuse of muscles. Take
a case of Collis’ fracture; it is common after a month’s
incarceration of the forearm and hand to find the wrist and
finger joints almost immovable. Here we have stiffness from
mere restraint of function, and it may be three weeks or three
months before normal mobility is restored; the muscles
and joints have to re-adapt themselves to their lost harmonious
co-relationship. Again, we will take a case of suppurative in-
flammation of the knee-joint. During the acute stage and
that of suppuration rest is not only essential but compulsory,
the acute pain of the joint, independently of the will of the
patient, inhibits the sub-conscious automatic functional
activity both of joints and muscles, and it is of little con-
sequence whether the limb is restrained or not, movement is
arrested, unless it be of a spasmodic or jerky character; ex-
tension of the foot and counter-extension at the hip are alone
required. If my knowledge of these conditions is of any value,
let me advise you never to incarcerate either muscles or
joints. Give your muscles liberty of action, as far as it is
reasonable and compatible with physiological rest, and in the
MASSAGE IN RHEUMATISM AND GOUT. 257

case of joints, let your great consideration be restoration of
function. I may be wrong, nevertheless it is my opinion, that
too great conservative action on the part of the surgeon in
reference to joints, is unsound in principle, and opposed to all
laws of physiology and common sense. It has established
impostors, charlatans, and quacks, when such as those could
never have existed if massage and mechano-therapy had not
been considered a violation of the system of so-called scientific
canonization. We know quite well that massage will not
break down adhesions, but we do not as yet know, and we have
no laws to guide us, when an attempt should be or should not
be made to break them down in a very large number of cases.
But the consideration of this subject in its entirety is not
within the scope of my lecture, although I could say very much
about it.

Now massage in all rheumatic and gouty affections is of the
utmost value, whether they be of muscles or of joints; and if
it be adopted, as it should be, at an early stage, much misery
and pain will be averted, and many a useless limb will be
made whole and sound.

17
Lecrure XII.

MASSAGE IN SLEEPLESSNESS, PAIN, DIPSOMANIA,
MORPHIOMANIA, AND MELANCHOLIA.

The value of Massage in these troublesome conditions, rousing dormant
faculties, preventing and subduing unnatural habits, restoring tone, strength
and failure of resisting power—Carpenter on Mental Physiology—Its moral
nature—The normal Relationship of Mind and Body—Hereditary transmission
of acquired habits—A sub-conscious state apart from the Moral, Mental,
and Psychical states—Bain on Mind and Body—Sleeplessness—Causes of
sleeplessness—Result of sleeplessness—Influence of Massage in producing
sleep—The attributes of the Masseur, and some conditions relating to the
patient—Massage manipulations of the head detailed—Pain a common
sensation—Ideal pain—Pains of Locomotor Ataxy treated by Massage and
Galvanism—Ferrier on pleasure and pain—Meynert on pain and feeling—
Dipsomania—Morphiomania—Melancholia.

To-pay I have to speak to you upon subjects relating to the
known as well as to the unknown subjects which are within the
comprehension of man up to a given standard, but over this
point it is beyond the human mind to do more than theorize,
and at the best our conclusions are: vague, uncertain, and
obscure. I allude to the inner consciousness of man. Dr.
Carpenter, in his work on ‘‘ Mental Physiology,” says, “To
whatever extent we may be ready to admit the dependence of
our mental operations upon the organization and functional
activity of our nervous system, we must also admit that there
is something beyond and above all this, to which, in the fully
developed, self-regulated intellect that activity is subordinated,
whilst in rudely trampling on the noblest conceptions of our
moral nature as mere delusions, the purely materialistic
hypothesis is so thoroughly repugnant to the intuitive con-
victions of mankind in general, that those who really
experience these are made to feel its fallacy with a certainty
that renders logical proof unnecessary.”

Unquestionably the normal relationship of mind and body is
co-existent with a self-determining power which adapts itself to
its specialized environment, and which can rise above all the
prompting of suggestion, mould itself to external circumstances,
to its requirements, and to that which is best and noblest and
purest in life. Is this correlative integrity of mind and body the
habitual and fundamental part of human nature? For myself,
I can scarcely realize it, and it must be admitted that the
material world outside ourselves must govern and act recipro-
cally with a self-determining power within ourselves ; though
the faculty of appreciation and perception and reasoning must
ON HABIT. 259

be in direct relationship with the integrity of our physical
organization. Retinal defects will lead to a perversion of colour
perception ; we derive our notion of solid form by a process of
mental construction which may be materially altered by some
visual defect.

All the phenomena which evidence the influence of the
body on the mind, of physical upon psychical states, demon-
strate in a marked manner how the metaphysical part of
our nature must be influenced by the physical. The
normal activity of the mind is dependent upon the due supply
of healthy pabulum to nourish the brain, and defects in
mental processes can frequently be traced to poisonous
material received from without, and generated within our-
selves, having marked effect upon our volitional control and
ideation. Hereditary transmission of acquired habits which
have modified the bodily constitution of the parent repeat
themselves in the offspring, but this reproduction of the
parental model may be attended with considerable variation.
This is not only delineated in character and temperament,
vices and virtues, but also, as Sir James Paget has pointed out,
“the formative power is often exercised, not only in maintain-.
ing the original type, but also in keeping up some acquired
peculiarity, as for example, in the perpetuation of the scar left
after the healing of a wound.”

The physiology of habit is intimately associated with our
being, and becomes part of our being, and may be counted
among the psychical principles of association. Unfortunately,
in bad as well as in good habits, the sequence of mental action
which has been frequently repeated tends to perpetuate itself, so
that we find ourselves automatically prompted to think, feel or
do what we have been before accustomed to think, feed or do under’
like circumstances, without any consciously formed purpose or
anticipation of results. Habit must be an inductive process
generated within ourselves, and by ourselves, but not necessarily
of ourselves; yet how often is it superior to ourselves, even in
spite of intense volitional effort to counteract it. ‘The dipso-
maniac can verify the truth of this statement. There is a subcon-
scious state in our existence (apart from the moral, mental, or
psychical), distinct altogether from what we know as our
conscious ego, and which we may term our unconscious ego ;
it is in direct continuity and relationship with our organic or
inner life, just as our conscious ego is in direct relationship
with our volitional or outer life. Both are alike acted upon
and impressed by surrounding media, but there is this difference,
that in the former we are only made aware of its existence by
effects, the impress is to us unknown, whilst in the latter the
impress is recognized and becomes converted into a conscious
260 MASSAGE IN SLEEPLESSNESS, PAIN, DIPSOMANIA, ETC.

volitional experience. And again, the former may produce
physical or psychical disturbance, or both, just in the same way
as the latter. It is quite possible that some may call this.
disease: I have no objection to this, but it must receive’ due
recognition if we are to comprehend, only in part, many of the
obscure phenomena, of undefined nervous states, of which there.
are not a few.

I will now quote to you a passage from Prof. Bain’s.
work on ‘“‘Mind and Body”; I shall then place you in a
position to follow some of my simple ideas concerning the
conditions we are about to discuss. ‘‘We have every reason for
believing that there is in company with all our mental pro-
cesses an unbroken material succession. From the ingress of
a sensation to the outgoing responses in action the mental
succession is not for an instant dissevered from a physical
succession. A new prospect bursts upon the view; there is a
mental result of sensation, emotion, thought, terminating in
outward display of speech or gesture. Parallel to this mental
series is the physical series of facts, the successive agitation of
the physical organs. . . . While we go the round of the
mental circle of sensation, emotion, and thought, there is an
unbroken physical circle of effects. It would be incompatible
with everything we know of cerebral action to suppose that
the physical chain ends abruptly in a physical void occupied
by an immaterial substance, which immaterial substance, after
working alone, imparts its results to the other edge of the
physical break, and determines the active response—two
shores of the material with an intervening ocean of the
immaterial. There is, in fact, no rupture of nervous con-
tinuity. The only tenable supposition is that mental and
physical proceed together as undivided twins. When, therefore,
we speak of a mental cause, a mental agency, we have always
a two-sided cause, the effect produced is not the effect of mind
alone, but of mind in company with body.”

Sleeplessness may be truly defined as an infirmity. It grows
surely and unconsciously by habit ; it becomes aggravated and
increased by continuance; it is the precursor of the most
gerious consequences; it is invariably associated with an
irritable, excitable, overtaxed condition of the brain ; it denotes
a laxity of the cerebral vessels, and a sluggishness of the
cerebral circulation; it is an unnatural and abnormal per-
version of one of the grandest of nature’s laws. Rest of mind
and body by sleep, untrammelled sleep, is essential to the due
performance of both mental and bodily labour, and to the
physical and mental well-being of man. The chief cause of
sleeplessness is an irritable state of the brain and its vascular
supply. The sleepless brain is almost invariably an over-taxed.
SLEEPLESSNESS. 261

brain: a brain may be unconsciously as well as consciously
over-taxed. It is a question how far nutritional changes take
place in the brain during sleep. There can be little doubt that
in sleep potential energy accumulates, and the freshness and
vigour of body, the clearness, brightness, and activity of
intellect after a good night’s rest are indicative of power and
capacity for work which did not exist previously. In health,
fatigue and sleep go hand in hand, but even in health one
finds sometimes that over-fatigue from too great muscular
exercise tends to an irritable state of the brain and sleepless-
ness, and this is usually attended with some amount of mental
excitement. There are degrees of sleeplessness: sleep pure
and unadulterated is free from dreams and bodily irritability.
Some people apparently sleep all night, but the brain is in
a state of fitful wakefulness, and this is perhaps more harmful
than no sleep; others, again, will go to bed feeling thoroughly
tired, wearied, and exhausted, but in the course of two or three
hours awake, and, do what they will, sleep does not return :
this is the most common form of sleeplessness. Sleep begets
sleep, and wakefulness begets wakefulness. Ordinary profound
sleep indicates a suspension of sensorial activity, but the spinal
cord in relation with the sympathetic system of nerves, and
their ganglionic reflex communications are ever in a state of
responsive and unwearying normal excitation. All reflex
movements necessary to the maintenance of organic life can be
excited by appropriate stimuli, and even ordinary volitional
movements can be stimulated into reflex action without the
conscious ego being aroused. Dr. Carpenter gives the following
amusing and, to us, instructive story in relation to this. “ It is
said that the Dacoits, or professional thieves of India, have been
known to steal a mattress from beneath a sleeper by taking
advantage of this tendency. They begin with intensifying his
sleep by gently fanning his face, and then, when they judge
him to be in a state of profound insensibility, they gently
tickle whatever part of his body may lie most conveniently for
that purpose. The sleeper, withdrawing himself from this
irritation towards the edge of the mattress, the thief again
fans his face for a while and repeats the tickling, which causes
a further movement, and at last the sleeper edges himself
off the mattress with which the thief makes away.”

It is interesting to note the requirements of different indi-
viduals with regard to sleep: some people seem to require
a great deal, others can do with a very little. Iam quite sure
that too much bed, if not too much sleep, is prejudicial, though
a certain amount is absolutely necessary.

The brain itself, no doubt, is essentially at fault in some
forms of sleeplessness, the causes being chiefly worry, anxiety,
262 MASSAGE IN SLEEPLESSNESS, PAIN, DIPSOMANIA, ETC.

trouble, over-work and mental distress. But these causes in
time’ pass away and still the sleeplessness continues: the
brain has got into the habit of wakefulness, and the nervous
system is irritable in consequence. Sleeplessness for a time
may be attended with an increase of brain power due to a
sthenic condition of its circulation, but the break-down, when.
it comes, is in some cases simply disastrous, and partial or
total failure of the intellectual and reasoning power may be
the result.

There are people who can will themselves to sleep. This
power has been ascribed to great generals, such as Wellington
and Napoleon. Others, again, are said to have the power to
will themselves not to sleep. For my own part, I scarcely
know which is the more difficult, but this I do know,
that it is a comparatively easy matter to get a patient to sleep
by massage manipulations, in fact much more easy than to
keep a patient awake who is dead beat.

It is astonishing what slight influences will often bring about
or retard sleep. Every one knows the influence of habit, not
only in regard to time, but also as to place and circumstances,
in predisposing to sleep. It is related of the Abbé Faria who
acquired notoriety through his power of inducing somnambu-
lism, that he was accustomed merely to place his patient in an
arm chair, and then, after telling him to shut his eyes and
collect himself, to pronounce in a strong voice and imperative
tone the word ‘‘dormez,” which was usually successful. Dr.
Carpenter states, ‘‘ It is one of the most curious phenomena of
the ‘biological’ state, that in many subjects, at least, sleep may
be induced in a minute or less, by the positive assurance with
which the mind of the individual becomes possessed that it
will and must supervene.” I hada curious but not uncommon
instance of this in a patient only a fortnight ago. He was
complaining sadly of want of sleep. After the night’s massage
he went to sleep comfortably for two or three hours, but then
awoke, and remained awake for some hours. Although he
tried and tried to go to sleep, his own will and determina-
tion were of no avail. He would not take opium, chloral, or
beladonna; he had taken bromide of potass in large doses,
but it had no effect. I prescribed for him a draught of
which he agreed not to know the composition : it contained
only ten grains of bromide and a little alkali, but I assured
him it would give him sleep, and my only fear was that he
would sleep too much. This gentleman, after being massaged,
took his draught and slept with only one slight intermission
for fourteen hours. His fire was lighted as usual at seven
o’clock in the morning without in any way disturbing his
slumbers, and at eleven o’clock when his masseur waited upon
NERVOUS SLEEPLESSNESS. 268

him he had to leave, because his patient was still sleeping
soundly. I might say I had the entire confidence of my
patient, and when I told him in a very decided way that he
could not fail to sleep, I have every reason to think that he
thoroughly believed me.

The psychology of sleep is a deeply interesting study, but it
leads us into a vast field of thought about which there is so
much that is ambiguous, delusive and hypothetical, that I
think we had better leave it alone; at all events, it is not
within my present range of thought or diction.

The question, however, which concerns us, is this: Have we
in massage an agent which, as a rule, will so far act upon and
suspend or inhibit sensorial activity in our patients as to
induce sleep? And if so, to what part of the body are our
manipulations to be applied? And in what are those manipu-
lations to consist? Ido not think that any person to whom
massage has been administered can for a moment doubt its
soothing and calmative influence. This should be the first
effect of our efforts, we cannot hope to induce sleep if we are
unable to tranquillize, calm, and soothe. It sometimes hap-
pens that our manipulations produce irritability rather than
composure, but this is not usually the case. I am willing to
admit that many otherwise excellent masseurs are quite
unfitted for this task; it requires and demands a special organi-
zation, a lightness of touch, a sense of confidence, and an
assurance of results, which all do not possess. The character
of the masseur must be imbued with motive, induction,
persuasion, solicitation, encouragement and inspiration; the
power of control, restraint, and authority must be so exercised
with purposiveness and intenseness that the patient is
made aware of his influence and yields himself to his treat-
ment with a spirit of obedience, subjection, and unswerving
trust.

You will not unfrequently find that patients suffering from
nervous sleeplessness, which is the most common form, will have
their novels by their bedside, their heating apparatus at hand
for warming beef tea, their dressing gown and their slippers
placed conveniently for them to get up and walk about, and
everything in fact arranged by their anxious friends to while
away the dreary hours of night. All these must be removed.
Ascertain exactly the precise position in which the patient lies;
see that the feet are to the south and the head to the north;
and under any circumstances have the bed freshly made, and
the pillows arranged quite in accordance with the patient’s
desires. Ensure the offices of nature being duly performed,
and place a hot water bottle at the foot of the bed, extinguish
all gas lights, and have one candle only burning, and if the
264 MASSAGE IN SLEEPLESSNESS, PAIN, DIPSOMANIA, ETC.

fire is blazing damp it down. Now make sure that your
patient’s feet and legs are warm and, if necessary, let the lower
half of the bed-clothes consist of flannel (nine-tenths of the
sleeplessness is created, maintained and supported by defective
circulation in the lower limbs); at all events, do not think that
you are going to compose your patient into sleep until you
have made the legs warm below the knees. If need be, they
must be well massaged, but you know I recommend, as a, rule,
the lower extremities, buttocks and abdomen, to be manipulated
in the morning, and the upper extremities, spine, head, and neck,
at night. But please to remember there are no rules without
exceptions, and that I am now telling you what, in my experi-
ence, I have found best to do for nervous sleeplessness. Well,
having thus far completed your arrangements, turn your
patient over towards the side and manipulate the spine by
effleurage movements for about five- minutes, then take the
arms and serve them in the same way; if the patient moves
hurriedly, check her or him at once. Hnjoin absolute silence.
Then you should make the patient take one dozen slow, pro-
longed inspirations with the mouth closed, and let the arms
lie loosely upon the fore part of the body; and now, after having
arranged the bedclothes with due consideration, you commence
to massage the head, the forehead, the eyes, and behind
the ears.

I called your attention to these manipulations in my
second lecture, but I will briefly allude to them again, particu-
larly in reference to the induction of sleep. Pass your extended
fingers over the forehead upwards and through the hair (making
the patient close the eyes and keep them closed) lightly, softly,
but effectively: repeat these movements twenty, thirty, or forty
times, according to the circumstances of the case; you can never
hope to be successful unless you acquire the habit of thinking
and judging for yourselves. Now place your thumbs upon the
nasal eminence, and carry each respectively upwards and out-
wards over the frontal eminences, say twenty times. These
movements should be performed with a slight degree of pressure,
but very slowly and deliberately; now carry your thumbs,
commencing from the nasal eminence, along the superciliary
ridges above the eyebrows to the external angular processes of
the frontal bone; after this, place the thumbs just above the
internal angular processes, and with very light, very slow
movements pass over the eyes to the external angular processes ;
next carry your thumbs from the internal angular process
downwards and outwards over the cheek beneath the malar
bone; last, but by no means least, place your fingers behind
the ears, over the superior portion of the mastoid process of
the temporal bone, and draw them lightly over this process, to
PAIN. 265

the angle of the jaws around their rami to the mental
eminence.

I have given you as good a description as I can well do, and

. now, if you will watch me carefully, I will go through these
movements upon this patient so that you may not only
see and judge for yourselves, but practice with a deter-
mination and will to learn. At all events, I shall expect
you to acquit yourselves creditably when I come to test your
capability. You know I cannot make you massage, I can
only direct and show you how these manipulations are best
performed.

I need scarcely tell you that massage for sleeplessness should
be carried out at night, the later Gn reason) the better. I
know of no other application of massage so interesting in its
results as this. Many times have I left patients in the sweetest
of profound slumbers, after carrying out the manipulations
which I have just briefly portrayed. I hope that I have made
this form of massage quite clear to you, as I have endeavoured
to givea somewhat detailed account, not only of the manipula-
tions themselves, but of other points of importance relative to
certain adjuncts, which, trifling as they appear, are nevertheless
of consequence. Upon another occasion I will give you some
curious particulars of cases of sleeplessness which have come
under my care, and which have been treated by massage. But
I must now pass on to the consideration of massage for the
relief of pain.

Pain.—With reference to pain, let me first tell you, by way
of repetition, that the first duty of the masseur is to relieve it
and never to inflict it unnecessarily. What is pain? We must
endeavour to know something about it, and we shall then be
ina better position to cureit. I have told you that the nervous
system of man is made up of specialized material having
correlative functions, forms of foree—sentient, motor, ideational,
of which mind is the evolutional outcome. As pain is a com-
mon sensation, we know that it is associated with the sensory
and sentient part of our being. If the sentient channels are
‘destroyed by inhibition or disease, the sensorium is incapable
of receiving by impression that (whatever it may be) which
gives rise to the sense of either pain or pleasure. A blind man
cannot appreciate in the ordinary way and derive pleasure
from an Alpine sunset, but it may be graphically described to
him, and the ideal impress which is thus conveyed to his brain
elicits an unquestionable acknowledgment of the sense of
pleasure. Neither can he witness some tragic occurrence, but
this, in like manner, may be made known to him, and it also
excites the sense of most painful anguish. Therefore from
this reasoning I think we may fairly conclude that both
266 MASSAGE IN SLEEPLESSNESS, PAIN, DIPSOMANIA, ETC.

pleasure and pain have an ideal side: we know they have a
moral aspect.

Aman known to suffer from an attack of asthma, when a
cat was in the room where he was sitting, upon hearing some- .
body remark that a cat had come in (when such was not the
case) was seized with a paroxysm, and nothing could persuade
him that no such animal had been there. This was the result
of ideation.

I merely draw your attention to this to show you that there
is an ideal side to sensory impressions. It is far too long a
story to go into carefully, therefore ideal, or, if you will,
imaginative pain is frequently as real to the patient as though
some excitation to a sensory nerve actually existed. When
the excitability of the nerves which administer to painful
impressions is increased, a slight touch of the skin or a breath
of cold air may excite the most violent pain. We all know
how pain is connected with inflammation, and even defects of
nutrition. The intensity of pain depends upon the excitability
of the sensory nerves, the larger the number of fibres affected
the more severe the pain. Pain is rarely continuous for any
great length of time, it has, particularly in some forms of
neuralgia, its periods of exacerbation and diminution. You
know how in some forms of neuralgia, particularly of the eye
and the brow, it will come on daily almost to a minute, take a
definite time to reach its pitch of intensity, and then decline,
so that its periods in reference to time can be easily calculated.
The pains sometimes associated with posterior spinal sclerosis
are very peculiar and very erratic; they come as quick as
lightning, and disappear in the same rapid manner, and when
the pain is at its height, it may be suddenly forgotten by some-
thing attracting the attention of the patient.

The pains of locomotor ataxy are worth considering, es-
pecially in reference to treatment by massage and galvanism,
for the reason that they are scarcely influenced by drugs or
ordinary external remedies. They may occur in any part of the
body, but their most frequent seat is in the legs. They rarely
correspond to the trunk of a nerve, but are usually located.
within a limited area, particularly of the skin, although they
may extend to the deeper parts. They are often described as.
lancinating, stabbing, burning, tearing and gnawing, and it is.
their nature to come on quite suddenly. They may last for
three or four days. These pains, however, are not always of
such an acute character: they may be dull, aching, and
diffuse, resembling the pains of rheumatism, for which they
are sometimes mistaken, and like the pains known as rheu-
matic, they may be influenced by change in atmospheric
conditions. I am bound to admit that I have tried almost
PAIN AND SENSATION. 267

every drug for the relief of these pains, both externally and
internally, without any appreciable advantage ; but for the past.
three years I have, both in hospital and private practice,
obtained great relief, and in some cases a cure for them by
massage and the continuous galvanic current. In more than
one case I remember to have removed them by charging the
patient with static electricity and making the point of discharge:
immediately over the painful part; but now my common
practice, and one which I invariably adopt with decidedly
satisfactory results, is to attach to the spine a long sponge
electrode (anode) and make a strong hot salt water foot-bath
(kathode), alternating the current about once in three
minutes. The greatest strength of current which I ever
employ does not exceed ten milliampéres in strength. I
have tried the combined current in this way, but, from
my experience, the voltaic current alone is much more
beneficial.

To revert to the nature of pain, we may say that it is a message
of suffering sent from an injured part through a chain of nerve
elements, as a message of word symbols is transmitted by a
telegraph wire. The purpose of pain may be looked upon as
protective. The sensation is the warning sign of injury, and
cries for relief, not simply for the avoidance of suffering, but
for the remedy of a state or condition which threatens the in-
tegrity of the tissue or organ in distress. It is in this light
that pain should be regarded. It may be heroic to bear
necessary pain, but to turn a deaf ear to its warning cry is to-
commit an act of folly. Meynert says, “‘ Pain is classified with
the feelings, but it is distinguished from sensory perceptions by
its widespread irradiation which interferes with localization.
Feelings without physical pain are termed emotions. Emotion
being expressive of psychical pain.” I think Ferrier puts this.
very clearly in his work on “ The functions of the brain.”
“« Sensations are accompanied in consciousness by feelings which
are divisible into two great classes—Pains and Pleasures. Just
as sensations are the subjective side of certain physical modifi-
cations of the nerves and nerve centres, so pleasurable or painful.
sensations may be regarded as the subjective expression of phy-
sical harmony or disharmony between the organism and the
influences acting upon it. A painful sensation is a physiological.
discord incompatible with health or comfort, a pleasurable
sensation is a physiological harmony promoting health and
comfort.” Bain expresses this fact as the law of self-
conservation: ‘States of pleasure are connected with an
increase, states of pain are connected with an abatement of
some or all of the vital functions. We know that abstraction
from existing pain lessens its quality and its intensity as.
268 MASSAGE IN SLEEPLESSNESS, PAIN, DIPSOMANIA, ETC.

evidenced in great writers and great lecturers.” It is said of
Sir Walter Scott when writing the Bride of Lammermoor, that
although the subject at this time of severe pain he was often
relieved of it by intensity of mental ideation.

Having made ourselves somewhat conversant with the nature
-of pain, and knowing that pain is the result of some physical
disruptive influence acting upon the sensory and sensorial side
of our being, and also knowing that according to the perception
of an impression, and the manner in which the impress is re-
ceived by the sensorium, we have pains varying in distribution,
character, and intensity, let us consider very briefly the different
kinds of massage which we find most useful for different kinds
of pain. Broadly speaking, we have defined effleurage move-
ments as being specially applicable to the head and body
surface; petrissage movements to the deep-seated muscles of
the extremities; tapotement movements to the back, loins,
buttocks, and masses of muscle wherever situated. By way of
-demonstration let us take a painful and irritable ovary. The
patient dreads having the parts touched on account of the pain
which the pressure exercises, or seems to her to exercise, and
do what you will, unless you are very clever, you cannot convince
her to the contrary. Let your manipulations in a case of this
-sort be of the most gentle and soothing kind, very superficial,
and rather away from the tender spot: after a short time you
will find that you have got over one stage of the difficulty,
and then your manipulations can be gradually made as deep
as you please.: In the pain of lumbago, if you wish your
massage manipulations to be curative, you must work deeply
into the muscles by both petrissage and tapotement. The
coarser the texture of the structure to be massaged, the coarser
the form of massage manipulation is required. For the relief
-of pain we have to consider at least two very important points,
whether we attack it locally, or whether we destroy the per-
ceptive nature of the sensorium upon which the impress is
made. If we put a patient to sleep by opium he is oblivious
to pain: the pain is still there, but he feels it not: after the
patient awakes, the sensibility of the sensorium returns and
the pain is again perceived. ‘Therefore, as we know that pain
must be of the head as well as of the part where it originates
-or is located, no matter to what part it is referred, we recom-
mend the painful part to be massaged, and the head as well. ; If
pain will keep (as it so frequently does) a patient from sleeping,
it is sometimes more necessary to procure sleep to relieve pain
than it is to relieve pain to procure sleep. If the pain be due
to some internal disease, to which local massage cannot be well
applied, masséeing the head will frequently soothe, comfort
and relieve pain, although it does not produce actual sleep.
DIPSOMANIA. 269°

You will not unfrequently find that the more severe and rapid
the manipulations the greater relief to pain they afford; the
sensibility of the part undergoes momentary excitability and
then sinks into a state of analgesia. The spine is more fre-
quently the seat of hysterical pain than the knee or hip-joint..
If you have a case of painful spine of hysterical origin to.
treat, you must work at it lightly at first, then you may
gradually increase your pressure. In all parts the seat of
acute pain, if you cannot reconcile the patient to submit to-
treatment, use an application of hot vinegar and water, or hot.
water alone, by means of a sponge; it must be kept to the part
for three or four minutes, and then re-applied,if necessary, until
the acute sense of pain is diminished, when any form of
manipulation can usually be tolerated. Strain, stress and
pressure are frequent causes of local pain, and strain, stress.
and pressure by massage are necessary to counteract these
conditions. I have already, I think, drawn your attention
to the various applications of massage to every part
of the body for the relief of pain and otherwise, and you know
I am always very glad to make clear to you any point with
which you do not feel thoroughly conversant, but massage in
all forms of pain is of great interest from the mental as well as
from the physical aspect.

I believe, but as yet I have failed to get much information
upon the subject, that in dipsomania and morphiomania.
massage should be of very great value. Thanks to men like
B. W. Richardson, Norman Kew and others, we know more of the
essential nature of dipsomania and morphiomania than we at
one time did, but these and other forms of so-called mania give
evidence of an associated weakness of the physical and moral
side of human nature which can be neither weighed nor
measured, nor even located in the cerebral substance. The
causes of mania must be evolved in the study of psychology,
and the underlying nature of psychology can only be evolved by
a careful analysis of clinical phenomena from which are to be
gathered the fundamental facts upon which these phenomena
are based. Morbid symptoms are not recognized by their
scientific substratum, but in studying this substratum we are
actuated by the desire to fathom the phenomena of disease.
Manias must be looked upon as psychical functional disease ;
by this we mean a deficiency in the normal development or
arrangement, hereditary or acquired, of the normal attributes
of the psychical side of man’s nature. Crichton Browne,
writing on mania in “ Brain,” advocates ‘the more minute.
study of the symptoms of mania with a view to determining
with more or less precision the position of the brain lesions
upon which mental disease depends.’ This, however, is &
‘270 MASSAGE IN SLEEPLESSNESS, PAIN, DIPSOMANIA, ETC.

pathological problem for future enquiry and research. We
know a great deal, and our knowledge of the effects of alcohol
upon the nervous system and of the tissues in general, is
gradually being developed, still it is a question as to how far
alcohol is really the cause of much tissue degenerative change
which is attributed to it. Sir James Paget has stated that it
is a point for serious consideration whether the alcohol is
more to blame than the deleterious material with which both
wines and spirits are adulterated, and Dr. Dickinson, in the
<liscussion upon tissue changes due to alcohol, now going on
at the Pathological Society, stated that we have to consider
whether some of the effects of alcohol are not really regenera-
tive as well as destructive.

I have long maintained that in destructive changes of the
spinal cord alcohol not only retards degenerative changes in
the nervous tissue, but aids very greatly in the building up of
‘compensatory material. The moral effgcts of dipsomania are
so well known and so deplorable that I need not allude to them.
There can be no question of doubt that if aleohol were banished
from the face of the earth we should be a far happier and
more powerful race. It is one, but only one of the many
scourges afflicting mankind. The term inebriety is unsatis-
factory, dipsomania is comprehensive. Any human being who
loses self-control (it does not matter from what cause) becomes
the creature of impulse, loses stability and resisting power, is
incapable of reason and human judgment, and, whilst this is
the case, such person is in every sense of the word an irrespon-
sible and maniacal entity. Dr. W. A. F. Browne, when the
first Medical Lunacy Commissioner for Scotland, stated, ‘The
drunkard not only injures and enfeebles his own nervous
system, but entails mental disease upon his family. His
daughters are nervous and hysterical, his sons are weak, way-
ward, and eccentric, and sink under the pressure of excitement
of some unforeseen exigency or the ordinary calls of duty.”
The experience of those who, like Hartley Coleridge, have
inherited the craving for alcoholic excitement, together with
the weakness of will which makes them powerless to resist it,
whilst all their better nature prompts the struggle, must satisfy
anyone who carefully weighs it, how closely connected their
psychical state is with the physical constitution which they
inherit, and how small is their own moral responsibility for
errors which are mainly attributable to the faults of their
progenitors. Dr. Carpenter, in his work on ‘‘ Mental Physi-
ology,” in writing of intoxication and delirium, says, ‘‘There
is no class of aberrant mental phenomena which is more
deserving of careful scientific study than that which is produced
by the introduction into the blood of substances which are
MORPHIOMANIA. 271

foreign to its composition, and which have the special property
of perverting its normal action upon the brain.”’

If one contrasts the brain of the dipsomaniac when free from
alcohol, full of intellect, reason, and judgment, with a disposi-
tion loving, kind, and genial, with a heart responsive to all
that is disinterested and truly noble, and compares it with the
brain under the influence of alcohol, the change seems scarcely
credible. In the latter condition we have a being destitute of
humanity, regardless of past, present, or future, abandoned to
vices which to him under ordinary circumstances are disgusting
and repulsive; indifferent to those whom he ought to cherish,
love, honour, and regard; careless of himself, his habits, his
associations, and acquaintances; the dupe and the prey of all
about him; fickle as the wind, faithless as the brute, steadfast-
ness and volition and will power absolutely gone, as instanced
by a weakness and vacillation deplorable and pitiable to
witness. We cannot say that there is much difference between
this form of brain and that of the morphiomaniac, in each there
is loss of that which constitutes humanity—“ will power and
resisting power.” In both conditions the cause is physical, but the
ultimate effects are psychical. We have to deal, then, essentially
with a psycho-physical element which gives rise to a craving
for alcohol or morphia, producing an unquenchable desire
for a poison, over which the unhappy individual has no
control.

A patient who was once under my care, full of religious
instincts and intellectual activity, said to me, ‘‘ Doctor, when
this craving for drink comes over me, I feel myself in an
atmosphere which can be none other than that of hell. I am
tempted by an unseen agency, my inner consciousness of wrong
writhes in mental agony, I even pray that I might be delivered
from this devilish temptation, but my will goes and I am
drawn imperceptibly into the arms of my most detested,
hateful, and degrading foe.”

There is unquestionably a remarkably close affinity between
dipsomania and other states of insanity. The power of voli-
tional control is easily overcome, being at the best of times
very feeble. It is sometimes surprising to witness how a small
quantity of alcohol will upset the normal balance of power,
and lead to mental disturbances truly astonishing; even
conditions of monomania have been induced under such cir-
cumstances. It is certainly quite true that the craving for
stimulants and sedatives is associated with those who are
unfortunately born with an ill-balanced nervous system. I
know this might mean anything or nothing, but there is
such a condition as physical craving, without any direct
propensity, which is found to be relieved by alcohol, chlorodyne,
272 MASSAGE IN SLEEPLESSNESS, PAIN, DIPSOMANIA, ETC.

or morphia, when a propensity becomes established and
culminates eventually in a mania.

