Popular Science Monthly/Volume 48/March 1896/Exercise as a Remedy
By HENRY LING TAYLOR, M. D,
EXERCISE is not a remedy which in some mysterious way may prove beneficial in disordered conditions of the system, still less a specific in any given disease, but it may be made the means of producing gentle or powerful effects of a definite kind, which vary with its form, intensity, duration, time of application, method of administration, and the condition of the patient. The problem presented to the physician in a given case is not merely the prescription of exercise, but rather such proportioning and contrasting of the muscular activity to periods of rest that the total result shall be beneficial; here, as always, the patient is to be treated rather than the disease. Exercise employed systematically and with discrimination is of the highest value in the prevention of debility and disease, and also in he treatment of certain chronic affections. In many acute and some chronic diseases exercise is positively and actively injurious, and it is always liable to prove so when employed without due regard to its physiological effects. Though most of the useful effects of exercise can be obtained under skilled supervision with little or no apparatus, its practical importance is ignored in hospitals, but little recognized in asylums and imperfectly appreciated in private practice. The neglect of exercise as a therapeutic resource is traceable to failure to appreciate the indications for its employment, and perhaps EXERCISE AS A REMEDY. 627
still more to lack of precision in its application. While its proper prescription is undoubtedly more difficult than that of drugs, no drug is capable of producing effects at all comparable, and the care and attention devoted to its intelligent application by physi- cian and patient are well repaid. It is a practical point of the first importance that individuals differ enormously according to con- stitution, temperament, training, and previous habits as to the amount of exercise that will be required to produce a given result. While those who have been trained may require severe or labo- rious exercise to produce physiological effects, the writer has met with individuals free from disease in whom the gentlest passive movements, lasting the fraction of a minute, would produce de- cided subsequent stiffness and constitutional disturbance. As it is just these sensitive and undisciplined people who may be most benefited by properly adapted exercise, it is evident that the kind and amount required must not be gauged by any absolute standard but by the reactive powers of the individual. Like some drugs, exercise may produce different and even opposite effects, according to the dosage and consequent intensity of ac- tion. Slow rhythmical passive movements are decidedly calming, while moderately active movements are stimulating to mental ac- tion. A careful distinction should be made between primary and remote effects. Exercise has also its synergists, antagonists, and incompatibles, its acute and chronic toxic effects, and their anti- dotes. The synergists of exercise are fresh air, a nourishing diet, sufficient rest, an unstrained and cheerful mind, and temperate and regular habits ; moderate cold and possibly certain tonic drugs are a help to exercise. Exercise is antagonized by the opposite of the above-mentioned, and by toxic substances in the blood. Some interesting facts have recently been observed as to the effect of the use of tobacco in checking growth and the de- veloping effect of exercise. From measurements of the one hun- dred and eighty-seven men of the class of 1891, Yale, Dr. J. W. Seaver found that the non-users of tobacco gained in weight during the college course 10'4 per cent more than the regular users, and 6"6 per cent more than the occasional users of tobacco. In height the non-users increased twenty- four per cent more than the regu- lar users and twelve per cent more than the occasional users. In increase of chest girth the non-users had an advantage of 26*7 per cent and twenty-two per cent, and an increase of lung capacity of 77"5 per cent and forty-nine per cent respectively. These facts in regard to the dwarfing effects of tobacco are corroborated by observations on the class of 1891, Amherst, made by Dr. Edward Hitchcock. He found that in weight the non-smokers increased during their course twenty-four per cent more than the smokers ; in increase in height they surpassed them thirty-seven per cent;
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in gain of chest girth, forty-two per cent ; and in gain of lung capacity, seventy-five per cent. It is probable that alcohol and other poisons have similar effects.