No one can doubt the vast good which the present wave of
temperance has produced in this country; the habit for drink
has been checked, and let us hope that in time inebriety as a
disease may become extinguished. Dr. Crothers, Superinten-
dent of Walnut Lodge Asylum, Hartford, Connecticut, writes.
very practically upon the disease of inebriety and its treatment.
(‘‘ Lancet,’ November 19th, 1887). In speaking of intemperance.
waves, he says, ‘“‘The evidence is steadily accumulating,
pointing out these great drink cycles, which like storms gather
and increase up to a certain period and then die away. The.
great unknown forces and laws which regulate these drink
epidemics await discovery. When they are known, then much
of the mystery of the strange temperance revivals and agitations.
which spring up and sweep over the land, dying away as.
suddenly as they appear, will be cleared away.”’ ‘‘ Temperance
agitations have a strange wave-like movement evidently con-
trolled by laws unknown.” Let me say that my experience of
massage in these cases is not sufficiently extensive to warrant
my advocating it, but from the definite action of this mode of
treatment, I can but think and believe that it should be of
great utility.

I hope soon to hear that a system of massage with galvanism
is being carried out in inebriate homes, where every opportunity
is offered to put its influence to a fair and impartial test. I
feel quite certain that in cases of morphia craving it can but
be useful. Dr. Oscar Jennings, of Paris, has written in the
“Tancet” of June 25th, 1887, an excellent article on this
form of mania. It is accompanied with sphygmographic
tracings. He says, ‘‘ Patients deprived of their morphia in
asylums are not thereby cured of the craving. They have been
forced by a compulsion which has provisionally taken place
of their will, and a morphio-maniac is no more cured of this
passion by this forced deprivation than is the dipsomaniac by
abstinence cured of the passion for drink.’’ He recommends
the use of sparteine and nitro-glycerine.

I have found massage and galvanism of great use in simple
melancholia. ‘‘A melancholy with depression,’ where the
sufferer feels the existence, mental and bodily, overwhelmed
and oppressed by gloom, anxiety, and foreboding, due to grief,
overwork, or worry. Possibly there may be some hereditary
predisposing cause, in fact this is very often the case, but the
marked characteristic feature is a depressed, melancholy state.
Tt is common in females at the change of life, and not unfre-
quently it is associated with some delusion. The despondency
may not be extreme, but there seems to be something on the
MELANCHOLIA. 273

mind from which it cannot be divorced. Such patients
invariably suffer from sleeplessness, and a ceaseless activity of
mind and body with weakness of purpose, and utter inability
to sustained effort; sometimes there may be functional
derangement, but this is by no means always the case. They
are manageable, but control over them is difficult, their feelings
are greatly at fault, and their interest in their surroundings
and their natural affections are completely perverted, and so is
their common sensation. General massage and spinal
galvanism, in my experience, has been exceedingly useful.

18

 
Lecture XIII.

MASSAGE IN THE WASTING DISEASES OF CHILDREN,
AND IN THE DISEASES OF SEDENTARY, CHANGING
AND ADVANCED LIFE.

Importance of studying the diseases of Infancy and Childhood—More

attention recently devoted to them by physicians—Opinion and remarks of
Dr. Cheadle—Deaths amongst children from preventable causes—Inability of
young children to endure fasting—Constant and rapid interchange of tissue
necessary to their growth and development—Danger of any arrest in the
formative power of the young—Medical treatment adopted for adults frequently
useless for children—Reasons for their lack of recuperative and enduring
power —Diabetes mellitus —Precociousness in children—The necessity of
continuously replenishing formative foree—Great care in diet requisite—
Wasting in children—Overfeeding very injurious—Susceptibility of children
generally to the good effects of massage manipulations—Children in hospital
—Drugs seldom used—Causes of Infantile atrophy—Dr. Eustace Smith on
massage for children—Children’s appreciation of the massage manipulations
—Lubricants not necessary—The use of drugs deprecated—Anterior polio-
myelitis—Causes of this disease—Efficacy of Massage and Galvanism—Change
of life, a period of much suffering—Physical and mental changes developed—
Severe symptoms and disturbances—The usefulness of massage—Sedentary
life; its dangers—Obesity; its causes, symptoms, and effects—Sedentary
habits and occupations; their effect on people of different temperaments ;
Treatment by massage—Advancing and advanced life—Professor Humphrey’s
paper on the “Maladies of old people’’—Proportion between the sexes in
different diseases—Power of recuperation in persons of advanced age—Useful-
ness of massage in restoring waning power, and in greatly conducing to
prolong life.
In my lectures I have dealt rather extensively with those forms
of disease which are the result of defective nutrition, and we
have seen how, under the influence of massage, digestion and
assimilation are promoted. I have to-day to bring before
your notice how especially applicable massage is in the wasting
diseases of childhood. This is to mea subject of particular
interest, and although I have not the time to enter into and
discuss everything in relation to this most important topic,
still I shall endeavour to lay before you some of the most
common landmarks, which I trust may guide you to the true
conception and rightful and serious consideration of what is to
my mind a question of illimitable magnitude, usefulness,
and significance.

Since the establishment of children’s hospitals in various parts
of London, it may be said that considerable impetus has been
given to the study of diseases of infancy and childhood from a
purely scientific ‘stand-point, by physicians of the highest
eminence, amongst whom may be mentioned the names of
Dickenson, Cheadle, Barlow, Gee, Eustace Smith, Robert Lee,
Goodhart, and Angel Money. Still there can be little doubt
CHILDHOOD. 275

that the general practitioners throughout the country have
unrivalled opportunities for accumulating a vast amount of
valuable knowledge, if they give their serious attention to the
wasting diseases of children. Unfortunately, these gentlemen,
who are in busy practice, can scarcely afford to devote the
time which is necessary to compiling and comparing facts and
putting them into book-form. I very often hear from them of
interesting cases which have occurred in their practice, and regret
that from some cause or the other they have not been duly
reported. Dr. Cheadle says, ‘‘ Address at the Annual Meeting
of the British Medical Association,” Glasgow, August, 1888:
‘Children form the majority of their patients, and the fragile and
growing bodies of young infants are singularly susceptible of
being influenced by treatment for good or evil. They require
a nicety of discrimination, a delicacy of skill in management
beyond the common. The first two years of childhood life
is the period when the congenital faults of structure and of
inherited disease betray themselves. It is the period when all
the troubles of feeding and dentition occur with the conse-
quences which they involve. It is the period of congenital
syphilis, of rickets, of scurvy, of diarrhea, of convulsions, of
intussusception. The ordinary diseases of childhood are
excluded, and even more severe and rarer diseases are usually
delayed until the symptoms become urgent, and the time for
early diagnosis is past and gone.’’ When we take into
consideration the fact that ‘“‘one third of those who are born
die before the completion of their fifth year,” the question
naturally arises as to what percentage die from preventable
causes. Hippocrates says, ‘‘Old persons endure fasting most
easily; next adults; young persons not nearly as well; and most
especially infants, and of them such as are of a particularly
active spirit.” It must be apparent to all that rapid inter-
change of tissue is intimately associated with the growth and
development of young life.

If the formative power of the young be arrested, it leads to
rapid and sometimes uncontrollable degeneration and death.
‘Children fail in recuperative power which is common to more
advanced life; the stability of the nervous system is far less
‘sure and defined. Tonic medicines rarely act with young
children in the same satisfactory manner that they do with
adults. From the period of birth up to the age of puberty
the vitality of production is intimately concerned with
development rather than with reproduction, hence the rapid
exhaustion of childhood can be easily explained and readily
comprehended. .

All life is intimately associated with a reserve of latent force
which responds to demands made upon it for recuperative and
276 MASSAGE IN THE WASTING DISEASES OF CHILDREN, ETC.

emergent occasions, but this is far less in childhood than at
any other period. We know quite well that sudden collapse
and death in the acute diseases of children are very common :
an excitant to the nervous centres in childhood often leads to
convulsions and death which would scarcely be experienced
in mature years. If we take, by way of example, children
whose tissues are, by heredity, contaminated with the
effects of syphilis or alcohol, we find that their forma-
tive powers are exceedingly inefficient, and if the utmost
care is not exercised in reference to the maintenance of heat
and oxygenation, retrogressive metamorphosis is sure to ensue,
and if this is not apparent as an objective sign, functional
troubles arise which are more serious. Take diabetes mellitus
for instance. It is known that this unfortunate condition
in children is rapid in its progress and leads inevitably to.
death ; in fact, this disease takes as few weeks or months to
kill a child as it would years in an adult. Let us for a
moment refer to the nervous side of a child’s organization, to
the mental capacity. Excessive precocity in a child is far
from being, as some would suppose, an enviable condition :
the balance of activity is invariably one sided ; the intellectual
draws too largely upon formative pabulum ; the grey matter of
the brain takes to itself an undue share of nutritive activity ;
an activity which is inconsistent with progressive and rational
correlative development and integrity. Excessive physical,
cerebral, and nervous activity can but be complicated with
instability and irritability, and the rapidity of discharge being
unequal to the nutritive demand, exhaustion, peculiarities of
character, fits and convulsions, not unfrequently supervene.
But I cannot—although I wish that I had time to do so—
carry this interesting subject farther : it is almost interminable.
Finally, let me say this: There are many of the finest.
intellects in youth and young manhood who fail to be the
brightest ornaments in the world of literature and science and
art, and who not uncommonly meet with a premature grave,
simply for the reason that their brain activity is not fondly
nursed, cherished, fed, and carefully and judiciously
nurtured and cultivated. Thus far I trust I have made this.
clear to you, that child life is far more readily exhausted than
adult life; that formative force must be continuously re-
plenished, not only for existence, but for progressive develop-
ment; hence we have not one but two nutritive factors in
increasing activity. Under normal conditions we are willing
to admit that the supply is equal to the demand, but the
standard of health must be maintained. Ifit is not, evil results.
will sure to follow.

Tam not speculative when I say that healthy nutrition in.
MASSAGE FOR CHILDREN. 277

childhood is most wofully neglected. Overfeeding is frequently
as disastrous as underfeeding, and it does not reflect wisely or
kindly on parents who allow their children to partake of
messes instead of good wholesome food, which they know by
instinct and common sense must be not only harmful but
actually pernicious. ‘‘ Wasting in children,” as stated by an
excellent authority, Dr. Eustace Smith, ‘‘is a sign of defective
nutrition ; the waste of the body continues, but new material is
introduced in quantity insufficient to supply the loss of tissue.”
In the processes of nutrition and assimilation the question
arises as to due normal functional and metabolic activity. I
maintain there is no such thing as excessive nutrition: any
attempt at excessive nutrition leads to stimulation of catabolic
energy and an arrest of anabolism; in other words, excessive
nutrition leads to plethora, inactivity and retrograde metamor-
phosis. There are lines of nutrition, as well as lines of
mal-nutrition; in different words, there are central agencies
which govern the one as well as the other. In health these
are equally balanced, but a deficiency in the controlling power
of either of them is incompatible with normal functional
activity and health.

I was first led to the consideration of the value of massage
in promoting and maintaining the due performance of the
nutritive processes by carefully noting and observing the
effects of our manipulations upon the children in our hospital,
and I have often been struck with astonishment at the healthy
appearance which they presented, the firmness of their flesh
and their general well-being. Children, let it be remembered,
who, when first admitted, were pale, sickly looking, careworn,
and dejected, pent up, so to speak, in the ward of a London
hospital, under no other hygienic conditions than those of
cleanliness and ‘plain diet, which consists of milk, bread and
butter, and meat once a day (usually mutton), but of massage
they have plenty. I thought over this matter very carefully
and thoroughly, and I came at last to the conclusion that it is
possible to advance healthful nutrition in children whose
nutritive processes are decidedly defective, and even where
their surroundings are in some ways anything but favourable,
by massage, and by massage alone, for as far as my little
patients are concerned, I rarely have recourse to those stereo-
typed remedies, cod liver oil and steel. As to the iodides and
phosphates of iron, I never think to prescribe them. Malt
extract, at one time, I used to administer largely; but since I
have learnt the value of massage I might say that the latter
is by far the best alterative and tonic which I have ever found,
and I will back its usefulness in this respect against all the
drugs in the pharmacopeia. If proof were wanting concerning
278 MASSAGE IN THE WASTING DISEASES OF CHILDREN, ETC.

the value of massage in aiding nutrition, we surely have it here.
The greatest sceptic must be convinced, if he will only take the
trouble to see, mark, learn, and inwardly digest the outward
and visible signs of the influence of massage. Aperients are
rarely, if ever, required, and the most sullen and morose child
seems gradually to be imbued under its influence with the
attributes of a docile, willing, and kindly disposition.

The wasting diseases of children comprise those which are
general and those which are local. Infantile atrophy, uncom-
plicated with organic disease, is, for the most part, due to an
insufficient supply of proper and appropriate nourishment, to
mal-assimilation, and to some hereditary taint, which is a
constant source of irritation, not only to the lymphatic and
glandular, but also to the mucous and nervous systems; acid
fermentations, congestions, and parasites are frequently the
results of improper and unwholesome feeding. © Hereditary
syphilis is one of the most important and perhaps one of the
most serious causes of atrophy and wasting. The nature of
these it is not our province to discuss, neither shall we consider
their treatment from any other point of view than that of
massage; and if this massage is capable of producing in the
child or in the infant what it does in the adult, then we have
a very valuable remedy which ought never to be neglected.
But its application must be carried on in a continuous, stead-
fast, and scientific manner; the effects which we know result.
from its use are precisely those which we believe are absolutely
required.

Tam not of opinion that the influence of massage is so
marked in aiding common digestion as it is in promoting due
assimilation and respiration of tissue, still it must be borne in
mind that digestion and assimilation are functions which work
together ; an arrest of one does not invariably lead to an arrest
of the other, although this is most frequently and commonly
the case. There are some physicians who appear, to my way
of thinking, to lay too much stress upon the advantages of
massage in children in promoting a healthy action of the skin.
Doubtless the rightfulness of this conclusion is one of degree
only, but the parts most concerned in the ultimate assimilative
processes are the muscles and connective tissue ; it is in these
that respiration is most active, and in these the ultimate
changes of secretion, excretion, and oxidation are elaborated
and perfected.

Iam glad to find that one so skilled in the study of the
wasting diseases of children as Dr. Eustace Smith seems fully
alive to the value of massage. In his excellent work on the
“‘ Diseases of Children”’ he writes as follows: ‘‘The subject of
manual therapeutics has lately received fresh attention, and
MASSAGE FOR CHILDREN. 279

the impetus which can be given to healthy tissue change by a
skilful kneading and working of the muscles and subcutaneous
structures, has been taken advantage of in the treatment of
various forms of chronic disease. Amongst others, in long-
standing cases of chorea great benefit may be derived from
energetic massage of muscles and manipulation of joints, so as
to excite active muscular waste, while at the same time the
increased tissue wants are satisfied by a copious dietary. In
rickety children, whose backs are limp and powerless, very
evident increase of strength quickly follows regular and vigorous
shampooing, and in obstinate costiveness important results can
be obtained by systematic kneading of the abdomen combined
with suitable frictions.” Interested as I am in the value of
massage, [am more than pleased to find that my ideas are
borne out by one whose experience and knowledge are worthy
of most serious consideration.

Dr. Smith does not state in what systematic kneading of
the abdomen consists, but I hope from what I have told you
you will be quite equal to the occasion whenever your services
are required. In masséeing children, the general principles
of this mode of treatment apply with equal force, as they
likewise do in masséeing adults; but in the management
of children, special attributes are called for: kindness,
sympathy, and love for children are required, as well as
manual dexterity. You will be surprised to find how very
fond children become of massage manipulations if they are
treated in the right way; they appreciate acutely and even
sensibly the manner in which these movements are being
performed. I cannot say that they are conscious of its tonic
and invigorating powers, but they never, in my experience, fail
to realize the soothing, calming, and composing influence
which it undoubtedly exerts. Every nurse should understand
massage, and every child’s limbs should be manipulated for a
quarter of an hour night and morning, with unswerving
punctuality. If this were done we should become a finer, a
hardier, a more enduring, and a more intellectual race than
we are at present, and we should hear much less of nervous
disease in the after-stages of our existence.

I would draw your attention to the anointing of children
with oils: this system doubtless has many advantages, but let
me impress upon you a hard and fast rule, from which I never
sanction any deviation: Apply your massage first; your own
skin should come into direct contact with that of your patient;
then you may work in cod oil or any other oil you like. In my
experience it matters not one iota what kind you use, but it
must be some natural animal grease. Experience proves, no
matter what the physiology may be, that oil rubbed into the

 
980 MASSAGE IN THE WASTING DISEASES OF CHILDREN, ETC.

skin of young children of a weakly and delicate constitution,
allays irritability and promotes nutrition; some say that it
gets absorbed and in this way supplies nourishment, of this I
have my doubts. I believe that its action is rather indirect
than direct. It certainly allays undue excitability, and this
secures normality of function, such as an increased perspiration
and secretion of urine; and, according to Bauer, of Tubingen,
the liver is rendered more active, and the stools from being
green and sour smelling become yellow and natural. Depend
upon it, much harm is done in child life by an indiscriminate
use of drugs. The artlessness of a child’s nature is consonant
with simplicity of its physical being: disarrangement in function
is often the result of the slightest causes, and the re-arrange-
ment is almost invariably best brought about by the most
simple and artless modes of treatment. The best intrinsic, and,
at the same time, objective, evidences of normal development of
tissue in infancy and in childhood relate to the osseous and
dental structures, the closure of the anterior fontanelle and
the eruption of the temporary teeth. The former should be
compact about fifteen months after birth, and the central
incision teeth should make their appearance about the seventh
month. Of course there are many other points to be taken
into consideration, to which I cannot possibly refer, and I
merely, in passing, mention these as initial signs for guidance
which should never be neglected, for failures in these develop-
mental processes are invariably attended with general
mal-nutrition and wasting, which is sometimes progressive and
fatal in an almost unaccountable manner.

The wasting diseases of children appear to be associated
with (a) inherited syphilis, (0) rickets, (c) scurvy, (d) scrofula.
These can scarcely be referred to as the cause of atrophy or
wasting; on the contrary, they are connected with a diathetic
condition, which has for its foundation, whatever the deficiency
of the superstructure may be, an incompleteness in the
formative force which is so essentially correlated with the
requirements necessary to the growth and differentiation of
tissue in childhood and youth. I feel sure that good regular
feeding, massage, perfect hygiene, warmth, sunlight, and fresh
air, will best stimulate the formative powers to increased
activity, and secure that vitality without which all artificial
modes of treatment are valueless and unprofitable.

I must now, before leaving this subject, call your attention
again to a state of local wasting, which is remarkable in
many ways, and is, in my experience, becoming more
common than formerly; and its seriousness should compel
us to know more about it in order that its disastrous and
ill effects might, at a much earlier period, be met and ,
INFANTILE PARALYSIS. 281

counteracted. I refer to what is known as “ infantile
paralysis,” or ‘‘anterior polio-myelitis,” ‘atrophic spinal
paralysis,” in which we find that muscular wasting is a
prominent symptom, the paralysis depending upon destruction
of the nerve cells, particularly in the anterior horns of the
spinal cord from which the axis cylinders of the motor nerves
originate. It may be said that this affection is particularly
one of childhood and infantile life, but it is by no means con-
fined exclusively to these periods. It may come on soon after
birth, but it is most commonly found in children of from one
to five years of age. Its etiology in many cases is questionable,
although a frequent cause is exposure to cold and chilling of
‘the body when the skin is in a state of perspirable activity.

I have two children of one family now under my care, where
the cause of this disease seems to have been excessive fright
‘during a thunder-storm. They went to bed apparently in
perfect health, and the following morning they were unable
to walk. The onset is sometimes attended with symptoms
akin to those which usher in a severe illness; shivering,
and fever; sometimes delirium supervenes, with an excessive
rise of temperature. The injury may be confined to one limb,
or all the extremities may be affected, although rarely in like
degree. The paralysis is motor only, without loss of sensation.
‘Gowers says, ‘‘ The growth of the bones is retarded,” but this
certainly is not distinctive. I have paid some attention to this
subject, and in growing children have frequently observed the
‘bones maintain their length of growth as compared with the
bones of the healthy limbs, although the general substance of
the bone is invariably wasted. This is a point of great interest.
I cannot enter into the many details of this peculiar affection,
‘suffice it for my purpose to say that the muscles undergo
rapid degeneration and present the degenerative reaction in
its most characteristic form, namely, loss of faradaic irritability
vith maintenance of voltaic irritability. The latter may be
increased for some time, but as the muscular fibres degenerate
the response to the continuous current is gradually lost. The
prognosis cannot be considered hopeless, as I could prove to
you if I had time by the records of a considerable number of
cases ; but in my opinion, and in this matter I can speak from
experience, local treatment should be adopted early. By treat-
ment I mean massage and a weak galvanic current. Many
of these cases unfortunately present themselves to our notice
when any form of treatment is irremediable and hopeless.

Change of Life.—lIt is usually between the ages of forty-five
and fifty-five that a woman is said to be passing through a
transition state of existence known as the change of life, and
there can be no doubt that this period forms an important event
282, MASSAGE IN THE WASTING DISEASES OF CHILDREN, ETC.

in every woman’s history. Every life reaching threescore
and ten years must undergo a cycle of changes; these waves
of alteration are, for the most part, gradual and almost
imperceptible, nevertheless time with its relentless and
unsparing hand marks its victim with unerring constancy.
The elixir of life has not been found to protract the verdure
and the elasticity of youth. Some women suffer severely at
this period of change, and when the great function of men-
struation ceases, when the ovaries have fulfilled their allotted
task, and the uterus fails to be the centre of an active discharge
of blood from the system, truly a momentous and revolutionary
epoch marks its advent, and exercises an influence upon the
circulation and nervous system, which—although some few
seem to enjoy comparative immunity—produces in the
majority such a condition of disturbance and discord
throughout their entire being that right glad are they when
the temporary derangement is over and everything has again
settled down to a state of definition, regularity, and harmony.
Nature has arranged that a change so vital and physically
omnipotent should be attended with as little distraction as.
possible, therefore the process is usually gradual. Its progress.
is sometimes considered to be too long in its action, neverthe-
less the future results are invariably of a similar nature, and
some women who have been ailing for years prior to the
climacteric event, will, after its departure, enjoy a good state
of health which has been hitherto unknown by them. We
must, if you please, take into our consideration very briefly
some of those ailments which are commonly associated with
change of life, and I think that I shall be able to prove to you.
that massage is one of the most valuable remedial agents in
bringing about a happy termination to a condition which is.
often feared and dreaded.

These changes are for the most part temporary and functional
in their nature, and the circulatory and nervous systems feel
the confusion most. For the sake of conciseness we will divide:
these into two classes, physical and mental. I may say with
truth that during this decade all perversities of nature, whether:
they be physical or metaphysical, inherent or acquired, make
themselves apparent in a manner, and sometimes with an
unconsciousness of them on the part of the individuals, which
is perplexing and astonishing to those with whom they are
daily and hourly associated, and on this account many

derangements of body are neglected and supposed to be due to:

natural causes when they really call for medical skill and

interference. The physical effects, then, of change of life are:
primarily due to an altered condition of the blood and its.
circulation throughout the body; spasms of vessels are-

few
MASSAGE AT CHANGE OF LIFE. 283-

attended with a deficiency of blood in parts most distant.
from the heart, dying away, as it is called, of the hands and
of the feet are peculiarly frequent and are constantly being
brought under the notice of the medical man. The woman
wakes in the morning with what is best known to her as a
sleepy state of the limbs; the hands and feet are icy cold, and
blanched, devoid of sensibility, causing for the time muscular
inco-ordination and a want of muscular sense, a ‘‘ dying away
condition.” Sometimes there is considerable pain and a.
feelmg of numbness, tingling, creeping, itching, and burning,
putting the hands into cold water creating a scalding and very
painful effect; but after a few hours of bodily activity the
circulation is restored and the normal state is regained. This
spasm of vessels may extend so as to lead to impairment of
the special senses ; vision is sometimes attended with obscurity
and absence of definition, varying in character from day to
day ; or it may be the cause of giddiness; there may also be
nervous deafness, as one frequently hears it called, accom-
panied with all sorts of ill-defined and strange noises in the
head; even taste and smell are occasionally perverted,
deranged and misleading; and the alteration in the voice
and respiration leads to the idea that something is really
wrong with the larynx and the lungs.

Hemorrhages of a vicarious kind sometimes occur, and not
unnaturally occasion considerable alarm. The eyes and tissues.
around may be the seats of hemorrhage, giving an appearance
similar to that produced by a violent blow, or large quantities
of blood may be ejected from the stomach and voided by the
anus or the bladder. There may be an arrest of function on
the part of any organ, the liver, the kidneys, and the stomach.
The metabolic processes of nutrition and repair may be
rendered inactive, and rapid waste of tissue may result ; or, on
the other hand, a woman may suddenly become inordinately
fat. The quantity of urine secreted may be excessive or limited
to a minimum. Cravings of a kind may arise hitherto unheard
of, and a sense of emptiness (which sounds vague to the inex-
perienced) may be felt at the head, stomach, heart, or bowels.
Of all physical disturbances I think those relating to the fifth
nerve are the most common.

Headaches of the hemicranial or megrim type often cease
altogether, and give place to a feeling of fulness and tightness or
sense of weight and pressure over the vertex, or dull indescrib-
able feeling at the back of the head, and behind the ears. Some-
times patients have told me that their heads felt like so much
putty. A not uncommon, though a most distressing symptom,
is that within the skull as of worms or insects crawling over the:
brain. Sometimes, but rarely, headaches will assume a most.
284 MASSAGE IN THE WASTING DISEASES OF CHILDREN, ETC.

distracting and intense type, so that patients will scarcely know
what to do with themselves. Formications of the skin of the
face are often very troublesome. Neuralgias of the head and
face which have been slumbering and inactive, only making
themselves occasionally evident, will light up with great energy
and become inveterate. And, again, it must not be forgotten
that, owing to the arrest of nutrition, the normal formative
efforts are liable at this time to become perverted, reversing
the natural order of things to that of abnormality, resulting
in cancerous and other erratic developments; and numerous
functional derangements which are common to any and every
period of life are still more prone to make themselves evident
at this.

These are a few only of the physical functional effects
common to the change of life. Now let us see what functional
mental disturbances are prone to arise at this period. The
self-same cause which we have briefly noticed in reference to
the production of physical effects gives rise also to mental
derangements, this cause being impure blood and its insufficient,
irregular, or excessive supply, and defective nutrition. The
mental results are, subsidence and inebriety of faculty;
in other words, an abnormality of reasoning power, as
well as intellectual alienation, amounting to an abrogation of
concrete conceptuality. The mind, as an organ of reason, is
diverted from its normal channels of ideational integrity, and
lends itself to a speculative and imaginary train of thought,
mystical, fanciful, and falsely representative—completing a
substantive representation of impaired functional capacity. At
one time melancholy is a prominent feature; at another,
dementia ; at another, aural and visual hallucinations, and at
another, sheer nervousness and perversity. It would be out of
place here if I gave you clinical evidences of associated signs
and symptoms relative to, and connected with, these conditions,
but you must clearly understand that they have a physical
basis, that certain areas of brain matter are involved, and that
vascular spasm is often at the bottom of these mental troubles.
Mental functions, like physical functions, are balanced by a
system or systems of antagonism, and by the natural process
of evolution in man we are rightfully led to the conclusion that
+he mental stands upon the highest level, the perfect integrity
cof the two is alone maintained by an absolute balance of power.
A few practical remarks will enable you to follow my simple
reasoning upon these points.

When the nervous system is affected at “ the change of life,”
we find that women are, not unfrequently, weak and feeble in
mind and character; if the lower centres are involved, the
vegult igs muscular asthenia, and the whole condition is that
MASSAGE IN SEDENTARY AND ADVANCED LIFE. 285

of pseudo-imbecility, irresolution, irritability, and exhaus-
tion.

An undue excitability is as sure a sign of mental weakness.
as is the undue excitability of a nerve or muscle; and we find
our patients simply as effusive in their loquaciousness without
any fixed point or continuity of reasoning, as would be
the inco-ordination of a muscle from exhaustion of its nervous.
supply. From the mental side of the ‘‘ change of life’’ we are:
thus led to conclude that the conditions are functional; that.
they are due to some defect of the circulation, consequent upon
nature’s process of re-adjustment and compensation ; that they
are usually of a temporary character, but that medication
is frequently required. The derangements of the nervous.
system, motor, sensory and sensorial, are secondary to-
the circulatory disarrangements, never forgetting the in-
fluences associated with predisposition. Admitting, if you
please, that anemia, mal-nutrition and exhaustion are.
the immediate factors. In all cases, resisting power is.
deficient both from the ego and vital points of view. Of course,.
the question now is—Can we do these patients any good by
massage and galvanism ? Can we aid nature in her efforts to
restore the normal balance of the circulation and promote
nutrition ? Well, I can tell you from my own experience that
we can do an immense deal. I do not like to speak with
too great certainty, but I firmly believe that many of these:
cases which have passed through my hands would have
drifted into a hopeless state of dementia had it not been
for the massage and electric treatment to which they were
subjected.

We have now to consider two other conditions where I think
you will find massage to be of unfailing and meritorious
service: these are in sedentary and advanced life. My
lamented friend, Dr. Milner Fothergill, wrote an excellent work.
entitled ‘‘ Diseases of Sedentary and Advanced Life,” of which
he was justly proud, and I am more than glad to quote a few
sentences from the writings of so illustrious a man, un-
fortunately taken from us in the prime of life, a life devoted to-
his work, fearless of opinion, careless of renown, honest in
purpose and intentions, serious and earnest, but withal,
practical in following out what he believed to be the true and.
righteous concepts of science—science as nature claims her,
simple and truthful, unadorned with canonical wreaths of
man’s aimless sanctity—such was John Milner Fothergill.
Requiescat in pace.

Sedentary life is not a healthful life, but I am disinclined to-
an impartial agreement with Dr. Fothergill that it is pro-
ductive of every form of derangement of function and tissue:

 
‘286 MASSAGE IN THE WASTING DISEASES OF CHILDREN, ETC.

change. On the contrary, a sedentary life, with definite rules
of hygiene and diet, indicates a conservation of power and
energy which, if misapplied in the production of excessive
activity, is likely to lead to undue friction and wear and tear
tending to premature exhaustion and its consequences. It
would be unwise if we did not take this into consideration. A
sedentary life with mental liveliness and animation is a very
different thing to the sedentary life of the slothful and the indo-
lent, yet withal a sedentary life has a train of evil consequences,
even under the best conditions, conditions which cannot fall to
the lot of those whose organs are occupied in the due fulfilment
of functions with which they were endowed. by nature towards
the achievement of certain ends. My object in bringing this
subject before you is merely to remind you that there are
bodily changes, the result of inactivity, which, if not of a
strictly degenerative kind, are attended with discomfort and
inconvenience. Let me take obesity by way of example.
Many persons are actually too stout for either health or
comfort. Dr. Fothergill refers to this in a somewhat quaint
but purposive style of diction. ‘‘ All must have seen an undue
obesity in corpulent ladies who live well and lie warm, who
take carriage exercise only, and are scant of breath if they
climb three stairs. In all these cases there may be a super-
abundance of fat in and upon the heart, but that is of less
‘significance than the general condition. The blood is always
charged with nitrogenized waste, whether the urine be clear or
laden with lithates. Such persons are fed to repletion, and,
like the lazy, over-fed monk of old, they ought to have less
sleep and more exercise. They remind one of the fat Italian
priest, the victim of gout, who was taken prisoner by the
Turks, and converted into a galley-slave. This position might
not be an enviable one by any means, but he regained his
health and lost his gout as the outcome of his new regimen.”
I think we may fairly look upon obesity as one of the
inflictions of a too sedentary life. If the individual cannot or
will not change this mode of existence, surely there is no
better means of compensation than that of massage, and
although I thoroughly believe in a well regulated dietary, with
an absence of saccharine elements, still I am sure it is a
mistake to carry on Bantingism to an unlimited extent. In
my own practice, during the past twelve months, I have had
‘some really excellent cures of obesity by massage in persons
who did and would lead sedentary lives whatever might be the
consequence. My experience certainly guides me to the con-
clusion that an unhealthy amount of fat causes a very
characteristic state of lethargy, indisposition, and laziness.
Unhealthy fat is associated with exhaustion and its train of
MASSAGE IN ADVANCED LIFE. 287

symptomatic troubles, equally as much as a deficiency of fat.
There can be little doubt that some people in this mixed world
of various and varying types can bear a life of restraint or a
sedentary life with much greater equanimity and with less
danger to health than others can: the thin, wiry, caustic
individual whose stomach can digest nails, and whose waste is
exactly equivalent to his repair, apparently loses nothing and
gains nothing; the interchanges, circulatory, nervous, and
mental, go on from day to day with wonderful rhythm and
regularity, his habits are punctuality itself, and his diet usually
of the plainest and most moderate kind. But this is not the
case with a man of more plethoric habit of body and with
naturally a good deal of gout in his blood. A sedentary life
would. not suit this individual unless he lived upon nothing but
whey and biscuits. But this type of man is fond of good
living, and with little or no exercise his blood very naturally
gets loaded with uric acid and he becomes lithemic. It is
quite possible that there may be no outward manifestation of
gout, still as is too frequently the case, it may be retrocedent,
suppressed, and latent, and this means a damping of the fires
and a choking of the flues, leading to inactivity of the liver,
indigestion, and a host of troubles, which may be only slight,
or may be severe and associated with the gravest forms of
arterial change. Well, all I can say to such as these is, “If
you will not or cannot take exercise, have your body masséed
regularly every morning for one hour from seven to eight
o’clock, and you will soon throw away your blue pills and your
black draughts, and your peptonizing powders.”

Advancing and Advanced Life.— Lastly, let us consider
whether massage can be of any value at all in advancing and
advanced life. Does it retard the dying out of tissue ? Does it
aid the structures to retain a fair amount of elasticity ? Does
it keep the joints supple and the muscles from getting stiff ?
Does it keep the skin in a healthy condition and prevent pre-
mature wrinkling and shrivelling? I certainly believe that it
does all this, and more even than this, I am sure that it
prolongs life.

Professor Humphrey, of Cambridge, in a paper on “ The
Maladies of Old People,” which is to be found in the Jedical
Journal of July 80th, 1867, presents an analysis of 824 persons.
Of these there were 840 males and 282 females between
80 and 90, and 92 males and 110 females between
90 and 100. With regard to diseases and failures of parti-
cular organs, the immunities were in favour of the women,
amounting to 55 per cent. as compared with 85 per cent. m
the case of the men. The affections of the urinary organs
especially preponderate (as we might expect) in the men.
288 MASSAGE IN THE WASTING DISEASES OF CHILDREN, ETC.

They are indeed twice as frequent in the men as in the women,
amounting to 42 per cent., whereas in the women they
are only 20 per cent. In the women brain affections are more.
frequent than in the men, being 16 per cent. to 7 per cent.
But the failures of the heart and of the lungs are about equal
in the two sexes. It is worthy of note that 85 per cent. of the
whole number are reported to be free from any evidence of
rheumatic affection of the hands. Of all diseases brain
affections and the recoveries from them in old people are
amongst the most remarkable of their maladies. Fifty-two
people were troubled with rheumatism in its various forms, “‘ for
which,” says Professor Humphrey, ‘‘I suppose a remedy is not
very easily to be found.” In this respect I beg to differ from
Mr. Humphrey, for massage, as far as my experience has gone
in the treatment of the rheumatic pains and stiffness of limbs
in old people, is most valuable, in fact, its usefulness in this
respect is second only to its power in the wasting diseases of
children. But now we come to the most interesting point in
the whole of Mr. Humphrey’s very valuable paper, and it refers
to the remarkable healing power of the aged, not only after
local lesions, such as fractures, wounds, and ulcers, but to the
reparative powers evinced by them after illnesses. He remarks
—‘‘ Those inferences are so contrary to pre-conceived notions,
indeed to probabilities, that it takes some time and effort and
frequent repetition to obtain for them a fair measure of
acceptance, but I think the reparative powers of age are
becoming more accredited, and that we shall ere long cease to
have age adduced as a reason against the hopeful and careful
treatment of fractures, wounds and sores in the octogenarian,
the nonagenarian, and even in the centenarian.” This is all
very well and very true, and it goes to confirm my previously
expressed opinion, that regular massage in advancing age tends
to prolong life ; but there is a stage in advancing life between
fifty-five and sixty-five, when in some people age creeps
on apace; they feel they are getting old, their muscles become
weary and even tender towards their fibrous attachments after
a small amount of exercise; after sitting down their lower
limbs become uncommonly stiff, and the least over-strain of the
muscles of the back gives them sharp pains about the lumbar
regions; the joints, particularly the knees and the hips, are
painful upon movement, feel dry and are given to crack; the
skin is wrinkled and the hair is white and very void ; they have
a sudden tendency to stoop, and the muscles are destitute of
firmness. Now, in some of these cases I have been truly
astonished to see the wonderful influence which massage has
had in restoring a healthy tone and giving to these people an
appearance of comparative youth really remarkable. A
STIFF LIMBS. 289

gentleman over seventy consulted me for what he called stiff-
ness, particularly about the lower limbs. After sitting down
for a little time he became so stiff that he had difficulty in
assuming the erect posture again. A course of massage cured
the stiffness entirely, and he declared that it had made a new
man of him.

We have now considered massage manipulations in almost
every way in which I should judge them likely to be of
great service. I shall in the next two lectures confine myself
to electricity and its practical application to the human body.

19
TWO LECTURES

ON

MEDICAL ELECTRICITY.

 

Lecture XIV.—ELECTRO-PHYSICS.

Lecrure X V.—ELECTRO-THERAPEUTICS.

THESE two Lectures on Mepicat ELecrricrry are
a necessary addition to the foregoing Lectures on
Massage. We find that massage and electricity have
a combined value; so much is this the case that the
best results of massage are frequently dependent upon
electricity as an auxiliary. Of the two modes of
treating disease, I certainly have met with more decided
therapeutic results from the former than I have from
the latter, but the medical use of electricity is still
capable of more extended application and experience.
I am quite sure that we must view both these
agents as aids to treatment only. It is simply irrational
and quackish to give to either massage or galvanism
an empirical value which it does not and never can
possess.
Lecture XIV.
ELECTRO-PHYSICS.

Massage an aid to Hlectricity—Electricity as an agent for transmitting
power compared with air and water—Galvanism and Faradism—Electrical
action and Chemical action—Generation of Electricity—Electro-motive force
——Leclanche’s cell—Amalgamation of zinc—Advantages of zinc and carbon
elements—Difference of potential—Potential at different points of a conductor
—Internal resistance-—Polarization—Circulation of the current—Polarity of
elements in the galvanic cell—Terms of poles, &c.—Conduction—Resistance —
Examples of resistance—Volt, Ohm, Ampére—Velocity of current—Rheostat—
Resistance of the human body—Collector—Voltaic alternatives—Voltameter,
description of —De Watteville—Galvanometer—Magnetic deflections—Nature
of Ohm’s law—Polarization—Apostoli Faradism—Galvano-faradic, Magneto-
Electric currents—Induced currents, strength of —Induced current, explanation
of, nature of —Gaiffe’s apparatus—Faradic battery—Galvanic battery—Elec-
tricity induces Magnetism—Temporary and permanent Magnetization by
Hlectricity—Figure for illustrating Galvano-faradic induced current—Action of
the induced coil--Galvanic cautery—Cautery battery—Static electricity—
Electrization—Dr. Morton on the use of Static Electricity.

Tuts lecture treats of some of the most simple fundamental
principles and attributes of certain phenomena or modes of
molecular motion embodied in the term electricity. I shall
deal with the subject in its concrete, rather than in its abstract
and differential forms, my object being to explain and make
clear to you that under given conditions we can generate a
something to which the name electricity is given, and which is
capable of transmitting power. My duty, then, is clear and
defined. Let me see if I can make my ideas clear to you also.
We can, if you like, consider electricity in the light of an
imaginary fluid and compare it with water. You know that
water pressure is capable of transmitting power, as illustrated
by the vast system of high pressure mains which have been
laid throughout London. Compressed air also is capable of
transmitting power, the ordinary pneumatic bell being an
example.

You will observe that I class together air, water, and elec-
tricity ; by that I do not mean to imply that electricity is a
fluid, although in many respects it acts like a fluid, like a fluid
of very little mass however, or, odd as it may seem, like a finid
moving extremely slowly, for electricity goes round sharp corners
with perfect ease and without any of the phenomena of
momentum possessed by rushing water. But what I particu-
larly wish to impress on you by classing air, water, and electricity
together is that electricity is not, as some people seem to think, a
something that can be burnt or in some way used up and so
work got out of it. Electricity is no more a source of power
294 ELECTRO-PHYSICS.

than a bell wire is; electricity is a marvellously convenient
agent for conveying a push or a pull toa great distance, but it
is not by the using up of the electricity that electric lights burn
or that electro-motors revolve. It is by the electricity losing
pressure exactly as water loses head when turning the miller’s
wheel as it flows down hill, that work is done electrically.

At the end of this lecture I shall have to say a word or
two to you concerning frictional electricity or static electricity
(Franklinism); but in consequence of the difficulties met with
in developing it, on account of the humid condition of the air
in this country, it has not been adopted in the treatment of
disease so much as it otherwise would be, but it has its uses
nevertheless. So I shall confine my observations especially to
those two forms of current electricity known as (1,) galvan-
ism, voltaism, contact electricity and the chemical or constant
current; (2), faradism, the magneto-electric, the interrupted,
or the induced current.

You must look upon current electricity as you would a
current of air or a current of water, moving at a given rate in
a certain time at a given velocity, exercising power and per-
forming work in direct ratio with the resistance it has to
overcome.

Current electricity or continuous flow of electricity is the result
of chemical action, or perhaps it might be more correct to say
that chemical action is accompanied by and probably produces
electrical action, and this I shall make evident to you by the
galvanometer and other means.

In ORDER TO GENERATE ELECTRICITY we take a couple of
dissimilar elementary substances (electro-motive). We may
select them from the following: Carbon, platinum, gold, silver,
copper, iron, tin, lead, zinc. For medical purposes carbon
and zine are.usually preferred. It is my intention to confine
my observations to these two elementary bodies. If they are
brought into contact in the presence of some exciting fluid, say
dilute sulphuric acid (1 to 9) or solution of chromic acid (4 to
20) or a saturated solution of sal ammoniac, in one of them
positive electricity, and in the other negative electricity can be
detected.

Directly the zinc and the carbon touch, either inside or
outside of the liquid, chemical action takes place. Bubbles of
gas appear on the carbon and rise to the surface of the liquid,
which may be shown to be hydrogen, whilst the zine (if
sulphuric acid be used) is gradually corroded and consumed,
the white solid sulphate of zinc being formed in the vessel.
The chemical action is thus expressed :—

Zn+H,80,=Zn80,+ Hy.
You will observe that the carbon undergoes no chemical
ELECTRO-MOTIVE FORCE. 295

change, but the chemical action upon the zinc by the sulphuric
acid has given rise to a force which is known as electro-motire
‘force.

HILECTRO-MOTIVE FoRCE must be looked upon as an imaginary
force; it is a property of matter giving it a capacity for work
just as energy in the world of mechanics is its capacity for
doing work. In man’s bodily organization there is the capacity
for work, and in the collection of parts that make up the steam
engine, holding certain relative positions and to bodies outside
them, there is the capacity of doing work. The possession of a
body of energy gives to it the power to do work, just as the
possession of electricity of electro-motor force gives to it the
power to do work, therefore a galvanic battery generating the
electric current depends for its strength upon its electro-motive
force, and the tension and strength of the current is due to this
electro-motive force, which is the outcome of difference of
potential, and this is why it is usual to say that electro-motive

S
‘

 

 

Fig. 37,—Leclanché’s cell.—A, outer vessel ; ‘I’, porous cylinder containing K,
carbon; B, binding screw of positive pole + (anode); Z, zinc, C, binding screw of
negative pole (kathode). The arrows denote the course of the current from
the zinc to the carbon inside the cell and from the carbon to the zine outside
the cell. a
296 ELECTRO-PHYSICS.

force and difference of potential are synonymous; and we shall
directly see how this force is measured, and other points in
reference to it.

I now show you a Leclanché cell (Fig. 37).

You see it consists of an outer vessel made of glass,in which we
note the jist element, a rod of amalgamated zinc. Let me say
a word here with regard to the amalgamation of the zinc. It
is very important that you should know how to do this for
yourselves, and understand the reason why amalgamation is
necessary. For uniformity of working, and for obtaining the
maximum effect, it is essential that all parts of the zinc should
be acted on equally by the solution. Ordinary commercial zinc,
besides other impurities in the process of cooling, becomes
unequally annealed, different parts of it are unequally hard,
and are attacked with different facilities by the same acid.
Pure zine carefully annealed is not attacked at ordinary
temperatures by pure sulphuric acid. Two pieces of zinc, one
of which is more easily attacked than the other, will, when in
contact with an acid and with one another, form a couple, the
more easily attacked being + and the less easily —, just like a
piece of zinc and copper respectively. Such an heterogeneous
piece of zinc when used as an element in a cell fritters away
some of its general electro-motive power by establishing local
currents. It seems that the chief cause of this inequality of
action is due to difference of hardness rather than metallic
impurities, for if the surface of the zinc be moistened with
sulphuric or hydrochloric acid and mercury smeared over its
surface until the zinc is uniformly amalgamated, such local
currents are completely arrested. The metallic impurities
cannot certainly be removed in the process of amalgamation.
But inequality in hardness, due to irregular cooling, can easily
be removed; for as the mercury penetrates, the mass softens
and molecular strains aré relieved, and uniformity results.
This is so complete that amalgamated plates may be left in con-
tact with dilute sulphuric acid for any length of time without
dissolving.

The second element is the plate of carbon, and the liquid
a solution of chloride of ammonium. The zine is in free
contact with the chloride of ammonium. The carbon is
in a porous cell; the space between the carbon pole and
the wall of the porous cell is filled tightly with a mixture
of carbon and peroxide of manganese in coarse powder.
Chloride of zine is formed, the separated ammonium imme-
diately decomposes into hydrogen and ammonia, the latter of
which at first dissolves in the solution and, when this is
saturated, escapes as a gas. The hydrogen, meanwhile, after
causing in the usual way successive decompositions of the
LECLANCHE’S CELL. 297

contiguous molecules of chloride of ammonium, appears through
the porous cell, and finds itself at last in contact with the
peroxide of manganese, this oxidises the hydrogen to water, being
itself in the first instance reduced to the form of sesquioxide,
according to the equation
Z4n+2CINH,+MnO,=ZnCl,+2NH,+H,0+Mn,0,.

The advantages of this combination is that the zinc is not
consumed when the cell is not in circuit. The object of the
peroxide of manganese is, as I have just stated, to give up its
oxygen to the nascent hydrogen to form water, and were it not
for this combination the hydrogen would collect in such
quantities over the surface of the carbon as to depolarise it,
bringing about an internal resistance which would be highly
adverse to the working of the cell.

The electro-motive force of a Leclanché cell is about 1°5 volt,
or more correctly 1°48 volt, and its internal resistance about
3°5 ohms.

I have here another and more recent form of Leclanché cell.
You see there is no porous cylinder in it, this simplifies the
thing very much and renders it easier to recharge and clean.
Now, I am anxious, as I cannot possibly describe to you each
of the different forms of cells which are in use (excepting in
a very off hand way, when speaking to you of current tension),
that you should keep this cell with its elements (electrodes) in
your mind, and remember, if you please, that it possesses so
many advantages that we may look upon it as the medical cell.
It is well suited for intermittent work, and it has the special
superiority that it is cheap and requires little attention. We
shall have to study this cell carefully, and if we know something
about it we shall have an idea of the foundation of the science
of galvanism. In the first place we have what is necessary
for the generation of the galvanic current, the two dissimilar
elements, carbon and zinc, separated by india-rubber bands,
and surrounding them we have our fluid which we may call the
exciting agent, which acts chemically on one of them. Volta
considered that the contact of two different metals was alone
necessary to the production of electricity, but our distinguished
physicist Faraday came to a different conclusion, namely, that
in order to create force there must be an expenditure of
energy, and that something more was required than the mere
contact of the metals, in fact that chemical. agency was
necessary to keep up the difference of potential between the
two metals.

DirFeRENcE oF Porentiau means a difference of level between
two points in order to bring about a flow of the electric
current, or, for example, a current of water. The point from
which electricity (or water) flows must be at a higher potential
298 ELECTRO-PHYSICS.

(or level) than the point to which it flows :-we have, then, with
regard to the electric current, a positive as well as a negative
flow, which always takes place from the higher to the lower
potential, so that by the positive or negative potential of a body
is meant that the electricity with which it is charged must be
of a kind positive or negative.

DIFFERENCE AT DIFFERENT POINTS oF A ConpDuUCTOR. —
Difference of Level bears the same relation to pressure in a
hydrostatic system as difference of potential bears to electro-
motive force in an electric one. Again, electric potential is
directly comparable with tension; for tension is proportional
to the pressure which is producing it. Accordingly, if the
two extremities of a conducting wire have the same potential,
the electro-motive forces along that wire will be equal and
opposite. In other words, there is no resultant electro-
motive force between the points, and no current passes. In
all cases, just as in mechanical problems, two equal and oppo-
site forces may be withdrawn or added without altering the
conditions; so we may suppose that any wire, through
which no current is passing, is simultaneously traversed
by equal and opposite currents. In doing so, we should,
however, be obliged to lose sight for a moment of the
generally received ‘‘explanation”’ of current motion, namely,
difference of potential, which is after all only a mode of
expression.

Now let us apply this difference of potential between the
elements in the battery itself, the internal electrodes, the zine
and the carbon, and this will lead on to the consideration of
polarity.

My Leclanché cell is now in action, for I have connected the
two elements by means of this piece of copper wire, and the
electric current is passing in circuit, or I should rather say the
two currents are passing in circuit, namely, the positive and
the negative, and my Leclanché cell is in its greatest state of
activity. It is what is usually known as short circuited;
by this is understood that the currents have no external
resistance to overcome, excepting that which they find in the
copper wire; the only resistance, then, to the two currents
meeting and neutralizing one another’s activity exists in the
fluid between the two elements, and this is called the internal
resistance. It is important, therefore, that the exciting liquid
in the cell should not only be such as will act chemically upon
one of the plates, but it must also be a compound of which
the particles or molecules are capable of polarization; with
bromine or with a solution of chlorine no current of electricity
is obtained, though these substances act powerfully on zinc.
With the compounds generally employed—either acids or
CIRCULATION OF GALVANIC CURRENT. 299

salts—the chemical force passes through the liquid from one
plate to the other, and doubtless the electrical force also passes
through the liquid from one plate to the other. Let ussee. The
two elements in the Leclanché cells are kept at different
potentials by chemical agency, and the highest level of these
potentials is to be found with that element upon which
chemical activity is exercised. By the difference of potentials
the generation of the electric current is maintained. When
there is no difference between the potentials, when they are
both at the same level, the battery is said to have run down.
Now the chenucally-active plate is that from which the positive
current flows to the chemically-passive plate through the liquid.
The chemically-active plate in this cellis the zinc, and the
chemically-passive plate is the carbon, so the chemically-
active plate, the zinc, is positive to the chemically-passive plate,
the carbon which is negative. By the law of potentiality the
positive current is found and withdrawn from the negative
plate and the negative current is found and withdrawn from
the positive plate. Hence it is invariably seen, and this is a
rule to which there is no exception, that when a current
passes from A to B it is the metal A which is mainly
attacked—generally it alone is attacked. The very fact that
the hydrogen is evolved on the carbon insures the latter
remaining unattacked. We are now in a position to consider
the

CIRCULATION OF THE CURRENT, means the continuous circula-
tion of the electrical force, and has given rise to the terms
electrical current and current electricity. When the circuit is
completed (1) the plates become polarized, (2) the molecules
or particles of the liquid between them also become polarized,
(83) chemical action (decomposition and recomposition) takes
place across the liquid, (4) positive electricity takes its origin,
as we have seen in the chemically-active plate, (5) across the
liquid to the negative plate, and (6) proceeds by the wire
outside the liquid to the positive plate. The negative current
may be traced the reverse way—trom the carbon through the
liquid to the zine and through the wire outside to the
carbon.

You can, I hope, now understand how it is that positive
electricity leaves the cell by the wire fastened to the carbon
element, whilst negative electricity leaves the cell by the wire
fastened to the zinc element: the place of junction therefore
by the wire and carbon element is called the positive pole and
is at the top of the negative plate, the negative pole is at the
top of the positive element, the zinc.

We can now make ourselves acquainted with certain
terms which have received general acceptance, and which are
3800 ELECTRO- PHYSICS.

applied to the terminals of the positive and negative poles, the
term Anode is given to the conductor which is attached to the
Positive pole, and the term Kathode is given to the conductor
attached to the Negative pole. In speaking of currents, instead
of using the words Positive and Negative, it is serviceable
sometimes to apply the words Anodic and Kathodic. The word
Electrode is common to any material which is applied to the
end of the conducting wire by which the current is made to
enter any part of the human body (the part by which the
current enters and leaves the body, electrolyte.) In
electrolysis, which we shall have to consider in our
next lecture, the products which appear at the Anode
are called Anions, those which appear at the Kathode are
called Kations. The Kathodic or Negative is the destructive
current when applied to tissue, but this I shall demonstrate to
you directly. It may not be quite scientific to speak of a
destructive current, but by this I mean that the electro-motive
force has an initial capacity or energy or intensity which
enables the current to overcome resistance which the positive
current does not possess.

So much for this galvanic cell and its electro-motive force
with which we must now become better acquainted. I attach
the ends of these two pieces of insulated copper wire—
(you see they are covered with gutta-percha which is a non-
conductor of electricity)—one to the positive, and the other to
the negative pole, and when I bring the ends of these
wires into contact I create a difference of potential in the cell,
and the electric current is immediately transmitted along the
wires. If I place their terminals to my tongue I experience a
sharp tingling sensation, and a distinct metallic taste, it is
thus seen that the wires are conductors of the electric current.
These wires are termed rheophores. This which I now show
you is termed a double rheophore, it thus divides the current
and diminishes its intensity, and by this means I can make
it act upon two points at the same time, or by further
subdivision I can make it act upon any number of
points. Let me make it more evident to you that I have
a current of electricity passing along the wires. I now
place this galvanometer in circuit, and you see the needle
is slightly deflected, and in direct ratio to this deflection
I am able to ascertain the strength of the current which
is passing. We shall have more to say about this, but
I must first make some reference to two conditions con-
cerning the onward flow and retardation of the current,
namely, conduction and resistance, and let me tell you at once
that unless you make yourselves thoroughly acquainted with
these you never ought to apply electricity to the human body.
RESISTANCE AND CONDUCTIVITY. 301

It is a very simple matter for all we want to know of it, but
to.the advanced scientist it is still a matter of almost un-
fathomable importance.

The conduction of the current is dependent upon the
resistance which it encounters. The strength of the current is
evidence of the quantity of electricity flowing at a given rate in
a given time, which is determined by the electro-motive force in
the cell, and by the diameter, length and purity of the wire or
rheophore. The strength of a current must be relative to the
difference of potential of the element in the cell to which the
electro-motive force of the cell is due, as well as to the
conductors in circuit.

Resistance is the reciprocal of conpucriviry. In speaking
of the electrical transmission of power we know that
it is dependent upon the medium through which the
current is transmitted, that is, to the resistance which this
medium offers to its conductivity; therefore for practical
purposes and for measurement we consider certain standards of
known resistance, and for this reason we speak of resistance
rather than conductivity of the electric current.

Electrical resistance weakens the current.— The strength
of a current depends upon the initial force—the electro-motive
force—set up in the battery, and the resistance which the
current meets with in the battery and in the external circuit, and

is expressed thus, 8 =75 when S =current strength, E = electro-

motive force, and R = resistance.

The electro-motive force varies with the greater or less
difference of potential of the plates, and depends upon the
substances used for plates and the solution acting upon the
positive plate.

The resistance consists of external or wire resistance, and
internal or liquid resistance, and the above equation may be
E
l+w.

The liquid resistance varies for different liquids, and also
directly as the distance asunder of the plates, and inversely as
the size of the plates.

The wire resistance varies directly as the length and
inversely as the area of cross section of the wire (or as the
diameter of the wire). The rules for variation of liquid and
wire resistance are identical, for distance asunder of the plates
equals length of liquid, and area of plates equals area of cross-
section of the liquid.

When two or more cells are joined abreast, copper to copper,
zine to zine, to form one compound cell, the effect is not to

expressed, § =
302 ELECTRO-PHYSICS.

increase the electro-motive foree, but to enlarge the area of the
plates, and hence to reduce the liquid resistance. os

When two or more cells are joined im series, copper to zinc,
the electro-motive force is multiplied by the number of
separate cells; but the liquid resistance is alsa multiplied by
the same number, for the current has to traverse each cell in
succession.

A battery works to best advantage when the external and
internal resistances are equal. Generally for strength in
electrolysis, &c., the series arrangement is best ; for heating
wires the compound arrangement is best.

Prof. Ayrton in his lecture before the members of the
British Medical Association, at Bath, last year, ‘‘ On, the
Electrical Transmission of Power,’ made the following
practical remarks, which may enable you to comprehend more
fully what I am about to tell you :—

‘Let us study this electric transmission a little in detail.
I pull this handle and the bell at the other end of the room
rings, but in this case there is no visible motion of anything
between the handle and the bell. (Electric bell rung by an
electric current produced by pulling the handle of a small
magneto-electric machine). Whether I ring the bell by
pulling a wire, or by sending an air puff, or by generating
an electric current by the exertion of my hand, the work
necessary for ringing the bell is done by my hand exactly
as if I took up a hand bell and rang it. In each of the
three cases I put in the power at one end of the arrangement,
and it produces its effect at the other. In the electric
transmission how does this power travel? Well, we do
not know; it may go through the wires, or through the
space outside them. But although we are really quite in
the dark as to the mechanism by means of which the
electric power is transmitted, one thing we do know from
experience, and that is this—given any arrangement of
familiar electrical combinations, then we can foretell the
result.”

Now my object is to be practical, simply practical. I am
anxious that the current of thought and ideation shall be
complete between my brain and your own, that the difference
of potential of my brain shall engender ideational force which
shall be transmitted or conducted by intellectual media in
such a manner that it overcomes any resistance which is
normally associated with the highest intellectual capacities,
and so equalize our potentialities of thought that no further
current can be called into existence.

The seat of the electro-motive force in a cell has given
rise to, and is still a subject of, controversy. There is
RESISTANCE AND CONDUCTIVITY. 303

no doubt whatever that at every contact between dissimilar
materials an abrupt change of potential occurs, and that the
algebraic sum of all these changes, when the two terminals are
of the same material, is the final electro-motive force. The
electro-motive force of a cell is a measure, and may be con-
sidered as the cause of the energy of the current it supplies.
Mere contacts cannot be sources of energy. All work done by
a cell, whether in the form of mechanical work or of its
equivalent heat, is the result of chemical changes occurring.
Since work can never be created or destroyed, the energy
(including heat) of the current must be equal to the energy of
the chemical change producing the current. For instance,
when a current is passed through water the liquid is decom-
posed, and its constituents, oaygen and hydrogen, escape. To
tear these gases apart, and set them free, requires exactly so
much work as is equivalent to the heat that they can produce
on recombining.

I have in my hand two ordinary electrodes. They are made,
as you see, of wooden handles to which are attached brass cups,
and in these brass cups are pieces of wetted sponge. I attach
the terminal wires of the galvanic cell to the brass cups, having
my galvanometer in circuit ; now I bring the wooden handles
in contact, and if you watch the needle of the galvanometer
you will see that it is motionless, the electric current cannot pass
through the wood because it is a non-conductor, its power of
resistance is complete. I now bring the sponges into contact
and make the current entire, and you see it is complete by the
deflection of the needle. Instead of bringing the sponges
together to complete the circuit, I now bring the brass cups
together, and you will see that the needle of the galvanometer
is much more active than before when I brought the sponges
into contact. What does this teach us? Merely that the
conducting power of the sponge is less than the conducting
power of the brass ; or, in other words, the resisting power of the
sponge to the current is greater than that of the brass. Here,
then, we have very definite examples of the comparative
difference of resistance between the sponge and the brass. This
resistance to the flowing current is, as you see, external to the
cell, but, as I have before told you, the current experiences
another form of resistance in the cell which is known as the
internal resistance. Do please bear in mind that every current
in circuit experiences two forms of resistance, the one in the
cell itself, called the internal resistance, and the one outside the
cell, called the external resistance.

Evecrric Currenr—tIn order to make ourselves familiar
with the electric current we have several points to consider,
namely, its energy or capacity for work, ‘‘ electro-motive force”’:
304 ELECTRO-PHYSICS.

The transmission of power by the current in reference to
velocity, time, and space, ‘‘ strength of current”’ : The ordinary
modes of determining the strength of the current, and the work
which a current is capable of effecting by the power transmitted
in overcoming resistance and inertia. Let me first draw your
attention to three terms, with which according to their
reasoning you must become accustomed. I will do my best
to make their meaning clear to you.

Vout, the unit of electro-motive force (a Daniells’ cell has an
E M F of 0°98 to 1°10 Volt).

Oum, the unit of resistance.

Ampsre, the unit of current strength furnished by an EK M F
of one volt through one Ohm.

We speak of a battery of so many volts as we would of an
engine of so many horse power, so that a unit of electro-motive
force is defined as that which is competent to send a current of
unit strength, through a unit resistance, and thereby send a unit
quantity in a unit time.

A unit current is said to be the current which in passing
through a conductor of unit length exerts a unit of force on a
unit magnetic pole at a unit distance. And a unit of work, or
its equivalent, is done per second by a unit current, passing
through a conductor of unit resistance.

The velocity of a voltaic current in its transit through a
thick iron wire has been shown to be after the rate of seven-
teen thousand miles per second in an air line.

You may wish to calculate the electro-motive of your
battery, and this you can do by means of the galvanometer,
for all medical purposes. Twenty freshly charged Leclanché
cells will give a deflection of about thirty milliampéres if the
resistance of the galvanometer is = 1000 Ohms, so that their
electro-motive force about equals thirty volts (1°5 volt per cell).

Oum’s taw.—The current of electricity will be directly
proportional to the electro-motive force, and inversely pro-
portional to the resistance in the circuit, or mathematically
E
R
encounters the external resistance say, of the human body,
but it also encounters the internal resistance in the cell,
therefore we have two resistances, expressed by the following
equation : —

 

expressed, C = ; but, as we haveseen, the current not only

E E
Cc FR Pecomes rE
where R’ is the resistance in the battery and R” that outside.
The Ohm, then, is the unit of resistance, and the resisting
medium taken is a standard coil of copper, wire 1 mm. in
INTERNAL AND EXTERNAL RESISTANCE. 805

diameter and 48°5 m. in length, or a column of mercury 1 sq.
mm. in area, 1°05 metre in height, known as a rheostat.

Rueosrar has its name from the possibility, by its use, of
reducing the strength of a current till it becomes of a certain
predetermined strength. This it effects by introducing into the
circuit a resistance which can be increased or diminished at
pleasure. We assume that the resistance in a wire increases
with the length of the wire; so that if we introduce a certain
length of wire into a circuit, we diminish the current strength
more than if we introduced a shorter wire of the same material
and thickness. We have seen that the total resistance is made
up of the internal resistance R’, that is, the resistance of the
battery and the external resistance R”, taking, for example, the
resistance of the human body and electrodes.

In order to estimate the internal resistance of a cell we note
the current strength by the galvanometer and call this C,
which, as we know, is the quotient E R (electro-motive force
and resistance). We now introduce into the circuit a rheostat
and put in resistances until the needle of the galvanometer
shows that C is reduced one half. It is evident that the
increased external resistance must be equal to the internal, for
since

E E ’ aw
R = 2 R’ 5 R’ R = R

To ascertain the resistance of the human body we first note
the deflection given when the human body is in circuit; we
then replace the human body by the rheostut, and so arrange
the artificial resistance that the deflection of the needle of the
galvanometer is the same as before. This resistance must be
the same as that of the body, for

BE
Oe ag
In both cases R must be the same.

Again, to ascertain the definite resistance of the human body

by Ohm’s law it would read thus : i
electro-motive force
strenyth of current

For instance, if we have a rheostat of known resistance, say
800 Ohms, the resistance of the galvanometer being 70 Ohms
and that of 5 Leclanché elements 5 Ohms, we calculate firstly
for this purpose, the electro-motive force of the 5 cells by the
following equation : Strength of current x resistance = electro-
motive force. If the deflection of the galvanometer shows
8 mms. amperes it would, under the above-mentioned circum-
stances, be 0°008 ampéres x 815 Ohms = 6°5 volts.

The galvanometer may then be used for testing the ae

= Resistance.
806 ELECTRO-PHYSICS.

of the human body. The electro-motive force of the battery
is known as 6°5 volts, the resistance of the galvanometer being
70 Ohms and that of the battery 5 Ohms, the galvanometer
showing a current strength of 9 mms. ampéres, the total
resistance in the current would be

6°5 volts
0-009 ampéres ~ 722, 2 Ohm.

Deducting from this the resistance of the galvanometer and
that of the elements, we have 647 Ohms as the resistance of
the body.

Various means have been devised for collecting the elements
or regulating the current strength by including in the circuit
the number of cells requisite, etc.

In practice we measure the strength of the current by the
amount of work which it is capable of doing—the strength of
the current being dependent, as we have seen, upon its capacity
for work varying according to the quantity of fluid conveyed in
a unit of time through any sectional area of the channel.

Ampure.—tThe unit of current strength, and by Ohm’s law is
that of a current furnished by an electro-motive force of one
volt through one Ohm. Now, if you please, let me make this
clear to you. We have before us connected in succession a
voltameter and a vertical galvanometer, we also have a solution
of potass iodide on one part of this plate and some white of an
egg on the other part. 1 now connect one of my wires to a
Stohrer’s continuous current battery, the elements of which
consist of a series of zinc and carbon plates dipping into a
weak solution of sulphuric acid (1 in 10 parts of water), and
the other wire I attach to the galvanometer. The voltameter
is connected also with the battery and the galvanometer. This
which I move up and down on the top of the cells is
termed a sledge collector. It runs, as you see, in a
groove, and carries on its inferior surface two springs
which come successively into contact with these metallic
pieces arranged in two rows. To these pieces the wires
from the cells are attached. The sledge, if you observe,
carries on its upper surface two binding screws connected with
the springs to which I have attached my rheophores ; the handle
works upon what is called the band commutator or current
reverser. By means of this I can reverse the current from
negative to positive, or vice versa. The alternations or
reversions of the current are known as voltaic alternatives.
When the handle is vertical, as you see it now, no current is
flowing, it is said to be broken or opened (break or opening).
When I put it so, or so, either to the anode or kathode, the
current is allowed to flow ; it is then said to be made or closed
VOLTAMETER. 807

(make or closure). We shall refer to this again when speaking
of the effects of the current upon the human body.

To the ends of the rheophores I attach these two needle
electrodes, and I set the current in motion. I wantto demon-
strate to you successively the effect of the current, first upon
the voltameter, which I shall explain, secondly upon the
galvanometer, which I shall also explain, thirdly its effect upon
the iodide of potass, fourthly its effect upon the albumen of
the egg, so that we shall in this manner be able to ascertain
the strength of the current and the mechanical, chemical, and
physiological work of which it is capable. It is my usual
practice in these lectures to adopt this mode of procedure
because it enables me to bring before you almost every point
of interest in reference to the current itself—its strength and
the power which it possesses in overcoming resistances
according to the capacity of its electro-motive force.

A VoLTaMETER is an arrangement in which the chemical action
of the current furnishes the index of its strength. The volta-
meter which I have here is known as Gaiffe’s; it is figured and
described very accurately by Dr. de Watteville in his book
entitled ‘‘ Medical Electricity,” so that I will give you his own
words, which are sure to be correct. But before I do so, let me
tell you that when I pass the current through the water, if it
is of sufficient strength, it will decompose it into its constituent
elements, namely, ‘“‘oxygen”’ and ‘‘hydrogen,” in the propor-
tion of one volume of the former to two volumes of the latter.
The gases will ascend in two columns of bubbles of unequal
size; the lesser, the “‘oxygen,”’ will be given off at the anode or
positive pole, whilst the larger, the ‘‘ hydrogen,”’ will be given
off at the kathode or negative pole. As the gases rise so the
water is displaced in the inner tube. Now let us have
de Watteville’s description of this instrument.