Exercise of the skeletal muscles is contraindicated in haemor- rhage, fever, inflammation, certain toxaemias, and serious injuries. Pain is an uncertain indication ; if it result from inflammation or local injury, exercise is contraindicated, otherwise not necessarily. In acute local inflammation exercise is very injurious, since it increases the local congestion. Severe or sudden exertion should not be permitted in cases of aneurism, atheromatous arteries, cardiac vegetations or extreme cardiac weakness, but systematic training may be beneficial in the latter condition. Severe exer- tion should also be avoided soon after eating and in states of great physical and mental fatigue. Nothing will break down the system more quickly than the combination of mental worry or strain with physical prostration, though gentle exercises are often of value in resting the brain by bringing new centers into play, and thus effecting a better distribution of cerebral activity. It is futile to add to the burden of individuals already overworked, and the proper remedy in such cases is the reduction or proper proportioning of their total work, better hygiene, and provision for adequate periods of rest, repose, and recreation, which are the efficient antidotes for the toxic effects of excessive exercise. Well-chosen exercise may often be made to minister to mental poise, and thus to restful effects. It has been pointed out that the individual patient usually needs not exercise or rest exclusively, but exercise and rest in the proper proportions and in the proper order. The beneficial effects of treatment may often be enhanced by placing the two in sharp contrast. Exercise produces a better impression on a background of rest, and rest on a background of exercise ; and particular attention should be paid to securing variety of action by contrasting one set of exercises with others involving different groups of muscles, or the same groups in a different manner. The level road may be the harder to travel in the long run. Neither its specific effect in any named disease, still less the piling up of enormous masses of muscle, is the thera- peutic object of exercise, but the production of definite local or general physiological effects. Increased muscular power is usual- ly an incidental result, but marked remedial effects are often pro- duced with very moderate muscular development. The too domi- nant idea of "gymnastics" should not make us lose sight of the vast therapeutic importance of the nervous reactions associated with muscular movements, and of the systematic culture and training of the involuntary neuromuscular apparatus, which cei- tainly depends in large degree on the activity of the skeletal muscles, but is often best elicited by massage, passive move-
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ments, hydrotherapy, and hygiene; all these involve exercise in a fundamental sense, and are of great therapeutic utility, even in febrile states, where exercise of the skeletal muscles is absolutely contraindicated.
The professional and domestic occupations, recreations, and sports have been noticed in their relation to the hygiene of exer- cise, and it is desirable that these means, which are within the reach of such large numbers of people, should be more often util- ized therapeutically. For this purpose it should be remembered that many exercises have a preponderating effect on certain organs.
"Rowing tells on the breathing organs; the work of dumb- bells, and of other exercises where muscles are moved without progression of the body, tells most on the muscles themselves ; and long pedestrian feats, with climbing, tell on the nervous sys- tem. In cycling, as in running, it is the heart and circulation that first give demonstrative evidence of important change of action" (Richardson).
Housework, chores, gardening, walking, climbing, cycling, run- ning, swimming, and many other sports give just the kind of exercise that is indicated in certain conditions, due regard being had to the physiological effects of varying dosage. Oertel has shown how the simple exercise of walking may be adapted to sufferers from cardiac debility by prescribing the distance and speed, and the number and length of the rests, on definite paths graduated according to their slope. His interesting and original work has not only given a new direction to the treatment of cer- tain cardiac affections, but is destined to have an important in- fluence in establishing accuracy in the prescription of exercise. Whoever has studied the map of the environs of Reichenhall, Ba- varia, prepared by Oertel for the application of his method, will acquire a vivid idea of what precision of dosing in exercise means. In this map the different paths suitable for the work are marked in four different colors, to indicate those that are nearly level, those slightly sloping, moderately sloping, and steep, and figures are placed along each route to show the space that should be traversed in each quarter hour. The locality itself is prepared for its remedial use by placing benches for resting at suitable dis- tances, and by marking on certain trees near the path circles, col- ored to correspond with the map, to indicate the difficulty of that particular section. By systematic practice on the easier paths the heart and system are progressively trained and strengthened. In- telligent analysis may do the same work for cycling, horseback riding, and many other familiar exercises. In this way the dosage is practically reduced to a definite number of kilogram metres in a giv^en time, and a step has been taken in placing the prescription of exercise upon a scientific basis.