‘A voltameter has recently been constructed by Gaiffe which
is calculated to fulfil many of the requirements of the physician
desirous of acquiring the means of estimating the strength of
his battery, or of the currents he uses for therapeutical
purposes. The instrument is represented in Fig. 38 and is
used as follows: The tubes are filled with water and the corks
fixed to their respective mouths. The current led by the
platinum wires or ‘electrodes’ decomposes the water into
oxygen and hydrogen, which ascend in the inner tube and
collect at the top. When the inner tube is filled with gas, the
inner cork is lifted out by means of the wire, the water enters
into the inner tube from the outer, and the instrument is ready
for further measuring. Now and then a little water has to be
poured into the instrument, so as to secure the refilling of the
inner tube when the cork is raised. This voltameter is a
808

ELECTRO-PHYSICS.

cheap, simple, and reliable instrument for estimating the

 

 

Fig. 388—T outer tube, C inner
tube, both fixed to a stand, P.—
6 and b' corks closing the upper
extremities of the tubes, b can
be lifted out of the inner tube by
pulling the wire A which passes
through the cork 0’.

O, O' apertures in the inner tube ;
FE’ platinum wires projecting
into the inner tube and connected
with the binding screws BB’ to
which the wires of the external
circuit are attached.

The inner tube is graduated, so
as to indicate the volume of gas
set free in cubic millimetres,

strength of currents, the electro-
motive force of the battery, and
the resistance in circuit. But its
applicability is limited to cases
where the current is allowed to
flow for one or more minutes.
For the measurement of currents.
of short duration, such as are used
in electro-diagnosis, for instance,
a galvanometer is necessary. A
few examples will assist the
reader in realizing the method
of measuring electrical magni-
tudes by means of the voltameter.

Place the voltameter in circuit
with the battery and the human
body. Note the amount of gas
collected in the graduated tube,
during any one minute, (1st, 2nd,
8rd,...10th, 11th, etc. minute).
Since 1 milliampére of electricity
sets free 10°3 cubic millimetres
of gas per minute, we have, in
order to know approximately the
strength of the current at any
time, only to divide the number of
c.mm. of gas set free during one
minute by ten. Or if we want to
know the total amount of elec-
tricity used during a certain
number of minutes, to divide the
total number of c.mm. of gas set
free by ten.”

I now close the current, and
you see the chemical combination.

of the gases is overcome by the power transmitted by the
current; the gases are being liberated, collecting and displacing
the water in the inner graduated tube. But now I want.
you to notice the deflection of the needle of the galvanometer
caused by the current which is in circuit, as well as its effects
in the electrolytic liquid of the voltameter. If we worked it
out carefully we should find that the amount of chemical work.
done, that is, the amount of decomposition effected, is directly
proportional to the current strength as measured by the
galvanometer.

GatvanometTeR.—The galvanometer is an instrument having
MILLIAMPERE. 309

a magnet freely suspended or pivoted in the centre of a gradu-
ated disk, which is easily acted upon or deflected by the passage,
in its neighbourhood, of a current of electricity in a coil of
insulated wire ; hence, if a magnetic needle be suspended, and
a current be passed either over or under it, the magnetic needle
is turned or deflected from its north and south position to a
direction east and west, in direct ratio with the strength of the
current.

A current from south to north over the needle causes a
deflection of the north point to the west. A reverse current
under the needle, that is, from north to south, also causes a
deflection west.

A current from north over the needle south causes a deflection
east. A reverse current under the needle, that is, from south to
north, also causes a deflection east.

It is clear, therefore, that a magnetic needle affords the
means of testing the presence, direction, and strength of current.
The strength of current is ascertained by the number of
degrees through which the needle is deflected, but it is remem-
bered in making galvanometers that the angle of deflection
does not increase proportionally to the current strength, and
this is instanced by the fact that whilst a current of 30 ma.
deflects the needle to about 45°, a current of 150 ma.. is
required to deflect it to 70°; of course, also, the magnetic
influence of the earth has to be taken into consideration.

Equal deflections on the same galvanometer always indicate
currents of the same strength. The galvanometer enables us
to calculate the strength of an electrical current by the amount
of deflection of the magnetic needle, this amount bearing a
certain proportion to the force exerted by the current in over-
coming the directive influence of the needle upon the earth.

The one-thousandth of an ampere, known as the MILLIAMPERE,
is the working unit as applied to our medical galvanometers,
and we have to thank Dr. de Watteville for its introduction.
He says, ‘This unit exactly suits the requirements of medical
practice, for a current of one milliampére is that given by three
Daniell’s through the average resistance of the human body—
that is, through parts of medium resistance and through
medium sized electrodes. Again, no system of measurement
is likely to be adopted unless its unit has a convenient name,
and it is obviously easier to record strengths of 1°5 or 15 ma. than
strengths of 001005 or ‘015 of an amptre. We havea parallel
instance in the use of the metre and millimetre. Experience
shows that applied with medium sized electrodes medical
currents range between 1 and 20 milliampéres, hence we may
conveniently designate such currents as ‘very weak,’ ‘weak,’
‘moderate,’ and ‘strong,’ according as they range from 1-5,
310 ELECTRO-PHYSICS.

5-10, 10-15, 15-20 milliampéres respectively; ‘very strong’
currents would in this classification range between 20 and 40
ma.”

Thé galvanometer which I now have in circuit is cailed
vertical as distinguished from another form called the horizontal
galvanometer. The work done by the current in deflecting the
needle of the vertical galvanometer consists in overcoming the
force of gravity acting on the needle instead of the direct
magnetic force of the earth, as is the case in the horizontal
galvanometer.

This instrument, which I now show you (Fig. 39), is called
Dr. Edelmann’s pocket gal-
vanometer; it indicates up to
80 ma.; if constructed only for
galvanization it indicates by
one-tenth of a ma. up to three,
and thence by single ma. up
to thirty ma. If the apparatus
is to serve for electrolysis as
well as for galvanization, it is
so divided that it indicates by
single ma. up to 25 ma. and
thence by divisions of 10 ma.
up to 250 ma. Mr. Schall
tells me that these instru-
ments are divided to meet the
horizontal intensity of London, and the greatest error in their
divisions is guaranteed not to exceed five per cent. If, for
instance, a galvanometer of this kind indicates 10 ma., the
actual value of the current measured by the most sensitive
apparatus would prove to be not higher than 10°5, and not
lower than 9°5 ma.

The magnet oscillates inside a solid copper block, in
consequence of which the needle after two or three short
oscillations takes its proper position.

In horizontal galvanometers the deflections depend upon the
strength of the current, the intensity of the local terrestrial
magnetism, where the galvanometer is used the inertia of the
needle which has to be overcome, but not upon the amvunt of
magnetism of the magnet rtself.

The inertia is slightest in the case of instruments, the
magnet of which is suspended on a cocoa fibre. I have such a
galvanometer here, Dr. Edelmann’s Universal Galvanometer;
it has a copper damper acting so perfectly that after two
oscillations the needle takes its proper position. From 0
to 8 the instrument indicates every tenth part of a milliam-
pére, and even the hundredth part of a milliampére can be

 

Fig. 39.
GALVANOMETER, 811

determined; it shows the milliamperes one by one from
0 to 80, and ten by ten from
0 to 800. The greatest error
is guaranteed not to exceed
0°5% (Fig. 40).

This instrument has the
great advantage, that in its
graduation, being correct for
a certain locality, it willalways
remain so.

This instrument (Fig. 41),
is the same construction in
another shape. In order to
enable the operator to read
the indications of the instru-
ment from a distance, the
scale igs vertical and very

Fig. 40. E large; the index, a straw, is

bent at the end in a right

angle. Owing to its large diameter and glass cover, the

instrument is not portable, but very convenient for the
consulting room of the physician.

 

     
 

  

 

Sit |

  
312 ELECTRO-PHYSICS.

I have just said the galvanometer before you has its magnet
vertical, and you see the needle is at rest and vertical, for the
current is shut off. The deflections of the needle are depen-
dent upon the strength of the current, the dip and magnetism
of the needle. I now turn on the current, and I would ask you
to denote the deflection of the needle. You say the needle
moves to the right and it points to 10. This shows me that 1
have a current passing of 10 milliampére strength, just the
strength of current you use for ordinary medical purposes. I
now reverse the current, and you see the needle moves in the
opposite direction, but it still points to ten. The strength of
current is exactly the same, but it is now travelling in the
opposite direction to what it was before, and influences the
needle as I have previously explained to you. If I increase
the strength of the current you will see that the magnet is
more deflected, and by the dial you can read off the strength
of the current whatever it may be.

Now let me call your attention again to current resistance.
You see the electrodes, which I have at the ends of my
wires, are simply steel needles, so that I have scarcely any
external resistance. I take this flat wet electrode (a piece of
zine covered with chamois leather) and I stick one needle into
one end and the other needle into the other end; I turn on the
current, and you observe the needle of the galvanometer instead
of registering 10 only registers 5 milliampéres, so that the
resisting power of this pad must be equivalent to so many
units of resistance, which we have no need here to calculate.
Thus far I hope I have made clear to you for practical purposes
the nature and the value of the voltameter and the galvano-
meter. We proceed now, if you please, to note the effect of
the current upon this clear white solution of iodide of potass.
You know that this salt is composed of a reddish brown element
known as iodine, and the element potassium in chemical
combination. J now dip the points of the needle electrodes
into this solution, and the result shows that the electro-motive
force is far stronger than the chemical force, and the elements
are liberated. The iodine, you see, by its red colour is found at
the positive pole, or anode, and the potass at the negative
pole, or kathode.

Here I have some white of an egg with which you are familiar,
I transmit the current into this albuminous substance, which is
composed of four elementary bodies, namely, carbon, hydrogen,
nitrogen, and oxygen. It forms the chief part of muscle,
nerve, and gland, and occurs in all the fluids of the body,
including the lymph, blood, and serous fluids. Now notice the
electrolytic effect of the current. You see the kathode is
becoming coated with a dense opaque mass, whilst the anode is
CURRENT RESISTANCE. 313

left free. But this is not actually the case, the water (H O) of
the albumen is decomposed, oxygen is set free at the anode,
and hydrogen with other products at the kathode; the action
of the kathode is decidedly catalytic compared to the anode. I
want you to observe the galvanometer whilst the points of the
needles are at the edge of this alouminous mass. You see the
deflection is greatly decreased, owing, of course, to the resist-
ance which the mass presents to the current, and to polarization
of the electrodes which weakens the current, just as polarization
within the cell does. Now this leads me to a practical point.
If instead of albumen I were operating upon a tumour, and I
directed my assistant to employ a current strength of so many
milliampére, I should mean that the galvanometer should regis-
ter this number of milliampéres after the needles were inserted
into the tumour. But this subject I shall refer to again when
speaking of the electrolysis of tissue, but remember once more
that the kathode is catalytic, and that the anode may be placed
upon an indifferent part ofthe body. By these four simple expert-
ments we learn that the current of electricity can decompose
water, influence the magnet, decompose chemical salts, and
destroy organic matter; and we can calculate by means of the
galvanometer the exact quantity of electricity or its electro-
motive force which is necessary to bring about these results ;
therefore the importance of the galvanometer as a mode of
measurement cannot be overestimated. By the use of the
galvanometer in circuit you are quite independent of the state
of your battery, because it must be evident to you, after a
moment’s consideration, that the electro-motive force of the
cells and their internal resistance differ from time to time in the
same battery, and from one battery as compared with another.
Sensory and motor phenomena are so variable that they
cannot be relied upon. Dr. de Watteville very truly observes
that, ‘A few days spent in observation with a cell, a rheostat
and a galvanometer will save many a misunderstanding, and
make aman a better electrician than as many months reading
about ‘Ohm’s law and its consequences.’”” Let me tell you
this much, do not think you know anything practically about
electricity until you have dissected a battery, rheostat, galvano-
scope, and primary and secondary coils of an induction appara-
tus, and found out for yourself how they act and react, the one
upon the other. I spend many a quiet hour in this way with
great pleasure, satisfaction, and instruction. ; ;

There are one or two other points in connection with the
galvanic current to which I should like to allude. We speak
of the constant current as regards its constancy, regularity,
maintenance and persistency. You know a battery cannot go on
working for ever: like everything else in action it must suffer
314 ELECTRO-PHYSICS.

from wear and tear, and the greater its activity the more rapidly
does it become exhausted. But as the battery becomes ex-
hausted, the current gets irregular, and fitful: this usually
depends upon a deficiency of chemical action, a diminution of
potential and electro-motive force, increase of internal resistance
and polarization.

Pouarization—of which I don’t think I have spoken to you
—is due to the evolution of hydrogen and oxygen in the cell
from the electrolysis of the water, the oxygen going to the zine
and the hydrogen going to the carbon. Inthe Leclanché cell,
for instance, the carbon plates are mixed with peroxide of
manganese, and the latter substance is also put in the cell in
order to remedy this very serious defect. If this is not done a
counter-current is generated from the hydrogen to the oxygen
which may be strong enough to neutralize the original current
altogether. Take a simple cell with copper and zinc elements
and watch the copper plate during action ; it quickly becomes
covered with a film of hydrogen bubbles, which adhere to its
surface, a very few of them rising through the liquid. This
film (1) offers increased resistance to the flow of electricity
between the plates, and (2) sets up a force in the opposite
direction, tending to produce a current from the hydrogen to
the zinc. The accumulation of the hydrogen bubbles on the
negative plate and consequent tendency to reverse the polarity
is called polarization: a cell or battery which shows a great
loss of current strength due to the presence of hydrogen on the
negative plate or plates is said to be polarized.

Remedies for Polarization: 1. Stirring the liquid or blowing
air through it, brushing the negative plates or lifting them out
of the liquid frequently, might get rid of the hydrogen by
mechanical means, which, however, would be troublesome, and
would interfere with the course and strength of the current.
A better contrivance is Smee’s Battery, which has zinc and
platinized silver plates immersed in dilute sulphuric acid.
The silver plates are sprinkled with fine platinum; this forms
points upon which the bubbles collect, and from which they
freely ascend to the surface of the liquid. Smee’s is a handy,
compact, single-liquid battery, but is rather expensive.

_ %. Certain substances—such as bichromate of potash and
bleaching-powder—if added to the acid, unite with the hydro-
gen, and prevent the film by chemical means. If used with
copper they would also unite with that metal; hence, with
these substances the negative plate must be platinum or
carbon. The Bichromate Battery is a useful form, consisting
of zine and carbon plates in a mixture of dilute sulphuric acid
and bichromate of potash. Usually a single cell is fitted with
three or five plates so arranged that the two sides of each zinc
THE RESISTANCE OF THE HUMAN BODY. 315

plate are opposite two carbon plates. This solution acts on
zine when the circuit is open; provision is therefore always
made for lifting the positive plates out of the fluid when the
battery is not in use.

THE RESISTING POWER OF THE HUMAN Bopy to the electric
current is more or less a negligible quantity, and this must be
the case. When we take into consideration that the epidermis
varies aS a resisting medium according’ to its density, its
thickness, its vitality, and its dryness or moistness, we are
not astonished when we hear that the resistance of the human
body is something varying between 1000 and 10,000 Ohms.
Perhaps if we set down the resisting power of the human
body as between 2500 and 3000 Ohms, we shall be fairly
within the mark.

In determining the measure of resistance it is, of course,
necessary to bear in mind that each tissue has its own re-
sisting power, the epidermis having a greater resistance than
all the other tissues put together, in fact, the epidermis may be
almost looked upon as an insulator; broadly, we shall not be
far wrong in stating, that in point of resisting power the tissues
may be arranged thus: ist, Skin; 2nd, Fat and areolar
tissue; 8rd, Muscle; 4th, The contents of the blood vessels.
If you are anxious to compare the resisting power of the
epidermis with that of the skin, make a scratch upon your
finger, place one flat electrode from a faradic battery at the
back of your patient’s neck and another at the back of your
own, increase the current to a comfortable degree of strength
as felt between the normal epidermal surfaces of both your
patient and yourself, now apply the raw surface of your
scratched finger, and the resistance will be so lessened as to
make the current painful, not only to yourself, but to your
patient. It is computed that the body resistance (sub-
epidermal) is about 500 Ohms, but here again there is con-
siderable difference of opinion, and even practically under the
same given conditions. The galvanometric readings differ, but
Ihave upon more than one occasion been astonished at the
loose way in which these examinations have been made, even
for statistical purposes. A very little pressure more or less
upon the skin by the electrode will alter the deflection of the
magnet. In the electrical treatment of uterine fibroids,
according to Dr. Apostoli’s mode of procedure, when the needle
is inserted into the body of the tumour, the resistance is usually
from 350 to 400 Ohms. ahs

As the resistance of a conductor varies inversely with ite
diameter, it is only fair to assume that the resistance of the
skin will be diminished by doubling, trebling, etc., the size of
the electrodes. The resistance of the body will vary not so
316 ELECTRO-PHYSICS.

much according to the distance of the electrodes from each
other as according to their diameter. The changes produced
in the skin by the galvanic current if too strong, or if applied
for too long a time, give rise to two different conditions at the
anode and kathode respectively. Under the anode an eschar
is formed with an acid re-action. Under the kathode an
ulceration is produced with an alkaline re-action.

Farapism.—Faradism or faradisation is named after our
great scientist, the late Faraday. He discovered that a gal-
vanic current which varied in its strength had a similar effect
upon a neighbouring circuit, so that the current produced in
the neighbouring circuit has been called a sECcONDARY or
INDUCED current. That is to say, the secondary current is a
current produced in a closed circuit by the influence of another
current either galvanic or magnetic. When the galvanic current
is the inducing agent the induced current is called Galvano-
faradic; when the magnet is the inducing agent, the
induced current is called Magneto-faradic. The magneto-
faradic machines are now rarely used for medical purposes.
They consist mainly of an armature of soft iron revolving in
front of the poles of a horse-shoe magnet and a pair of coils of
insulated copper wire.

We have, therefore, two currents to consider, the primary,
extra, or inducing current, and the current induced, or secondary
current. If a spark discharge of frictional electricity is sent

through a wire, a neighbouring
(PA closed wire circuit in close prox-
imity is simultaneously traversed
by a discharge capable of leaping
across a breach in the second
circuit and igniting gun cotton.
Pe = RR. Further, the secondary discharge
so produced is itself able to cause
a tertiary dischargein athird wire.

Uy Again, if a magnet is moved in
Uf the neighbourhood of a closed
B metal circuit, such as a ring, a

Fig. 42. current of electricity is generated

in that circuit of metal. We now consider by the help of this
diagram (Fig. 42), galvanic induction phenomena similar to the
frictional electric induction phenomena just described. <A
galvanometer (G) having been tested to see what direction
of motion of the needle corresponds to the passage of the
electricity in at one terminal, is attached to a straight wire (8).
Another straight wire (P) can be fastened to the poles of a
battery, and, by means of a rheotrope, the current in P can be
started, stopped, or reversed. The following relations im-
FARADIC OR INDUCED CURRENT. 317

mediately declare themselves. Whena current is started in P
from left to right, the galvanometer needle turns in such a
direction as to show that a current passes through S in the
opposite direction. The current in P being continued from L
to R, the current in S ceases. On stopping the current going
in P from L to R, a current traverses § also from L to R, but
immediately ceases. If the current be now started in P from
R to L a momentary current from L to R passes along 8. On
stopping the P current from R to L, a current from R to L
passes along 8. So that, in general terms, the current in the
secondary is in the opposite direction to that of the primary
when the primary is started ; when the primary is stopped the
current in the secondary is in the same direction as that in
which the current flowed before stoppage in the primary.

Strength of Induced Currents.—The strength of an induced
current depends upon the strength of the inducing current, its
nearness to the induced current, and the length of the opposed
parts. The induced current, other things remaining the same,
varies directly with the strength of the primary current, both
when the latter is started or stopped. It varies also as the
product of the lengths of the two currents. Accordingly, the
strength of the induced current is much exalted, if its folds
of wire are many and parallel to the many folds of wire of the
primary.

Electricity induces Magnetism.—Not only will magnetism
induce electrical currents, but electricity will induce magnetism.
Take a piece of soft iron—a poker will do—make a coil round
it with insulated wire connected with a battery. The wire
may be covered, or paper may be rolled round the iron to keep
the current from passing to it, since the action is to be
induction. Immediately on starting, and during the whole
time of the flow of the current, the iron becomes and remains a
magnet. If we dip into iron filings the wire of a closed circuit
having a strong current passing through it, the filings around
become magnetic, and cling together in masses round the
wire, as if it were magnetic also.

Temporary and Permanent Magnetization by Hlectricity.—
With soft or wrought iron, the magnetism ceases when the
current is stopped, and we have a temporary magnet. With
steel, the magnetism, or a large portion of it, remains after the
current has ceased, and we have a permanent magnet. Soft
iron is more readily and more strongly magnetized than steel
by a current circulating around it, and electro-magnets are
usually temporary magnets. They are used to impart their
magnetic properties to steel in the manufacture of permanent
magnets, to obtain induction currents, and in telegraphy.

In the ordinary apparatus for cwrrent induction we have two
318 ELECTRO-PHYSICS.

separate and distinct coils of wire wound round a reel. (1,) The
primary coil, for the primary or extra current is usually made
of much coarser wire than that for the secondary, and is wound
round the reel first. (2,) The secondary coil, for the induced
current is usually made of much finer wire than that for the
primary. When the wires are thoroughly insulated they can
be adapted to the same reel. (8,) The core, which consists of
a bundle of soft iron wires of equal lengths, fills the hollow of
the cylinder and projects a little outside the hole of the reel.
A soft solid iron core may be used, but the wires are capable
of stronger magnetization. The core may be either (1) fixed
or (2) fitted so as to be wholly or partially withdrawn, or (3)
covered with a brass tube which may be withdrawn at-pleasure
so as to expose the whole or part of the core to the inductive
influence of the primary. Thus far we have our coils of wire,
primary and secondary, wound round one reel, and the magnet
fastened on one block of wood. We must now have a contact-
breaker and a bichromate or Leclanché’s cell. Two binding
screws are fastened to the wood for receiving the wires from
the Leclanché cell. To one of these binding screws one end
of the primary is joined. The other end of the primary is
fastened to the pillar which carries the screw of the contact-
breaker ; a wire between the other half of the contact-breaker
and the remaining binding screw completes the circuit. The
contact-breaker consists of two parts, of which one carries an
iron hammer head upon a spring, the other has a screw with a
platinum point. The hammer is fixed on the same block of
wood as the wire coil and the core, so that the head of the
hammer is about a quarter of an inch from the end of the core.
The screw is fastened so that when at rest it touches the head,
and is so arranged that by turning the screw the head may be
pressed nearer the core when necessary.

Explanation of figure for demonstrating galvano-induction (Fig.
48).—The wires of the Leclanché’s cell (LC) generating the
primitive (not primary) current are attached to C C, and the
galvanometer (G) is attached by the primary current wires to
P P, or it may be attached to the secondary current wires SC’
SC’. The current may be made or broken at B.

The primary coil (PC) is attached by its two extremities (1)
with P and P, and (2) with the stud under Band C. The
spring at B when pressed down connects the stud with C. The
letter M denotes the soft iron rods for magnetization which are
placed in a hollow space surrounded by the primary coil (PC)
The letters S C denote the secondary coil, and the extremities
of the thin wire which is bound round it are connected with
the binding screws (SC’ SC’). Of course the secondary coil
(8 C) is hollow so that it may fit over the primary coil (P C). The
319

 

 

 

Fig. 48. Figure for demonstrating the galvano-faradic or induced current.

 

See explanation on opposite page.
320 ELECTRO-PHYSICS.

primary current through P C is alternately made and broken
by means of the spring (B). Therefore the primary or extra
current is obtained at P P, whilst the secondary or induced
current is obtained at SC’ SC’ through the binding screws at
the top of the secondary coil.

The induction current from the secondary coil (S C) isalways
increased with the strength of the current in the primary coil
(P C) and of the intensity of the magnetism in M, and, as before
observed, the two currents increase according to the number
of turns in the wires in the primary coil (P C) and the secondary
(SC), and the juxtaposition entire or in part of the secondary
coil (S C) with the primary (P C). From this description, and
from the plate, we see that a galvano-faradic machine consists
of a battery (L C) generating the primitive current of an inter-
ruptor (B) of a primary coil of thick wire (P C), of a bundle
of iron rods inside the primary coil and of the secondary coil
(S C) made of thin wire.

Action of the Induction Coil_—The terminals of the secondary
wires are brought near one another; the binding screws con-
nected with the primary are joined to the battery wires, either
through the commutator or directly. (1) A current sweeps
round the primary, which both converts the core into a magnet
and induces amomentary reverse current in the secondary. (2)
The sudden magnetization of the core would alone start a
reverse current in the secondary; its effect is therefore to
strengthen this secondary current. (8) This magnetization also
attracts the hammer of the contact breaker and stops the current
by breaking the connection between the hammer and the screw.
(4) This stopping of the current causes a demagnetization of
the core—a direct current in the secondary, due to the ceasing
of both the primary and the magnet—a return of the hammer-
head to the screw, since the head is no longer attracted, while
the tension of the spring restores it to its place. .A second
current now passes through the primary, and the whole process
isrepeated. The hammer vibrates automatically, i.e., of its own
accord, or rather as the result of the action of the instrument ;
each make of contact causes a reverse current, and each break
of contact causes a direct current in the secondary. The result
is a rapid series of momentary secondary currents which over-
leap the space between the terminals or electrodes, and appear
as bright sparks. When the hammer is held by the hand and
made to vibrate very slowly, the separate sparks, due to make
and break, may be seen.

It may be also noticed that the spark on break of contact
is stronger than on make of contact. This is the effect of the
extra current which wéakens the primary on starting and
strengthens the primary on stopping. The difference is seen at
SCHALL’S FARADIC BATTERY. 821

the platinum screw of the contact breaker. The great heat of
the spark on break of contact rapidly spoils the end of the
screw unless it is made of platinum, which is very difficult to
fuse.

At each make of the galvanic current we have two induced
currents, the self-induction in the coils of the primary wire
itself, and the secondary induced current in the secondary coil
of wire, opposed to it in its direction. At each break there are
also two induced currents flowing in the same direction as the
battery current; from this it is rightly inferred that the
primary induced current is weaker than the secondary induced
current. What we say is, the finer wire in the secondary coil
gives a current of higher tension. Dr. Apostoli speaks of a
faradic current of high tension; this really means, as far as I
understand it, that the induced current is made to pass
through in the secondary coil a series of loopings of very
fine wire.

This little faradic apparatus, which I now show you, is made
by M. Gaiffe, of Paris, and its great advantage is its portability.
The galvanic current is generated from these two chloride of
silver cells, and the secondary coil for the secondary current is
made up of two parts, and reversible, so that the secondary
current obtained from one part is of a higher tension than that
obtained from the other part. In point of fact the wire of one coil
is much thicker than that of the other coil. The current obtained
from the thicker coil of wire is superior for the purpose of
stimulating the muscles through the wetted skin where the
resistance is less, whilst the current obtained from the finer
wire is used for exciting the dry skin where the resistance, as
you know, is very great.

The little faradic battery
I now show you (Fig. 44)
consists of an induction coil
with commutator for primary
or secondary current. The
exciting fluid is a solution of
chromic acid, and it is very
convenient and portable, and
quite powerful enough for all
ordinary purposes. It is put
in or out of action by raising
or depressing a stem at the
back of the box which is
connected with the zinc plate
80 as to elevate it above the
fluid, the carbon only re-
maining immersed, or to lower

 
822 ELECTRO-PHYSICS.

it into the fluid and set up galvanic action. The variations
of power are here controlled by a small lever moving over
a number of brass studs placed as a segment of a circle and in
contact with the coil at different points of its length. The
mode of charging the battery is as follows. Unscrew the nuts
at the side of the piston and turn the bars from under them ;
take out the back part of the battery and turn the lid round
until it comes off ; fill the bottle about half full with a mixture of
bichromate of potash and sulphuric acid (or solution of chromic
acid), replace the cover and the battery ; turn back the brass
arms and screw the nuts tightly down upon them as before ;
insert the connecting wires in the clamps and push down the
piston, when the battery will act at once. The power of either
current is increased by turning the lever from right to left.
The piston should be drawn up when the battery is no longer
in use, and folded down by means of a hinge adapted to it for
this purpose. When the action of the battery becomes feeble
throw away the old fluid, rinse the bottle, and pour in a fresh
charge. It is very important in all electrical applications to
make sure that contact is everywhere complete, and that all
the parts are clean, want of cleanliness is often the cause of
failure, and the absence of it gives rise to more disappointment
and annoyance than is usually believed. Ifa battery is found
to be out of order and no work can be got out of it, the reason
will frequently be that some dirt has accumulated between one
or other of the connexions, thus severing the continuity of
metallic contact ; this should be diligently sought for step by
step ; a very thin film of non-conducting matter will interrupt
the course of the current. The bichromate solution should be
prepared as follows: Dissolve 3 to 4 oz. of bichromate of potash in
164 ounces (fluid measure) of boiling water; when cold, or
nearly so, add one fluid ounce of strong sulphuric acid. The
chromic acid solution is made by dissolving four ounces of
Byng’s salt in one pint of water. The strength of the dilute
sulphuric is usually one part of acid to nine or twelve of water.
The solution of ammonium chloride is made by dissolving as
much of the salt in boiling water as it will take up, and using
the clear fluid when it is cold.

The combined battery which I now show you possesses many
advantages (Fig. 45). I will endeavour to describe its
constituent parts to you. In the lower part of the case we
find placed the required number of Leclanché’s cells, which are
connected together in ‘‘ series,” by means of screws, and a
well insulated copper wire unites each single element with one
of the pegs of the current selector, which are placed here upon
the left side. By turning the crank of the current selector
in this manner, the number of the cells in action may be
SCHALL’S COMBINED BATTERY. 323

 

conveniently and without shocks increased or diminished, so

“as to regulate the strength of the current. The current
selector is so arranged that you may begin with the last cells
as well as with the first, or with any cell you like. The
advantage of this is that the first cells shall not be more
quickly used up than the last.

Tn addition, we find provided a current interrupter and a
current reverser, and also one of Edelmann’s galvanometers
which indicates from 25 to 250 milliamperes and shows
with great accuracy the strength of current passing through
the patient.

Mr. Schall tells me the batteries which he is now con-
structing are provided in addition with a powerful Dubois
Reymond sledge coil, whose strength of current can be
conveniently regulated, a commutator for adapting the

“primary current, and Dr. de Watteville’s key for obtaining
324 ELECTRO-PHYSICS.

from the same terminals the galvanic or faradic, or both
currents combined, without changing the cords. There is
certainly one very great advantage possessed by Mr. Schall’s
arrangement of the Leclanché’s cells which one does not find
in batteries generally, and this is that they can be thoroughly
re-charged by any person without difficulty, thus obviating the
troublesome necessity of constantly sending them back to the
manufacturer.

Gatvanic Cautery.—I wish you to understand that currents
of electricity can be caused by heat. This is called thermo-
electricity, concerning which I have nothing to say to you.
My object now is to call your attention to the heating effects
of a galvanic current, and the best form of apparatus with
which I am acquainted to bring about this condition for
surgical use, and to which the term galvanic cautery is applied.
Cauterization has long been adopted by surgeons for the
removal of diseased parts by heat; that is by the trans-
formation of electric energy into that of heat energy. The
stronger the electric current, and the greater the resistance of
the wire, the more intense will be the heat produced, according
to what is known among the physicists as Joule’s law. ‘‘ The
quantity of heat generated in a certain time in any part of the
galvanic circuit is directly proportional to the resistance of this
part of the circuit, and to the square of the strength of the
current.”

The total amount of heat generated in a battery is
proportional to the amount of zinc used, and is equal to the
quantity of heat which becomes free by the chemical action in
the battery. If the elements are short circuited, such as we
find them in our cautery batteries, the two electricities
neutralize each other in the proportion in which they are
generated, without doing any other work than producing heat
in the burners, so you see the energy of our battery, finding
no other vent, expends itself, and is actually converted into heat.
The temperature of the burner depending upon the difference
of the heat generated and the heat radiated will be the higher
the greater the current and its own resistance, and the
smaller its surface and power of radiation, hence under these
conditions we find, as I now demonstrate to you, this burner first
passes to a dull red heat, then to a bright red heat, and finally,
as you now see, to a white heat. Batteries with the Leclanché’s
elements are of little use for heat generating purposes, on
account of their internal resistance being too great, and also
that the chemical action is too feeble; and for this reason the
resistance in the battery is reduced as far as practicable by
selecting elements with large plates, and having resistances
diminished as much as possible by closeness of juxtaposition
VOLTOLINI'S BATTERY. 325

without coming into actual contact. By this method most of
the heat generated by the electricity shows itself on the
platinum wire. The total quantity of heat generated in the
circuit is proportional to the amount of zinc consumed in the
battery. You have before you one of Prof. Voltolini’s batteries
modified and manufactured by the well-known electrician
Mr. Schall (Fig. 46).

 

Fig. 46.

This battery is made up of eight carbon and four zinc
plates ; the latter are mixed together with some mercury, 80
that it is not necessary to amalgamate them.

The chemical exciting agent is contained in an ebonite
vessel, which can be raised or lowered by means of a crank,
and can be fixed at any height. A rheostat of wire of ten
Ohm’s resistance allows a very fine graduation of the current
strength for lamps as well as for cautery purposes, and by
means of two straight or two bent wires the cells may be
connected parallel when required for cautery purposes, or in
series if intended for electric light.

Mr, Schall informs me that one charge of the battery
will last for several weeks, but this of course depends upon
how frequently it is used. The wire carriers and handles are
made of various shapes, but it requires a little practice to
become familiar with their use. It is quite a vexed question
as to how far the galvanic cautery is superior to the knife, but
326 ELECTRO-PHYSICS.

in all minor operations, electrolysis should be equal to,
and in some cases superior, to galvano-cauterization.