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Recreations and sports have the inestimable advantage of being taken in the open air and being interesting to those who take them two factors whose absence in any form of therapeutic exercise is with diflQculty atoned for. Athletics, though sharing in these advantages, are not well adapted to most therapeutic pur- poses, on account of their excesses, indefinite dosage, and lack of variety, each contestant being a specialist in one or a few forms of exercise. There remain for consideration the formal exercises of drill of various kinds, gymnastics, Swedish exercises, including passive and mechanical movements, and massage, which is else- where treated of in this work.
As the primary purpose of military, fire, and other drills is not therapeutic, they are not well suited to the treatment of dis- ease, though they share in the beneficial effects of systematic ex- ercise. The manual of arms is not adapted to young children, being too formal and too strenuous ; the writer has seen cases of lateral curvature, knock-knees, nervousness, and debility in young boys which had apparently been aggravated if not produced by military drill.
Modern gymnastics has been largely shaped with reference to military purposes, and, while gymnastic exercises, if well selected and proportioned, do promote muscular development and physical grace and vigor, they are easily carried to an extreme, and in- stances are not rare where they have broken down the constitu- tion, instead of building it up. Feats of skill train the nerve cen- ters more than the muscles, and once the trick is acquired, their value as exercise is slight. Feats of strength often put an inju- rious strain upon the organism, with no corresponding benefit. The arm appears to be the object of all the exercises of modern gymnastics (Legrange) ; breasting and other movements which throw the suspension or support of the body upon the arms and shoulders give them unsuitable work, and result in disproportion- ate development of the muscles of the shoulder girdle, often asso- ciated'with a rounded back, and little or no increased power of ventilation, since all such feats are performed with a chest fixed and constricted by muscular effort. The gymnastics of the mod- ern gymnasium are in marked contrast with the athletic exercises of the Greeks, with whom the striving for physical perfection amounted to a passion. Their exercises were running, wrestling, boxing, fencing, and throwing the discus, taken in the open air, without apparatus, and exercising the body throughout, and espe- cially in the fundamental associated movements of the trunk and limbs. The defects of ordinary gymnastics have been felt by those interested in physical culture, and have been partly obviated by the introduction of free movements, like running, jumping, and wrestling, and partly by the use of resistance machines, usually
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constructions of levers, pulleys, and weights, designed to exercise special groups of muscles, as in the Sargent system of apparatus. These reward effort, however, with depressing monotony, are devoid of most of the beneficial general effects of exercise, and appear to the writer to lack the elements of a coherent system.
The old gymnastic idea, in the endeavor to accomplish certain feats and to pile up large masses of muscle, ignored the intimate co-operation between muscle and nerve, and the delicate balance between co-operating and modifying muscular groups necessary to build up a clear-sighted, well-balanced mind, in perfect and harmonious but largely unconscious mastery of the bodily move- ments. The wise teacher and physician have small interest in gymnastic feats, but direct muscular activity into those channels best suited to promote harmonious mental and bodily develop- ment and adjustment.
"With the Swedish system of exercises, devised by Ling and elaborated by his pupils, totally different ground is reached. Peter Henrik Ling was a fencing master, who became interested in ex- ercise as a stimulus to development and as a remedy from observ- ing its beneficial effects on his own health. He never took a med- ical degree, but developed remedial exercises into a system, which remains to-day as the basis of the most valuable procedures in therapeutic kinesiology. He also devised systems of educational, military, and aesthetic exercises. These exercises are based on the physiological actions of the different muscle groups and their relations to each other, and consist in free voluntary movements executed by the patient in different positions and in a determined order. The remedial movements include, in addition, passive movements executed by a manipulator, and assistive and resistive movements, in which the operator opposes resistance to the move- ments of the patient, or vice versa. To these are added the vari- ous manipulations of massage.
The Swedish therapeutic exercises emphasize strongly the local effect of movements, and hence have been called localized movements, and are largely used for specific local purposes. They proceed from the simple to the complex, aiming to establish cor- rect fundamental attitudes and relations, and to invigorate and develop deficient parts through exercises adapted to the particular condition and situation. The value of gentle and passive exercise in conditions of debility, and of the systematic progressive adap- tation of the exercise to the strength of the patient, is recognized and practiced.
The Swedish system avoids the abnormal development of spe- cial parts and the gratuitous feats of ordinary gymnastics, and produces normally acting viscera, a graceful carriage, and good muscular and mental control. One school of the Swedes, led by
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Zander, has in the last thirty years developed a system of mechan- ical movements, both active and passive, given by means of appa- ratus. In these the resistance and amount of motion can be grad- uated to the patient's needs, and the personal element of the operator is eliminated. Each system fulfills certain indications, and neither can wholly supplant the other. If the Swedish school had given us nothing more than passive movements in therapeu- tics, our debt would have been great. The extraordinary promi- nence in recent years of massage as a remedial agent, in so far as it is justified by results, rests largely on the employment with it of passive movements. These enable the patient to obtain many of the benefits of exercise without effort and without undue fatigue, and can be employed in thousands of cases when active exercises are contraindicated or impracticable. Through passive exercises may be obtained the local effects of exercise on the cir- culation, easing of cardiac action or its gentle stimulation, mental discipline, or mental sedation, as in the soothing effects of rocking or swaying movements on infants ; in a word, the more harmoni- ous distribution of nervous and vascular activity.
It is well to remember Ling's adage that every movement properly performed is a respiratory exercise, and it is probable that respiratory development may be best attained through climbing, running, and similar exercises by those who are strong enough and energetic enough to take them. Those who most need them, however, are neither strong nor energetic, and it is often impossible to get patients to practice the purely respiratory exercises with sufficient care and persistence. In such cases, where more thorough pulmonary ventilation and respiratory power are required, passive respiratory movements, manually or mechanically given, often serve a useful purpose.
There is no more promising field for the therapeutic applica- tion of exercise than in the treatment of the insane and mentally unbalanced and defective. The elder Seguin has shown that the idiotic brain could be most effectively reached and developed through neuromuscular training, especially of the hand, and the value of manual employments, industrial training, and social life has been to some extent recognized in provision for the epileptic, idiotic, insane, and criminal. The striking and oft-quoted results obtained by Dr. Wey in the physical training of vicious and stupid criminals at the Elmira Reformatory by means of im- proved diet and systematic bathing, massage, drill, and gymnas- tics, mark an era in the treatment of the defective classes. A large proportion of previously incorrigibly dull and vicious in- dividuals submitted to a few months of this treatment improved remarkably in physical and mental condition. It is safe to say that better provision will be made in future in our public institu-
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tions for the proper application of exercise in its various forms of manual training, sports, drill, gymnastics, and special exercises.