Mr. Schall has now an excellent form of storage battery for
surgical work, which is likely to come into extensive use; it
has the advantage over the primary battery inasmuch as the
accumulator gives an absolutely constant current during the
specified period of discharge, and is always ready for use: it
not only answers the purpose of cauterization, but is also
useful for small glow lamps, induction coils, dental motors, &c.

The two sizes of accumulators for these purposes most
commonly adopted and made in a portable form are a 4-cell
battery of three plates in each and a 2-cell battery of seven
plates in each.

The accumulators are refilled as required.

Static Exzcrriciry—Electrization.—This mode of applying
electricity is convenient and effective. In the first place it
can be applied without the electrodes coming into contact with
the skin; in other words, there is no occasion for the patient
to undress. It is largely used upon the continent, and I believe
I am right in stating that M. Charcot thinks it useful and
prescribes it in certain neurosal affections. I have used it
extensively both in hospital and private practice. The greatest
drawback to its becoming more general is due to the fact that
the ordinary machines will not act well unless atmospheric
influences are favourable, for the air must be dry and the
friction maintained with regularity, by means of a small gas
engine. I have been particularly struck with its effects in
muscular atrophy, and it certainly has produced unquestionably
good results when both faradization and galvanization have
seemed to be useless.

These conclusions are borne out by the remarks of Dr.
William J, Morton, in a paper read before the American
Neurological Association, entitled ‘‘ Notes on a year’s progress
in medical electro-therapeutics by statical electrization.” Dr.
Morton says that while conceding the comparative incon-
venience of static machines he felt more confidence than
formerly, even that statical electricity, as a curative form of
treatment, was fully equal, if not superior, to galvanism and
faradism. The diseases in which, in his opinion, static
electricity was equal or superior to other forms of electricity
were paralyses, where other forms of electricity would be
advised, neuralgias in every form, spinal irritation, rheu-
matism in all its forms except the acute, and hysteria in all
its manifestations. I must say that my experience is quite in
agreement with that of Dr. Morton, and I cannot commend it too
highly in muscular atrophies of protopathic origin, but I have
no time to discuss the therapeutic effects of static electricity
STATIC ELECTRICITY. 327

in this lecture. The machine which I have here is a
modification of ‘‘ Wimshurst’s Influence Machine.” If you
sit upon this well insulated stool and take hold of the brass
rod which is known as the prime conductor, the surface of
your body will become charged with positive electricity, whilst
the surrounding air is rendered negative. You are now in an
electric bath; that is to say, the surface of your body is
bathed in the electric fluid. I have here all kinds of
electrodes of varying resisting power, we say some are bad
and some good conductors. So long as the machine is in
operation I can withdraw the electricity from your body in a
dense or in a diffused form just according to the nature of the
electrode which I employ.

The following illustrations demonstrate a new form of
electric ‘‘ influence’ machine for medical purposes, designed
by Professor Lewandowski, of Vienna.

Fig. 47 represents the machine ; Fig. 48 the whole apparatus
for franklinisation ; and Fig. 49 the internal arrangement of the
essential parts of the machine.

The two vertical iron supports, aa, and bb, (Fig. 47), are
screwed to the four-legged wooden frame Ra Ra,, their tops
being joined together by the vulcanite rod a b. These two
uprights support the axles e f, W, and W,, which are parallel
to each other. The axle ef is fixed, and made of steel. Upon
the chief axle e f, there are two vulcanite collars, one of which
is joined to the pulley r, and the other to the pulley r, (Figs. 47
and 49). In the middle of these two collars there are, on the
chief axle, two hard-gum cylinders T (Fig. 47), one within the
other; T T, (Fig. 49). The pulley r is connected with the
internal cylinder T,, whereas the pulley r, is connected to
the external cylinder T so that the internal cylinder T,
and the external one T can be rotated quite independently
(Fig. 49).

The two lower axles W, W, (Fig. 47) each carry a large
pulley, R R,, and a toothed wheel. The large pulleys, R R,
are respectively united by means of straps to the superior
pulleysrr, (Fig. 47 and Fig. 48). Theaxle W, moreover carries
the handle k (Fig. 47). This whole arrangement allows the
two cylinders to be turned in the reverse direction when the
handle is rotated only in one direction. The wooden frame
carries besides two uprights, the lower parts of which are made
of glass and the upper of metal; they terminate in the metallic
knobs mn (Fig. 47 and Fig. 48). In the middle of these
supports are two metallic knobs Sk Sk, (Fig. 47), each carrying
a collecting comb in close proximity to the external cylinder.
The fixed steel axle ef carries a vertical metal rod inside the
cylinder. In the knobs mn (Fig. 47) the conductors A, A, can
328 ELECTRO-PHYSICS.

be moved to and fro in the horizontal direction. If the knobs
of the conductors are brought near each other so as to come

A,

 

into contact when the handle is turned in any direction, it
suffices to touch the surface of the external cylinder with a
strip of hard caoutchoue which has been rubbed with cloth
(for instance, with the coat) for exciting or charging the
machine. This manifests itself by a whizzing sound. The
strip of hard caoutchouc must be approached just in the
middle of the two collecting combs Sk Sk, (Fig. 47).

When the rotation is again interrupted, the charge of the
cylinders with electricity lasts for several hours as the result
LEWANDOWSKI’S MACHINE. 329

of a single rotation. The advantage of this over all other
machines of the kind consists in the very convenient and
durable form of the electro-motors, that is, the cylindrical
form ; furthermore, in the choice of the material (hard gum),
which is more durable than glass, as well as in the hermetical
closure of the hard gum cylinders. Owing to the latter
quality, the machine could be kept in any place, in dry as well
as in moist air, and used at any time, without being damaged,
as neither air nor dust could change the internal surface of the
external cylinder and the two surfaces of the internal cylinder.
The machine is moreover very portable, and not dear (75
florins, about £6). Other advantages are the long duration of the
electricity once produced, even after the rotation of the handle
has ceased; the possibility of rotating the latter in an inverse
direction without discharging the machine; and the easy
change of the poles.

 

 

Fig. 48.

In Fig. 48 the rest of the apparatus necessary for franklinisa-
tion as devised by Professor Lewandowski is illustrated. It
must first be remarked that when the machine is charged
without the insertion of Leydenjars (L, L,, Fig. 48), and the
discharging rods are removed from each other, a few sparks
appear between the knobs of the conductors. If, however, the
330 ELECTRO-PHYSICS.

Leyden jars are inserted, quite powerful white sparks appear
between the discharging rods. The rest of the apparatus is
composed of two stands (St, St,, Fig.48) for different electrodes,
as, for instance, for the cap K (Fig. 48) for the electric head
douche, which is fixed to a stand (St,, Fig. 48), and is movable

 

Fig. 49.

in all directions. The cap K is provided with spikes; the cap
KK, on the table (Fig. 48) is smooth. The apparatus also com-
prises the four-legged insulating stool J (Fig. 48), the legs
being made of porcelain, for the chair S, where the patient is
placed. The insulated cords L,, 1, (Fig. 48) unite the collecting
combs of the machine with the insulated stool J and the
electrodes. #, EH, are hand electrodes, O an ear electrode, D
a discharging rod for the discharge of the bottles (Fig. 48).

As to the methods of franklinisation, they comprise a, the
electrical charge; 6, the electrical wind; c, the discharge of
sparks. These three methods in the order here enumerated
also represent the three degrees of intensity of franklinisation,
the charge representing the mildest, and the sparks the most
intense method. The charge is thus given. The patient is
placed on the insulated stool J (Fig. 48) and unites the bottles
to the positive or negative pole of the machine, whereas the
second pole is conducted downwards into the earth.

The electrical wind, which is also called the electrical air
bath, and also, though wrongly, general franklinisation, is pro-
duced in the following way :—The patient is placed on the
stool, which is as before united to one of the poles of the
machine ; the second pole, however, is not conducted into the
earth, but is brought into contact with an electrode terminating
in a point which can be approximated to the corresponding
part of the patient by means of the hand or by means of the
stand St, (Mig. 48).
FRANKLINISATION. 8381

In general, the last two methods in Professor Lewandowski’s
experience had the same effects as induction currents, the
only advantage they presented being, that the patient might be
electrified through his clothes, that he need not undress, a point
of considerable importance in female patients. On the other
hand, the three methods had also peculiar effects, which could
neither be obtained by the galvanic currents nor by the
induction currents.
LEcTURE XV.
ELECTRO-THERAPEUTICS.

Electrodes, Varieties of, Application of—Density of current—Difference of
Potential of electrodes—Size, position and nature of electrodes—Strength
of current—Diffusion of currents—Place of poles—Relative size of Electrodes
according to effect required—Selection of current—Faradic, Galvanic,
Combined current—Object of Electricity—Action of Faradic and Galvanic
currents—Use of the terms stabile, labile, anode, kathode, unipolar,
bipolar—Indications for the disuse of faradization in Nerve degeneration—
Dosage of electricity in reference to Strength of current and Time—Polarity
and Direction of current—Ascending and descending currents—Action of
Kathode and Anode--Electrotonus—Hlectro-diagnosis—Pfltiger’s Law—Ana-
lectrotonus—Katalectrotonus—Creation of polarity—Polar zone—Peripolar
zone—Density of current—Derived and Diffused cyrrents—-Unipolar influence
converted into Bipolar—Katalectrotonus or increased excitability—Analec-
trotonus or diminished excitability—Contraction in reference to Opening and
Closing the current—KCC, ACC, KOC, AOC—Experiment upon Patient demon-
strating electrotonus—Reaction of Degeneration in ant. polio-myelitis—Reaction
of muscles in Brain disease—In Spinal disease—Increased muscular excitability
—Diminished muscular excitability—Motor points of muscle—Polarity con-
sidered from its Therapeutical aspect—Torticollis, treatment of—Nutritionai
effect of kathode Voltaic alternatives—Labile galvanization—Faradization,
Duchenne’s theory of the Two currents—Althau’s opinion of Skin fara-
dization—Galvano-faradization—Electrolysis, Apostoli’s method—Sir Spencer
Wells’ electrolytic treatment of Uterine disease—Electrolysis of Nevi,
of Goitre, of Aneurisms, of Strictures—Ovarian pain—Galvano-fara-
dization for muscles and joints, in Locomotor ataxy—Neuralgia—Hlec-
trization of Brain and Spinal cord—Chorea—Epilepsy—Incontinence of
urine—Writer’s cramp—Facial paralysis—Lead paralysis.

In my last lecture I endeavoured to give you some idea of an
electric current, its agency for the transmission of power, how
for medical purposes it was best generated, its capacity
through its electro-motive force in producing physical,
chemical, physiological and mechanical effects, the strength
of the current varying according to the potential of the cells
in the battery, the resistance of the human body to the
current, the value of using a galvanometer in circuit to
measure its strength, and so on. ‘To-day we have to consider
practically and as concisely as possible the effect of both the
galvanic and faradic currents upon the human body as a whole
and upon certain constituent parts, and I am anxious that my
remarks shall refer to the practical application of electricity
and its therapeutic influence, rather than to its physiological
effects. Of course, therapy and physiology can scarcely be
disassociated, but everything which I have to say shall have a
practical rather than a scientific potentiality. No one should
apply the electric current to the human body unless he possesses a
knowledge of its power, and also a knowledge of the capacity of
resistance which certain parts of the body have over other parts.
ELECTRODES. 333

ELEctRopEs.—We apply electricity to the human body, as
you know, by means of electrodes ; you have various kinds of
electrodes before you, in fact, one might say their name is
legion. This fine needle which I have in my hand is an electrode,
and so is the large sponge with a piece of metal attached to it ;
here we have a spinal sponge electrode, and here is an electrode
for the liver ; this large flat electrode for the feet is a piece of
perforated zinc covered with three or four layers of flannel, and
this foot-bath, to be used with plain or salt water, forms an
electrode; you know I also make my hand an electrode; the
most common form of electrode is this cup, made of copper or
vulcanite, into which a sponge is inserted ; this is, perhaps, the
most useful form of electrode when you want labile applications
of electricity to extend over large surfaces; it is well to remove
the sponges for cleanliness after each application and keep
them in a weak solution of ammonia or com-
mon salt. The sponge electrode I now show
you has many good points (the drawing is
about one fourth its ordinary size), the chief
feature of it is that the sponge is firmly fixed,
and for general faradization this is important;
it was invented by Dr. Herschell (Fig. 50).

Equally as useful as the sponges are the carbon discs : they
consist of carbon enclosed in a cover of flannel or wash
leather ; the advantage is
that their resistance is
less variable than that
of sponge and a more
definite pressure can be
exercised and maintained
without experiencing any
discomfort from an over-
flow of water, it is easy
also to apply a fresh piece Fig, 51.
of chamois leather at any or every application (Fig. 51).

The plate electrode I now show you is very useful and inex-
pensive, itis simply a piece of sheet lead, and can be made of any
size most convenient, it is pliable and fits accurately to the skin,
and it can be easily slipped under the patient’s dress, and kept
in position by the pressure of the clothes; you see the lead is
covered with flannel or chamois leather. You will remember that
these electrodes must be made thoroughly wet either with plain
or salt and water, and you know that by so doing you lessen
resistance and aid conduction. It is necessary that you have
a series of these electrodes of various sizes for the sake of
convenience. Prof. Erb speaks of electrodes of varying sizes
under the names of fine, small, medium, large, and very large,

 

  
334 ELECTRO-THERAPEUTICS.

these sizes are upon the table. This may be called a fine
electrode, its tip comes almost to a point, it is serviceable for
electro-diagnosis, in the application of the current to motor
points, to small nerves and muscles. You will soon find out by
practice the kind and size of electrode which is required to do
certain forms of work ; your own common sense will tell you if
you have to apply electricity; to a large nerve or a mass of
muscle you must use an electrode of proportionate size.

In passing, let me draw your attention to special forms of elec-
trodes for the application of the current to special parts. This
is for the larynx, this for the stomach, this for the uterus, this
for the bladder, this for the rectum. These rectum electrodes
were introduced a short time since by Mr. Benton, and he
tells me that he finds them very useful in the treatment of
stricture of the rectum (Fig. 52). Their application is a
very easy matter. When the stricture is of a fibrous annular
character the negative pole must be used with a current
strength of from six to ten milliampéres, but if the stricture is
spasmodic the faradic does as well or better than the galvanic.

 

Fig. 52.

Fig. 58 is called Gartner’s belt electrode. You see it has a
spring and cylinder by which it can be fixed upon any part of
the body. sane

 

 
APOSTOLI’S ELECTRODES. 885

Fig. 54 is called a brush electrode. It is made of various
sizes, and comes under the class of dry electrodes, they are used
for cutaneous faradization. It is
usually made of nickelized copper
wire, and resembles an ordinary
painting brush; sometimes it is
made of the size of a clothes brush, Fig. 54.
in fact it can be made of any size.

These instruments are for the treatment of fibroid tumours
of the uterus, according to Dr. Apostoli’s method, of which I
shall have something to say directly (Fig. 55).

 

 

 

 

Fig. 55,

Fig. 56 is a needle holder for electrolysis, for the reception
of different sized steel or platinum needles, and these are
needles with flat platinum points and
with shafts insulated by ebonite. They
are also made blunt pointed and can
be used for stenosis of the lachrymal Fig. 56.
duct.

These are other electrodes used by Dr. Apostoli. Fig. 57 is a
double concentric dise electrode; Fig. 58 is a double conic disc
electrode; Hig. 59 is a vaginal electrode, and Fig. 60 is an
electrode for the urethra and uterus. The electrodes Figs. 57—
60 are specially for localizing the effect of galvanic and faradic
currents.

 

 

 

 

 

The electrodes here figured are arranged for making and
breaking the current.

No. 1, Simple electrode holder (Fig. 61). No. 2, Hlectrode
holder with current interrupter (Fig. 62). No. 3, Electrode
holder with contact maker (Fig. 63).
336 ELECTRO-THERAPEUTICS.

The electrode which I now show you is admirably adapted

for electrical diagnosis, it has been arranged
by Dr. Hughes Bennett; he calls it ‘‘the
combined handle electrode,” and it cer-
tainly possesses many advantages. By
means of this instrument the operator’s
attention can. be given to his operating
without constant reference to the element
board; it contains all the necessary
elements for scientific clinical investigation,
namely, first, a current graduator, second,
a current interrupter, and a means of
opening and closing it, and third, a z :
current reverser. It may be attached to ry.61 Fig.68 Fig. 62
either the faradic or galvanic currents.
When in the hand of the operator all the accessories can be
put in action by the movement of one finger, thus greatly
facilitating the delicate manipulations of the investigator, and
obviating the necessity of dividing his attention and altering
his position, as he is compelled to do when working with an
element board.”

So much for electrodes. We next have to consider the
rational application of electrodes, in order to produce definite
results, and we must not forget that ‘‘the action of a given
current is proportionate to its density,” and the density of a
current may be described as the quantity of electricity flowing
through a unit of sectional area in a unit of time, this follows
the laws of diffusion and resistance, which are quite as applic-
able to air and water as to electricity. I now apply these
medium electrodes to the arm of this patient, and I know that
the current is most dense in the wire, less dense in the
electrodes, and least dense in the arm between the electrodes.

We say that there must be a difference of potential between
the elements of the battery in order that the electric current
may be generated, and we also say that in order for a current
to flow from one point to another there must be a difference of
potential between those two points, if we want intensity of
action at any given point. Hence the different parts of a
conductor through which a current flows must be at different
potentials. The current of electricity which I now cause to
flow through this arm must diminish or increase according to
the nature and size of the electrodes which I employ; this is
self-evident. You see by the galvanometer that I have a
current of five milliampére strength, and I have attached
to the terminals two jine electrodes ; by making and breaking
the current, the muscles respond actively. I now take two
medium size electrodes and use the same strength of current,

      
ELECTRODES. 337

but the muscles respond only feebly, showing that the density
of the current is inversely proportional to the area of the
electrodes, therefore the size, position, and nature of the
electrodes are of great importance in the application of the
electric current. It is a question of intensity and diffusion.
In applying electricity to the human body, in order to be
definite, our strength of current should be known and absolute,
the electrodes should be of uniform size and shape, and so
adapted to the parts that a certain density of current may
diffuse itself amongst the tissues; therefore, if we wish to
concentrate the effect of one pole upon a small superficial
structure, such as a nerve or motor point, the electrode applied
over it must be small, and the other electrode must, of course,
according to this mode of reasoning, be large, and may be
applied to any distant part of the body, the force of this will
be more evident when speaking of electrolysis. You must not,
if you please, imagine for one moment that the larger the
electrode the more electricity is being conveyed to the part to
which it is applied, you have simply the same force acting,
but being diffused over a larger area.

By way of example, I take these two large sponge electrodes
of Dr. Herschell’s, they are of the same size; you see by the
galvanometer that my current is still of the strength of five
milliampére. I know that my battery is working at so many
volts (units of electro-motive force), but this we do not trouble
about for our present demonstration. I place one of the
electrodes upon the sternum and the other upon the opposite
vertebra of my patient, now by the common ordinary law of
diffusion and direction I know that the two currents in this
respect, positive and negative, are of the same density (they
are, however, potentially different), but the waves of diffusion,
just as the waves of water upon the sea shore, lose their
intensity until physiologically they become almost inactive,
still they are continuous and operative. In the human body we
have to deal with a variety of structures, it is difficult to
estimate its resistance, as a whole, in the same way that we
would an elementary body; we know little more of internal
polarization than we do of vital force, the whole thing is at
the present time hypothetical. Currents at their make and
break, anodal and kathodal, produce certain effects, physical,
psychical, chemical, and vital, upon structures immediate and
upon structures remote, according to the density of the current
by which they are influenced. os

SELECTION OF CURRENT.— We apply currents of electricity to the
human body known as galvanic and faradic; we may use these
currents singly or combined, but we must remember that their

effects are distinctly different, so that it isa matter of " oe
338 ELECTRO-THERAPEUTICS.

importance for us to consider when we are determining the
kind of current which we ought toemploy. There is a prevalent
idea which, to a certain extent, is justifiable, that the faradic
or induced current acts more directly upon nerve, and that the
galvanic current acts more especially upon muscular tissue.
Again, some people apparently entertain the idea that it is
unimportant which current is used, so long as the muscles are
brought.into a state of violent activity. I hope we shall see
directly that these ideas are wrong. The object of electricity
is to excite and stimulate the tissues. To produce muscular
contraction is to aid the muscle to perform a normal function,
and we know that due performance of function is essential in
any organ to maintain its normal standard of vitality;
faradization does this rather by its action upon the nerve than
by any power which it exercises upon the muscular tissue. On
the other hand, the galvanic current reaches the nerve through
the muscle, molecule by molecule it influences the metabolism
of the muscle quite independent of the induction of any
contractile agency, so that we say the galvanic current is
specially concerned in nutritional changes. The most that the
faradic current can do is to stimulate a nerve into activity by
vibration and percussion, and if by so doing it restores function,
it unquestionably aids nutrition ; there are many other points
to be taken into account, and we shall, I hope, reflect upon
them as we proceed.

e have just seen that electrodes are used as means to
apply the current to the body. When the two electrodes are
stationary the application is called stabile, when one or both
are moved about it is called labile; the electrode carrying the
positive current: is called the anode, whilst the electrode
carrying the negative current is called the kathode; the current
may be applied by fixing one electrode to a determinate part
of the body, whilst the other is applied to an indifferent part;
this is called the unipolar method; or both poles may be
brought to bear upon a single muscle; this is designated the
bipolar method. The terms ascending and descending are
sometimes spoken of in referring to currents.

In nerve degeneration there is a stage when the induced
current fails to meet with any response, and this is called the
reaction of degeneration; but the galvanic current will bring
about muscular contraction. There is also a stage of degenera-
tion prior to this, when the nerve responds feebly to the faradic
current and readily, although irritably, to a weak galvanic
current; now to use powerful faradization to a nerve in this
condition is unwarrantable and unjustifiable, although the
application of a weak galvanic current with slow alternatives
may be exceedingly useful. Let me take a case of sciatica,
DOSAGE OF ELECTRICITY. 339

rather than one of anterior polio-myelitis; in the first stages of
sciatica the molecular activity of the nerve is merely deranged,
but should the condition become inveterate and attended with
myotatic irritability, we are naturally led to conclude that
some degeneration has commenced in the nerve. In the former
condition the faradic current is superior in its effects to the
galvanic, but the use of faradization in the latter is to be
condemned. I have seen the function of a nerve when in a
state of degeneration hopelessly ruined by faradization, when
a cure might have resulted by means of a galvanic current
with slow alternatives. If you have any doubt about which
current to employ, especially where there is a possibility of
nerve degeneration, choose the galvanic, use it weak, continue
it for ten or fifteen minutes, and alternately slowly once in
thirty seconds.

If, on the other hand, you merely want the physiological
effects or influence of an electric current to stimulate an
inhibitory state of certain nerves or nerve centres, you can
use faradization or the current from a static machine.

Dosacz.—As I have said before, in using electricity you must
know what you want to do and how best to do it; do not think
that because a muscle is weakened that you are going to
strengthen it by pouring electricity into it: remember this,
the weaker the muscle or nerve the weaker (as a rule) must be
the current of electricity employed: as the muscle or nerve
grows in strength so you may increase the strength of the
current, therefore in the administration of electricity you
have at least three things to consider, namely, the strength
of the current, the nature and size of the electrodes, and the
time during which the current is allowed to flow. With regard
to the strength of the current, in my own practice I never use
strong currents, preferring a weak current to extend in its
administration over a lengthened period of time; of course if
this mode be adopted it is necessary to maintain the strength
of the current during its flow, and in order todo this you must
have a galvanometer in circuit, and ensure the moisture of the
electrodes: do not misunderstand me, I am speaking now of
applying electricity in a general way, knowledge and experience
are very safe guides in all questions of this kind. In reference
to time, I think five, ten, or, at the outside, fifteen minutes quite
long enough for a single application ; we must not forget that
certain parts of the body are much more sensitive to the
current than other parts—the trunk less than the head and
neck; a current of strength borne comfortably by the
extremities would be intolerable when applied to the eye or
forehead, so you must please take all these things into
consideration; stimulating muscles and nerves by electrical
840 ELECTRO-THERAPEUTICS.

agency is like exciting the brain by the influence of alcohol,
and the former should be regulated by dosage in the same way.
as the latter, tonicity and depression are inversely
proportionate to the quantity administered. and the duration
of time in administration.

Poxartry anD Direction or Current.—A great deal is often
written concerning the right application of the negative and
positive poles, and of ascending and- descending currents: I am
somewhat sceptical concerning the soundness of these views
in the purely therapeutical sense, although much might be
said in favour of polarity.

Currents are said to have a descending or ascending direction
according as they flow with or against the natural volitional
impulse in motor nerves. Dr. de Watteville dissents from this
view for the following reasons; ‘1st, That in physiological
experiments on human, as well as on frogs’ nerves, all the
phenomena observed are best explained on the theory of polar
influences only ; 2nd, That it is impossible to send a current of
any density in a given direction through a moderately long
piece of embedded nerve; 8rd, That catalytical effects are
independent of the direction ; 4th, That the theoretical claims
set up in favour of specific indications for the use of ascending
or descending currents in the treatment of various disorders is
not justified by experience.”

We know in reference to the galvanic current that
the action of the kathode is catalytic, exciting and destructive,
whilst the anode is anodyne and sedative, therefore an
arrangement of poles may be credited with some advantage,
and it cannot be denied that from the physiological point of
view it has a rational and definite bearing. In the
consideration of this question I take the opportunity of
reminding you of variations produced in nerves (electrotonus)
by the two currents, positive and negative, respectively, and not
only by the currents themselves, but also upon their being
made and broken ; but before I show you this experimentally
let me draw your attention to certain terms which are well
known in electrodiagnosis. We admit, by way of preface,
following the classical researches of Pfliiger, that the passage
of a galvanic current through a nerve alters its condition and
throws it into a state of electrotonus.

When a single current is made to enter a nerve through the
tissues a difference of polarity is created, the current as it
enters is most dense, and here it is known as the polar zone.
When it becomes extended, weakened, and diffused, the zone
of extreme diffusion is known as the peri-polar zone. I take
this long glass and fill it with water, and upon its surface I
drop, very gently, some tincture of iodine; now you see as
KATELECTROTONUS AND ANELECTROTONUS. 841

the iodine diffuses itself through the water, currents are
created, some seen and some unseen, arising from the
formation of different densities in the fluid. At the point of
prime contact of the iodine with the water, let us say the
currents are most dense, and we will call this the polar zone ;
‘but as the colour given to the water extends, the greater its
‘extension the less do we find the intensity of colour, that is its
minimum of density, therefore this I choose to call the peri-
polar zone. Tadmit that it is simply diagrammatic, but it shows
us for practical purposes, how, when the human nerve is placed
under unipolar influence of the electric current, the latter
diffuses itself in the surrounding tissues and brings about a
difference of density in the current itself, and we know that the
human nerve is surrounded by textures and fluids which are
better conductors than the nerve, so that derived and diffused
currents are immediately established. It does not matter
whether the current is anodic or kathodic, if it be anodic at the
point of entrance its limits of diffusion (peri-polar zone) are
kathodic, and if at its point of entrance the current is kathodic
its limits of diffusion are anodic. So directly we place the
electrode upon the nerve we create a unipolar influence into
that of bipolarity. With regard to the following, then, let us be
clear, remembering that contractions of muscle follow upon
‘opening and closing the current.

At the point and time of application to a nerve of the
negative pole (kathode) we make or close the current the
excitability of the nerve is increased (KATELECTROTONUS).

At the point of application of the positive pole (anode) the
excitability of the nerve is diminished (ANELECTROTONUS).

The contraction produced by making, or, as it is called,
closing the kathodic current (katelectrotonus), is represented
by the letters KCC (kathodal closure contraction). The
contraction produced by making or closing the anodic current
(anelectrotonus) is represented by the letters AAC (anodal
closure contraction) whereas :

The contraction produced by opening the kathodic current is
represented by the letters KOC (kathodal opening contraction).
The contraction produced by opening the anodic current is
represented by the letters AOC (anodal opening contraction).

Let me make conrracrion upon opening and closing the
circuit in reference to polarity evident to you by actual
experiment. This Stéhrer’s battery has on the top of it a
sledge collector and a current reverser, by moving this handle
I can not only open or close the current flow, but I can alter or
reverse the polarity, making the current either kathodic or
anodic. My battery is now in action, but the circuit 1s open,
the handle is vertical; I now place, quite indifferently, one
342 ELECTRO-THERAPEUTICS.

electrode at the nape of the neck and the other upon the ulnar
nerve at the lower third of the inner part of the forearm,
please watch attentively the contractions which will arise, they
vary in time and differ in degree according to the polarity of
the current; the electrodes are well wetted, and my galva-
nometer denotes five milliampérecurrent strength. When I move
‘the handle this way the current is negative, and this way it is
-positive; now I want you to observe the openings and closings
in relative order: ist, I shall establish kathodal closure
contraction (KCC); 2nd, Anodal closure contraction (ACC) ;
8rd, Anodal opening contraction (AOC); 4th, Kathodal opening
contraction (KOC). From the contractions which I have just
produced I think you must come to the following conclusions
:which I have noted upon this board, namely :—

Kathodal closure contraction (KCC) comes first.

Anodal closure contraction (ACC) comes next.

Anodal opening contraction (AOC) comes next.

Kathodal opening contraction (KOC) comes last.

I want you to remember what you have just seen, that these
contractions varied in time and degree ; 1st, the KCC was very
active; 2nd, the ACC was active; 8rd, the AOC was less
active and followed rapidly upon ACC; 4th, the KOC was
scarcely visible. Let us repeat the experiment with a
current strength of three milliampére, we now find activity
with KCC, slight with ACC, very slight with AOC, and absent
with KOC, therefore it is clear that the current must be
relatively very strong to excite contraction with KOC,
compared to that which is necessary to excite contiaction with
KCC; the following list will show you the effect of variations
of current necessary to bring about contractions.

1, Weak current (KCC).

2, Medium current (ACC, AOC).

3, Stronger current (KOC).

It is absolutely necessary that we consider these contractions
in reference to time and strength in the degeneration and
regeneration of nerves and muscle in anterior polio-myelitis.
(For example, see Lecture V.)

' The reaction in both nerve and muscle is qualitative and
quantitative ; when there are changes in normal conditions
they are called degenerative, and the reactions of these
struetures to the galvanic and faradic currents are said to
denote ‘“‘ reactions of degeneration,” when the muscular con-
tractions to the kathodic and anodic make and break are altered
and fail in normal strength to the galvanic current, they are
called ‘‘ serial alterations,’’ when the mode or course of the
contractions are altered, they are called ‘ model alterations.”
Let us consider for a moment diseases of those parts of the
REACTION TO CURRENTS. 3438

nervous and muscular apparatus in which the re-actions are
usually found to be normal.

1. Atu ParatysEs of cerebral origin or hysteria are not
accompanied by change of normal electrical reaction, so long,
of course, a8 no secondary changes have arisen in the spinal
cord. Muscles and nerves which are hopelessly paralyzed may
still respond normally to either current.

2, Diseases such as lateral sclerosis, locomotor atary, and
disseminated sclerosis, so long as the anterior horns of the
grey matter remain intact, respond normally to the electrical
excitation.

3. SprnaL Lesions will engender the RD only in those
nerves and muscles which are directly associated with the
lesion wherever it may be. For instance, degenerative changes
will exist in the muscles in proportion to the seat and extent
of the lesion in the anterior horns of the grey matter. On the
other hand, when the trunk of a nerve is diseased the
degenerative processes extend over and are limited to all the
muscles supplied by that nerve.

The electrical excitability of a nerve and its power of con-
duction are generally lost together, but regenerated nerve fibres
may regain conducting power before they can be excited by
electricity, and a muscle may continue to show the reaction of
degeneration when it is susceptible to a voluntary stimulus
sent from the brain.

Increased excitability of muscles to galvanic excitation is
frequently met with in the early stages of degenerative re-
action, ‘“‘ myotatic irritability.” I have often found increased
faradic muscular irritability in the limb opposed to that which
has been the seat of paralysis from polio-myelitis.

Diminished excitability, independent of the ordinary forms of
degenerative reaction, may occur in many of the stages of old-
standing chronic disease of both the nervous and muscular
systems, and leads us to the conclusion that hysterical and
cerebral disturbances and shamming do not exist.

Motor Pornts or Muscuu.—lIf you examine these drawings,
which have been enlarged from woodcuts (woodcuts to be
found at the end of the book), you will see markings. Hach
mark indicates the motor points of certain muscles, or that
part of the muscle at which the nerve enters. Duchenne called
these the points of election. Ziemmsen has more recently
investigated this subject with care. When the electrode from
afaradic battery is placed over the points as indicated, it is
quite clear that every fibre of the muscle is brought into a
state of activity, but if the electrode be applied indifferently,
only certain groups of fibres will be influenced, some nerves
going to muscles take a superficial course before they enter the
344 ELECTRO-THERAPEUTICS.

muscular substance, and are readily stimulated by the current,
and thus groups of muscles are brought into action. Such
nerves are, for example, the median, the ulnar, the radial, the
erural, the perineal and the tibial. Intra-muscular faradiza-
tion is best made by placing one electrode at the back of the.
neck and applying a large sponge electrode to the body of the
muscle; one advantage of this is that the current has far less
effect upon the sentient nerves, and consequently causes less
pain than if a small conductor be used.

An electrical stimulus applied to a healthy muscle should
call forth a well-defined, short-lived jerk, instead of a slow,
lazy, indifferent contraction, which is indicative of some in-
trinsic change. There are several extrinsic factors to be taken
into consideration in the production of muscular contraction.
First, strength of current; 2nd, the size of the existing elec-
trode; 8rd, the relative position of the exciting electrode, and
the motor point of the muscle, and also to the presence or
absence of motor nerve filaments. In cases of partial muscular
degeneration the maximal contractions are usually diminished
whilst the minimal may be obtained with low current strengths.
In testing the excitability or contractibility of a muscle, that is,
its electrical reaction, it is necessary to compare it with a
corresponding spot of the same muscle on the opposite side of
the body.