As exercise is a fundamental factor in the development and culture of the mind, it can be used to modify mental states, and has most important general and special applications in many nervous diseases. The repetition of rather gentle monotonous movements, especially of the automatic or passive kind, tends to allay mental excitement and nervous irritability. If the excite- ment is of the active insistent type, more vigorous exercise of duration to the point of fatigue may be beneficial, but should be semi-automatic, like walking, cycling, or rowing. These prin- ciples find a useful application in the treatment of insomnia. If the patient is dull and apathetic, with sluggish circulation and nutrition, exercises involving quickness and skill that is, a more lively mental co-operation, like fencing, tennis, or boxing should be used. In other cases the brain may need to be pro- gressively trained through manual employments. The finer and more delicately adjusted the movements the less their value as muscular exercise, and the more the nerve centers are called into play. Writing, sewing knitting, playing on instruments, and in general the use of the hands mainly are valuable as mental train- ing, but lack the beneficial general effects of vigorous exercise of the more fundamental groups. From its action as a cerebral sedative or tonic, exercise may be used as a m.eans of influencing certain definite areas in the centers, in order to soothe, to stimu- late, or to distribute and proportion mental action ; and certain exercises may be abstained from to deprive certain areas of stim- ulation. We know no drug that acts mainly on the arm centers or mainly on the leg centers, but we can with certainty bring either of these centers into action by prescribing indicated exer- cises. In an important group of neuroses due to the excessive repetition of certain fine movements, usually of the accessory kind, involving accurate co-ordination, such as writer's, teleg- rapher's, and piano-player's cramp, and similar troubles, char- acterized by local pain and inco-ordination, usually associated with extreme mental anxiety, the hurtful practice should be stopped and massage and more general exercises involving more fundamental groups substituted. In another class of cases the bedfast neurasthenics the nutrition must first be built up by seclusion and systematic feeding, and the neuromuscular system, both voluntary and involuntary, aroused and strengthened by bathing, massage, and passive movements. Patients that would be injured at first by attempts at active movements will thrive on gentle passive movements of the arms and legs, and will soon be actively co-operating. When sufficiently advanced they can be taught to walk, and before they can do much at this they can
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take with great benefit some forms of passive mechanical move- ments, given after the Swedish system with power machinery, and which cause them to execute walking movements, respira- tory movements, and trunk flexions while reclining, and with a minimum of effort and fatigue. Neurasthenics less severely affected can take such movements from the start, and they are indicated where the effects of exercise in equalizing the circula- tion and nervous activity, developing respiratory capacity and the supply of oxygen, increasing peristaltic and hepatic action, and nutrition, are desired for patients who are physically too delicate or who have too little energy or persistence to be able to get much benefit from exercise where vigorous volitional co- operation is involved. When the latter can be successfully pre- scribed the patient is well on the way to recovery.
Exercises of endurance, like cycling, rowing, and running, pushed to the point of considerable fatigue, are the most effective aids to continence, since the procreative impulse is the expression of a surplus of energy, and is abated if enough energy is regu- larly used up through muscular work.
As the larger number of functional disorders of the digestive system, such as dyspepsia and constipation, are the result either of the habitual neglect of muscular exercise or else of exercise taken under conditions of hurry, nervous tension, or fatigue, it is clear that the regulation of exercise and habits of life must be urgently indicated. In conditions of atony the patient must be trained to a variety of exercises, especially those involving the waist, abdomen, and trunk, among which the more active ones may be gradually introduced. In the cases due to debility from nerve tire, exercises requiring much skill should not be chosen, since these involve increased demands on the higher nerve centers. As there is usually sluggishness of the abdominal circu- lation, those exercises should be selected which will act on the abdominal organs through the muscles of the waist and trunk and upon respiration. Among the best of these is riding, which, moreover, affords just enough variety of scene and interest in the control of the horse to turn the current of an incessantly active brain into new and more restful channels. Riding may be as accurately dosed as walking, and may range from very gentle to exceedingly severe exercise, according to the gait, training, and disposition of the horse, the muscular development, tempera- ment, and expertness of the rider, and the character of the ride. Changing from one mount to another also gives more variety of exercise than always riding the same horse. Abdominal massage is sometimes useful in constipation, as are also the arm, leg, and trunk movements of the Swedes or of the gymnasium, and walk- ing, running, leaping, tennis, and other sports have their uses.
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Whatever form of exercise is used, absolute regularity in attend- ing to the calls of Nature must be observed.
Disorders of nutrition are powerfully affected by exercise, through the voluntary and involuntary muscles as well as through the nerve centers. Respiratory exercises and the exer- cises stimulating respiration and circulation are beneficial in angemia, as are also the scientific application of massage and cold water to promote tissue interchange. By quickening oxygena- tion, the circulation, and the nutritive processes, moderate system- atic exercise causes thin and poorly nourished people to gain in weight as well as in vigor.