Poxrarity, considered from its therapeutical aspect.—I cannot
divest myself of the conclusion that the unipolar method of
treatment has great advantages. The energy and capacity for
action which distinguishes so markedly the current at the
negative pole, ought to give to it decided and marked results
over the positive pole. If the two poles (bipolar method) are
placed upon the part which is diseased, the influence of elec-
trotonus fails to have an existence; on the other hand, it is
possible that the catalytic influence of the negative pole may
be increased, but in the ordinary process of galvanization this
is scarcely borne out in practice. It is possible, and to me it
seems most probable, that by using the negative pole over the
diseased part, you bring about both electrotonic and catalytic
effects. However, the general rule is that the indifferent pole
be placed upon any part of the body, whilst the executive pole
be placed upon the seat of the disease. If we want to obtain a
soothing anodyne or even a depressing effect in a painful or
spasmodic nerve, such as we find, for instance, in neuralgia and
torticollis, we use the positive pole so as to produce diminished
excitability in the nerve (anelectrotonus). If, on the other’
hand, we want to stimulate a nerve into increased activity, to
permeate it with nutritional influence, to increase its metabolic
energy, we use the negative pole to produce these results
POLARITY OF CURRENT. 845

(katelectrotonus). Whatever theories may exist relative to
polar arrangements (bipolar or unipolar) you know my
practice is to adopt the unipolar method. I am not sucha
firm believer in the anodyne influence of the anelectrotonic
pole, but I am a very staunch believer in the good results
which I obtain from katelectrotonic agency. You know the
case of torticollis now under treatment. She was faradized in
hospital for six weeks without the slightest benefit, and for
the ‘past month I have been applying the unipolar galvanic
current with rather active voltaic alternatives with the most
excellent results. I have occasionally employed galvano-
faradization, which, in my opinion, has hastened the cure. The
anode, if you remember, was placed at the nape of the neck,
whilst the kathode (sponge) was applied to the spasmodic
muscles. The nutritional effect produced by either pole
depends mainly upon the strength of current. This is usually
ascribed to the positive pole, but the catalytical agency of the
negative pole is distinctly and unquestionably nutritional, if
the current is of moderate strength; if, however, it is too strong
and maintained for too great a length of time, it is not only
exciting, but it is degenerating. The more one thinks of polar
action, I mean, of course, in the application of electricity to
nerve and muscle as a therapeutic agent, the more one
feels convinced that success can only be dependent upon a
thorough understanding, not only of the right application of
the poles, but also to the precise strength of current which
is called into action. The little which I know of electricity is
entirely the result of-a fair amount of practice, combined with
careful and painstaking observation both of cause and effect.
In applying the galvanic current (stabile) for any length of
time, say twenty or thirty minutes, always keep your galva-
nometer in circuit and do not use a current strength of more
than ten milliampéres, and let the negative pole have a fair
area as well as rheostatic influence, otherwise you may find the
epidermis of a very significant black colour upon its removal,
which may be somewhat alarming to the patient and un-
pleasant for the operator. ;

I have spoken to you before of current reversals or voltaic
alternatives. I believe thoroughly in exercising the alternative
influence of both poles, but I prefer the reversals to be made
slowly and infrequently.

GavanisaTion means, then, in order to be explanatory, the
application of electricity to the human body to bring
about certain results according to the nature and strength of
current used, taking polarity into consideration. We have seen
that its effects may be sedative, anodyne, alterative, catalytic,
exciting and nutritive. It may be applied according to the
346 ELECTRO-THERAPEUTICS.

bipolar method, having both poles near each other upon the
diseased part, or it may be applied according to the unipolar
method, placing one of the poles at some indifferent part of the
body. Its application may be stabile or stationary, labile or
mobile, extending by movement of the electrode over a given
area; and that the current is continuous in its action, but con-
tractions of muscle result from opening and closing the current,
and shocks are experienced, sometimes of a disagreeable
character, if the current be too strong; therefore to avoid these
shocks the current at the commencement and at the end of
the application must be gradually made and broken. From
what I have previously said you must see the importance of
this. There are many valuable hints which I should like to
give you of incalculable importance in applying galvanism to
the head and the sympathetics in the neck, but I must leave a
full consideration of these for another lecture; but before
applying the current to these regions, which you must do after
the labile method, by means of a fairly large sponge electrode,
you will hold one electrode in your hand and apply the sponge
to your own temple, and thus have satisfactory evidence
of the strength of the current before administering it to your
patient. The labile method of applying the galvanic current
is not so popular as the stabile with alternatives, nevertheless,
it has advantages, which may be worth a moment’s considera-
tion. You take this flat electrode, fairly well moistened, and
place it at the nape of the neck or a little lower, you then take
a good sized sponge electrode, moistened with water, or, as I
generally use it, salt and water, the sponge must then be
passed over the limb with a fair amount of pressure, the sur-
face of the sponge must be kept in contact with the skin; it
must be evident to you that any breach of contact will pro-
duce muscular contraction and influence polarity: if such is
required, this is one means of bringing it about.
Farapization.—You are aware that every induction
apparatus is capable of giving rise to two currents, namely,
the primary, or extra current of the thick wire, and the
secondary current of the fine wire. There are some physicians
who disbelieve in the physiological difference in action of these
two currents, but Duchenne’s testimony is to the effect that
there is a decided difference. He says that the primary current
acts chiefly upon the contractile power of the muscles, whilst
the latter has more effect upon the sentient nerves. Duchenne
has referred this difference of action to a special elective power
in each of these currents, but Althau agrees with Berguerel
that the difference in the physiological effects of the two
currents is chiefly due to the difference which exists in theit
tension, but he does not believe that this difference of tension
FARADIZATION OF THE SKIN. 347

is quite explanatory, for it should be recollected that the
primary or extra current always moves in the same direction,
and has, therefore, feeble electrolytic effects, while the
secondary current which alternately moves in different direc-
tions has the electrolytic effect of one intermittence neutralised
by that of the next.

FaraDIZATION OF THE Sxin.—You are so constantly faradizing
the skin that I need scarcely say anything to you about it, but
-there are one or two points to be taken into consideration in
carrying out thoroughly this procedure, and its effects are
usually so agreeable that I might just call your attention to
them. You can, of course, use any electrode you like, or wire
brush, but my mode is to use the hand ; in the first place, the
skin of your patient must be free from moisture, if not, it must
be made so by the use of starch powder ; in the second place,
your hand must be dry ; in the third place, the electrodes, one
of which is applied to the body of your patient and the other
to your own body, must be not too freely moistened.

Faradization by fine metallic wire brushes fixed on insulating
handles is not an uncommon method, but is sometimes exceed-
ingly painful. The neck and trunk are more sensitive than
the extremities, the cervical and lumbar region more than the
other parts of the back, the inner and anterior surface of the
extremities more than the external. The wire brush appli-
cation is more useful'in cases of anesthesia and in hysterical
paralysis. In skin faradization by the direct mode the conductors
must be dry, or otherwise the electric current will traverse it
and enter the muscles. I should advise you in applying the
faradic current to the head always to use the hand as the
conductor. The lively crepitation which you hear is due to
the passage of sparks between the skin and electrode. The
size of the electrodes should be small for localized faradization
of single muscles, motor points and nerve trunks. I always
use large sponge electrodes for exciting large muscles or groups
of muscles.

Gatvano-FarapizaTIon.—I believe Dr. de Watteville claims
the merit of having introduced this method of treatment into
electrotherapeutics. I have, like many other physicians, used
it for many years, and I cannot speak too highly in its praise.
Many cases of paralysis and spasm of muscle and brain and
nerve exhaustion and neuralgia have yielded to its effects in
the most satisfactory manner, when single currents have been
of no avail. Many machines are now arranged by connecting
the wires so that the combined current can be applied just as
easily as a single current. The combination consists in uniting
the secondary induction coil and the galvanic battery in one
circuit, by connecting with a wire the negative pole of the one
348 ELECTRO-THERAPEUTICS.

with the positive pole of the other, attaching the electrodes to
the two extreme poles and sending both currents together
through the body.

I find this combined form of electricity particularly useful in
cases of nerve exhaustion and general prostration, but I have
yet to learn its precise mode of action; it may be that the re-
storing, strengthening, and tonic effect of the galvanic current
overcomes any debilitating influence which might, and some-
times does, follow faradization. A gentleman who frequently
comes to me for what he calls his pick-me-up, says it acts upon
him like champagne without its subsequent depressing tendency.
I find it necessary to graduate the combination. Some cases
require galvanism plus faradism and others faradism plus
galvanism. In spasm and painful muscular affections its
utility is unquestionable, and the same holds good for a
paralyzed muscle with trophic changes (protopathic and
deuteropathic). In faradizing a muscle we cause artificial
movements to prevent the degeneration which would otherwise
ensue from inaction, and we also, by means of the galvanic
current, stimulate the trophic nerves, and this means the
engenderment of activity in the nutritive processes, so that in
the combined current we have effects distinct but essential to
growth, repair and regeneration. Now let me draw your
attention to

Exxecrroiysis.— Wherever electric tension is sufficiently high,
or more correctly speaking, when a current has sufficient electro-
motive force, its first effort is to overcome resistance by tearing
the particles, molecules, or atoms asunder with which it comes
into contact; this is known by the term electrolysis, and the
substance which by this agency undergoes decomposition is
called an electrolyte. I endeavoured at the beginning of the
lecture to show you this by the decomposition of water,
iodide of potass and the white of egg. Remember that
large cells, as evidenced by the galvanometer in circuit, give a
much more powerful current through needles inserted into the
tissues than small ones. I will now bring before you examples
of the value of electrolysis a3 a mode of therapeutics. When the
galvanic current for the electrolytic dissolution of tumours was
first made known, it was too hastily and rashly concluded that
the barbarous system of surgery would be replaced by the
elegant and refined system of electrolysis, but it was soon found
by all practical and sensible, and, I might add, honest men,
that operations by electrolysis (I will take, for example, can-
cerous growths) were, instead of being elegant and refined,
cruel, barbarous, protracted and disgusting ; still, for some very
minor operations, such as the destruction of nevi and small
non-cystic growths, it was deserving of passing attention ; but
ELECTRICITY AS USED BY APOSTOLI. 349

the credit of the revival of electrolysis in medicine is due to M.
Apostoli, of Paris, and when the results of his labours became
known an extensive field was at once opened for the desultory
use of electricity by men of enterprise who previously knew
nothing whatever of a galvanic battery or electrolytic opera-
tions. Wonderful results were recorded, in some cases tumours
disappeared as if by magic, when the results were in all proba-
bility more due to the potter’s clay than to any ele¢tric agency.

Apostoli’s use of electricity (for instruments see Figs. 57-60).
From what I have told you in this and the preceding lecture,
J feel sure that with a little explanation you will readily see
and comprehend the nature of M. Apostoli’s operation for the
treatment of fibroid tumours of the uterus. The apparatus to
be complete must consist of—

1st, A battery of sufficient electro-motive force.

2nd, A galvanometer for measuring strength of current.

8rd, An electrode (kathode) for uterine or inter-uterine
application of the current.

4th, An electrode (anode) consisting of a mass of potter’s
clay.

The strength of current used varies from 50 to 150 and 250
milliamperes. .

“These large doses,” says M. Apostoli, ‘‘ are rendered tolerable
in consequence of a new form of electrode, the wetted clay,
which renders the cutaneous pole innocuous, and permits us
to transmit through it easily and without injury a current of
signal medical intensity.”’

The active pole, or kathode, is applied directly to the uterus,
either in its cavity or in the substance of the fibroid deposit.

The positive pole (anode), or potter’s clay, is applied upon the
abdomen. ,

The effect resulting from the circulation of the current
M. Apostoli designates ‘‘interpolar action,’ which sets up a
subsequent process of ‘‘chemical disintegration’ (proportionably
wide and lasting) of the morbid products through which it is
made to pass; he says, ‘‘In availing myself to the utmost of
the ‘polar’ and ‘interpolar’ effects of the electric current for
the treatment of fibromata, I adopt always a galvano-caustic
(kathodic) intra-uterine and monopolar action. I thus only use
directly one active pole, closing the circuit outside the abdomen
by a second pole, made nearly as inert as possible. At the
same time I reckon upon the interpolar effects of the current,
as it necessarily finds its way through the entire uterine
substance from the internal pole to the external cutaneous pole.”

M. Apostoli speaks of the difference of the action of the two
poles as follows, they are worth remembering: ‘‘I have been
able to demonstrate in the clearest manner that we have in
850 ELECTRO-THERAPEUTICS.

our hands a double-edged agent that we can make use of at
discretion, to afford us local effects quite different. On the one
side is a hemostatic more or less ‘rapid in its action, and either
direct and immediate or secondary and remote. I allude to
the positive pole, with which we can arrest hemorrhage, either
instantly, if the cavity of the uterus be of normal dimensions,
if the action be relatively intense, and if the hemorrhage be
not excessive; or more deliberately and gradually, after several
successive operations, by the formation of contractile cicatrices.
The various gradations of the narrowing of the uterine canal
are the plain evidence of this secondary and prolonged effect of
positive cauterisations. The positive pole will therefore be the
remedy par excellence in cases of bleeding of hemorrhagic
fibromata. On the other hand, with the negative pole we
obtain a state of temporary congestion, without direct hemo-
static effect. The interstitial circulation of the uterus, thus
momentarily stimulated, will be hurried on, and a regression
of the non-hemorrhagic fibromata is the consequence, either
of this state of congestion, or of the supplementary artificial
and salutary hemorrhages which take place. The negative
pole will therefore be found to render invaluable benefit (though
with the positive pole it is possible to arrive at the same point
by a way more indirect and tedious,) in those cases of fibroids
accompanied by amenorrhea and dysmenorrhea, which are
only too often the despair both of patients and medical men
without such means at command.”

Concerning galvano-puncture M. Apostoli says, ‘“ The indi-
cations for galvano-puncture are twofold; first as a matter of
necessity in consequence of uterine atresia, or where there is
such displacement of the organ as to prevent any introduction
of a sound; second, by preference when we see that we can
advantageously combine punctures with intra-uterine cauteri-
sation, so a8 to expedite and make sure of the effects that,
with the cauterisations only, we should tardily or perhaps
imperfectly realise. We must, therefore, undertake the
galvano-punctures alone whenever the case will fairly admit of
them, or use them in other cases as adjuncts to the intra-
uterine cauterisations previously tried.

“The manipulations in the operation of galvano-puncture
will always be more difficult and even dangerous in incautious
hands. I cannot, therefore, too much insist upon a rigid
observance of the directions and precautions I have elsewhere
given at length. I can now only offer a very short summary
of them:

‘(1,) Absolute and regular antiseptic irrigation of the vagina,
before and after each operation.

““(2,) Use as the puncturing instrument a small steel trocar
ELECTRICITY AS USED BY APOSTOLI. 351

or needle, and let the punctures be shallow, that is, not deeper
than from one to two centimetres.

«(3,) Make the punctures on the most prominent part of the
fibroid ; whenever possible in the posterior cwl-de-sac.

*(4,) Make the punctures without speculum. Slide the trocar
through the celluloid sheath which protects the vagina, after
having examined and chosen by touch the point where the
puncture is to be made.

“(5,) Take the precaution of ascertaining the seat of any
pulsation, so as to avoid wounding an important vessel.

*(6,) In case of any unusual hemorrhage, immediately dilate
the vagina with an expanding speculum, and, if necessary, put
on pressure forceps to the bleeding point.”

Clinically—The results are less striking; they are not only
matter of proof by the examination of the surgeon, but the
patient herself is the living exhibition of them. We may
generalise the extent and importance of these results by
saying that ninety-five times out of a hundred they comprise
the suppression of all the miseries constituting the fibroidal
symptomatology, which may be thus categorically enumerated:
hemorrhages, the troubles of menstruation, dysmenorrhea,
amenorrhcea, nervous disturbances, the direct pains in the
growth itself and from mechanical pressure, and the harassing
series of reflex actions.

Dr. Apostoli’s internal electrode consists of a rod of platinum
twelve inches long, of the thickness of an ordinary uterine
sound, rounded as a probe at one end and pointed at the other.
This platinum rod can be fastened into a handle by a screw-
swivel on its side, so that either end of the rod can be passed
into the handle and secured there when the other end is wanted
for use. A certain length only of the platinum is required to
be bare so as to act within the uterus, the other part of the
long rod is covered by a celluloid or vulcanite tube, which acts
as a sheath and protects the vagina and other soft parts from
the action of the current.

Dr. Stevenson makes the following practical suggestion with
regard to the positive pole: ‘‘When the positive pole is used,
the electrode must be made of platinum, as all other metals are
more easily oxidised, and are decomposed by the action of the
current. This would often cause them to adhere to the
electrolysed tissue, and their forcible removal might cause
hemorrhage. The positive pole is generally used in soft,
bleeding fibromata on account of its hemostatic action ; there-
fore, if the electrode were not composed of platinum, the object
wished for might not be obtained, but, on the contrary, a risk
might be incurred of making matters worse. The negative
pole is used for dense, hard fibroids when the patient suffers
352 ELECTRO-THERAPEUTICS.

from dysmenorrhea, amenorrhea, and pressure and ‘ bearing
down’ troubles resulting from the size and weight of the
tumour.”

Dr. Apostoli gives the following rules for the electric treat-
ment of peri-uterine inflammation (perimetritis, parametritis,
phlegmon cellulitis). He varies the treatment according to the
acute, sub-acute, and chronic stages of the disease :

(1,) Acute stage—bipolar faradization—The application is
simply vaginal by means of a large bipolar electrode, the
point of which is placed against the inflamed part; the
strength of current must be bearable and the sitting should
last five, ten, fifteen, twenty, or twenty-five minutes, and
should not terminate before the patient spontaneously declares
that she suffers less pain. The action of the current is seda-
tive. Every faradization should be preceded and followed by a
vaginal irrigation of sublimate solution.

(2,) Sub-acute stage——When the inflammation has subsided
the galvanic current is called into action and carried within the
uterine cavity, the positive electrode only being used to the
uterus itself; the sittings at the commencement extending
only to three or four minutes, and the intensity of the current
must not be more than from twenty to forty milliamperes.
One or two sittings a week may be made, regulating the inter-
vals by the strength and condition of the patient. Rest in bed
after each operation must be enforced.

(8,) Chronic stage.—In this stage the operation is that of intra-
uterine chemical galvano-puncture, negative pole, monopolar ;
the negative pole is pushed into the most prominent part of the
exudated mass, if possible, on the parts posterior to the uterus;
the speculum is not used. The central or projecting part of
the deposit is ascertained by the finger, and the trocar is
guided by the finger and passed into the swelling to a depth of
not more than one centimetre. The punctures must be as
short as possible, long punctures are both dangerous and useless,
and may injure the peritoneum or pierce a vessel and give rise
to troublesome hemorrhage. The strength of current may be
raised from fifty to two hundred and fifty milliampéres, and
the current should be kept running for five minutes—antisep-
tics and great cleanliness are necessary from first to last.

Dr. Apostoli speaks of the essentials of his treatment in the
following words: ‘To sum up in a few words the essential
parts of my researches, and the clinical results which have
been worked out from them, I may say:

“‘(1,) Electricity, in the form of faradic currents of tension,
can, and ought to be made to calm the pain at the outset
of an acute attack of perimetritis, and is a sedative of the first
importance in abridging the first stage of inflammation.
APOSTOLI ON THE TREATMENT OF UTERINE DISEASE. 853

“(2,) The continued current is a power which we use in two
ways: first, in the form of intra-uterine chemical galvano-
cauterisation, to cut short the acute stage; second, as vaginal,
negative, galvano-punctures, to get rid of the chronic condition
in all its forms and stages.

“Ts the restoration ad integrum, complete and definitive, the
prevailing result of my treatment? Ido not pretend that such
is the case; I do not even expect it; and I content myself with
offering for trial a method of relief and cure which I believe to
be more speedy than any others.

‘Again, we may force electricity into our service in another
way. Given a case of actual suppuration, or of threatening
suppuration, we have only to use our negative galvano-puncture,
form an eschar, open up a sinus, and direct the exit of the pus
to the nearest point of the vagina. And this we can do at will,
when it is most fit to do it, and in the most convenient way.

“We have, then, in the galvano-puncture, an effective means
of arresting an inflammation, and of dispersing an inflamma-
tory deposit. Or, we may use it as a sure and direct way of
opening a profound and ready formed collection of pus. No
plan of setting up a vaginal drainage, controllable as to amount
and duration, can be more simple; and this we may associate
with any local and antiseptic treatment that may be desirable,
as I have shown elsewhere in relation with the subject of
hamatocele.

“The subject, of which I have just jotted down the salient
points for your consideration, is new and undeniably full of
interest. You must not suppose that 1 think I have done
much for it, as I may fairly claim to have done for fibromata
and endometritis, but what I have seen and watched with
painstaking anxiety, is so rich in clinical results, so fertile in
unexpected therapeutical consequences, that I feel I cannot too
carnestly urge you to study the subject for yourselves, and to
fathom it to the utmost, if possible.”’

Sir Spencer Wells, in a masterly review of the electrical treat-
ment of diseases of the uterus,read before the Brighton and Sussex
Medico-Chirurgical Society, sums up as follows: ‘‘ Experience
seems to show that there is a group of cases, numerous as they
are troublesome, of chronic metritis with enlargement and
surrounding deposits, which may be cited as pre-eminently
eligible for electric treatment. They are, as regards the
patient, painful and exhausting. To the judicious surgeon
they are exasperating by their rebelliousness, and in some rash
hands they have opened the way to practice more lamentable
than the disease. It will be one of the crowning merits of
electro-therapeutics if proved to be equal to bring relief to these
patients. Recent reports give good reason to hope es this
354 ELECTRO-THERAPEUTICS.

end may be realised by a careful use of the positive galvano-
puncture.”

Execrrotysis or Nav1.—The electrolytic treatment of nevi
commends itself specially to our notice. Itis a simple process,
easy of application, invariably successful, and never leaves a
scar, and in many cases it is almost painless. Of this there
can be no doubt. The current should be from 20 to 60
milliampére strength, and the duration of the current flow must
be judged according to the size of the tumour to be operated
upon. Some operators use both poles, and if the swelling be
large it may be better to do so, but care must be taken that
the needles do not come into contact within the nevus, as this
would short circuit the current and stop all action. The
needle attached to the negative pole is the prime actor. As
we have seen, it produces complete disintegration of all the
structures with which it comes into contact. When once
introduced it should be moved about freely in every direction.
If the tumour is large it may be removed and introduced into
some other part of its substance. The needles are such as we
find represented in Fig. 56, and are insulated in the great part
of their course. A solution of cocaine previously injected will
insure the operation being quite free from pain.

Exxcrroiysis 1n Gorrre.—The galvanic current is very
often serviceable in goitre, and the treatment to be adopted
must be precisely similar to that of which I have just spoken
to you for nevi.

Eecrrotysis In ANEURIsMs.—Dr. de Watteville emphasises
that the utmost confusion and uncertainty reigns in the litera-
ture of the electrolytic treatment of various tumours and the
like. He says, ‘‘The hopelessness of arriving at any conclusion
from the recorded observations of electrolysis in aneurism is
manifest the moment we look through the tabulated lists of
cases given by Poore, Bartholow and others.” The following
rules are laid down by him as the result of his experience, and
are worthy of respect.

1. To introduce into the sac several needles connected
with the positive pole of the battery, which obviously must
have the requisite electro-motive force and depolarizing energy
(the bichromate of potash or Grenat element). The usual small
medical Leclanché elements are scarcely suited to the purpose.
The current must be closed with one or more very large plate
electrodes, which may be applied to any part of the body.

2. To use needles with thoroughly insulated shaft with
spear-headed points, taking care that the whole exposed part
of the metal be within the sac.

3. To use a measured current strength of 20 or 30 milliam-
peres at most per needle.
ELECTROLYSIS. 855

4, To allow the current to flow for about half an hour at
the first sitting, and increase the duration subsequently
according to the results obtained.

The needles should be removed very gently with a rotatory
movement, and the external wound immediately closed with
lin soaked in collodion, and a bag of ice applied over the
aneurism.

Dr. John Duncan, of Edinburgh, has written a very inter-
esting paper which will be found in the “ British Medical
Journal”? for November 8rd, 1888, on the value of electrolysis
in angeioma, goitre, and cirsoid aneurisms.

Evectrouysis oF Srricrurses of the urethra and lachrymal
duct.—There seems a probability that this mode of treatment
may become more fully recognized than at present. Dr.
Steavenson has given to this subject considerable attention,
and has written favourably of its effects. It appears to have
originated in America, and good reasons are brought forward
for its general application. From the purely electrolytic point
of view it should be acknowledged as a mode of treatment
for these troublesome affections. The negative pole should be
used with a strength of current just sufficient to decompose
water.

Ovarian Pain, vaginismus, and hyperesthesia of the external
genital orifice in women.—I have again to refer to the work
done by M. Apostoli in this line of treatment, because his
experience is so large and his statements so thoroughly reliable
that they need no commendation from me. I can from my
own practice bear out the usefulness of his advice in the
electric treatment of ovarian pain, but this is not the case in
the other conditions to which Iam about to refer. I cannot
attach too much importance to this subject, for I am quite
sure if we relieve a woman of these distressing symptoms as
M. Apostoli’s treatment seems to do, we at once transform a
miserable, wretched existence into that of happiness and
comfort. For ovarian pain the induced current of tension is
used in one of two ways, intra-uterine bipolar and vaginal
bipolar ; the intra-uterine will always.be preferable, as more
active and efficacious, whereas the vaginal operation is forced
upon us by such circumstances as the impossibility of passing
a sound into the uterus. This will be our dilemma in
pregnancy, in virginity, or in an acute stage of peri-uterine
inflammation.

The length of the sitting should continue until the pain has
diminished or disappeared. The sittings should be continue.
daily. No pain ought to be inflicted on the patient, first,
because it is useless, and secondly, because too strong an
application might do harm.
356 ELECTRO-THERAPEUTICS.

It is a peculiarity of the greater number of hysterical women
that they bear easily the faradic currents of tension, even with
the fullest dose, so well, in fact, that after a short time
they will affirm that they feel nothing. A novice might thus
imagine that his apparatus had failed or that there was an
interruption of the current.

The following is what Dr. Apostoli calls his last and third
contribution to gynecological therapeutics, and to my mind
it is of great significance: ‘‘There are many women who,
independently of ovarian neuralgia, have intense and very
localized sensibility about the entrance and lower part of the
vagina. These are cases of imperfect vaginismus in which the
torment is so unbearable and the hindrance to connection so
complete that life is rendered miserable. The difficulty of
overcoming this trouble is only too well known. I have had to
do with a large number of interesting and instructive instances
of this affection. For example, in one woman I found a
single neuralgic spot not larger than the tip of the index finger
just at the end of the right nympha. Another had the same
condition exactly at the posterior commissure. In a third the
excessive sensibility was confined to the orifice of the urethra.
The fourth case had a similar neuralgic area on the left side of
the vestibule. Beside these single spot cases I have seen
many others in which the localization was not single, and the
extent varied. The remedy of which I have availed myself
and now recommend for ridding women of these harassing
annoyances is the faradic current of tension well and methodi-
cally applied. Faradism only relieves when we observe certain
fixed and precise rules in its application.” A fuller account of
these modes of treatment can be found in the “ British
Medical Journal’”’ for January 14th, 1888.

Muscizs anp Jorrs.—It is quite possible that galvano-
faradisation is more useful in the ordinary affections of muscles.
and joints than in any other class of disease. It relieves pain,
promotes nutrition, and restores function, and especially when.
it is used in association with massage. Massage, however,
comes first in point of value, but second in period of time ;.
everyone in a climate like ours must be familiar with.
cases of chronic rheumatism. The pain may be located.
in a few muscles, or it may be extended over a considerable:
area, there may or may not be absolute tenderness, the pain
may be greatly increased upon movement, and both joints and.
nerves may be involved. In all such cases the parts must be.
thoroughly faradized and submitted to the current, applied by
means of large sponge electrodes. The sponges may be saturated.
with hot vinegar and water, which I find in these cases increases
its efficacy. The relief to pain is sometimes remarkable. The.
FARADISM IN RHEUMATISM. 357

operation should last for about ten minutes; the current
should be gradually increased until it just becomes painful,
and it should be repeated every day, not only until the pain
has been entirely relieved, but for a few times after, as this
seems to prevent a relapse. At the end of each application, to
ensure absolute contraction of muscle, it is my practice to
place one of the electrodes over the motor point of each
muscle, and stimulate it and the nerve by a succession of
some dozen current interruptions; after this a series of.
massage manipulations hasten the cure. In joint pain’
from sprain, rheumatism or gout, my mode of procedure is
very simple, but efficacious; the joint is swathed in flannels
which have been wrung out of hot vinegar and water, and
over this is placed a piece of very thin perforated zinc which
forms the positive electrode. The negative electrode, which
should be large and not too wet, is applied to the most con-
venient part of the body ; the current is allowed to flow for ten
minutes, and is wound up with a few voltaic alternatives ;
after this the joint must be well extended and flexed some
twenty times, and then masséed. This mode of procedure
will be found very advantageous for the knee, shoulder, and
elbow joints, but for the wrist and ankle joints the foot
and arm bath are very convenient and useful. A joint which
is too tender to bear movement or pressure before these appli-
cations of electricity will be comparatively painless after, and
the opportunity should be taken to manipulate them freely.
You must clearly understand that I do not advise the
application of electricity or massage to a joint in a state of
acute inflammation, but I can honestly recommend galvano-
faradization as particularly useful in all chronic joint
affections, and in simple muscular’ atrophy from disuse, take
the muscles of the forearm, for instance, after Colle’s fracture.
By massage and galvano-faradization the arm is restored to
use in one third of the time that it would be if left to the
ordinary modes of manipulation, and without the patient ex-
periencing a tithe part of the pain.

AspomInaL Farapization.—In many obscure abdominal
neuroses galvano-faradization is unquestionably useful. very
one must be acquainted with vague abdominal sensations and
pains which cannot be traced to any definite assignable cause.
They are classed under the head of neuralgias for this reason,
and, as well as being very distressing, they are not curable by
ordinary remedies. The pains are frequently periodic, and
have a stage of intensity, they are sometimes referred to the
stomach, and known as gastralgia or dyspepsia. They are
often cured by galvano-faradization, even when they are of
long standing. My mode of operating is to place a large
358 ELECTRC-THERAPEUTICS.

sponge electrode (positive pole) over the region of the celiac
plexus (a large sponge attached to a zine plate) and the
negative sponge electrode must be placed upon the spine in the
mid dorsal region. The current should be allowed to flow for
ten or fifteen minutes, occasionally interrupted by voltaic
alternatives. I have had some very satisfactory results from
this plan of treatment, and I can therefore speak of its value
from my own experience. Vomiting, of functional or nervous
origin, which we know sometimes to be very intractable, will
yield at once to galvano-faradization in the manner just des-
cribed. Chronic constipation may be similarly treated with
like good results. I have no time to enter fully into these
conditions, and there is no necessity to do so. ‘They require
nothing for their treatment but the most ordinary and
generally recognized simple methods of procedure.

Locomotor Ataxy.—If we cannot cure this troublesome
disease, we can relieve many of its vicious and distressing
symptoms by galvano-faradization, by static electricity, and by
suspension. Of the last mode of treatment I have at present
nothing to say, butin the treatment of the troubles associated
with locomotor ataxy, if we are unable to cure the disease and
initigate the symptoms by drugs, surely no means under heaven
should be left untried to relieve a class of affections which are
as deplorable and disastrous as any with which poor human
creatures are afflicted; there is no special sense or function from
the crown of the head to the soles of the feet which may not
have to run the gauntlet of its vile and baneful influence. I
cannot speak too strongly upon this matter, neither can I even
enumerate the perverse functions due to sensori-motor derange-
ments arising from degenerative changes in the postero-root
zones of the spinal cord. I will mention one or two of the
common troubles merely for distinction, such as the following :
lightning and other pains commonly known as rheumatic
derangements of vision, spasm of involuntary muscles in all or
any of its regions, nervous pains, respiratory and cardiac
defects, gastric pains and vomiting, abdominal neuroses, rectal
and bladder troubles, inco-ordination of movement and dyses-
thesia. Now what are the usual remedies adopted to meet
these nerve derangements? As a rule the pains are palliated
by the use of cocaine, opium, chloral, and the like, the
obstinate vomiting by gastric sedatives and counter-irritation
to the epigastrium, the bladder troubles by henbane, potash,
pareira-brava, couch grass, and so on; in fact, the local
symptoms are frequently treated as cause and effect, when
they are too often the effect of a remote cause.

I have met with considerable success in the treatment of the
symptoms just referred to by the galvano-faradic current, more
LOCOMOTOR ATAXY. 859

so with hospital than with private patients, for the reason that
they have followed up this means of relief with greater assiduity.
It is now rather the exception than the rule for patients not to
be relieved of one, certainly, of the most distressing symptoms,
“the lightning pains,” by galvano-faradization ; the positive
electrode (a flat zine plate well covered) is applied to the nape
of the neck, and the negative electrode is a water metal foot
bath half filled with salt'and water, the current has a minimum
of faradism compared .with galvanism, and the strength of
currents must be gradually increased (without alternatives). In
the first six sittings I prescribe a current of only six milliam-
pere strength daily, for six days, ten minutes being the time of
duration of each sitting, but this is gradually increased until
the sitting extends to half an hour and the current strength
equivalent to twenty or even thirty milliampére. In some
cases the bladder and rectum have been quite restored to normal
functional activity, and co-ordination has improved to such an
extent that patients have been able to dispense with their
walking sticks as aids to progression. Of course I may be told
that these are cases of peripheral rather than central nerve
change, but, nevertheless, there has been an absence of knee
reflex as well as the usual ocular symptoms significant of
central disease, with which I venture to think I am fairly well
acquainted. I have never yet satisfied myself that locomotor
ataxy is the incurable disease that it has generally been
considered, and the time must come when we shall find means
to combat with greater certainty some of its more inveterate
symptoms, and render the lives of the unfortunate people more
tolerable than we at present find them. I am quite sure that
the mode of treatment to which I have just called attention
acts directly upon the nutritive processes of the spinal cord,
allays its irritability, and helps to promote its initial normal
reflex activity. If we gain and maintain so much there is no
knowing what we might effect in arresting the onward progress
of the disease, and possibly bring about compensafory measures
of which we are at present very ill-informed. It has been
proved that electrical excitation of a peripheral nerve does
give rise to change in the medulla oblongata, and furthermore
we have evidence in proof that the motor nerves, or their
terminal endings, exercise an influence on the nutrition of the
cord. Therefore it is quite possible that the influence of the
current upon the peripheral endings, innervated by a diseased
centre, sets up certain changes in that centre, which restore
to them, in a measure, a fair amount of normal power.
Nevrate1a.—lI cannot say that I have ever been very success-
fulin the permanent cure of neuralgias by electricity alone.
I have certainly tried the currents, both faradic and galvanic,
360 ELECTRO-THERAPEUTICS.

in all forms of neuralgia over and over again, unipolar, bipolar,
and so on, but it has only in exceptional cases given permanent
relief; in those where I have used the faradic current, say
in cervico-brachial neuralgia and sciatica, the pain has been
relieved completely for the time, but it has invariably returned.
From my own experience, I have come rightly or wrongly to
the conclusion that the positive galvanic current applied directly
to the nerve is the most efficient mode and the one most likely
to lead to permanent results; but massage, aided by the
galvanic current, has been much more effective than either
massage or electricity alone. In old standing cases of neuralgia,
‘sciatica particularly,” where the power and function of the
nerve have become much weakened, strong faradization
is quite inadmissible.

Brain anp Spinat Corp, Evecrrization or.—In functional
diseases of the brain and spinal cord the combined faradic and
galvanic currents are of value as aids to treatment; I prefer
the combined current in every case. Sometimes the galvanic
current should be in excéss, at other times the faradic current,
and I cannot lay down any definite rule as to the quantity of
either or of both, so much depends upon the sensibility and
sensitiveness of the patient. I have failed to obtain either in
chorea or epilepsy any good effects which I could positively
ascribe to these agents. I have sometimes thought that
charging the body with the static positive current has been
useful in chorea, but I have had no striking results, and after
a very large number of trials, both in hospital and private
practice, I am compelled to leave the question undecided. Now
and again one gets remarkable and apparently direct beneficial
influences, but these are negatived by a succession of cases
where the effects are nil, and when such cases exist it would be
unwise to laud a mode of treatment where success is doubtful
and equivocal. Ido not wish to give an adverse statement,
but from a large experience this is simply the opinion which I
have formed. As regards epilepsy I donot think that electricity
is of any good whatever.

INCONTINENCE OF URINE IN CHILDREN may sometimes be
cured by the application of a weak combined current to the
spine for three or four minutes every night at bedtime. I
think this affection may be classed among the neuroses. Some
authorities believe that it is frequently due to excentric irri-
tation; this may be so, but in my opinion it is caused by
inhibition of the normal control centre for the bladder sphincter
in profound sleep. This incontinence, which, to say the least
of it, isa very annoying affection, is not confined alone to
children, it sometimes occurs in persons over twenty years of
age. A gentleman, an epileptic, twenty-three years of age,
ELECTRIZATION OF BRAIN AND CORD. 361

consulted me a few months ago for this condition which gave
him very great trouble; large doses of bromide of potassium
and belladonna did him no good, but a brisk galvano-faradization
of the spine for ten minutes before going to bed quite cured
him. I have tried the same treatment in children with very
good results, so I can commend it.

Wariter’s Cramp.—lI have spoken of this troublesome affection,
and laid down rules for its treatment in Lecture V. A great
deal of harm might be done in these cases by injudicious
faradization.

NeuRAsTHENIA anD Hysrert1a.—Electricity in these affections
is of uncertain value when applied alone, but as part of a
system of treatment it certainly has advantages which cannot
be ignored. Electricity is a valuable aid to massage manipu-
lations, but I quite agree with Weir Mitchell, given the two
remedies for choice, massage is far more effectual, reliable, and
efficient than electricity, as a remedial agent.

SprmvaL Corp.—I am inckned to the belief that galvanization
or faradization applied directly to the spinal cord in chronic
myelitis is not attended with very beneficial results. There
are, however, functional states of the spine, not referable
absolutely to the cord alone, where the combined current seems
to do good.

The choice of the pole may be said to depend upon the
state of the spine: if there be irritability and great tenderness
over certain areas the anode or positive pole should be applied ;
on the other hand, if there be an atonic condition the negative
pole or kathode should be applied; the current must be
gradually increased in strength from five, ten to twenty
milliamperes; it may be labile or stabile, but what I generally
prefer and find much more efficacious is faradic manipulation,
it has in my practice quite superseded the other methods, and
the results obtained are much more uniform and satisfactory ;
but I have referred to this at length in my former lectures: in
spastic paralysis any local application of electricity to the
spine is quite useless, and so it is in paraplegia from pressure
in angular curvature.

Tue Bramw.— The galvanic current should exercise an
important influence upon the circulation as well as upon the
nutrition of the brain. I am quite sure that I have some-
times obtained good results from this mode of treatment
in hysteria, hysterial headaches, and migraine; I know nothing
of the effects of electricity in organic disease of the bratn.
Dr. de Watteville, who seems to agree with Erb in this matter,
writes as follows: ‘For the purpose of electrizing the brain
the galvanic current should be used, the electrodes should be
large and made to fit closely the surfaces to which they are
362 ELECTRO-THERAPEUTICS.

applied, the flexible plates covered with chamois leather answer
this purpose very well, and should be placed so as to secure the
utmost density in the region of the lesion. The current should
be weak or very weak (4-12 cells according to the state of the
battery and the resistance of the patient’s tissues), duration to
be limited to one to three minutes at a time, cautiously
increased if the subject bears it well. No sudden alterations
should be made (stabile current). The following directions for
galvanic applications to the head will be found useful.

“1. Longitudinal galvanization ; one large flexible plate on
the forehead, another on the occipital region.

“2. Transverse galvanization ; one large or medium plate
on the mastoid region on each side.

“3. Subaural galvanization ; a medium sized electrode under
the ear, the other on the opposite side of the head, forehead or
nape of the neck.

“4, Localized galvanization ; one medium electrode over
the actual convolution, &c., supposed to be the seat of the
lesion, the other on the opposite side of the neck (oblique
galvanization, Erb) or in the subaural position.”’

My own method of galvanizing the brain (labile) is
somewhat different to the foregoing, and as far as I can judge
it has all its advantages; it is a mode of procedure which I
have occasion to adopt nearly every day of my life. I apply
the flexible pad (anode) to the nape of the neck high up, and
the other electrode (kathode), a large sponge, I move about
from point to point, never releasing it from contact with the
tissues unless the strength of the current has been previously
tested; the current is thus carried to different parts of the
brain. The special points of application for the kathode are the
frontal region, the mastoid region, the subaural region and the
submental region. It is only for functional diseases that I
galvanize the brain, the more special of which are cerebral
hyperemia, cerebral anemia, insomnia, hysteria, functional
aphasia, hemicrania, hemi-cerebral anesthesia, and cerebral
neurasthenia. I make it a rule to use the galvanic current
only, but sometimes I throw in a moiety of the faradic, and 1
think with advantage.

Factan Paratysis.—This very common affection of the
seventh nerve should in the majority of cases be treated by
galvano-faradization as early as possible; of course I am
alluding to what is called peripheral paralysis generally due to
exposure to cold, the objective features of which are so well
known and so characteristic; the electric treatment should be
labile ; I prefer, and always use as the labile electrode a fairly
sized sponge (kathode), placing the carbon electrode (anode)
upon the point of exit of the nerves; it is well if the case is
ELECTRIC BATH. 863

not of very recent date to test the degenerative reactions of
the nerve before giving an opinion as to prognosis, but the
great point in the treatment is to begin electrization as soon
as possible after the receipt of injury.

Leap Paratysis.—Paralysis of the extensors of the hand
and fingers from lead poisoning.—I thoroughly endorse
Dr. de Watteville’s view as to the causation of this condition,
namely, that it is of spinal origin, “‘and consists in a
functional disturbance of the grey matter, a poisoning of the
zells, giving rise to an arrest of their functions, motor and
trophic.”” In reference to prognosis, test for the reaction of
degeneration ; for treatment, use a labile current (kathode),
placing the anode at the back of the neck low down.

Exzcrric Barn.—The common form of electric bath consists
in immersing the patient in an ordinary water bath of the
temperature of 100° F; one pole of the battery is usually
made of a large sponge connected to a metal electrode, and
upon this the patient may sit, or 11 may be moved or fixed to
any part of the spine as may be desired; the other pole is
made of a large piece of metal which is fixed to the foot of the
bath, or it may be made of a flat piece of metal which is
attached to a long insulating handle so that the current can
be concentrated upon and carried to any part of the body;
either current may be used, but the faradic is usually
preferred. At one time I used to order the administration of
electricity in this manner, but I have long since abandoned it
as untrustworthy, and of very doubtful therapeutical value.

 
 

MOTOR POINTS.

   

M Lumbricales M Lumbricales

 
   
   
  
   
  
 

   

M Abductor brev. pollicis, 0
M Opponens minimi digiti
M Flexor minimi digiti
M Abductor minimi digiti
M Palmaris brevis

M Flexor brev. pollicis
M Opponens pollicis
M Abductor brev. pollicis

Median nerve
M Flexor long. pollicis

Ulnar nerve

M Flexor digit. sublimis

M Flexor carpi radialis
M Flexor digit. profundus
M Pronator radii teres MM Milesan eamptulnazs

Med.nerve
M Brach.
Anticus

Ulnar nerve
M Biceps

Mus. -cut.
nerve

M Deltoi-

deus Ant, 2

Motor points of muscles supplied by the median and ulnar nerves. Upper
extremity—Anterior view.

PLATE I.
MOTOR POINTS.

M Inteross. Dors.
1, 2, 3,4

%

(N Ulnaris)

M Abduct. min.
digit.

  
    
   
   
    
  
 

M Ext. long. pollicis
M Ext. brev. pollicis
M Abduct. long. pollicis

N

‘ > ___ M Ext. indicis

\ | —————- M Ext. minimi digiti

: M Ext, communis digitorum
M Ext. radialis brev.

 

M Supinator brev.
M Ext. carpi ulnaris
M Ext. radialis long.
M Supinator long.

M Brachialis
Radial nerve

M Triceps
| M Deltoid

an © Circumflex nerve

Motor points of muscles supplied by the radial nerve. Upper extremity—
Posterior view.

PLATE II.
MOTOR POINTS.

 

M Gluteus maximus
M Biceps Ischiatic nerve
(Caput longus) | M Adduct, magnus
M Semitendinosus
M Biceps
(Caput brevis)

Tibial nerve

  
 

Peroneal nerve

M Gastrocnemius
(ext.)

M Gastrocnemius
(int.)

Soleus

M Flex. digit com,
M Flex. long. poll.

 

Tibial nerve

Motor points of muscles supplied by Sciatic Nerve and its branches.
Posterior views of lower extremity.

PLATE III,

24
MOTOR POINTS.

  
  
   
  
 
 
  
  
  
  

Crural nerve

{ M Tensor vaginz
femoris
Obturator nerve
M Pectineus M Quadriceps fe-
{ moris

a eT cect M Rectus femoris

M Adductor longus
M Crureus

M Vastus externus

M Vast us internus
Peroneal nerve ;
M Gastrocnemius

M Tibialis anticus sais M Soleus

M Ext. com. digit.

M Peroneus longus

M Peroneus brevis
M Ext. prop. poll. M Peroneus brevis

M Abd. min. digiti

M Ext, digit. brevis
communis

M Dorsal interossei

Motor points of muscles Motor points of muscles
supplied by peroneal nerve. supplied by anterior nerve.

Anterior view of lower extremity.

PLATE IV.
GENERAL INDEX.

PAGES
ABDOMEN, faradization of, 177, 357
— massage of 151, 279

Absorption by lymphatics,
~ 111, 112, 118, 118, 122, 240, 255
Accumulators .. 826
Adhesions in joints, ‘29, 97,

101, 112, 243, 256, 356
Advanced age, diseases of, 274, 287

Albumen Be 312
Alcohol, the use of’. “145, 146, 270
Amblyopia OL, 195, 242
Amenorrhea ... ... 168
Ampére 304, 306
Anabolism 10, 244

Anemia, 58, 117, 146, 147,
161, 236, 281, 285

Anesthesia 77, 93, 199, 218
Analgesia 77, 98, 218, 269
Anelectrotonus w. B41
Aneurism .. 854
Anode. ‘ "300, 313, 316
Anodal ‘opening contraction
(AOC) eis ; 82, 342
Anodal closure contraction
(ACC) 82, 342
Anstie.. ss 226
Antagonism, the law of, 9,
108, 109, 284
Anterior polio-myelitis 8, 839
Aphonia .. 92, 93, 195
Apostoli .. 21, 815, 849
Arterial tension 19, 70, 121
Arthritis, see Joints.
Asthenopia ... see 61, 242
Ataxy, locomotor, 251, 266,
358, 359
Atrophy, infantile eee 297
Atrophy, various forms of,
80, 88, 85, 86, 100, 101, 243,
250, 357
Aural vertigo... 59, 283
Auzony die ws = 16
Ayrton 302
BaINn 260, 267
Baker ... 251
Barlow 274

i

 

PAGES
Barwell 235, 287, 251
Basedow’s Disease 52, 58, 354

Bath, the electric, 98, 101,
106, 141, 168, 231, 252, 363

— the thermal baths of 253
Battery, bichromate .. 814
— combined ... 822, 823
— Faradic, Gaiffe . 821
—_ »  schall 821
-- storage ©... sin ... 826
—— Stéhrer’s ... 9, 306
Beard ... Soi se 226
Bell, Sir C.... ele con AN
Benedikt es bee ae SL
Benton, 8S. . .. «©8384
Bernard, Claude 25, 55
Bert ... sa we 25
ees oe was we BL,
Bipolar we 845
Blood, circulation of, ‘18, 27,
109, 111
— colouring matter of, 24, 25, 149
-—~ corpuscles, Bleorptive
area of ae 25
— gaseous constituents of “21, 25

— nutrition conveyed by 111, 244

— pressure ... 109, 110, 112, 115
Boyle’s law ... ee we (22
Brain, electrization of 360
— irritable 260
— railway ... 260
Brandt, Major Thur.. 169
Braun and Tiirk 224
Breaking current 306
Browne, Crichton .. 269
—W.AF. ... si ... 270
Budge ... an ai v.55
Bunge, Otto ... «» 171
Bunsen nes we = 28
Burse ... “24s, 254, 255
Busch ... ‘s 235, 241
Czacum, massage of ... 152
Cancerous disease 195
Cardiac neuralgia 96, 176

Carpenter

"958, 262, 270
Catabolism on .. 10
374

PAGES
Cauterization 824
Cell, exhaustion of ... 314

Change of life, 73, 272, 274,

281, 282, 285
Charcot 81, 98, 94, 174, 197, 251
Cheadle : is wae 294
Chemical action 5, 294, 297
Chest, massage of 38, 149
Children, diseases of 274
— hospitals for 274
— precocious 276
Chlorosis 117
Chorea... 279

Circulation, arterial, ‘19, 109,
118, 119, 121, 168

— of blood 18, 27, 108, 110, 121
— disordered 129, 282, 285
— hepatic 17, 162

— lymphatic, 21, 26, 38, 108,

109, 112, 114, 118, 119, 223

— ‘ vagaries ” ee)
— venous, 21, 26, ‘38, 109,

112, 114, 118, 121, 223

Clarke, Sir A. 181, 184

Coil, induction, prnbalys se-

condary ve 320
Colles’s Fracture 88, 256
Colon, massage of . 152
Combined battery ... w. 821
Compensation 109, 118, 122, 172
Commutator ... ws .- 806
Conduction 300, 801, 804
Confidence in treatment 10, 137

Congestions, 30, 115, 117, 167,
169, 172, 174

Constipation, electricity in,
157, 167, 178, 358

— massage in, 28, 151, 154,
156, 160, 167, 178, 279

Convulsions we. 195
Cramps 91, "102, 104, 176
Crothers sis wee O12
Cruorine ei wee we <2)
Crural neuralgia 100
Cupping, dry... Ne ws. 226
Current, ascending ss 338, 340
— breaking ... w. 806
—- choice of . 339
— constant ... 313
— degrees of ... 3809
— descending 338, 340
— diffusion of aia w. 837
— direction of 238, 809, 340
— Faradic 337, 338
— galvanic 387, 338
— induced 316

 

MASSAGE AND ELECTRICITY.

PAGES
Current, intensity 337
— labile 338
— magnetic ... _ 309
— magneto-faradic .. 316
— selection of 337
— stabile .. 838
— strength of, ‘81, 307, 309,
312, 339
Daniet’s cell.. a .. B04
Davy, Sir Humphrey sax 22
Death . sy 7
— of tissue ... in 28
Degeneration, reaction of ... 342
Deltoid muscle sie 81, 84
De Watteville 233, 307, "318
Diabetes 14, 15, 17, 91, 276
Dickenson sis 270, 274

Dictionary, Quain’s 165, 175, 252
Diet tables, 139, 141, 143, 144,

145, 146, 147, 192, 277
Diogenes, the cup of 48

Dipsomania ... 258, 269
Donders -- = 62
Dropsies, 18, 20, 109, ‘118, sts sii
Duckworth, Sir Dyce ws 15
Duncan wits ies «. B55
Dysmenorrhcea 167
Ear affections .. 59, 67, 283

Effieurage, 32, 83, 65, 68, 227,
230, 264, 268

Electric compress, 157, 165,
166, 167

Electric current, 5, 294, 298,
299, 300

— current, resistance to, 74,
75, 81, 83, 178, 183, 227,
298, 800, 301, 302, 303, 304,
305, oe oe au 316
— heat aun 5
— light a 5
Electric stimulation “demon-
strated : 54, 80, 177, 231
Electricity, the term . 293
— dosage of ... : 339
— negative and _ positive,
298, 299, 300
— physiological effects of,
8, 9, 52, 54, 81, 140, 232,
234, 816, 345
— static 238, 267, 826
Electrode ais 300, 308, 338
Electrolysis, 300, 312, 387,
349, 354, 855
INDEX. 875
PAGES PAGES
Electro-motive force, 294, Gases, absephen of by
295, 301, 802, 804, 307 fluids sis ..22, 24
Electro-physics .. 298 | — in blood ... 21, 84, ‘49
Electrotonus ... 340 | Gastralgia 357
Emmenagogues 168 | Gastric pues 197
Endosmosis ... .. 10 | Gee... we DT4
Energy, exchange of. .. 7,68 | Glands, massage of, ‘66, 69,
— and aaa 295 115, 124
— potential .. Glycosuria, massage and elec-
— vital dis 2, ‘86, 79 tricity in 17, 159
Epidermis, the ..69,75 | Goitre.. 52, 58, 854
Epileptoid sweats... =. 1 | Goodhart |. vee 24
Erb... * 104 | Gout, 14, 15, 17, 18, 228, 256,
Erysipelas ... “a . = 86 287, 356
Esmarch a .. 81 | — Rheumatic 293, 256
Eulenberg “ot 55, 57, 71 | Gouty Sciatica : . 99
Examination before massage 87 | Gowers, 88, 93, 94, 99, 105,
Exciting fluids we. ©8822 175, 281
Exosmosis... .. 10 | Gradeingo ... ved B81
Experiments in absorptive Graham 61, 62, 110, 188, 169
processes ... ile ... 118 | Granville’s perceutor «. 86
Eyeball, massage of... 61, 66 | Graves’ Disease 52, 58, 854
; Co force of .. 3810
Rises . 159 room Ae 116
Faradic battery, Gaiffe 321 pee Sir William .. 105
— current 887,888 | Gorn ee
~— machine ... 318, 319 Gy ane : Bby BY
— massage of skin - ee ymnastics, active and pas-
ay an sive, 8, 29, 30, 37, 89, 42, 46,

Faradization, 9, 97, 121, 125,
229, 289, 316, 346, 847
.. 24

Fernet

Ferrier aa .. 267
Fever, McAlister on .. =12
Fick ... ar oe .. 14
Force ... ‘ we 2A
Foster... . 7,18
Fothergill 35, 285
Freeman, W. H. . 258
GAIFFE wi 307, 321
Gall bladder ... 162, 165
— stones 165

Galvanic current, 8, 9, 52, 54,
81, 98, 105, ‘106, 337, 338, 345

_— cautery sis 324, 325

Galvanism, effects of on cir-
culation... iis w. 54

Galvano- faradization 347

Galvano-puncture «» 850
Galvanometer, 305, 306, 308,

310, 311, 312
Ganglia ia ee 54
Gardner ean aie 3
Garrod , aah 251, 252

 

98, 100, 105, 188, 149, 235,
241, 243, 247, 259
Gymnastic massage, 67, 86,

93, 105, 138

Hasir, the physiology of ... 259
— influence of eats 262

— spasms... . 68
Hacking the muscles, 9, 36, 229, 243
Hemoglobin ... ra 24, 25, 149
Hand, the human ... say, ve
— the massage wins ww. +» 49
Haward Warrington 160

Head and Neck, aa of 52

Headaches... . 56
Heart derangements v.20
— Stroke of . ‘ 21, 27
Hemicrania ... . 56

Hepatic cells, exhaustion of 17
— derangements, mass. and
electricity in 163, 177

Herschell 333, 3387
Hervieux a sie as 981
Hilton... we ios a. §=©56
Hoppe-Seyler vss we 25
House-maid’s knee ... 255
Humphrey 287
376

PAGES
Hitter ... sa ai ww. = 81
Huxley ass 7
Hydrogen, to set free 803, 307
Hyperemia ... .. 58, 117, 170
Hypereesthesia es eee 175

Hypochondriasis,massagein,
156, 163, 167, 187

Hysteria, 86, 92, 129, 139,

168, 174, 180, 193, 225, 230,
238, 861
Hysteria in the Male, 93, 194, 196
Hystero-epilepsy 195, 209, 220

InpvuceED current
Infancy, diseases of... 275
Infants, mortality amongst 275
Infantile paralysis ... ..-9, 281
Inflammations, massage in,

101, 118, 154, 246

316, 317

Instruments in massage ... 36
Intercostal muscles, massage
of... ei 98, 164
Intercostal neuralgia 242
Intestinal movements, physi-
ology of 155, 162
Intussusception, massage in 159

Jacxson, Hughlings, 125, 155, 170
Jennings, Oscar ea wee 272
Joints, anatomy and func-

tions of 248, 250
— diseases of ... 29, 112, 248
— dislocations of ... we. «244
— dropsies of ... 119, 121, 255
— faradization of 356, 357

— massage of, 29, 97, 101,
112, 243, 256
— and muscles, relationship

between 248, 250, 256
KATELECTROTONUS ... . B41
Kathodal closure contraction

(KCC) a 82, 342
Kathodal opening contraction

(KOC) 2 ste 82, 342
Kathode 81, 300, 318, 316
Kerr, Norman w. =269
Klemm’s Muscle Beater w=:
LaBYRINTHINE vertigo . =59
Lagrange... w+ 22

Landois and Stirling, 7, 70,
71, 110, Lif, 142

Laryngeal gymnastics ve = 67
Larynx, massage of... 67
Latham 14, 16, 17, 18

 

MASSAGE AND EBLECTRICITY.

PAGES
Lavoisier... wes we = 22,
Laycock ess vee wie, OF:
Lead Palsy oe 89, 363
Leclanché’s cell 295, 296
Lee, Robert ... a. 274
Leucocytes 111, 114
Leucocythzemia w. 117
Lewandowski "327, 328, 329
Liebig ... es . ..28, 25
Liebrich as sis o. =661
Life... 7
Liver, the functions “and de-
rangements of ... 17, 162
Locomotor ataxy, 251, 266,
358, 359
Lotion for skin 51, 78, 97, 99

Lubricants, use of, 78, 97,
151, 247, 252, 279
Ludwig si .- 112
Lumbago, massage in 242, 268
Lymphatics, absorption by,
111, 113, 118, 340, 255
Lymphatic circulation, ‘the
21, 26, 33, 109, 110, 112,
114, 118, 119, 223

Lymphatic system, the 110
McKEwnDRICK... 21, 22, 28
Macpherson, Laurie 63, 254
Magnetic Needle 309
Magnetism, permanent and
temporary .. «= 3817
Marshall and Horsley . 58
Mass wee 2
Massage, dosage of . 189, 247

— effects on circulation of,
19, 29, 54, 62, 108, 110, 111,
112, 129, 188, 223, 224

— electric 68, 74, 229

— experiments by Zablu-
dowski ae ah .. 28

— and Induction ... .. 68

— influence on temperature,
8, 9, 88, 55, 118, 188, 224

— influence on weight, 28,
148, 144, 161, 192, 198

— in Joint and Bursal affec-
tions 243
— of lower extremity ww. «= 44
— of lymph and venous cir-
culations ~ 108, 110
— mechanical principles of 1, 9

— mode and method of
application 31, 65, 151
— objects of . 9, 38, 128, 128
INDEX.

PAGES
Meeees, physiological effects
of, 6, 9, 29, 66, 69, 84, 109,
112, 118, 128, 162, 169, 249
_ sedative effects of, 28, 66,
87, 99, 225, 242, 250, 262,
268, 265, 279
— of spine and back 223
— of upper extremity ... 37
— time of operating, 47, 50,
139, 247, 264
— manipulations, careful
and careless, 32, 38, 34, 36,
87, 121, 183, 184, 188, 151,
153, 159, 232, 278
— constant practice required 35
— described and demon-
strated, 32, 46, 188, 151,
227, 247, 264, 268
-- direction of, 24, 33, 89, 46,
97, 114, 121, 152, 164, 173, 227
Masseur and masseuse, diet
and health of er ww. =49
— qualifications of, 47,127,263,279
Matter, definition of the term 1

Matteucci... ies, vasa 220)
Meade-Smith.. aKa . 14
Mechanical effect of tapote-
ment ws a. «=—BB
— treatment of tissue w= -28

Megrim (or Migraine) 17, 56, 283
Melancholia . * 258, 272
Mendelson... aa ow. 81
Metabolic changes in tissue,

11, 70, 80, 120, 147
Metabolism, 3,17, 140, 142, 277, 283

Meyer .. 226
Meynert ee 267
Milliampére ... . 809
Molliere we 287
Money, Angel... 274

Morphiomania, : massage in, 258, 269

Mortality amongst infants... 275
Morton ais -» 826
Mosengeil “12, 118, 114
Mosso, Angello ee .. 103
Motion ae . 2,3
Moullins, Mansell 249

Muscle, atrophy of, 8, 80, 83,
85, 86, 100, 101, 248, 250, 357
— cramp of, 102 250 (see Cramps)
— fatigue of, 14, 29, 79, 81,
101, 104, 241
— galvanization of ..
—and Joint, relationship
between ..248, 250, 256
— Motor points of ... 348

 

356, 357 |

377

PAGES

Muscle, movements of, 79, 112, 243
—and Nerve, relationship

between 79, 86, 107, 186

— oxidation in 1, 13, 228, 278
— stimulation of, 8, 80, 81,

86, 90, 118, 138, 151, 223

Miller, Johannes ee we =—-.22
Miller, L. & W. dee we «= «24
Myopia 61, 242
Myxcedema .. 123
Navi, electrolysis of 354
Nerve cells, physiology of ... 16
— fibres classified ... sis 1D
— Fifth Cranial... .. «=
— and Muscle, action of
electricity upon 81, 86, 140

— — relationship between,
79, 86, 107, 186
— — degenerative changes
in, 84, 89, 95, 100, 101, 103, 180
— Sympathetic «. 176
Nervous exhaustion, eee
in S 16, 180
—_— = “electricity i in, 180, 225,
230, 359
Nervous System, diseases of 180
— -- massage effects on,
108, 130, 138
— —shockto 60, 197, 199, 281
Neuralgia from ‘decayed teeth 56
Neuralgias, various, 52, 94, 95,
96, 97, 98, 100, 176, 177, 239,

242, 284, 359
Neurasthenia 19, 181, 230, 861
Neuritis, Multiple ... ww. «OL

Neuroses, occupation, 101,
102, 104, 361, 363
Nitrogenous food, excess of, 17, 286
Norstrém, Gustaf... .. 169
Nurses, qualifications of 137
Nussbaum’s Apparatus 104
Nutrition, cold and heat in... 11
— Vaso-motor centrein ... 16

Nutritive action of massage,

11, 84, 107, 116, 181, 138,
148, 280, 274, 277

Nutritive processes of lym-
phatics ae .. 116

OBESITY, massage in, 132, 146,
152, 160, 162, 286

Cidema .. 118
| Ohm "304, 806, 313
Onimus 2 A w. 226
Opening current 306
378

PAGES
Ovarian derangements, mass.
and electricity in, 173, 174,
268, 355
Ovaries, position and func-

tions of . 178
Oxidation in the muscles, 1 2

18, 223, 278

— of tissue 9, 80, 144, 149

Oxygen, amounts of necessary 23

— inhalation of ... 149
— to set free... 303, 307
PAGENSTECHER «~ 62
Paget, Sir J. 56, 951, 259, 270

Pain, 58, 63, 64, 97, 100, 107,
176, 195, O45, 256, 258, 265, 356
Panas ... . 62

Paralysis, facial "63, 362
— gall bladder . 166
— infantile 8, 281
— lead 89, 363
— muscular ... ue w= 85
— spastic ... sie we 115
— various forms of... w= = 85

Passive gymnastics, 37, 38, 40,
42, 86, 97, 106, 107, 112, 150, 252

Perceutor, Dr. Granville’s... 86
Peri-polar zone 340
Perityphlitis ... 154
Perspiration ... . 70
Petrissage, 5, 10, 8B, ‘89, 65,

227, 247, 268
Pfliiger 27, 340
Philpots é a 125
Phlegmasia dolens ... 120
Plaster jacket : ve 285
Playfair sci .. 127
Polarity "340, 344, 345
Polarization ... 298, 314
Poles, positive and negative 300
Positive electricity 298, 299, 300
Position in writing ... 241

Potential, difference of, 296,
297, 298, 299, 300

Poore, G. V. ... : 103
Precocious children .. we 276
Pressure _ . 2, 4, 5, 24, 89, 177
Protoplasm 38, 26
“ Raruway”’ brain 196
— spine wih ses 196
Ranvier 118

Raymond, Du Bois 14, 56, 57, 823

Reaction of degeneration we 842
Recuperative power . 275, 288
Reece ... sie an ww = 68

 

MASSAGE AND ELECTRICITY.

PAGES

Reflex action, 29, 55, 78, 96,

99, 168, 175, 176, 223, 282, 252, 261
Regnault and Reiset we = 28
Remak..

Resistance to ‘electric current,
74, 75, 81, 83, 178, 183, 227,
298, 300, 301, 302, 308, 805,

309, 315, 316

Resistance, internal, 298, 300,

226

302, 803
Respiration, artificial 149
— cutaneous... .. 70, 149, 224
— mechanism of 12, 149

— of tissue, 9, 10, 13, 21, 22,
25, 26, '70, 80, 149, 223, 278

_ pulmonary ar

Rest after electricity. 158
— after massage... -. 650
— in hysteria 185
— of inflamed joints we $246
Rheophore 79, 300
Rheostat wes i w» 805
Rheumatic arthritis... 251
Rheumatic gout 223, 256
Richardson, B. W. 21, 269
Rickets... do 280
Roberts 165
Rockwell . ee w. 226
Rolling the muscles ... 33, 39, 42
Romberg .. 56
Roth 235
ScHALL 8238, 324, 325, 326

School life, influence of, 61,241, 242
Schreiber, 29, 31, 101, 104, 118, 241
Sciatica or 99, 338
Sciatic Nerve, stretching the,

; 46, 101
Scrofula 280
Scurvy ; 280
Scybale, massage for .. 159
Sea voyages ... 148, 182, 190
Seamstresses’ Cramp . 102
Seclusion of patients 185, 192

Sedentary life, diseases of, 274, 285
Sensation, phenomena of, 68, 7, 15
Sensibility, conscious and un-

conscious ... ae -. 68
Sequard, Brown... aden, AD
Seguin’... : 134
Silence during massage -. 650
Skin, applications to the 51,

78, 97, 99
— faradization of the we B47

— functions of the ... 70, 78
— reflexes of the, 69, 73, 75,157,158
INDEX. 379

; Ae PAGES PAGES
Skin, sensitiveness of the ... 75 | Throat deafness ee ve = 67
Sledge collector 806 | Thyroid gland 52, 58, 59, 354
Sleeplessness, massage and Tic douloureux a we 68

electricity in, 225, 258, 260,

262, 273

Smith, Eustace ..194, 274, 278

Snow ... a At -. 60

Spallanzani ... 22, 25
Spasms, various, 63, ‘166, 176,

178, 283, 284

— of muscles, 63, 64, 93, 195, 256
Spine, hysterical 225, 269
— electricity to, 55, 177, 225,

230, 231, 283, 273, 361
— irritable, 98, 189,224, 225,
226, 22'7, 230, 242

— “Railway” 196
Spine and back, massage to 223
Spinal abscess 235

Spinal cord, 9, 12, 55, 57, 84,
96, 107, 176, 223, 224, 230,
236, 242, 251, 261, 270, 281, 361
Spinal curvature 61, 235, 240
Spine, massage of, 55, 59, 61,
62, 73, 86, 96, 98, 107, 125,
156, 158, 177, 223, 224, 225,
226, 227, 280, 235, 252, 264, 269

Sprains ... 244, 249, 357
-Stevenson ... w- B51
Stéhrer’s battery -.9, 306
Stokes... : ates a. 24
Storage battery .. 826
Strassburg... . 26
Strength of current, ‘307, 309,
312, 317
Strictures, electrolysis in ... 355
Sukjanow... ‘a0  =6-14
Sweat glands... 7 - 70

Sylvester’s treatment 150
Sympathetic ganglia of neck 54
Synovial membrane and fluid 244

TAPOTEMENT 385, 36, 228, 229, 268
— mechanical effects of ... 36
Telegraphist’s Cramp «» 102
Temperature of body 11, 18, 25
— in massage 12
-- of massage operating room 50
Tension, arterial and venous,

19, 109, 122
— of gases ... ane 23
Thermogenesis a ws «=D.
Thermolysis ... #8 sa
Thermotaxic mechanism ... 12

Thomson and Tait ... sat 1

 

Time for massage operations,
47, 50, 1389, 247, 264

Tissue, atrophy of, 80, 83, 85,
86, 100, 101, "043, 250, 357
— changes ‘produced i in 182, 162
— death of ... an)

— fatty, 132, 142, 146, 151,
152, 160, 161, 162

— respiration of, 9, 10, 13,21,
22, 25, 26, 70, 80, 149, 223, 278

Torticollis ae -. «68
Trousseau "196, 224, 226
UNIPOLAR 845
Uric acid

16, 17, 157, 223, 287
Urine, incontinence of . 860
Uterus, position, functions,
and derangements of, 167,
168, 355
— Apostoli’s treatment of,
849, 350, 352, 353

Vauves in heart 121
— in lymphatics 112
— in veins .. 114
Varicose veius 110, 114
Vaso-motor centres in med.
oblongata ... 16, 58, 157
Veins, inflammation of 114
— structure of 114
Vital mechanics se we ZL
Visual defeats: manne? in 61, 242
Voisin . Z a we «=—s« 5H
Volt : ... 804
Voltaic alternatives. 306, 345
Voltameter '306, 307, 308
Vou Marxow ... tn, DT
Von Ziemssen od 157, 285
Voyages, sea ... ...148, 183, 190
Water, Augustus ... ae 108

Wasting diseases of children 274
Weight influenced by massage,
28, 143, 144, 161, 192, 198

Weir Mitchell 11, 194
— treatment.. ates wen LT
Wells, Sir Spencer ise 175, 358

Will power, defective 92, 185, 188
Winiwarter ... wn OL
Work ... 2
Writer’s Cramp “102, 104, 361
JOHN WRIGHT AND CO.,
PRINTERS AND PUBLISHERS, BRISTOL.
ANNOUNCEMENT. Seventh Annual Issue.
THE INTERNATIONAL

MEDICAL
ANNUAL, 1889.