In most wasting and febrile diseases, toxaemias and inflamma- tions, the strength of the patient is needed to combat the circulat- ing poison, heal the local lesions, and keep the vital processes going, and for these reasons, as well as on account of cardiac debility, muscular exercise is contraindicated, in some instances even during convalescence. Heart failure after diphtheria from changing from the recumbent to the sitting posture, and serious and even fatal relapse following too early sitting up after typhoid fever, are notable instances in point. Exercise of the unstri]3ed muscles by friction and bathing may, notwithstanding, be ex- tremely useful. It is noteworthy that under the supporting treat- ment afforded by cold bathing with friction much greater liberty is allowable. Not only do the patients bear well the lifting into and out of the tub, but some eminent physicians do not hesitate to let their typhoid patients sit up to adjust compresses to the body, to step into the tub, and even to walk to it with some assistance.
Exercise in the open air is of the greatest utility in the prophylaxis of phthisis. After the disease is developed exercise must be used with more caution, and in such a way as not to put great demands upon the vital powers of the patient. Moderate exercise out of doors and gentle respiratory exercises may be made beneficial, especially if directed to their gentle tonic effect and toward the better aeration of the pulmonary tissue.
There is a large class, especially among women, Avho habitu- ally neglect exercise and lay up large amounts of reserve material in the shape of fat, which becomes burdensome by its bulk, and injurious by impeding the action of the organs in whose sub- stance or vicinity it has been deposited. These people are not always large eaters, but having accumulated a physiological surplus, they have never been able to oxidize it. Exercise of endurance and respiratory exercises are well adapted to aid in burning up this surplus and to improve the health. It may, in addition, be necessary to reduce the ingestive fluids and fat- forming foods.
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For those who habitually ingest too much rich and nitroge- nous food and take too little exercise, whether suffering from typ- ical gout or not, the systematic use of the muscles, together with a less hearty diet, is of the greatest value. It should be remembered, however, that when gout is developed, severe or unaccustomed exercise may precipitate an attack ; systematically and judicious- ly employed in the intervals, exercise will tend to ameliorate the condition and prevent the recurrence of attacks. In diabetes, another disorder of imperfect metabolism, it has not been suffi- ciently appreciated that the surplus of sugar may be largely oxi- dized through carefully prescribed exercise. Walking is the most convenient form, and the amount should be graduated ac- cording to the patient's capacity and training. The aversion of the diabetic to exertion may be overcome by allowing limited amounts of bread as a reward for each mile walked. Those who have tried this plan find a decided advantage over a stricter diet and insufficient exercise.
The relation of exercise to the treatment of cardiac and circu- latory affections has entered on a new phase since Oertel's original work. The dominant idea had been hitherto to relieve a weak or damaged heart of strain by avoiding exercise. Oertel teaches that the work of the staggering or flagging heart may be cut down by reducing the amount of ingested fluids, and the heart trained and strengthened by graduated daily exercise in walking on level and sloping paths. The results reported confirm the value of the method, and it is hardly too much to say that by accurately dosing and systematically applying this common ex- ercise to meet the need of individual patients he has not only given the profession a valuable remedy, but a new point of view in the treatment of these serious affections. Oertel's cases are largely those of cardiac debility from imperfect nutrition of the heart and system, evidenced by fatty deposits in or about the heart, and not rarely elsewhere. This condition is usually the result of a too inactive muscular life, and in Germany is often associated with the ingestion of large quantities of beer, so that the ill-nourished heart has an increased amount of fluid to pump. In such cases a large reduction of ingested fluids is a necessity while attempting to invigorate the heart by graduated and divided doses, at first small, of walking and climbing exercise. Where valvular disease, with or without dilatation, presents similar indications, a similar course may be followed, but such prescriptions must be made with accurate discrimination and analysis of the actual state and needs of the economy.
- From advance sheets of Handbook of Therapeutics, edited by Frank P. Foster, M. D., in press of D. Appleton & Co.