A Complete Work of Reference for Medical Practitioners,
Epirep sy PERCY WILDE, M.D.

Assisted by a Corps of Twenty-two Distinguished Collaborators widely known in
Europe and America.

OUTLINE OF CONTENTS:
First, The Dictionary of New Remedies.

With this is incorporated a review of the general Therapeutics of the year
and to which is added an Index of Diseases showing at a glance the new
remedies which have been recommended in any given disease, and the page
upon which the prescription will be found. It formsa very comprehensive
and useful survey of the multitude of new remedies that have been recently
brought under the notice of the medical profession in Europe and America.
The fact that it includes the results of recent experiments with many value-
ble drugs that have lost the charm of novelty makes the volume more com-
plete asa reference book; arranged in dictionary order under the name of
the remedy.

Second. The Dictionary of New Treatment.

Comprises a remarkably full reswmé of the medical literature of the year
giving the new methods of treatment in Medicine and Surgery which have
come to light in all parts of the world and been recommended since the pub-
lication of the Dictionary of New Treatment of 1888; with original articles,
suggestions, and observations by specialists and the editors in charge of the
several departments. A veritable multum in parvo of information of great
value for the dispensing chemist as well as the medical practitioner. Alpha-
betically arranged under the name of the disease ; each article bearing the
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diseases will be incorporated in this department. ; ;

Each yearly edition is complete in itself and contains entirely new
matter. (Uniform with ‘Medical Classics Series.”

 

In one large octavo Volume. Illustrated. Nearly 600 pages. $2.75.

E, B, TREAT, Publisher, 5 Cooper Union, New York.
DISEASES

OF THE

HEART AND LUNGS,

By JAMES R. LEAMING, M.D.,

Emeritus Professor of Diseases of the Chest and Physical Diognosis in
the New York Polyclinic ; and President of the Faculty,
Special Consulting Physician in Chest Diseases,
St. Luke’s Hospital, New York, etc.

The author of this treatise has made the diseases of the
heart and lungs his special study for many years. His care-
ful investigations as a Practitioner and Professor in New
York, his observations in Public Hospitals and private con-
sultations were occasionally embodied in papers, read before
the Academy of Medicine or published in Medical Journals.
‘These having been discussed, the views presented being some-
times modified, strengthened or confirmed, were afterwards
tested and in their revision, are given to the profession in this
permanent form, :

Dr. Leaming’s well-known acute faculty of discriminating
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effects are recorded with great particularity and with very
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consideration of the class of diseases pertaining to the heart
and lungs, that the most advanced investigations have ascer-
tained or the most skillful practioners have found remedial
or beneficial,

The book is therefore submitted to the profession as a
valuable contribution to the fuller knowledge and treatment
of diseased or abnormal conditions of the cardiac and respi-
tory system,

In one large oct, vol, 300 pages. Price, $2.75,
E. B. TREAT, Publisher, 5 Cooper Union, New York.
EXCESSIVE
VENERY, MASTURBATION

AND

CONTINENCE.

THEIR ETIOLOGY, PATHOLOGY AND TREATMENT IN-
CLUDING DISEASES RESULTING
THEREFROM.

JOSEPH W. HOWE, M.D.

Late Professor of Clinical Surgery in Bellevue Hospital Medical College,
Fellow of the New York Baeee PE. of Medicine, Visiting Sur-
geon to Charity and St. Francis Hospitals.

Second Edition Revised, )

This volume contains in addition to the results of the author’s experi-
ence obtained in hospital and private practice, the substance of a course of
lectures delivered in the Medical Department of the University of New
York, on the Results of Excessive Venery, Masturbation and Continence,
to which is added the peculiar methods of treatment employed by various
authorities in Europe and America, The causes, diagnosis and treatment
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curious experiences detailed bearing upon the mental influences connected
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This is a judiciously written book from the standpoint of a practical
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well stated, and the various methods of treatment are ably discussed. No
resources known to modern medicine or surgery being neglected. —Lozisville
Medical News,

To say that the book is readable is putting it very mildly. That it is
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The work is concise and practical, and yet sufficiently full to make it
a valuable work of reference. The chapters on treatment are especially
complete.—Baltimore Medical Chronicle.

Tn one large Octavo Volume. 300 pages. Handsomely Bound, $2.76.
E. B. TREAT, Publisher, 5 Cooper Union, New York.
~ HANDBOOK OF TREATMENT.

ARRANGED AS AN ALPHABETICAL INDEX OF DISEASES, TO FA
CILITATE REFERENCE, AND CONTAINING NEARLY
ONE THOUSAND FORMULA.

By WILLIAM AITKEN, M.D., (EDINBURGH,) F. R, S., =
Professor of Pathology in the Army Medical School; Examiner in Medicine for the Mili-
tary Medical Services of the Queen; Fellow ofthe Sanitary Institute of Great
Britian; Corresponding Member of the Royal Imperial Society
of Physicians of Vienna; and of the Society of Medi-
cine and Natural History of Dresden, etc.
Epitep witH Notes anp ADDITIONS
By A. D. ROCKWELL, A.M., M.D.,
‘Late Electro Therapeutist to the New York State Woman’s Hospital.

There is, perhaps, no more striking characteristic of the medical prac-
titioner of to-day, and none better illustrating the pervading spirit of the
age, than the universally observed tendency among medical men to shun (in
medical literature) the unrealities of theoretical discussion, and to appropri-
ate with avidity only facts which they can instantly transform into working
force,

A book which is at once concise and comprehensive, arranged so that
the practitioner, given a disease to treat, may have before him in a nutshell
the latest treatment recommended by the best authorities; and a book
which is above all else a book of TREATMENT, we here offer to the profession.
It is composed of the chapters on Zveatment compiled from the seventh
(latest) edition of Dr. Aitken’s classical work on the Science and Practice
of Medicine, which chapters have been revised and rearrenzed, by Dr.
Aitken, soas to make them more availahle for reference. The work not
only embrace the experience of its distinguished author, but also that of
many widely known authorities.

 

The WV. Y. Medical Recora says: ‘‘ This book is a compilation from the
last edition of Dr. Aitken’s well-known work on ‘ The Science and Practice
of Medicine,’ and comprises the chapters on treatment as written by that
author. The diseases are arranged in alphabetical order, with numerous
cross references, whereby the reader is enabled to turn at once to any de-
sired subject without being obliged to refer to an index. Under each
heading is found a short definition of the disease, and then follows imme-
diately the portion on treatment. Dr. Aitken’s work is too well known to
require any discussion here.

The New England Medical Monthly says: ‘‘ From beginning to end
it proves itself to be one ot those rare books which the general practitioner
should have and always wants on his desk. At a glance he finds in a nut-
shell many things which to work out from from his library would consume
too much valuable time.

The Medical Age says: ‘‘ The characteristics of the book before us ar
its conciseness and its comprehensiveness. It aims to be thoroughly prac-
tical, and to this end devotes the smallest possible space to definitions of
the diseases which it discusses, and the largest possible space to treatment.
Its formula will commend it to a large class of practitioners.

In one large octavo vol., 444 pages, handsomely bound. Pricc, $2.75.

E. B. TREAT, Publisher, 5 Cooper Union, New York.
HAMILTON'S

MEDICAL JURISPRODENGE.

A MANUAL OF MEDICAL JURISPRUDENCE,
WITH SPECIAL REFERENCE TO
DISEASES AND INJURIES
OF THE NERVOUS
SYSTEM.

-BY—

ALLAN McLANE HAMILTON, M.D.,

One of the Consulting Physicians to the Insane AsyJums of
New York City, etc.

Second Edition Revised:

This is a practical work, doing away with those long and tiresome details which works
on this subject so frequently give ; yet all necessary details are given—plain, clear, and
concise,

It is very fully illustrated with cases drawn largely from American sources, and hence
better calculated to meet the wants of American physicians and legal advisers—a feature
that is not always to be found in similar treatises. The leading chapters embrace Insanity
in its Medico-legal Relations; Hysteroid Condition and Feigned Disease; Epilepsy ;
Alcoholism ; Suicide ; Cranial Injuries and Spinal Injuries.

The first chapter defines Insanity, its general indications, classification and Hereditary
Influence—Including Post Mortem Examination of the Insane (with plates of the typical
and a typical brain. Under the legal Relations of Insanity we have Legal Tests—The
Guiteau case—Physical Tests—Duties of Medical Experts—Tricks of Counsel—IIlusions,
Hallucinations and Delusions—Reasoning Mania—Contracts made by the Insane—Testa-
mentary Capacity—Old Age and Dementia—Undue Influence—Medico-Legal Relations of
Aphasia—Marriage and Insanity—Insurance Frauds—Responsibility of Deaf and Dumb—
Criminal Responsibility—Responsibility in Relation to Imbecility—English Test of Re-
sponsibility ; American Decisions on it—The Test of Right and Wrong—Impulsive
Insanity—Commitment of Lunatics and State Laws Kegulating it—Concealed and Feigned
Insanity,etc. The chapters on Cranial and Spinal Injuries are particularly valuable, for
the numerous decisions cited from our courts in connection with suits for damages from
Railroad Collisions, ete.

 

‘* An Examination of this work demonstrates itsworth. In these days of malingering
the slightest injury form a fall is too often held to have caused injury to the spine, a mul-
titude of symptoms being referred to concussion, Works upon‘ Concussion of the Spine’
have given an impetus to this imposition, and the needy member of the bar has often
utilized it to Hill his coffers through the mulcting of corporations for this put up condition,
We do not mean tw say, nor does Dr. Hamilton, that concussion of the spine never does
take piace, but the instances of its occurrence are verytare. Every physician and surgeon
should haveacopy.”— The Therapeutic Gazette.

“« There is a good deal of value in it and a large number of illustrative cases are given,
both old and recent, which have never before been collected in book form, though mostly
familiar to the alienist, and will prove of particular value te he lawyer who wishes to
crowd the interstices of his elastic brain with numerous facts for the morrow’s fray, in
which he will give the spectator the impression that for years he has made a special study
of insanity.— The Boston Medical and Surgical fournal

‘The lawyer who wants something to the point in a pending case, and the physician
who is on the eve of running the gauntlet of the court as an expert witness upon some
vexed questions of mental deflections, will find a treasure in this work,”—~ The Louisville
Medical News. 2

Onelarge Octavo Vol. 380 pages. Illustrated. Handsomely Bound, $2.75
E. B. TREAT, Publisher, 5 Cooper Union, New York.
— ‘The Pathology, Diagnosis and Treatiieul

OF THE

DISEASES OF WOMEN,

GRAILY HEWITT, M,D., London, F.R.C.P,,

Professor of Midwifery and Diseases of Women, University Co'lege, and
Obstetric Physician to the Hospital: Formerly Presidcat of the
Obstetrical Society of London; Honorary Fellow of the
Obstetrical Society of Berlin; Honorary Fellow cf
the Gynaecological Society of Boston.

A New American from the Fourth Revised ant Enlarged
London Edition.

EDITED, WITH NOTEs, ADDITIONS AND ILLUSTRATIONS,

BY

H. MARION-SIMS, M.D.,
Attending Surgeon to St. Elizabeth’s Hospital, N. Y., Etc.

THREE OcTAvo VoLuMES, OVER 1,000 Paces, WITH 240
ILLUSTRATIONS.

It may seem superfluous to say a word in commendation of Dr.
Graily Hewitt’s great work—a work which has been accepted as the
standard by the profession both in England and America, and which has
been adopted as a text book in twenty or more medical colleges.

The author, in the preface, says:—‘'Ten years have elapsed
since the last edition of this work was published. What I have gained
from observation and experience during these ten years has been here faith-
fully and truly set down. * * * The greater part of this new edition
has been rewritten.”

Dr. Sims has given the work a thorough revision, freely criticising,
and commenting on the authors’s views, and making many valuable addi-
tions in the text and illustrations,

In three large octavo volumes, handsomely bound.

Vol. I. contains 350 pages and 1o4 Illustrations, Price, $2 75
“ II. “ce 322 66 64 6c 2 75
ia Ill. “ 365 “ 72 “ 2 75

E. B. TREAT, Publisher, 5 Cooper Union, New York.
A PRACTICAL- TREATISE |

ON THE

DISEASES OF THE HAIR AND SCALP.

GEORGE THOMAS JACKSON, M.D.
Instructor in Dermatology in the New York Polyclinic ; Assistant
Visiting Physician to the New York Skin and Cancer
Hospital ; Member of the New York
Dermatological Society ; etc.

This work discusses the various phases pertaining to the care of the
Scalp and Hair, and to the treatment of its diseases. The parasitic, as
well as the non-parasitic diseases, which affect it, and those of the Scalp
in which the Hair is implicated are allcarefully explained. The hygiene
of the hair, even to minute points, is fully described and directions
given for its care in every particular. The best plans of treatment by
the most eminent men of this country and Europe for the various dis-
eases of the Hair and Scalp are also fully set forth.

With the object in view of rendering this volume of still greater
practical value, its contents are illustrated by numerous and specially
selected wood-cuts which demonstrate to the eye what the text places
before the understanding.

The Dermatological specialist will also find in this volume a most
carefully arranged and voluminous bibliography collected from over
six hundred journal articles, besides special and general treatises,

To the general medical practitioner who finds it so difficult to
learn what is the proper thing to do for a ‘hair case,” this book will
prove invaluable, as he will find scattered through it many prescriptions
that cannot fail of being useful to him. The author has made the mat-
ters of diagnosis and treatment specially prominent, carefully pointing
out the differences between the various diseases of the hair, the
special and appropriate remedy needed for each, and the best means for
their prevention.

In One Octavo Volume, 356 pages. Illustrated by
special drawings and photographs from life. Price, $2.75.

E. B. TREAT, Publisher, 5 Cooper Union, New York.
INS ANI T x:

Tits Classification, Diagnosis and Treatment;
A Manual for Students and Practitioners of Medicine.
BY

E. C. SPITZKA, M. D.,

Professor of Medical Jurisprudence and of the Anatomy and Physiology of the
Nervous System, at the New York Post-Graduate School of Medi-
cine, President of the New York Neurological Society, etc.

In this, the first systematic treatise

on Insanity published in America since

the days of the immortal Rush, the author has made its definitions, classifica-
tions, diagnosis and treatment plain and practical; and has laid particular
stress upon points comparatively new and has succeeded in presenting the sub-
ject in such a manner that the rudiments of this difficult and intricate branch

of medicine may be easily acquired and

understood.

(G¥" This important work has already been adopted as the Standard Text-

Book in the College of Physicians and
Physicians and Surgeons of Baltimore,
the College of Physicians and Surgeons
cal College of Philadelphia.

The Boston Medical and Surgi-
cal Journalsays: *‘ Conservative and
in accordance with the highest principle
of scientific investigation, which accepts
no half-truth, but proven facts alone.
. . © Its chief merit consists in its
effort to present the subject in a clear,
accurate, and scientific manner.”

 

The Louisville Medical News
says: ‘* The book is written in a clear
and forcible style, and while the practi-
cal side of the question is kept constant-
fy in the foreground, it abounds in inci-
dents, historical and modern, which
admirably illustrate the points made by
the author, and contribute largely to the
entertainment of the reader.’

The Weekly Medical Review
says: ‘‘It cannot be neglected by any
one desiring a clear and comprehensive
review of the whole subject of insanity.”

 

In One Large Octavo Volume,

E. B. TREAT, Publisher, 5

Surgeons of New York, the College of
the Rush Medical College of Chicago,
of St: Louis, and the Medical-Chirurgi-

The New York Medical Record
says: ‘' The accomplished author dis-
plays throughout a masterly grasp of his
intricate subject, and a familiarity with
its bibliography which is in the highest
degree commendable. . .° The pre-
sentation of his arguments is direct ana
decided, his illustrations usually apt and
well put, and his expositions of the
most important points forcible.”

 

The Cincinnati Lancet and Clinic
says: ‘‘A great variety of useful infor-
mation and an intelligent discussion.”

The American Medical Weekly
says: ‘*It is clear, it is up to the times,
and last but not least, it is practical.”

 

The New England Medical
Monthly says: ‘* By far the best book
that has appeared in English in this

 

department of Science.”

424 pages. Illustrated. $2.75.

Cooper Union, New York.
DISEASES or THE HEART.

By ALONZO CLARK, M.D., LL.D,

Emeritus Professor of the Principles and Practice of Medicine, etc.

College of Physicians and Surgeons, New York.

This book is the crowning cffort of its distinguished author.
Few, if any, in the medical profession have attained to higher
eminence as a skillful diagnostician. Filling for many years the
chair of Professor of the Principles and Practice of Medicine in
the College of Physicians and Surgeons, New York; and standing
in the front rank, if not che first of “Consulting Physicians” in
his specialty, he enjoyed unsurpassed opportunities from personal
observation, original investigation and familiarity with the literature
of the subject, of becoming the ablest expert of his time.

The information gathered in this volume embodies the sub-
stance of his teachings and lectures on “ Diseases of the Heart”
given to his students, Nothing is omitted which would tend to
give a clear exposition of the views which he inculcated as teacher.

The volume cannot therefore fail of being of great value to
practioners, as it contains the results of a singularly calm and
judicious mind of one who had long and pre-eminent experience,
and whose ripened harvest of thought is gathered into this sheaf,
which ought to find an honored place in the medical granary
among other distinguished sheaves.

It gives emphasis and increased interest to this book to know
that it is the only portion of Dr. Clark’s many and valuable articles,
lectures, teachings, and medical examinations given to the Pro-
fession in permanent published form.

One Octavo Volume, 251 pages. Price, $2.75.
E. B. TREAT, Publisher, 5 Cooper Union, New York.
BROWN'S MEDICAL DIAGNOSIS.

A MANUAL OF CLINICAL METHODS By J GRAHAM BRowN
M.D., Fellow of the Royal College of Physicians of Edinburgh,
Late Senior President of the Royal Medical So-
ciety of Edinburgh.

SECOND EDITION

ILLUSTRATED.

This work is the embodiment of the thorough and conscientious labors of
Dr. Brown of Edinburgh, who has won a just celebrity in his
department of medicine. Its contents are
summarized as follows :

CHAPTER I, THE GENERAL ASPECT,

Condition and Circumstances of
a Patient. Preliminary Inquiries.

II. ALIMENTARY SYSTEM.
Objective — Subjective — Excretory
Phenomena,

III. EXAMINATION OF THE
ABDOMEN,
Its palpitation and Percussion.

IV. H4@MopolgTIc SYSTEM.
Lymphatic Vessels and Glands—Ex-
amination of the Blood.

V. CIRCULATORY SYSTEM.
Subjective Phenomena,—Palpation.
—Percussion.—Auscultaton of the
Heart.—Examination of the Arte-
ries, Capillaries, and Veins,

VI. RESPIRATORY SYSTEM.
Subjective Phenomena. — Examina-

tion of Nares and Larynx. Pal.
pation.—Percussion of the Chest.
—Anscultation.—Respiration.

VII. INTEGUMENTARY SYSTEM.
Subjective and Objective Symptoms
—Enruptions.
VIII. Urinary System.
Subjective Symptoms.—Normal con-
stitutents of Urine. — Abnormal
Constitutents of Urine.—Urinary
Sediments.
IX, REPRODUCTIVE SYSTEM.
The Female Reproductive Organs
and Functions—Physical Exami-
nation,
X. NERvous Sysi‘EM.
Sensory—Motor—T rophic- Cerebral
and Mental Functions.— Condi-
tion of Cranium and Spine.
-XI, LocomoTory SysTEM,
Bones—Joints—Muscles.

 

PRESS NOTICES.

“A clearness and completeness which is not to be found in any book
of the kind with which we are acquainted.”—British Medical Fournad,

‘©The author of this manual deserves the thanks of all clinical students
(and we may add, of teachers also) for the excellent work he has pro-

duced.” — The Lancet.

‘On voit que cet ouvrage, qui d’ailleurs est tres au courant de la

svience, n’est pas une simple compilation, mais qu'il renferme des parties
vraiment originales.” —Paris Revue de Medicine. ;

‘* His plan is not that found in many other works on Diagnosis—that
of taking up leading symptoms and tracing them in various diseases. He
pnrsues what we may call the anatomical method, thus passing in review
the whole body. This is a natural and easy plan of arranging his material,
and is quite as advantageous as any other.” —Phila, Medical and Surgicat
Reporter,

One Large 8vo Vol, 285 Pages, Handsomely Bound, $2.75.
E. B. TREAT, Publisher, 5 Cooper Union, New York.
Favorite Prescriptions

DISTINGUISHED PRACTITIONERS

WITH

NOTES ON TREATMENT.

Compiled from the Published Writings or Unpublished Records of Drs,
Fordyce Barker, Roberts Bartholow, Samuel D. Gross, Austin Flint,
Alonzo Clark, Alfred L. Loomis, F. J. Bumstead. T, G. Thomas,

H. C. Wood, Wm. Goodell, A. Jacobi, J. M. Fothergill, N.

S. Davis, J. Marion-Sims, Wm. EH. Byford, L. A. Duh-
ring, E. O. Janeway, J. M. Da Costa, J. Solis Cohen,

Meredith Clymer, J. LewisSmith, W. H. Thom-
son, C. E. Brown-Sequard, M. A. Pallen,

Geo. H. Fox, W. A. Hammond,

E. C. Spitzka, etc., etc,

BY

B. W. PALMER, A.M., M.D.

New, Enlarged and Revised Edition, with Blank Pages inter-
leaved in tts Several Departments for Registering
formule worth Preserving.

 

“We believe that the physician will find that this guide
will very materially lighten his labor in searching for the
most reliable agents in treatment, indeed will be an aid to him
which he cannot well dispense with after once possessing it.’
—Medical Gazette.

 

“The modest volume in hand contains a large number
of good prescriptions. It is gotten up in dainty style, and
the publisher has done his work well.’’—S¢. Zouzs Clin. Rec.

———

In one large Octavo volume. 256 pages. Handsomely bound, $2.73.
E. B. TREAT, Publisher, 5 Cooper Union, New York.
NERVOUS EXHAUSTION

[Neurasthenia],
Its Hygiene, Causes, Symptoms and Treatment,

By GEORGE M. BEARD, AM., M.D.,

Formerly Lecturer on Nervous Diseases in the University of the City of New
York ; Fellow of the New Vork Academy of Medicine, etc.

Second Edition Revised and Enlarged by A. D. ROCKWELL, A,M., M.D.,

Professor of Electro-Therapeutics in the New York Post-Graduate Medical
School and Hospital, Fellow of the New York Academy of Medicine, etc.

NEURASTHENIA.—In spite of its frequency and importance, although long
recognized in a vague way among the people and the profession under such
terms as ‘‘general debility,” ‘‘nervous prostration,” “nervous debility,”
‘nervous asthenia,” ‘‘spinal weakness,” it is beginning to find recognition
in the literature of nervous diseases. It is the most frequent, most interest-
ing, and most neglected nervous disease of modern times.

Among specialists and general practitioners alike, there has been, on the
whole subject, a fearful and wondrous confusion of ideas.

The present work is the result of the experience and study of my entire
professional life in the subject to which it relates.—(From Author’s Preface.)

Neurasthenia is now almost a household word, and equally with the
term malaria, affords to the profession a convenient refuge when perplexed
at the recital of a multitude of symptoms seemingly without logical connection
or adequate cause.

The diagnosis of neurasthenia, moreover, is often as satisfactory to the
patient as it iseasy to the physician, and by no means helps to reduce the
number who have been duly certified to as neurasthenic, and who ever after,
with an air too conscious to be concealed, allude to themselves as the victims
of nervous exhaustion. The doctrine to be taught and strongly enforced is
that many of these patients are not neurasthenic, and under any hardly con-
ceivable circumstance could they become neurasthenic. They do not belong
to the tyep out of which neurasthenia is born, either mentally or physically.

Many of them are unintellectual, phlegmatic, and intolerably indolent,
and are pleased at a diagnosis which touches the nerves rather than the
stomach, bowels and liver. Instead of rest, quiet and soothing draughts, they
need mental and physical activity, less rather than more food, depletion rather
than repletion.— from Editor's Preface.

In one large octavo vol., nearly 300 pages. Price, $2.75.

Uniform in style with Medical Classtes, Price of the 12 Vols., $
E. B. TREAT, Publisher, 5 Cooper Union, New York.
A PRACTICAL TREATISE

HEADACHE, NEURALGIA,

Sleep and its Derangements,

AND SPINAL IRRITATION.
By J, LEONARD CORNING, M.A., M.D.,

Consultant in Nervous Diseases to St. Francis Hospital; Fellow of the New
York Academy of Medicine; Member of the New York
Neurological Suciety; &c.

AUTHOR OF
A Treatise on Hysteria and Epilepsy,” ‘‘ Local Anesthesia,” ‘‘ Brain
Exhaustion, with some Preliminary Considerations on Cerebral Dy-
namics,” ‘‘ Carotid Compression,” ‘‘ Brain Rest, being
a Disquisition on the Curative Properties
of Prolonged Sleep,” etc., etc.

In this volume the author has undertaken the difficult task
of explaining the nature and treatment of those pains about the
head, which constitute such a fruitful source of misery. Dr.
Corning is eminently qualified for the work, and has long been
known to the profession as a brilliant and indefatigable laborer
in the cause of practical neurology. His contributions to neuro-
therapeutics are among the most practical and suggestive
additions which have been recorded during recent years. To
rare powers of perception Dr. Corning unites, in an eminent
degree, the faculty of imparting knowledge in an entertaining
manner. His style is at once lucid and forcible, not the least
of his charms.being the power to awaken thought as well as
to impart information.

In all matters involving the treatment of pain Dr. Corning
is an acknowledged authority, and the precepts which he
inculcates are alike worthy of the physiologist and the accom-
plished physician.

The present treatise on “Headache and Neuralgia” is
replete with suggestion and useful matter, and no thoughtful
physician can fail to derive both inspiration and practical
assistance from its perusal.

In one large oct. vol., nearly 300 pages. Price, $2.75,
Uniform in style with Medical Classics; Price of the 12 Volumes.

E. B. TREAT, Publisher, 5 Cooper Union, New York.
BRIG = Diseae =.

A SERIES OF POST GRADUATE LECTURES.
By ROBERT SAUNDBY, M.D., Edinburgh.

Fellow of the Royal College of Physicians, London; Emeritus
Senior President of the Royal Medical Society ; Fellow
of the Royal Medical Chirurgical Society, etc., etc.

ITS CONTENTS ¢: Patruo.tocicat Skcrion I. Comprises: ALBUM-
INURIA—PATHOLOGY OF Dropsy—or PoLyuRIA—oF URAMJA—CokDIO-
VASCULAR, and RETINAL CHANGES. II. CLINICAL EXAMINATIONS AND
TESTS OF THE URINE IN HEALTH AND DiskAse. III. Bricut’s DISEASE,
ITs HistoRyY—CLASSIFICATION—ETIOLOGY—ANATOMY OF THE KIDNEY—
FEBRILE LITHEMIC AND OBSTRUCTIVE NEPHRITIS— COMPLICATIONS OF
CHRONIC CASES—T REATMENT — FIFTY ILLUSTRATIONS,

These Lectures are specially designed for Practiticners, and
are an expansion of a Post Graduate Course on “Brigh?’s Disease,”
and coming from a thoroughly competent hand will be welcomed
by the medical profession. The author, by talent, position, study,
long experience and special attention to Renal diseases is amply
qualified to present such a volume. The whole subject has been
thoroughly investigated, the present state of contemporary knowl-
edge on this disease is clearly stated, and additions and suggestions
which have resulted from thirteen years Clinical and Pathological
study of Bright’s Disease under the most favorable environments
have been made. Fifty illustrations from microscopical prepara-
tions of Urinary and Renal diseases are given and iuserted in
their appropriate places throughout the work. An alphabetical in-
dex closes this valuable addition to the Medical Classic Series.

In one large octavo vol., nearly 300 pages. Illustrated. Price, $2.75.

Uniform in style with Medical Classics; Price of the 16 Vols., $

E. B, TREAT, Publisher, 5 Cooper Union, New York.
HOW TO USE THE FORCEPS:

WITH AN INTRODUCTORY ACCOUNT OF THE

FEMALE PELVIS;

AND OF

THE MECHANISM OF LABOR.

HENRY G. LANDIS, AM., M.D.,

Professor of Obstetrics and Diseases of Women and Children in Starling Medical
College, Columbus, O.

This handy volume is an eminently practical work and must prove
invaluable to the student, obstetrician, and physicians generally.

Twenty years ago it would not have been difficult to have found
many respectable physicians in full practice who had never used obstet-
tical forceps, and among that number some who considered the employ-
ment of forceps as meddlesome midwifery of the worst sort. To-day
the best masters of the art of obstetrics teach with great earnestness
their proper use, and our medical literature abounds with able articles
on the subject. In this work the subject is discussed from an entirely
new standpoint, and is endorsed by our best informed obstetricians. It
is issued in a handy volume, which is more convenient to consult, and
will be found much more full than the section on this subject in most of
the text-books.

It is an eminently practical work, the subject is fully presented in
every aspect ; a clear and forcible argument is made for the proper use of
the forceps. The practitioner and student will, in this well-written
treatise, obtain many valuable hints, more likely to be treasured and
retained than those scattered throughout the elaborate and diffuse
works on obstetrics.

The New York Medical Record says: ‘* Prof. LANpDIs has given
us a very practical, comprehensive and interesting work upon the
mechanism of labor and the use of the forceps. It can be read and
studied with profit by every general practitioner.”

 

One 12mo Volume, fully illustrated with 28 practical outlines,
In extra cloth binding. PRICE, $1.50.

E. B. TREAT, Publisher, 5 Cooper Union, New York.
PHOTOGRAPHIC ILLUSTRATIONS OF

SKIN DISEASES.

{Forty-eight Quarto Plates, Sixty Cases from Life.]
By GEORGE HENRY FOX, A.M., M.D.,

Clinical Lecturer on Skin Diseases, College of Physicians and Surgeons, New York;
Surgeon to the New York Dispensary, Department of Skin and Venereal Diseases ;
Fellow of the American Academy of Medicine; Member of the New York
Dermatological Society, the American Dermatological Association, etc.

The large experience and reputation of Dr. Fox in this department
eminently qualify him for the preparation of so important a work.
As Surgeon to the Skin and Venereal Department of the New York
Dispensary, where upward of five thousand cases are treated annu-
ally, he has had ample amount of clinical material from which to
select cases. He has had access to and selected from several thou-
sand negatives, taken from patients in Bellevue and Charity Hos-
pitals. He has also drawn from other Dispensaries and Hospitals,
both in New York and Brooklyn, through the kindness of physicians
in charge. :

The COLORING is a special feature of the work, which has been
entrusted to a skillful anatomical artist, J. GAERTNER, M.D., for-
merly a physician and student under Hepra, in the General Hospital
of Vienna, These plates are carefully colored by hand and more ac-
curately represent disease than any lithographs or colored photo-
graphs which have ever been offéred to the profession,

wv Saar
CONDITIONS.—The work is published in Twelve Parts, each part consisting of
four plates printed from the original photographic negatives, by a new and indelible
process, on fine quality of heavy card-board, 10 x 12 inches, colored by hand, giving
in each case the characteristic and life-like effects of the disease. Two pages of
text accompany each plate.

This work will be sold only by our duly authorized Canvassing Agents.

No Subscriber’s name will be taken for less than the entire work.

PRICE, PER PART, $2.
Complete, Half Roan Binding, $26.75; in Half Turkey Morocco, $28.

———+o—___

NOW READY. PHOTOGRAPHIC ILLUSTRATIONS OF

CUTANEOUS SYPHILIS

By GEORGE HENRY ‘FOX, A.M., M.D.

48 Plates, Seventy Cases from Life. Terms and conditions as above.

E.B. TREAT, Publisher, 5 Cooper Union, N.Y.
 

 

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